workers during the covid-19 pandemic. >> our response to the covid-19 pandemic and those on the frontlines of the fight against this virus. ranking member burr and i will each have an opening statement and then i'll introduce dr. shah, dr. abraham and dr. jha and introduce dr. fuchs. five minutes for a round of questions. before we begin, i again, want to walk through the covid-19 safety protocols in place. we will follow the advice of the attending physician and the sergeant at arms in conducting this hearing. committee members are seated at least six feet apart. and some senators are participating by video conference. and while we were unable to have the hearing open to the public or media for in-person attendance, live video is available on our committee website at help.senate.gov. if you are in need of accommodations including closed captions, you can reach out to the committee or office of accessible services. we are all grateful to everyone including our committee clerks who worked so hard to set up a hearing like this and help everyone stay safe and healthy during this pandemic. life for families across the country has changed a lot over the past year. and while we are familiar with the staggering number of this pandemic, over 29 million infected, over a half million dead. the full toll of that loss and so much else families have gone through missed birthdays, weddings, graduations and even funerals. the fear, the loss, the isolation we have gone through, individually and as a nation. and the impact that it is causing our mental health and substance use among other issues cannot be measured. the true cost of this pandemic so far is unthinkable. and it should be just as unthinkable we would do anything short of everything when it comes to ending this crisis as soon as possible and rebuilding our nation stronger and fairer. i'm glad president biden has put forward a bold comprehensive vision to see our country through this pandemic. and we took a critical step towards making that vision a reality by passing in short order the historic american rescue plan, which provides funding for testing, contact tracing and sequencing so we can identify new variants ofcovid and slow the spread. distribute quickly, widely and promote vaccine confidence and communities hard to reach. funding to recruit and train 100,000 new public health workers for these efforts and funding to address inequities that have made this pandemic more deadly for communities of color to address mental health, behavioral health and substance abuse challenges. this pandemic has worsened to support home and community-based services that help people with disabilities and older americans. and to support community health centers which continue to be a lifeline to so many hard hit and hard to reach communities. this bill represents important progress, as does president biden's announcement that our country will have enough vaccines for every adult by the end of may. but we are all well aware it is not mission accomplished. we have to roll up our sleeves, literally and figuratively and get vaccines in arms. we have to make sure communities that are often overlooked and underserved are getting vaccines and getting answers to questions people are asking, like when can i get a vaccine? where do i go for my vaccine? how do i know the vaccines are safe and effective? we have some promising tools here but also still have work to do to make them accessible to people with disabilities, people who do not speak english and people who do not have internet or smartphones. we have skilled experts promoting vaccine confidence, but we still have to engage trusted community partners, as well. in my home state of washington, the pacific islander community has been hit harder than anyone during this pandemic and while we still don't have good data on the extent of that problem it is clear when it comes to vaccinating this community, we're already behind. that's why when joseph of washington state saw how online booking for vaccines was missing elders in their community and worked to set up the first in the nation pop-up vaccination clinic. as he told the "seattle times" it's an equity thing. people don't have technology and people don't have the time. it's essentially privileged people who are signing up for these appointments and the impacted folks are not able to do it, unquote. the clinic kept things intentionally low tech to help prioritize reaching vulnerable seniors. we need to continue seeking out community partners like that to make sure that we are understanding the challenges they face and working through them together. because this pandemic will not truly be over for anyone until we can vaccinate everyone we can. even when it ends, we need to make sure nothing like this ever happens again. so, i'll be saying more about how we do that later this week when i reintroduce the public health infrastructure save lives act. it was hard to imagine when this pandemic began a year ago where we would be today. but the question before us in this moment is how soon will students be back in the classrooms. how soon will those people not already at work be back? how soon will we be able to visit safely our friends and family for special occasions and greet them with smiles and handshakes and hugs. we all want to get there as soon as possible but that starts with the work all of our witnesses are here today to discuss and the steps we take right now to support it. i look forward to hearing from our witnesses about how we end this pandemic and working with them to get all of our communities there. as ranking member burr and i have been talking about since early in january, covid-19 has defined this committee's work over the last year and in many ways, will define it over the next two years. for all of my committee members, hearings like this are just a beginning of our effort to look comprehensively at the impact of the pandemic we are in the middle of. i look forward to working with ranking member burr and every member of this committee as we continue those efforts and work to respond to the covid-19 pandemic and its aftermath. keys to this work will also be helping american workers and families recover from all impacts of the virus and the dire economic situation they face. addressing the devastating impacts of learning loss, so many children are facing. and the symptoms long haulers continue to fight and ensuring this country's response to all the ways this pandemic will stay with us for a long time. as well as all the things we should be doing to prepare for pandemics in the future. i know every single member of this committee no matter how different our politics or our states is unified in feeling the deep loss caused by this crisis. deep gratitude to all of those on the front lines fighting it and the importance of responding to this moment by building a stronger, fairer, better nation for the people we represent. i look forward to this hearing and working with all of you in the days and months ahead. with that, i will turn it over to ranking member senator burr for his opening remarks. >> thank you, senator murray. good morning to our witnesses, dr. abraham and our other witnesses who join us virtually. one year ago today, march 9th, there were 1,020 ca covid cases the united states and 30 had died from complications from the disease. this was at that time still not a threat based on what cdc and other agencies said. since then 28 million people have contracted covid-19 in this country and more than 514,000 americans have died from it. globally 116 million have contracted covid and 2.5 million have died from this once in a century pandemic. the committee has an awesome responsibility ahead of it. we must take stock of lessons learned from response to covid pandemic and learn together to see what worked, what didn't work and what needs to be done to be more prepared in the future. we should be proud of the work, proud of the important laws programs and policies we've worked on together in this committee to create and fund because so much of it worked exactly as we envisioned. fda used its emergency use authority to get vaccines and therapeutics to the americans in record time. while maintaining the gold standard of safety and efficacy. the assistant secretary for preparedness and response coordinated with health care providers on the ground to ensure the sharing of critical information and supplies as quickly as possible during the response and coordinated with nih and barta to kick out countermeasurement development into high gear. using the authorities operation warp speed developed and scaled manufacturing for multiple vaccines in record, life-saving time. but we should also be humble enough to know that more needs to be done to be prepared for the future. i hope now that the partisan spending bill is over that only had 5% of its funding dedicated to public health, to the public health portion to covid response and dedicated to covid vaccines. we can shift our attention back to working together. as we start this thorough review process, it's important that we remember we're still in the midst of our current response. but the tools we have today look very different than where we started over one year ago. largely because of the authorities that we've given to the executive branch. in may of last year, some experts were predicting that a vaccine could take years. in partnership with the private sector, we did it in ten months. testing is now widely available with the fda announcing just last week that emergency authorization of another test that delivers results at home thanks to public private partnership and leadership from the nih. our doctors and nurses have found new ways to better deal, to treat our sickest covid patients improving outcomes with better clinical practice guidelines and our state and local officials have led the charge in tailoring our response to their community needs as they should. alongside our success, we must acknowledge our failures. at the beginning of the academic year just 17% of our nation's schools had fully returned to in-person learning. jeopardizing the future and potential of an entire generation of americans. businesses are still closed with the restaurant association estimating that 100,000 restaurants will not ever be back to welcome customers. and the tools we have to solve these urgent problems, a vaccine should be reaching more americans faster. the cdc stating that we are averaging 2 million shots in arms per day. but this administration has not updated its goal to reach 100 million shots in 100 days. which was already the trajectory when the president took office in january. instead, we should set aspirational goals like we did with the development of the vaccine. not easily attainable ones. when we look at where we are in response today, the data shows a significant decline in covid cases and hospitalizations. i share this with my colleagues not because we should let up on our response, because i believe we are at the greatest moment right now to learn from our progress and to learn from our failures. the time to capture the lessons we are learning is now. in realtime. and not months down the road when case levels are low, tension spans are shortened and urgency fades. i remind my colleague in the life of barda as an institution, it's been on life support three different times because congress lost interest in funding advance development. to our witnesses, welcome. each of you spent the last year in the thick of covid-19 response. 24 hours a day, seven days a week. thank you for your tireless efforts. i hope we can learn from each of you today about what the most, what was most important during the days of pandemic and the strategies that were most effective at the height of cases and deaths over the holidays. and the ways your response is changing as the vaccine is made available to more and more americans. your input is critical as we begin to consider the next phase of the current response. and as we look to the next public health threat that we will face. it's not a matter of if, but of when we'll need to turn to the tools and policies we're using today for yet another novel or emerging threat to our nation's health and its security. the questions i'll raise with each of you today are what did we get right? what did we get wrong? and what parts of our response were not part of the anticipated plan of action originally? throughout this year, the committee's held many bipartisan hearings and bipartisan briefings and we spent countless hours on the phone and in meetings with experts from around the country. this was a wise decision. despite its logistical difficulties, because it allowed us to begin to build the record necessary to move forward. this is our first hearing on covid response this congress and i look forward to working with senator murray to make these hearings and these conversations a regular practice of the committee. i know that we're in the process of securing administration witnesses for a hearing in the near future and i'd like to set the expectation for all of us on this committee on both sides of the aisle that we should expect to hear from administration officials on a regular basis, just like we did with the last administration, if not more often. they have an obligation to be open and transparent with congress and the american people about what they're doing in realtime. and i know all of my colleagues on both sides of the aisle will join us in this request. dr. abraham, to you and the other witnesses today, thank you for being here. please share with us, if you can, those personal experiences, those personal decisions that you made that may have gone counter to what the federal guidelines were but they were unique to your community and your area, in your state and your community health center and why that decision was so crucial for you to pivot to something you thought would work and, in fact, did work. with that, madam chairwoman, i thank the chair and yield the floor. >> thank you, ranking member burr. we will now introduce today's witnesses. i'm pleased to start by welcoming dr. umair hah from my home state of washington. appointed as secretary of health last year and on the frontline of our state's efforts to get vaccines into arms and keep families safe. the progress we've seen is encouraging, especially as new vaccinations per day now outpace new cases and cases are down 70% from the peak this winter. i'm grateful to dr. shah for the work he's done to help get us here. the work he continues to do to help us finally end this pandemic for everyone and for taking the time to join us today to share his insight and expertise. before his current role, dr. shah served for several years as the executive director and local health authority for harris county public health in texas. the third largest county in the nation. he served as a term as president of the national association of city and county health officials and he served as an emergency medicine