Transcripts For CSPAN Congressional Seminar On The Ebola Outbreak In West Africa 20140928

Epidemics and disasters. We are so pleased to be here today with you. Ofare here for a discussion the urgent ebola crisis in west africa. There have been estimates in the last few days the project as many as 20,000 cases of ebola by november and as many as 1. 4 million cases of ebola by the end of january, without an immediate and massive response. In the affected countries, there is a terrible consequence and academic hardship on the ground and epidemic hardship on the ground. Ebola combines an extraordinary case fatality rate with the capacity to spread by contact, an inability to treat with medicines or prevent with vaccine, and dublin time as short as 20 days. Theres no other Infectious Disease like this. A disease once relegated to remote villages is now threatening to take hold in major cities in africa. But there are also major new efforts underway the u. S. Government and by the who, and other governments in the world. Cdc is making its Largest International response in history. More than 100 people on the ground in west africa. Hundreds of people in the cdc Emergency Operation center. Usaid is providing hundreds of thousands of Home Protection kits and training and information. Its people are moving 100,000 units of personal protective equipment to west africa. The u. S. To farming of defense is providing 3000 u. S. Forces for the response, establishing a regional staging base to facilitate the arrival of equipment and supplies and preparing to trains hundreds to train hundreds of health care providers. We know who has provided a roadmap for response and is providing expertise in africa and is seeking funding from governments around the world. Ngos like Doctors Without Borders are heroically leading the efforts on the ground. In our discussion today, we will hear about the situation on the ground in west africa by people who have been there quite recently and to our leading the effort. We will learn about what the u. S. Government is doing in more detail and, perhaps most important me, we can take to end this crisis perhaps most importantly, we will discuss what measures we can take to end this crisis. Our speakers today, who we are so fortunate to have, given all that they are doing in this response first, the director of the usaid office of u. S. Foreign disaster assistance. Tom frieden, director of the u. S. Center for disease control. Joseph, cofounder of the well known organization and the assistant secretary of defense for nuclear, chemical, and biological programs. We are sorry not to have keiji kejii fukada. His boss said she needed him in new york today. Feel free to make your comments from there or come to the podium. Thanks for the opportunity to speak. It is great to see this level of interest on the hill. This is a remarkable challenge. I think it will take it is taking the whole of government and it will take a whole of Society Response for us to fully support the liberians the liberian, sierra leone, and guinean governments. This is a crucial piece to our ultimate success. I will talk for just a few minutes about the over arching u. S. Strategy that the president laid out last tuesday and usaids specific pieces of that, then turn it over to my colleagues to go into more depth on their respective pieces. As the president laid out on tuesday, we have a fourpillar strategy that the u. S. Government is pursuing across all of its many capacities to try and control and ultimately defeat this outbreak, but also to look beyond the immediate outbreak at the longerterm needs of Health Systems and the resilience of these countries to what will be a likely