physician at the houston va. dr. shah received his md from the ledo health science center and completed residency at the university of texas while earning mph there. dr. shah, welcome. thanks for joining us today. next i'll introduce dr. ashish jha. dean of brown university school of public health and led the harvard global health institute. dr. jha a renowned expert on pandemic preparedness whose work has been published in over 200 research publications. he has led ground-breaking research on ebola and a key adviser to policymakers looking for thoughtful analysis as they work to respond to covid-19. dr. jha received his md from harvard medical school, completed internal medicine training at university of california san francisco and fellowship in general medicine at harvard. he was also elected to the national academy of medicine in 2013. dr. jha, i'm glad to have you with us today. dr. jerry abraham is the director of kedren vaccine at kedren health in los angeles, california, where he also serves as a family medicine physician. dr. abraham has publicly championed the importance of vaccine equity and how we achieve it. and has worked to make it a reality in his role leading vaccination efforts in underserved communities that have been hit especially hard by this pandemic. he's a graduate of the university of southern california's school of medicine where he also completed his family medicine training. dr. abraham, community health centers like yours are a lifeline to patients across the country and one that has become all the more important during this pandemic. i look forward to your testimony about the work happening in your community and what we can learn from it. so, thank you for joining us. now, i'll turn it over to ranking member burr to introduce dr. fuchs. >> thank you, senator murray, for the opportunity to introduce mary ann fuchs. served as vice president of patient care and chief nurse executive for duke university health system where she is responsible for overseeing the nursing prablthss and ensuring the high-quality care across the health cystic. dr. fuchs also serves as the associate dean of clinical affairs for duke university school of nursing and serves on the american hospital association covid-19 pathways to recovery task force. in her role as the president of the american organization of nursing leadership, dr. fuchs advocates for nurses in leadership roles across the country, a position that has been particularly important during covid-19 pandemic, highlighting the role nurses have played in caring for patients on the front lines. earned her post masterate certificate from duke university, her bachelor of science degree in nursing from the state university of new york at birmingham. bingen ham and a fellow in the american academy of nursing, a fellow in the warten fellows program and management for nurse executives and a robert wood johnson executive nurse fellow. dr. fuchs, thank you for all the important work you're doing and what you're doing on behalf of north carolina and the country and nurses across the country during this challenging time. i look forward to hearing your perspective from the frontlines of the covid pandemic. >> we'll now move on to testimony. dr. shah, you may begin your remarks. >> good morning. chair member murray, senator burr, members of the committee, thank you for your leadership and for inviting me to testify to share my observations on the covid-19 response today. let me start by saying this pandemic is far from over and we need to stay the course and using every tool available to end it. we're all tired of the pandemic, but we cannot forget the more than 500,000 americans who have lost their lives to date in our state of washington that means 5,000 wash tonians whose lives have been lost. it is my hope we're on the right road. this pandemic is an inflection point on real sustained change to protect the safety of all americans. my name is dr. umair shah and i have responded to emergencies tropical storms and chemical incidents and even global earthquakes. my family and i experienced firsthand the massive power outage in texas just a few weeks back. an emergency department taking care of our nation's veterans for over 20 years. in late december i was honored to be nominated for the great state of washington. honored because washington has been a leader in responding to this pandemic and this is a testament to governor insley's leadership and countless partners on the role. i have been on the front lines fighting this pandemic and leading the public health efforts in texas and as the previous president recognized the absolute importance of what happens in local communities. that said, i am now a proud member of the association of state and territory health officials representing the state public health agencies across the country who serve as a key intersection between the federal government and local communities. over this past year, we have all witnessed the loss of life impact on countless patients and their families and communities devastated by covid-19. watching this play out, i have been frustrated by seeing the strain on our public health system to ramp up, surveillance, laboratory testing, communications, contact tracing and now getting vaccines into arms. i'm here today, though, not to just express frustration but to work towards solutions. please refer to my full written testimony. today i will touch on two mab points. we need to stay the course using health tools to end this pandemic and public help truly matters and public underfunding. the first point from staying the course. we remain focused on three things. getting americans to continue everyday precautions and distributing and administrating covid vaccines and three safely reopening schools and businesses. overall we may see the light at the end of the tunnel due to vaccines but must support preventive measures that have gotten us to where we are today. we cannot let our guard down or this pandemic will make us pay yet again. we must emphasize the importance of following health guidance wearing masks, avoiding large gatheringings. second the focus around the country getting covid-19 vaccine into the arms of people quickly and equitably. vaccine supply, number two, logistics and operations and number three vaccine demand. currently our biggest challenge is limited supply but we expect this to improve, as you know. as far as operations go, we're grateful to congress working to get resources to support our efforts on the frontline and within states. as we ramp up supply and capacity, we must pay attention to demand as vaccine hesitancy is real, whether due to mistrust or misinformation. third, we all want our schools and businesses to reopen for in-person learning and get our economy moving ahead. but we want to do so safely. if communities continue to spread the control of covid-19 better than the one we have been on. public health number two truly matters and cost of chronic underfunding. everyone, everywhere should rely on systems including emergency response. this is due to the fact that we have not adequately invested it. protect americans from all hazards. this has been hortiffic in so many ways yet a transformational event. now is the time to make smart, strategic and sustained funding in public health infrastructure making these investments miss also do dross long-standing health inequities. covid-19 has not started these but made it worth. death and disease means we have seen communities with disproportionate impacts from this pandemic. this is simply unacceptable. to rebuild federal investments must prioritize in resource equity and now is the time for congress to act. we can see the light at the end of the tunnel, but leaders must stay the course because still threats ahead including covid-19 variants and covid-19 fatigue. let me close by saying public health is the invisible line of a football team and we're not doing enough to invest in that offensive line. we keep focusing on the quarterbac. if nothing changes, we'll get more of the same without the robust capabilities to respond to the next emergency. we're truly at a crossroads. either we can act now and invest in public health and react later and spend to which could have been prevented. on behalf of the state of washington, thank you senator murray and my colleagues across the nation, i appreciate the opportunity to testify today. we look forward to working with all of you, all of us in public health in building safe, healthy and protected communities across this great nation of ours. thank you. >> thank you, dr. shah. we'll turn to dr. jha. >> good morning chairwoman murray, ranking member bburr. one year into a global pandemic that has caused unimaginable suffering and loss. we are also seeing the beginning of the end of this pandemic. infections and hospitalizations are down, more than 2 million vaccines are going into arms every day, and we will have enough vaccines for every american adult by the end of may. this is an extraordinary achievement of what has been a long and difficult road. but as you've heard already this morning. the pandemic is not done with us. there is important work ahead to get back to a time where americans feel safe living their daily lives, where our economy is thriving again. so, let's talk about what remains to be done. first and foremost, we need to continue to focus on equitably expanding national and global vaccine supply and distribution. we're at a time when new variants and strains pose real risks and the longer the virus circulates, the more it will mutate. our full efforts and attention must be focused on vaccinating as many americans as quickly as possible. and we have to do it far more equitably. far more equitably. so far vaccinations for people of color has lagged far behind those of white americans. we need a renewed strategy that ensures that those at the highest risk of this pandemic are getting vaccinated quickly. and congress should demand that we systematically collect and publicly report data on vaccinations by race, ethnicity, age and income to ensure americans who need vaccinations are getting them. next, we need an aggressive global vaccination strategy. because if the pandemic has taught us anything, it's that viruses don't respect borders. if we continue a slow global rollout of the vaccine, it is entirely possible that strains will emerge else where that threaten the efficacy of our current vaccines and possibly even render them useless. we will then have to reformulate, retest and redistribute vaccines and revaccinate our population. at current global vaccination rates, it will take three to four years to reach widespread global immunity. now, the biden administration has taken important steps including joining w.h.o. and funds. these are good things, but, unfortunately, they're not enough. we need a strategy that is not just about more money but substantially ramping up production of these vaccines. this will require more global collaboration and it will require u.s. leadership. next, closer to home, we need to build up more rapid testing. some americans will choose not to get vaccinated. and vaccines as good as they are are not 100% effective. that means we will continue to see some outbreaks of covid for the foreseeable future. we need a testing and surveillance system that can help prevent outbreaks and keep us all safe. in a world of low transmission and high vaccine coverage, we need cheap, easy to administer tests that are widely available. these exist today. now, the fda should work through the regulatory challenges to make many more of these tests available to the american people. and congress should continue to make investments to ensure these tests are affordable. even with vaccinations and testing, people will get infected and some people will get very sick. and we need more investments in therapeutics, particularly outpatient therapies. we identified several good treatments for critically ill patients, but we have very little to offer to people before they get very sick. congress should work with nih to continue to support development of new outpatient treatments that can render this disease far less harmful. and, finally, we need a renewed set of investments in public health as you heard from dr. shah. investing in our public cost infrastructure and the economic and human cost, which are not born by all of us equally. born by more of us more than others. a new set of investments in public health infrastructure that puts equity at the heart of its mission. over the long run, we need to remember that we are entering anige of pandemics. infectious diseases jumping from animal to humans will become more common as a result of economic development and climate change and globalization means an outbreak anywhere will quickly become an outbreak everywhere. that's the world we are looking at. so, to conclude, we are at a critical moment in this pandemic. we can see the time when we get our lives back. but we must do a few key things. invest in vaccinations, testing, therapeutics and public health infrastructure to ensure that we bring this pandemic to a close and to ensure that we prevent the next one. thank you. >> thank you, dr. jha. we'll now turn to dr. abraham. >> madam chair, senator patty murray, ranking member senator richard burr, senators, i would like to thank the committee for this opportunity to discuss this paramount issue, the covid-19 pandemic. my name is jerry abraham and i'm a family and community medicine physician, a global epidemiologist and a medical quality specialist, practicing in south los angeles. i provide care to patients at kedren health, a federally qualified health center serving low-income patients, diverse patient populations of south los angeles. first, on behalf of kedren and our president dr. john griffith, we extend the warmest thanksgiving and gratitude for each of you to share our experience and perspective on the issue of health care service and public health delivery to underserved populations during this time of this covid-19 pandemic. before i begin, we at kedren want to acknowledge the local leaders who make it possible for our measured success, governor gavin newsom and the state of california department of public health, our los angeles county department board of supervisors and our supervisor holly mitchell, our local l.a. county board of supervisors specifically the city of los angeles and mayor eric garcetti, our counselor and, of course, our very own congressional representative maxine waters who represents us here in washington. i also want to beginning by thanking the biden administration for working with physicians and other providers across the country to address the covid-19 pandemic. it has made a tremendous difference to have leadership, transparency and communication about the pandemic and this vaccination effort. across this country, the pandemic has exposed deep-seeded divides within our communities. data from the cdc shows that black and latin x populations who contract this disease are dying at twice the rate of other populations. no where is this felt more deeply than in south los angeles where we work. those living in poor communities struggle daily with access to medical care, amongst the worst pandemic in over 100 years. this population is more likely to utilize public transportation to struggle with limited access to mental health services, to have difficulties related to language and insecurity due to the lack of immigration documentation. they usually lack medical insurance, underinsurance, our population suffers from higher rates of hypertension and diabetes and obesity. racial and economic lack of equitable access to health care and a whole rath of other issues related to disparities result in health outcomes that are different. while it is easy to unmask this effect related to vaccination rates, the same forces play out throughout the entire health care system. but, really why i'm here today is to tell you about the story of the little kedren that could. the historically black institution from south los angeles that started in the '60s by 22 black psychiatrists when african-americans in south l.a. had no where to turn when in mental health crisis. that's the place i work and that's the place that answered the call march 2020 when we knew we had to be a part of the response of this pandemic. we became a resource, safe haven, safe harbor. truly that light for testing right away for our county and our city. we knew that testing strategy and contact tracing would be critical in ending in this epidemic. when the fda approved pfizer and moderna and we knew we needed vaccines and we picked up the phone and we do what we do best every day overcoming health despairties and social determinance and achieving health equity and we called and asked, where are our vaccine and worked with our local public health jurisdictions to make sure we got vaccines. our nurses had covid and our patients had covid and we knew we had to vaccinate our community now. we ended up getting 100 doses. christmas eve eve we started calling and by new year's eve eve we put 50 doses into the arms of our staff and next day 100 and today over 52,000 doses into the arms of people in south los angeles. we said don't give us enough just for us, give us enough for our brothers and sisters to our right and left. other health care workers who had no where else to turn and after that, we said give us enough for all of our frail and our elderly and our vulnerable that needed a vaccine today. what we do and what we do exceptionally well is we took down every barrier that stood in the way of our patients and their vaccine. internet, e-mail, phone, transportation, i can't speak english, i cannot walk, i cannot see, hear, talk, none of those are reasons not to get vaccinated in this country and we made sure we broke down every one of those barriers. we're the center for excellence and role modals and we vaccinate a high volume of individuals as equitably as we can and we report that data back accurately and timely back to the appropriate jurisdictions. no barrier stands in the way with our patients. what stands in the way, we need more vaccines. we need more hands to administer them. we're thankful for every volunteer that comes and helps over 200 volunteers daily and we need more resources and very thankful for the work of congress and this senate in making sure that is achievable. this is our shot. we must end this epidemic. we must engage and educate and vaccinate our communities. we can achieve 100 million vaccines and more as senator burr mentioned. and we will and we can get back to work, get back to school and loving our loved ones and doing all those wonderful things we used to do before this pandemic. loving and hugging and kissing everyone and that is the story that we have to tell and thank you so much for allowing us this opportunity to be here before you today. thank you. >> thank you, dr. abraham. we'll turn to dr. fuchs. >> thank you, chair murray, ranking member burr and members of the committee. i'm honored to represent the many frontline staff who have worked tirelessly to care for all of our patients including those suffering with covid-19. duke university health system is comprised of a health care network that spans the care continuum and we're dedicated to providing high-quality patient care and educating health care leaders and discovering new and better ways to treat disease. we appreciate the committee's leadership in addressing the current pandemic. and on behalf of duke health, thank you for the critical support congress has provided over the last year, including through the c.a.r.e.s. act and subsequent legislation. over the last year, covid-19 has posed persistent challenges for the communities we serve, our patients and our team members. and as chief nurse of our health system, i know these issues first hand. as covid-19 persisted, i worked with multiple teams to create new strategies to meet patient care needs, reallocated internal resources to adapt to influxes of patients and quickly pivoted when circumstances changed. we set up new delivery models and care practices, established testing and treatment sites and stood up vaccination sites for our employees and patients. we served our community as a major transfer center for the sickest patients and provided resources to skilled nursing facilities in the form of testing, staffing and training. we responded to the ever-changing information by regularly updating our care, holding town halls and virtual forums for our employees in the community and like many health systems, we were the hub of the covid-19 response in our community. this past year has offered us many lessons learned which i hope can inform future actions of this committee. we are committed to protecting our workforce. we were impacted by a real and global shortage of n95 masks and other ppe and stockpiles that contained expired ppe. our supply chain team worked around the clock sourcing from around the globe to ensure we had adequate and effective ppe. our workforce must be cared for and offered resbit. caring for critically ill patients and comforting families of loved ones suffering in isolation and fearing bringing the virus home to our families has taken a significant toll on the mental well being of our workforce. we're seeing their exhaustion compounded by pandemic relief responsibilities. we continue to advocate for resources to protect the physical and mental health care of the workforce. and we know through a recent national study that the ability of health care workers is a major issue along with burnout and resilience. duke health also joins other organizations including the hha and supporting the dr. breen health care provider act. and before the pandemic, our nursing workforce needs outpaced our supply. thus we continue to support increase funding to title 8 workforce development programs in support the future advancement of academic nursing act, which would make critical investments in nursing infrastructure. covid-19 has also served as a blunt reminder that we cannot afford to overlook our public health infrastructure and workforce. thanks to a grant from our state, duke health's covid-19 support services program has been able to assist community members requiring to isolate or quarantine. over 30,000 people have been provided relief payments, meals, supplies, transportation and medication delivery. we established a vaccine equitable distribution committee to better understand our data and reach marginalized populations, including those who are disproportionately impacted by the virus. we have dedicated appointments and vaccines and we partner intentionally with community organizations. this work has improved the rate of african-americans vaccinated in our community from 8.8 to more than 15% today. the impact of the expansion of telehealth services has facilitated a connection to our communities and demonstrated the efficacy and divry of care. we want to ensure that telehealth will remain to patients on the other side of this crisis. the substantial financial impacts of covid-19 on hospital and health systems will also have lasting effects. systems now face difficult decisions to reduce costs. additional support is needed, including eliminating further reductions in payments through federal programs, including medicare and medicaid to maintain access to care. in closing, as the number of vaccinations increase in combination with preventive measures, we need to acknowledge pandemic fatigue, be patient with each other and work together to continue to provide the highest quality care in the safest manner. thank you for the opportunity to serve on the witness panel for this important conversation. >> thank you, dr. fuchs, and thank you to all of our witnesses today. we look forward to your responses and to our questions. we will now begin a round of five-minute questions and i ask my colleagues, please keep track of your clock. stay within those five minutes. dr. shah, for over a year, we have been responding to the greatest public health crisis in over a century. covid-19 has pushed our public health system to the brink and underscored a lack of desperately needed resources. that's why democrats, included probust funding for vaccines and awareness campaigns testing public health workforce in the american rescue plan among other critical public health priorities. in the all hands on deck effort to end the pandemic, we must center our response on equity and reach every community. populations hardest hit by covid-19 including communities of color, tribes and other underserved populations must be prioritized and outreach efforts and websites and information tools must be accessible to people with disabilities and english language learners. dr. shah, can you tell us what is washington state doing to make sure that things like testing and vaccines are accessible to everyone? >> thank you, senator murray. and thank you, again, to all of you for your leadership on this issue. i would say that there are a number of things that we have been doing and it starts not just today but starts way back in the fall. it was really around a number of dialogue and sessions where we reached 18,000, 20,000 washingtonians on what their thoughts were. in addition to that, we have put together as in my written testimony which is public private partnership coming together to help with really efficiencies and numbers and also a combination of really dialogue sessions and feedback sessions with stakeholders for equity. covid-19 did not start these inequities. it has only made them worse. so we have really an incredible amount of work ahead of us to make sure that we're really underscoring all the feedback from these communities and all the people that are impacted disproportionately by covid-19 but also addressing them by giving them a voice in the work that we're doing. and i think that's critical, as well. >> okay, thank you very much. and dr. abraham, we do have a long history of health inequities in this country, which have only been exacerbated by the pandemic as dr. shah just said. it is completely unacceptable that black people are dying from covid-19 at 1.4 times the rate of white people. and that native hawaiian and pacific islander populations are contracting covid-19 at over three times the rate of white populations. despite this in nearly all states black and latino people have received a lower share of vaccinations compared to share of cases, death and population. we know vaccinations are an essential tool to end this pandemic and they need to reach communities that are hurting the most. i am impressed with your health center's success in vaccinating communities of color you serve. tell us how we can make sure vaccines and information about them are reaching communities of color. >> sure, thank you for that question, senator murray. you know, as dr. shah and dr. jha mentioned, we have to build this public health infrastructure yesterday. and we really needed those networks and what we have really strong in south l.a. are net, withes of black and brown physicians who knew we had to work together to race to get our patients vaccinated. so, we've been in close collaboration with the physician community in south l.a. to figure how we can better coordinate our response. we work lock in step this whole rollout has been a series of marriages. a series of marriages between kedren and our department of public health. it has been working lock in step with our government and making sure the supply chain reached health centers to make sure that we get clinicians and providers access to the essential medicines because this is what we do every day. we vaccinate our patients. we care for them and we educate them. so, trust us to continue to do our job and we will get more of america vaccinated. but what we built today is really a revolutionized health care delivery system. there is an opportunity in this crisis and that really is to bring a public health infrastructure that has been lacking and we must wed public health and the health care delivery system together. >> thank you very much. senator burr, i'll turn it over to you. >> thank you, madam chairwoman. all of you talked about inequities. let me put together one on the table. rule verse rurl rural versus urban. how difficult it is to reach. dr. aabraham, unbelievably refreshing in hearing you say we just built our system, what we needed. regardless of what washington said, we built what works. that's what is so unique about the local communities and the empowerment of those communities. dr. shah, as i mentioned in my opening statement. we are closely examining the first year of our response to the novel coronavirus and we've seen things we didn't expect. one most recent things relationship with pharma companies and now a big pharma company that takes on a contract manufacturing role of finish and fill. we never dreamed that these things would happen, but they're happening. our successes are due in large part to the ability of state and public health officials to address the unique needs of their community during the pandemic. the way that raleigh handles covid-19 in north carolina is not the same as seattle and we need to address it. let me ask you, dr. shah, do you agree state and local officials should be the leading voices for the needs of their community as we continue to respond to covid-19? >> senator, thank you for that. and absolutely state and local officials have an incredible role to play, and we do need to lead because we do know our states. we do know our localities. so absolutely. that said, we also have a responsibility to make sure our federal partners are also at the table and also leading. there are certain things that the cdc can do that the guidance that allows for consistency across the country is also incredibly helpful. i will tell you on the front lines it has been so challenging this entire year of up and down, back and forth, left and right, this and that to try to fight a pandemic. and so all the tools that we can have, there are roles of government at the state, federal, and local level that work together. so ultimately we are protecting the community member. and that consistency of either policy or communications is absolutely critical to the success not just in this pandemic but in future emergencies. >> we've spent millions to set up an early detection system. hopefully it would've seen pandemic earlier, responded to it faster. did our surveillance system fail, and what should we do? >> yeah. so, senator, thank you for that question. and, you know, a year ago in january of 2020, actually i wrote a piece in which i said i thought the u.s. would have a relatively robust response to the pandemic because we had such a good surveillance system. we had great laboratories, great doctors, great nurses, great hospitals. it obviously clearly did not work. i think our surveillance systems are not as robust as we need them to be. we don't do enough surveillance out in the community. one of the things that we learned, for instance, is wastewater surveillance is a very good way of finding diseases before we start detecting them in humans. we haven't really made a national effort to try to do that surveillance. there are things that are much more public health and not who comes into the door's office that we need to be investing in. and then the other part that really failed us was the data infrastructure. even if you could identify cases or diseases, we could not aggregate it and look at the broader pattern in individual states or let alone across the country. just yesterday covid tracking, which was an effort by a group of journalists popped up after a year of pulling together data and making it widely available. that's the data that we all use as a nation was data coming from a group of journalists. we need the government to be able to pull together data across states, do surveillance and make it available for policymakers and academics. none of that worked as well as it would've needed to have. >> dr. jha, how can the private sector be better leveraged and incorporated into biosurveillance system to support federal, state, and local public health decisionmaking? >> well, the private sector's got the tools. if you think about genomic surveillance, for instance, there are some fabulous american companies that have that technology. and the u.s. government's got to partner with them. i completely agree with the premise of this and your other questions that so much of the success of this pandemic has come from the federal government and sometimes state governments partnering with the private sector. that's how we have beaten this thing. and when we think about future investments, that's the mindset we're going to have to use. >> thank you, doctor, thank you, witnesses. >> senator casey? >> i want to thank chair murray. and i want to start as well by thanking the witnesses for the focus on public health infrastructure. and i want to thank chair murray for her dedication to this issue over time because we don't talk about it enough, and frankly have not moved forward in a manner that would prepare us for the next pandemic. i'll start with dr. jha. you talked about the need to build resilience in the public health system and about the relationship between both public health infrastructure and public health preparedness. do you think it's possible, doctor, to be as prepared as possible for a public health emergency without investing in public health infrastructure? >> well, thank you, senator, for that question. i will say that it becomes extremely difficult. it's really about building the capacity not in the middle of the crisis or not reactively trying to throw dollars at it, but in advance of to build out capacity so public health can respond. when dr. jha just mentioned about the surveillance and the data systems, he's absolutely right. these are systems that in advance of covid-19 if we had this investment in public health infrastructure, would've been robust, would've been strong. now, we can look back, but we really need to be looking forward. that's really investing in systems in a really smart, strategic, and sustainable way. >> and part of that, i guess, is at the local level. and i guess the follow-up to that is who are the people you would hire and the other investments you'd make, and what other resources would be used when we're not in the middle of a public health emergency, as you suggest, to be prepared for what's ahead of us? >> well, i think we need to be thinking -- look, our department of health in washington has stood up for 400 plus days. that's remarkable. same thing, harris county down in texas, for 300 plus days. we're talking about a year plus -- public health systems are fatigued both physically and, honestly, emotionally. i think the key message is that we need to be thinking about how do we make smart investments in that workforce. so we support the workforce. we make sure it is both physically and emotionally and behaviorally supported. and we also think about bringing in the technology, the logistics, folks that have that, you know, the cost-effectiveness, who understand process flow, who have efficiencies of that. and also we in public health have to do a better job of communications. we have to do a better job of really making sure that we can engage with our communities so people recognize that we are part of the solution, not part of the problem. >> doctor, thanks very much. i want to move to dr. jha regarding children. and i want to start by thanking him for being such a great communicator at a time when we needed clear and science-based communication across the country. but the one issue that relates to our children that has gotten some attention but probably not enough that while children are less likely to become seriously ill from covid-19 by way of comparison to adults, they still can spread the virus. and you and others have spoken about misc, the multisystem inflammatory system in children. a very serious condition. after we prioritized the higher risk populations and are immunizing now tens of millions of people, once we get to the immunization of children and teens, to reduce community transmission in cases in this m.i.s.c., and we know that all of the major drug companies are running or plan to run pediatric vaccine trials, can you speak to the process that's underway and assess the safety and efficacy of these vaccines for children and teens as you see it right now? >> yeah. so, senator casey, thank you. critically important question because it will make -- it's going to be very hard to reach population herd immunity if everybody under 18 is not vaccinated. and while the disease does have a much milder effect on most kids, there are high-risk children with chronic diseases for whom this could be quite substantial. and then of course we do ultimately want to get kids vaccinated. i think we can. and i think the question is when are we going to have the data to feel comfortable about the safety of these vaccines in children? now, i do believe we have trials running, moderna, but some of the others are for kids 12 and over, and i expect a lot of that data to be available by mid- to late summer. the problem will be the younger children and looking for efficacy, looking to say does the vaccine actually work. and when the infection numbers get very, very low, you're going to need very large trials to prove that the vaccines are effective. we may need to think about this a bit differently. we may need to say these things are safe in children and use that as a barb. there's a lot of work to be done. we do have to get our kids vaccinated. and i worry especially for younger ones it may take a while to have the data to feel comfortable doing it. >> doctor, thank you very much. thanks, chair murray. >> thank you. we'll turn to senator cassidy. >> thank you, madam chairman. dr. jha, there was just an article in mmwr about the strong relationship between obesity, even that which people would think, and its risk factor for hospitalization and death. dr. abraham and i did our training in the same area of southwest los angeles, and my own medical practice was with the poorly insured in louisiana. and, as we know, there is more risk factors such as obesity and those who are lower socioeconomic regardless of race. do what degree do you think we can explain this disproportionate impact upon some subpopulations relative to their associated increased risk of having obesity? >> so, senator cassidy, it's a really good question, and i think you're absolutely right that we're still really learning about the impact of obesity on this disease. but no doubt about it based on all the data that i've seen that obesity is a meaningful risk factor for having poor outcomes. i think if you look at the broader picture of the fact that, for instance, african-americans have died at much higher rate. a lot of it is i think rates of infection which is i think driven by work conditions -- >> that is increased rates of infection, but we know that there's a lot of folks who are infected and we don't know they're infected, correct? so do you have surveillance testing to establish that point, or is that intuition? >> well, we have very good data that they are identified more often and given that testing rates have been lower in african-american communities, it stands to reason that the level of infections in these communities are much, much higher as well. >> so that's more of an intuition than actually having data on that. but, nonetheless, everybody respects your intuition, but that's still an issue there. while secondly we are looking at an outcome of prevention of infection. but it does seem as if there are surrogates for prevention of infection, specifically the development of antibody response to vaccination than perhaps the hike of the antibody response. cannot be surrogate measures be used to measure efficacy in children? while obviously their immune systems are robust, they typically respond better than adults to vaccines. what are your thoughts about using a surrogate as a -- community? >> it's a great question. and, senator cassidy, as a physician, you know that the science here is evolving but getting better. i think the key question you're asking is how confident are we about the correlates of community, how confident are we that -- or t-cells really reflect somebody's immune status. and my sense is that we're pretty close to that point, but we haven't really nailed it down. i can easily imagine, especially as infection numbers get very, very low into the summer if we want to measure efficacy in children or in other populations. we may need to get to using correlates of immunity as opposed to direct infections. that seems to me to be reasonable, as long as we've established that those correlates are in fact right. obviously there's been a lot of concern regarding schools not re-opening. -- heavily flavored by teachers unions did not. even though the cdc continually said that you could safely reopen as long as you take precautions. >> we found that the teachers and the students who were infected typically brought the infection -- they always brought the infection into the school. it did not spread within the school. so what are your feelings about the ability for schools to safely reopen, like, now? >> so, senator cassidy, i believe and i've been pretty vocal in the last several months that i think most schools in america can open safely as long as we put in important mitigation efforts, universal masking, reasonable ventilation, and i believe testing does add a layer of protection. i have at this point believe given how much vaccines we have that we should go ahead and vaccinate teachers and staff. it would certainly add a very important layer of protection. but there's no doubt in my mind that we can get schools open in a way that can keep teachers and staff safe. >> two more things. let me just say thank you for giving a shoutout to the act. that is something i am sponsoring with tim kaine. thank you for the shoutout. we want to take care of our health care providers. and i did do my training at l.a. county usc. and the patients i've seen are your patients as well. we're caring for the less fortunate. so thank you for all the work you do. with that i yield back. >> thank you very much. we will turn to senator baldwin. >> thank you, chair murray. and thank you to our expert panel today. public health experts have warned that the coronavirus continues to adapt, mutate, and change. and i'm increasingly concerned about the rise of new and potentially more harmful variants. this is why i authored "the tracking covid-19 variants act." and it would provide resources necessary to dramatically scale up our country's sequencing surveillance and outbreak analytics capacity. now, i was proud to see a version of my bill included as part of the senate passed american rescue plan. and i look forward into seeing the president sign that bill into law hopefully very soon. dr. jha, many experts we noted that we could see another spike of new infections due to a rise of variants. what can states do to respond to these emerging variants, and how will scaling up our surveillance efforts and our ability to do genomic sequencing for coronavirus make us better prepared for the future of this pandemic and future pandemics? >> senator baldwin, thank you for the set of questions. let me say that the number one thing that states can do is what i said is stay the course, that we have to make sure that those mitigation efforts for prevention, which is really the robust measures around wearing a mask and making sure that we're careful as we reopen, that we do so based on evidence and the best we can for not dialing up too quickly because, as you know, that can also be challenging when you have to dial back or if there's another surge. but the other thing in the state of washington and one of the things i'm really proud from the department of health standpoint is that we are in the top five in states when it comes to genomic sequencing when it's come the variants. and we have discovered variants in the state of washington. the other piece of it is that we've actually invested in more laboratory capacity in the public health lab at the state level and working in partnership with university of washington. so i think there is -- what we can do to invest in our state public health systems from a laboratory surveillance standpoint but also working with our partners in the academic centers. we need to do a better job and more of genomic sequencing. because, remember, as you said, viruses, this is what they do. they love to mutate. they love to change. they're trying to get the next human being to try to figure out how to infect. so this is what variants do. but our job is to make sure those public health measures are robust and strong while we're also searching and seeking out so we can get data to individuals, policymakers and obviously to public health officials so we can continue to monitor what's happening. >> ideally and pragmatically, what percent of positive covid tests should receive genomic sequencing to really keep on top of or keep close track of emerging variants? >> this is a tough one because across the globe there are certain countries that are doing a better job. in europe, for example, united kingdom where it's somewhere in that 5, 7% rate, we're not there. we're obviously markedly lower than that. i think it's really about continuing to make sure that we continue to make progress on it. but we do need to be working with cdc and public health laboratories to really learn what exactly the optimal percentage is. but it's really not about just a percentage. it's about making sure it's distributed throughout the country so we have strong surveillance systems, and then we're also looking and using those surveillance systems to really discover pockets of where things are happening across the country. >> thank you. i know my time's running out, but i did want to ask a question to dr. abraham. community health centers like the one you lead plays a critical role in providing health services to underserved populations. in my home state of wisconsin, there are nearly 20 federally qualified health centers providing really important care around the state. now, last month the biden administration established a partnership with community health centers to expand their role in covid-19 vaccinations. and in wisconsin the 16th street community health center in milwaukee was named one of the participating sites. i'm curious to hear from you, are the successes that you're having being replicated at community health centers across the country? or do you think your experience is unique, and do you think more needs to be done to help community health centers in their vital mission in serving the underserved, especially as it concerns vaccines? >> thank you so much, senator baldwin. and also reminds me of the question that senator burr had mentioned about rural populations as well. so community health centers and fqhcs really play a critical role. they play a lifeblood whether it's rural or urban. we've learned that the heroic work at kedrin and public/private partnerships really is an example for other community health centers throughout this country, especially where there is unequal access within those communities, whether they are rural or urban to anyone who's underserved or vulnerable. those that are differentlyabled or at risk during this pandemic. what we do is not a secret. we just need more vaccines, more hands and more resources. and the more of those that go to the places where we receive our care, whether those are fqhcs, whether those are small and solo physician practices, that's how we're going to get everyone vaccinated. that's what we do every day, covid or no covid. >> thank you. senator collins? >> thank you, chairman murray. dr. jha, i would like to talk with you about the critical issue of re-opening our schools. i've been very concerned about the fact that so many of our students, particularly in the more urban areas of the country still are not back in school. maine i'm pleased to say is doing a good job in this regard. just last week i talked to the head of maine's cdc who made the point that children are actually safer in schools in many cases than they would be in their community or in their home doing remote learning. i have tremendous respect for the cdc, but i'm very disappointed in its latest guidance on school re-openings. you have talked about that for some people in public health that it did not appear to be particularly well grounded in the evidence and science. similarly, dr. allen from harvard has questioned the advice on distancing, suggesting that for children 3 feet might be adequate as long as they're wearing masks. you've also talked about the need and important role for ventilation. could you please give us your views on schools re-opening and what could be done to expedite re-opening of virtually all schools so that we don't have more and more children falling behind, additional mental health problems, social development not progressing and all of the adverse side effects from children not being in school? >> yeah. senator collins, it's a really good question, and it's a really important question. the effects of children not being in school over the last year have been i think very substantial. they have not been born by everyone equally. i think kids, children from poorer backgrounds have born disproportionately the impact of this. and then let's also be honest that when kids are at home, the caretaker is often the mother, and therefore has had very negative effects on -- especially very negative labor effects on women and their ability to work. one of the things i've been frustrated by is we've set up what i think has been a false dichotomy. we've set up kids' education versus teachers' safety. and the truth is we need both. and you need both if you're going to do this over the long run. and i believe there is a way to get kids back into school full time now and certainly into the future that keeps teachers and staff safe and kids learning. and the principles of that, in my mind, are, and this is really based on where we are today. right now you need to have universal masking in school and you've got to have pretty high levels of adherence. second is ventilation. i really do think that having reasonable ventilation in schools is critical. and i think most schools can get that. third is i have argued that testing is i think an important component of keeping schools safe. look, you catch outbreaks early. you offer a level of assurance to everybody that you can do this. and, last but not least, vaccinations, and i said this to senator cassidy. given how much vaccines we now have, i believe it is important to prioritize teachers. and when i say teachers i also mean other staff in schools. i did not mention 3 feet versus 6 feet. i did not mention deep cleaning of surfaces. i think there's a lot that's gotten us distracted. i think if we focus on these things, we can keep teachers safe, keep kids safe and open schools. and we have the ability to do all of this now, not six months or a year from now. that's what we need to focus on. >> i could not agree with you more. and i hope that school officials, teachers, parents, and others will follow the advice that you just gave. thank you so much. >> senator kaine? >> thank you, chair murray and ranking member burr. and thank you to the witnesses for this important hearing. there fuchs, i want to thank you about the testimony to the challenges that our nurse workforce is facing, mental health challenges. and you indicated in your testimony as a result we're starting to see more of our skilled workforce leave or planning to leave, which is also being reported in recent surveys this kind of high turnover will have a significant impact on the future of delivering health care. i want to thank chair murray and others, senator cassidy mentioned the brene act to start to deal with mental health needs of our workers and public safety professionals. what would you suggest to the committee that we might want to consider going forward to make sure we provide resources so that we don't see the kind of high turnover that you are concerned about? >> thank you for that question, senator kaine. you know, this actually is a complex issue because indeed some of the factors for individuals may very well be different depending upon individual situations. but one i would say is that, you know, clearly providing consistent support and education and access to services i think is extremely important for not just the nursing workforce, for others. the acts that you have sponsored i think will be very helpful. i think there is a direct need to really study the impacts of the pandemic on the workforce to be able to really look at different strategies that may be helpful in addition. and i think we have to continue to support our workforce. what we're starting to see now with patients re-entering care facilities is that the public is stressed. >> yes. >> and the public is now acting out more so in addition and placing largely nurses and those in the direct care environments in a position to be disrespected and more violent situations. and so i think that we're going to have to place emphasis on the support of workplace violence initiatives to be able to support our staff, amongst other initiatives. >> let me ask a question. thank you for that, dr. jha, about long covid and how we should be thinking about that as we're thinking about what we need to do. i had covid in march and april nearly a year ago. and it was a mild case, thank goodness. but one of the effects of it was nerve tingling 24/7, every nerve tingling in my body and a heating sensation where it happens four or five times a day where it feels like someone turns a heating ba pad on. it doesn't stop me working and the tingling helps keep me awake in long hearings. [ laughter ] obviously there's nothing wrong with my skin and his nurse, it's a neurological probably just altered the thalamus or something like that. but these are not debilitating symptoms, but many have debilitating symptoms, fatigue, heart impairment, respiratory problems, brain fog. i did get asked if i had that and i said no, but my friend said how would anyone know? but as we're thinking about sort of going forward in the way we look at the health magnitude of this crisis, there will be a day where the president will declare that the emergency is over. but there is this huge category of kind of these long covid consequences that we still don't completely understand. so maybe for dr. jha, how should we be thinking about that as we are, you know, trying to put together the right plan to take care of the nation's health needs going forward? >> yeah. senator, that's a fabulous question, and, first of all, i'm happy to hear that your symptoms are mild. but, as you pointed out, there are people who struggle with substantial symptoms. i think one of the things that i found most frustrating over the last year for people who like to focus on mortality rates and essentially argued to let americans get infected is that we did not appreciate the effects for the large number of people who got infected and recovered, didn't die thankfully but had substantial chronic debilitating symptoms. so i would say two or three things. one is, first of all we need to study this much more carefully. and nih i think has been doing some really good work in building cohorts and really trying to figure out what are the predictors, how long do these things last. obviously we need to work on therapeutics to try to address some of these symptoms. there's some preliminary data that actually vaccinations can potentially be helpful for long covid. i don't want to overstate how good the science on that is, but there is some preliminary data that might be the case. i'm hoping that as more people get vaccinated that'll show up. the last point i'll say is when our president declares the public health emergency over, we are going to find a large number of americans with substantial disability from this virus from this infection. and the cost of that far human and financial is going to be long term. and we're going to have to manage that as a country. >> thank you, dr. jha. thank you, chair murray. >> thank you. senator murkowski? >> thank you, madam chairman. and thank you to all of our witnesses. i really appreciate this discussion about the mental health side of what we're dealing with, with this covid. i think last year at this time we were all very keenly focused on the health impact, what was happening to people who were coming down with a virus. and then shortly after that we saw the economic crisis that came following the health. and now i think we are into this third wave of a crisis. and i think it's the mental health behavioral health side of it. and you want to talk about long haul and those longlasting impacts, whether it's the impacts on kids, it's the societal impact that has been referenced here today. and so as we think about our providers and what we need to do to ensure that they have the help and support and also recognizing the stigma that attaches. if you are the mental health provider that says i need mental health, help now, there was an article in the sunday news about the doctor who took her own life after dealing with covid and then coming back and the stress of handling it all. so i think we need to be very cognisant of what we are doing to address the behavioral and the mental health needs of not only our medical professionals, our children, but at all levels now. i was looking at a full page, it was an advertisement but not really an advertisement. it was an informational piece that was put out by the alaska mental health trust authority, full page in our newspaper yesterday. but they are partnering with the department -- state department of health and social services. they are bringing together a coalition of health care organizations, government agencies, social service providers, and community members. and they call it crisis now. and it's a framework for expanding the behavioral health crisis response. they're doing it in our larger communities. the big components of it are a mobile crisis team, a 23-hour and crisis short-term stabilization centers where those who are experiencing mental health or substance use emergency can go for safe care. so the question, and i don't know, maybe this is to dr. jha or to mr. shah, maybe any of you, i understand that this crisis now framework is based off samhsa's national guidelines for behavioral health crisis care model. so the question is, is whether or not folks are familiar with these guidelines or if there are similar models that are being implemented to address the behavioral needs that we're seeing within the hospitals but more particularly in the emergency rooms. because it's in the emergency rooms that you get them first and the ability to be able to respond is perhaps limited. i throw that out as a jump ball to who would ever receive it. >> senator, this is dr. abraham, i work at an acute psychiatric hospital, kedrin is a federally qualified health center that has an outpatient mental health center as well. if you come and visit us in south l.a., you'll visibly see there is joy, music, dancing. we are turning this story around. we're at war with covid and we are winning, and that is part of improving people's mental health. i'm hoping that with our strategies to really combat this pandemic we do get back to work, back to school, back to loving our loved ones. and i think that has a significant impact on the burden of mental health both for our workforce and also the patients and the public that receive the care that we provide them. what i've noticed about the over 200 volunteers that come and show up every day from the americorps and the red cross and the salvation army, they are happy. and we are now a part of the solution. we are solutions-oriented at kedrid. people have been morally injured by this pandemic. those that are dealing with the realities of burnout for mental health care providers, this is the antidote, this is the cure, this is the shot. let's get everybody vaccinated. we've seen how positively it has impacted our community. >> thank you, doctor. >> yeah. this is umair shah in washington. i also want to give a shoutout to dr. zinc who is the state health official in alaska. and she does a fantastic job. >> she's our rockstar really. >> she absolutely. i'm not familiar with that program. i think one of the biggest concerns from a patient standpoint is that across the country we've had, prior to the pandemic, some one in ten americans had some sort of anxiety disorder or anxiety symptom. and during the pandemic that's increased to four out of ten. so we've had an increase in that. and on the provider side we've had compassion fatigue as well where there's also been the concern that some, you know, even psychiatrists or responders have not been able to cope with their own challenges from a mental health/behavioral health standpoint as they're now addressing the person in front of them. and i will agree with dr. abraham is there are moments that we need to -- first of all, we need to support our workforce. but there are also moments that we need to champion. for example, in the state of washington we celebrated several weeks ago our millionth dose, governor inslee recognized the millionth dose which is ruby t., a 90-year-old from eastern washington who received -- it was the symbolic millionth dose of washingtonians who had received a vaccine. and there was a big celebration. confetti and things like that. and it brought such an incredible, a positive uplifting to our team at the department of health. and i will say that now as we are closing on our 2 millionth dose this week. in fact we just passed it yesterday. there are moments of celebration in the midst of this horrific pandemic. but we do need to not just celebrate. we also need to support. we need to put the resources in not just for physical health but really emotional/behavioral health. and you know as well as i do, this is what providers are least likely to come forward and say i've got a problem, i've got an issue, i've got a challenge, i am burned out, and this is why we really need to be very careful, methodical, and forthright in supporting our health care and public health professionals with emotional health support. >> thank you. >> we'll turn to senator hassan. >> well, thank you, chair murray, and our ranking member, senator burr. and thank you to all of our witnesses for your testimony today and for the optimism that you have been expressing as well. i think it's much needed. i want to start with the issue of long-term care facilities. i want to start with a question first to dr. jha and then to dr. shah. in new hampshire more than 70% of covid deaths happened within our long-term care facilities. the previous administration failed to provide the clear and consistent guidance and resources that these facilities needed to protect their residents and their staff. secretary shah, moving forward, what steps should we be taking to better support long-term care facilities and ensure that they are protecting their residents against covid-19 and other infectious diseases? >> senator, thank you for that question. i will say one thing that is absolutely critical, which is that as we are continuing to prioritize populations for vaccines across the country, we cannot forget that the absolute critical importance of vaccinating seniors, those who are older in our communities, especially in long-term care facilities. as you remember in the state of washington very early on in this pandemic, we had a long-term care facility where there were real issues. and that was the first, if you will, focus across the country of what we needed to do as a system to respond to the needs within those long-term care facilities. so i think it's really threefold. first of all, we have to continue with the process of vaccinations. and we need to make sure that the staff and the people, the persons who are within those facilities are vaccinated. we have to prioritize that. fortunately we have been. but we need a continued prioritization in that especially as we have turnover in either staff or people. number two is we need to make sure we have those resources within those facilities so they also can continue to have all the protective measures, the personal protective equipment, masks and hand sanitizers, et cetera, and they have enough room to be able to cordone off individuals who are sick or have symptoms to be able to get them out of that facility or at least away from others. and, number three, which is back to that additional question i answered previously around behavioral health. we have to be thinking about the impact on seniors or those who are in long-term care facilities by the isolation away from families who they normally would be relying on to be able to touch and feel and be a part of a family. and that is absolutely critical for us to be do not is to make sure those resources are also there from a behavioral health standpoint as we also continue to fight the pandemic. >> thank you. now i want to turn to dr. jha because of outside of congregate care settings, home health workers receive unique challenges in paid sick leave and personal protective equipment. and many individuals who receive home-based care are struggling to access vaccines. so, dr. jha, what steps can we take to improve vaccine availability for workers and patients across all types of care settings including for those who are unable to travel to centralized vaccine sites? >> senator, this is such an important question and a couple of components to that. first i want to talk about home health workers. these are some of our least well paid people in our society. a lot of them are hourly in their wages, and the idea that we've often or a lot of them have turned down the opportunity to get the vaccine, and we say, well, they're vaccine deniers or they're being hesitant, we fail to understand that these people have lives where they can't take time off if they end up having side effects in a way that i could when i had my vaccine shot i could take a day off if i needed it. many people cannot. so, i think there are some really important issues about understanding the context in which people are turning down vaccinations and finding policies as well as really having kind of organizations themselves being able to pay people to take that time off or help them get vaccinated. i think that's a really important area that has not gotten enough attention and we've been quick to dismiss these individuals who work incredibly hard, often multiple jobs and get paid so very little. more broadly i think, you know, right now in terms of getting people vaccinated across the country, my take is we really need an all of the above strategy. and i think the administration has been doing this. large sites, fema sites that'll attract a lot of people and will get a lot of people through. but there are a lot of homebound individuals who can't get to these sites. that's why we need things like mobile vans or we need community-based organizations that know where these people are and can reach out and connect with them. so, my overall thinking on this has been we've got to let states do a lot of this. then states have to push this out to community-based organizations who actually understand the community at large and can implement a lot of these vaccination strategies. >> well, thank you very much. and i see that i'm over time, chair murray. so i will submit the rest of my questions for the record. thank you. >> thank you. senator marshall? >> all right. thank youchairwoman. my first question will be for dr. abraham. like you, i'm a physician who oversaw three county health departments, i volunteered in federally qualified health clinics. we have 21 in kansas, they proud of them. i'm used to dealing with finite resources. and you are too. and i just want to talk for a second. i wrote an op-ed for the "wall street journal" published last night and just kind of talk to you about how do we save the most lives. how do we save the most lives? are you familiar with some of the new studies coming out saying the effectiveness of the one shot of the vaccine -- have you been following those stories? well, good. i think what we're seeing is one shot of either the moderna or the pfizer vaccine, 75 to 90% effective after one shot, and the other big news is that 12 weeks you can still get the second shot 12 weeks later and be just as effective and raise it. if you have a finite set of number of shots and you're trying to get to herd immunity as quickly as possible, after you get the high-risk people, seniors and everybody with diabetes and heart disease, you know your clinic better than i do. the if we would give you the flexibility of getting everybody one shot now and then coming back in the next three months and picking up that second shot, does it make sense to you that we could impact a greater number of folks and just a quick example. if i gave you 200 vaccinations and you had your choice to give 100 people two shots or 200 people one shot, which would result in the greater number of people that are effectively vaccinated? and the answer's the latter, 150 people in my latter scenario, the first scenario maybe 90. just what would your thoughts be if i could give you the flexibility to do that? >> thank you so much for that question, senator. i would gladly take those 200 vaccines and i will make sure they get into the arms of americans. and that's what we have to do. we've got a race against time right now. we don't have a moment to waste, not a drop to waste of this vaccine. whichever vaccine you are offered, whether it's pfizer, moderna, or johnson & johnson. and i'm sure we will see the updated versions as we continue to combat variants. i believe that we must get this vaccine out. it is, as previously stated, it is not either/or, it is all. my second-dose patients need their second dose and they are lining up outside my gate. if you get your first dose from dr. abraham, we will do our best to get you your second dose. i do believe achieving that herd immunity as quick as we can is critical. and some of the points made earlier about mobile units, getting those vaccines out to the homebound homeless encampments, to jails, single-dose vaccines, it is all, not either/or. >> and i visited a federally qualified health clinic last week in wichita that has the mobile center and we're out there doing it. i want to talk about the disparity, about the lack of equality of opportunity for vaccines in kansas i'm ashamed to tell you as of about a week ago that 10% of white americans already had the vaccine and 5% of african-americans or minorities were vaccinated. and this was so predictable. i could just bang my head against the wall what happened. what did we do wrong? we knew this was going to be the case that it would be a challenge. and i knew the places to cure the problems were federally qualified health clinics and the county health departments. those are the ones that can get the vaccines to those people. was it that you didn't get the vaccines or that people didn't want to get them? i just can't imagine you didn't give everything you had out. did our governors not make the right choices on where to distribute the vaccines? maybe, dr. shah, you could tell me. we know it's been a bad deal. what did we do wrong? >> senator, thanks for that question. i will tell you one of the things that we have to recognize is that we've also been moving in throughout almost every, if not all 50 states that the vaccines have been not just in general to the communities but going to specific priority populations. health workers, as you know, long-term care facilities and seniors. and then essential workers. and so we have to make sure that our denominator is correct that we're looking and comparing it not just to the general population of the percentage of certain populations within our states but really those who are eligible for the vaccine. so i think the reason i bring that comment is that this is not an excuse, it's an explanation. we need to be thinking about all of this information. but as we move into populations, you are absolutely correct. we need to continue to prioritize equity. we need to continue to be thinking throughout the system what can we be doing. the challenge has been that these public health systems and health care delivery symptoms, whether it's what's happening within the health care facilities or pharmacies that all are ramping up with limited supply. so as we get more vaccine, we are going to see more logistics and more operations. but then we've got to then shift into vaccine hesitancy. so, this is just continuing to follow and move and evolve as the vaccine process evolves as well as the pandemic itself. >> my time is expired. but i think we got something wrong. and until we identify what we got wrong, it's going to be hard to correct it. so thank you. i yield back. >> thank you. senator hickenlooper? >> let me get that set up. sorry. i appreciate all of your service and your time on this issue. covid and the distribution of the vaccines has been one of the greatest public health challenges this country has faced. and it did obviously start with a lot of bumps in the road. but i am very impressed that the resolution that a lot of these issues and obviously there are 50 different governors in this country. i know that too well. and i think the responses and the evolution of the effort has really been dramatically improved. yesterday you guys have discussed this. the new guidelines and allowing fully vaccinate some more freedom but still with constraints. i spent a lot of my time in small business and was curious what rays of hope you see more small businesses and what kind of time line that looks like. and i'm thinking specifically of the retail small businesses. cafes, beauty salons, places where they, in many cases, have less than ten and sometimes have only two or three employees. what kind of guidelines and what kind of support do you see helping facilitate them coming out of this as quickly as possible? >> senator, i'm not sure if that question is for me or for someone else, but i can take a quick stab at it, and then maybe turn it over to my colleagues. i would just say that from the standpoint of what we have been really very, very interested in throughout and supportive of throughout is to be able to reopen and to reopen safely. vaccines provides us that glimpse of hope. and why does it do that? because now we have patrons in restaurants and in bars and throughout different establishments, retail establishments who are vaccinated, who have little chance or markedly lower chance of transmitting to the person next to them in the cafe or next to them somewhere else. so as we continue to see increases in vaccine rates, we are going to start to see decrease in transmission, and that's where vaccines really promises us. however, we have to continue to be thinking about all those mitigation efforts that, you know, dr. fuchs, dr. abraham, dr. jha mentioned throughout is these public health measures cannot just go away. we have to continue to dial up while we're also thinking about very carefully what we can dial down. but unless we do that carefully, unfortunately we can see another surge, and that's what this virus has taught me this entire year. it is a super slick virus that has broken every rule in the playbook. if we are not super smart in response, then exactly what will happen will be another potential surge. >> senator hickenlooper, i just wanted to add to that, that it's critical that we get the vaccines to where people live, work, and play. and so for smaller businesses, it's impossible to close your doors. how are you going to send everyone to a vaccination site? you may not have pto or childcare or transportation. those are all barriers to small businesses getting their workforce vaccinated. so it's critical that we take those mobile units, we partner with our roots in the ground, the network of our business leaders and let's get to your business and vaccinate your staff so that they can safely continue the services they provide. >> i couldn't agree more. i think that and being willing to work on weekends which i see where you have made that evolution. last thing i'll throw out there just as a concern. years and years and years ago i was a scientist. got my masters in geology, published a couple papers. but i can't ever remember seeing so much distrust of science. and at a time where it's so important. and, again, i won't direct this to any one of you. feel free to chime in. but how do we go about rebuilding trust in science, especially in terms of rebuilding our public health department? >> really quickly, this is dr. abraham. we deal with this every day on the front lines. we are vaccinating over 2,500 people a day. whether you're black or brown, white or yellow, you legitimately have every reason to have questions. it is your body, your health. what is mrna? what is an mrna vaccine? these are real questions and you have every right to ask them. there are questions around health literacy. there is sometimes a lack of basic science understanding and we must meet people where they are. and so it's critical that we take the time, we engage them, we answer their questions and educate them. and those that are medically eligible, we've seen they roll up their sleeves. let's not confuse a lack of access for hesitancy. and let's not confuse not finding parking in south l.a. as i don't have time for a vaccine or i don't want a vaccine. so those are all critical issues that we look at black and brown vaccination rates. you've got to start teasing a lot of those things out. take time, answer people's questions. let's be honest with them. and those who choose to get vaccinated, we will vaccinate you. >> great. thank you. i'm out of time. i have many more questions, but thank you so much. >> thank you. senator tuberville? >> thank you very much. thanks for all your service and what you're going through at a very tough time. what a tough time for the world and our country. i worked in education for the last 40 years, and the last 20 years i saw a huge uptick in mental health problems with our kids. i don't know whether it has anything to do with drugs, i'm sure it does, lack of family. but we have a huge uptick. now, the question i got for all of you, if anybody wants to answer this. we're getting ready just watching our doctors and our first responders work for the last year, overworked, stressed, which can cause a lot of problems. do we have a plan to help these people that are first responders once hopefully we see the light at the end of the tunnel in this pandemic? are we preparing for what we can do for these people that have done so much for us and then at the end of the day it's going to hit us right between the eyes of what the problems that they're going to have? >> dr. abraham here. i'll answer really quickly. thank you for that question, senator. the mantra that we have is more vaccines, more hands to administer them and more resources in funding. there just are not enough health care workers in our communities. we don't have enough nurses and doctors and every other health care worker that helps us with public health in this country. so part of it is we've got to build up the workforce because myself included has not taken a day off since the day before christmas. that just can't keep happening. that's not sustainable. but my colleagues are racing against time in icus, keeping ventilators operating and keeping people from dying. the least we can do is race against time to get this vaccine out. but it's not sustainable and we need more health care infrastructure and more public health and more hands. and that means we do need to train people to do health work well. >> would anybody else like to answer that? >> senator tuberville, sorry. one thing i would just quickly add is during this last year, what we saw was a pretty unkind of mitigated attack on health care professionals, people accusing doctors and nurses of lying about how many cases of covid there were. a real turning on these heroes who i think have saved so many lives across the country. and so one of the things that we got to do moving forward is make sure that we are not doing that going ahead, that we're not attacking front line health care providers as somehow being dishonest when i think they have been anything but that. and then is as we come out of this pandemic, we really do need to from a policy point of view need to look at our payment systems that have made it very difficult for our primary care and independent practices to survive in this pandemic. we need to find new ways of paying doctors and nurses and health care providers. so there's a lot of work ahead. but it certainly begins by i think showing people respect and understanding what health care workers have gone through and not questioning their motivations. >> thank you. >> senator tuberville. >> i was just going to -- first of all, i'm from cincinnati originally so i just wanted to give a shoutout to you with that jog with your career there. i will say that in addition to dr. abraham and what dr. jha just mentioned, i do think there is an incredible need for us to invest in that workforce both in terms of more of them and trained and supported but also behavioral healthwise. your question was are we ready for that for the future? and my answer is i don't think so. i don't think we are. i don't think we've done enough. i don't think we have done enough. i don't think we did enough prior to this pandemic. i don't think we've done enough during this pandemic. and i don't think we're doing enough moving forward to make sure that the health and the health care needs and the mental health and behavioral health needs of our health care workers and our public health workers are addressed. we have not done enough to support it. we've got to do more. and if we do not get this right, we are going to care workers is supported. if we don't get this right, there's going to be a terrible loss for this country in the public health system. >> i can't agree with my colleagues enough on the panel today. this is a big issue, and we are not prepared for the future of workforce for health care. i recently had the opportunity to speak with both rear admiral vix and ortega about the public health force and the large gaps and the numbers of people and nurses that we have prepared in the workforce or in the reserves. this is an extreme area, an opportunity for us moving forward and then that, too, the concept of howie with ear caring for people within our organizations, wherever they are delivering care, we have to have flexible services that meet individual needs in -- in a place where they can accept and be comfortable with those resources, and so that will take a very broad approach. that will require additional sources of resources to be able to impact our workforce. >> thank you very much, and if i could just make one statement, mrs. chairwoman. i told this to general a pierre last week who is over in operation warp speed and i've watched things work. a lot of people are not taking this vaccine and we've got to have more take it even when there's more vaccines to be given. we need to come up with a marketing plan. at the end of the day when we've got vaccines and 30%, 40%, 50% of the people won't take it, we need a marketing plan, television and radio and say this is why you've got to take it. we can't set back and expect people to take it. it's not going to happen, and so i think at the end of the day, probably here in a month or so, we're going to be at a point where we've got to make a statement of marketing and getting this thing out to get this thing behind us. thank you very much. thank you for your service. thank you, madam chairwoman. >> can i make a comment please. >> we need a sensitive approach to how we educate the american people. we need to meet them where they are at as dr. abraham has said. we need to recognize that we have a great opportunity here. as a nurse on this panel and the front lines of our country, nurses are the most trusted professionals, as rated by our public for years, and i don't believe we've taken the opportunity to really maximize the potential that we've had in order to impact a vaccination, and so i look forward to partnering with many to be able to help in this work in the future. >> great. thank you. senator rosen. >> thank you, madam chair and ranking member burr for holding this really important hearing today, and i just want to thank all of the doctors here for your compassion during the pandemic, not just you, but all of our health care work foxx all of our first responders who have gone above and beyond to serve of our nation. we are eternally grateful what you have done for us, for the 500,000 families, plus families who have lost loved ones alone and just all of it. i'm just so grateful and i thank you on behalf of our nation. so it's encouraging to see that 92 million americans have been getting vaccinated. about 856,000 so far in nevada, but greater access to the vaccine can't come soon enough. far more needs to be done, so despite our progress, there's been challenges with appointment scheduling systems, long lines, too many individuals in underserved areas, rural communities being left out, and many americans still waiting for their first or second shot as we know that the virus variants continue to mutate. it's critical that we rapidly review what's working and make changes to ensure that no one is left behind so dr. jah, from a broad systemic perspective, what do you see as the long-term changes that we need to do to improve vaccine delivery, especially to our most vulnerable communities and then i think part of this would be to address our public health infrastructure, our data systems, our creative ways to meet people where they are at regardless of their communities. the what else can we do to help you with this? >> great. so let me kind of lay out what i think we know nationally and then obviously folks like dr. shah can talk more about the individual state level experience. when we look across the country we see a lot of variation. some people doing very, very well, some states doing very well and other states struggle, and if you look at what differentiates states that are doing well and states that are struggling, keeping things very simple s&l probably the most important. a lot of states i think have made this far too complicated and have made it very difficult for people to sign up and arrive at a vaccination place and the more difficult we make it, the harder we make it for people with fewer resources and capabilities and support systems to actually make it through the system so we real very to have a ground game where we go out to people and make this incredibly easy so we've heard some of this from dr. abraham of what he's doing in l.a., but it has got to be much more about getting out into the communities, and i worry a lot about the rural areas of the united states because i just feel like we have not paid enough attention to how we're going to get vaccines out there. you know, the problem here is that we're trying to recreate a public health system that we have hollowed out over the last decade, and now we find ourselves saying, boy, it would really be useful if we had a system with good data, that had a really terrific workforce that we could plug into. we don't, and so we've got to build it for the short run because vaccines are a short-term problem. we've got to get people vaccinated quickly, but then we've got to make sure that we don't pull all those investments away once those people are vaccinated and say we're leaving. we've got to leave a lot of those resources in infrastructure behind, not just for future pandemics but other crises, opioids and other things that continue to plague our nation. we've got continue to make investments in those. i'm hoping that the vaccines really become the step that we need to leave a public health sector that we need to address. >> senator, i wanted to add really quickly. the digital divide and digital fortress that we've created as barriers to people and their vaccines, we really need to transform some of the digital demons that have stalled grandma's shot and train and teach them to be digital angels that help us use these systems. these technologies are supposed to help us, not harm us, stand in the way between people and their vaccines. we need to understand why we need this data and there may be more creative ways of having it than having a 65-year-old senior in our community fighting with their community so they can get a vaccine. >> i couldn't agree more. i have a few seconds left and i want to talk quickly about therapeutics and research and access. we know we're having vaccines and people still become ill. quickly, i just really want to ask what suggestions do you have to improve access for covid-19's therapeutics for vulnerable patients, maybe particularly in rural areas or in our areas that are underserved and folks not able to get to a tier one hospital perhaps, and that's going to be our challenge now as people become vaccinated. >> so, let me start by quickly saying i think that this is an area -- we've done a lot of things well. the scientific community has been extraordinary and the nih has been extraordinary and i think therapeutics is one area where we've underestimated. we've done pretty well with inpatient treatments and we're actually underusing antibody treatments and the hundreds of billions appropriately invested in vaccines would i like to see a similar thing for therapeutics. the virus is not going away even when we're vaccinated. we would like to get to a point where if you get infected you can take a five or seven-day oral course of something to reduce your chances of getting sick. we've got to let science drive this and let nih spend a lot more research to promote knew therapies. we don't know what will work but we need to put more effort into that area. >> and we also have to support our rural systems to dr. jah's point, rural hospitals and rural health care providers and rural health departments that are doing just an incredible amount of work both on the vaccine side but also on the therapeutic side. we need to make sure we continue to support them pause they have challenges that are quite different than what's happening in the frank urban areas. we need to make sure that we're also thinking about those in a very methodical way. >> and i would also add that -- i would also add that, you know, different innovative models of care delivery are really important so the work going on at hospital-at-home programs, being able to deliver services from an enhanced home care perspective is some of the work that we have done in our health system and we've seen the ability to treat people at home versus bringing them into the hospital so these therapeutics i think have to be available to be able to be delivered in multiple places. lyrics for example, we believe we can deliver remdesivir in the patient's home. we're not able to do that right now because of the restrictions around it, so we have to think innovatively about how we can deliver care differently to be able to touch, the people wherever they are and especially in our rural communities. >> thank you. >> thank you. i yield back. thank you, madam chair. >> thank you very much, and i will turn to senator burr. >> thank you, senator murray. i have one question and then some comments, and on the comments any of you that want to refute what i say feel free to do it. jah, some covid-19 models have started to incorporate weather patterns into their predictors for the trajectory of pandemics. are there other data points or sources of information that we should be including in our surveillance and predictive models to provide a better picture of the virus pathway? >> oh, senator, this is a fabulous question, and let me say throughout this entire pandemic as i have tracked this pandemic in our nation, sometimes i look at public health data, but a large chunk of what i look at is not traditional public health data at all. i look at google mobility data and open table datas reservation, not because i'm trying to get a restaurant reservation but because it tells about how people are behaving. we in the public health word, a broader societal problem, have not thought through how the incredible proliferation of data that's out there is getting incorporated and used into public health modling. of course we need basic laboratory data and all that, the standard stuff and we need a new approach t.raises a serious question because countries like china, for instance, use incredible amounts of personal generated data but do it in a way not consistent with our values. not the way we would want to do it in a democracy with privacy and security so we need to find ways. these are policy issues, regulatory issues, where we can access and use this kind of data in a way that people feel that their privacy is still being conserved. we've barely begun to scratch the surface therefore tissue. >> i'm delighted to hear you say that because we do need to think outside the box as we talk about a layered surveillance system, one that leverages tech. and we've prone in medical research that you can de-identify data and it can be used and used very successfully. a few comments. with the flu every year we flood the zone to use a football analogy that coach would say. we flood the zone with vaccines and we make it as easy as possible, in plarnlg part because we've got unlimited vaccine production. we never thought about the multi-use manufacturing needs that we were going to have and we've got to rethink that and got to incorporate that into our architecture of the future. when airlines adopted a mask policy and put hepa filters in every airplane and people started flying with mandatory masks and with filtration but no social distancing, we never had an instance of superspreader off an airline from the time that restarted that new system. i'm not sure why we're so scared on schools. if we've got a mask and we've got filtration and got distancing which is the third thing and the fourth thing is we've got a population of kids that we have the data that shows they are less likely to contract, and it's just amazing to me that we have put off so long putting these kids back to school and letting mothers and fathers go back to work and to resume some normalcy in their lives. three, the vaccine process, i agree with i think dr. jah. we made it way too difficult, and i think dr. abraham you've simplified it where you are. i remember i was in a hospital one day that was known for heart bypass surgery, and when they explained to me what a typical day was like and the first two operations they require them to stay inpatient the night before. my question is why? there's an added expense? and they made it clear that any missed operation the next day probing their -- their model of how they reduced costs in health care but make money at the end. day, so if you can't assure that your first two people wake up and show on time for their pre-on, you've missed up the entire day of bypass surgery. every time we have an interruption in the line of people sticking in arms, when we've got a limited number of stickers, dr. abraham alluded to it we've missed an opportunity. we've got simplify this as this was said. we've got to make sure our focus is on sticking as many arms as we can on a given day with the number of vaccines that we have and the system today was not set up to do it. we have a limited number of health care professionals that can do it. this is not new. we identified this in the early 2000s when we started the pandemic legislation, and we identified that we needed a parallel effort to try to find an oral delivery system because sticking people in arms is a very difficult thing in a national and global picture. well, thank god we've had health care professionals that were retired that have come back to the front lines and volunteered pro bono to come out and stick people because they are already trained and we've got to tap into that supply even greater. are either dr. jah or dr. shah alluded to the fact we can't get there if we've got 147 million americans that aren't going to be vaccinated because they are under the age of 18, and i agree totally. as this infection begins to decline, the pediatric indications that are needed for an historical determination to make safety and efficacy pass the test is going to be impossible. it will take years, and we really need to do that population at least down to an 8-year-old before school goes back next year, so i hope that some of the words that you go out and create your worlds will accept the standard that we'll have to use technology to close the gap on making those determinations which is not the historical model that fda and others have used. we're asking federal agencies quite frankly to do historical things that they haven't done historically in large measure because technology gives us the ability to gap that now, but let me assure all of our witnesses government is the last one that will take advantage of it unless it's the medical community that are pushes congress to make the changes that pushes the federal agencies to make those changes. partnering with the private sector is absolutely essential to mapping out the way to address pandemics of the future, and we are the worst partner for the private sector, we the government, that exists in the marketplace. we've got to change that. it can no longer be the cdc is in charge of all testing which is where we were one year ago on march the 9th and not until we created radek over at nih with dr. collins' leadership did they start to partner with the private sector to bring all sorts of new testing capabilities, both in office, in home and we're going to continue to expand on that, but we've got to get outside of the historical paradigms that exist. technology, innovation and investment are the only way that we will improve the future. and that's in all aspects of pandemics. the heroes in this story are the individuals on the front line. without them we fail. the with them we have accomplished something that 12 months ago people believed we couldn't do. we've developed three vaccines and hopefully a fourth very soon. we have immunized now millions of americans, and i agree with the comments that were made. we can't stop with looking at america saying when are we going to be immunized until a way to find to be the driver of global immunization, then we will not feel comfortable about where we are. america needs to open up our schools. we need to open up our business and we need commerce outside of the united states and until we find a way to immunize globally that is not going to happen at the levels that we've got to get it to, so it's not just about how do we buy 600 million doses for the united states which can vaccinate every american. it's how can we use american assets to leverage capabilities here and globally to where we manufacture cost-effective vaccines maybe with u.s. technology, maybe with u.s. companies, and we leverage the rest of the world to do it. you'll never get them to do it if we don't display a willingness to partner between the federal government and the private sector going forward, so chair murray i thank you for this hearing, i thank our witnesses for their expertise, and i'm willing to take any criticism about my observations from any of you. >> well, thank you, ranking member burr. i just have a couple more questions and, again, i want to thank all of our witnesses. dr. jah, if you can answer me, in december the u.s. ranked 43rd in sequencing of coronavirus variants. dr. shah, what do you see as the biggest problems ahead in terms of identifying tracking and stopping these emerging variants? >> yeah, two things, senator. first, i think your push for more sequencing was exactly right. that's what we need. i do believe, look, there's no reason why the uk has to be the global leader in sequencing. there's no reason why. we have so much sequencing capacity in our country and we just need to be doing a lot more of it, even a lot more that we've ramped up and even a lot more than we've ramped up right now. i remain as i said in my opening remarks that i'm pretty worried we're not taking variants serious enough. within a year of the disease outbreak we've seen multiple variants that challenge our vaccines. none will defeat them yet but we're on a track for three, four more years before the world is vaccinated and the question is how lucky do we see that we'll see the rise of a variant that will make all of our vaccines ineffective? we need a surveillance program in the u.s. that's far more robust and one globally that's far more robust but identifying the variants is not enough. we need to get the world vaccinated. it's in our national political health interests to get the entire world vaccinated as quickly as possible, and we're not on track to keep the american people safe that we need to in terms of getting the whole world vaccinated. >> thank you. i'm not for relying on luck myself. dr. abraham, the healthy care safety net has never been more important and millions of people rely on our community health centers and they are really a lifeline for our families as you know and i'm really glad we were able to secure billions in the american rescue plan. that rescue plan will help our health centers continue to care for covid-19 patients but we've solely centered on covid-19, i wanted to ask you in addition to your work addressing covid-19, how have you been able to manage the other primary care needs of your community throughout this pandemic? >> the short answer it has not been's. it's required an all hands on deck approval. whether you're the receptionist in our clinic or the medical assistant or every single person including the person that wears that business hat, we've all had to race to help every patient because despite covid our patients still have their needs, their diabetes, their hypertension and their heart disease and they need their refills and need access to diagnostics and to treatments, and we can't delay that because ever this pandemic that. creates a whole other storm so what we do definitely is we need more hands on deck, more team-based health care delivery. we need more of all of it so that every dollar you send from this act on to a community health center really helps us better care for our communities. it get more hands hired and more resources whether it's roofs or getting out into the community, a mobile mammogram unit, all of those things are required, but they do take resources and with more resource we can really do more for our communities. >> thank you, and i think that's one of the things that we've not focused on is the other cost therefore pandemic has really been all of those other health care needs that we've not been focused on that have been neglected for a variety of reasons, including people not going in to get their care but also because of the lack of access, so we need to really be aware of that have and focus. i want to thank all of our witnesses today and all of our colleagues for a really thoughtful discussion. especially, i want to thank dr. jah, dr. futures and dr. abraham and sharing your knowledge and intelligence with all of us and for all the work you're doing on front lines and for so many working their way through it. for any senators who wish to ask additional questions, questions for the record will be due in ten business days, tuesday, march 23rd at 5:00 p.m. this hearing record will also remain open until then for those members who wish to submit additional questions for the roar. this committee will meet tuesday, march 15th in dirkson 106 for the hearing on the nomination of julie sioux to be deputy secretary of labor. the committee stands adjourned. with the biden administration now leading the federal response to the coronavirus pandemic follow the latest at c-span.org/coronavirus. search c-span's coverage of news conferences as well as remarks from members of congress. use the interactive gallery of maps to follow cases in the u.s. and worldwide. go to c-span.org/coronavirus. coming up this afternoon, house speaker nancy pelosi and several of the nation's mayors will be speaking at a national leaving city's conference. live coverage starts at 12 350k eastern here on c-span 3 and also online at c-span.org or you can also listen with your free c-span radio app. we can nights this month we're featuring american history tv programs as a preview of what's available every weekend on c-span3. tonight, david wilkins looks at 18th and 19th century u.s. policy towards native americans. mr. wins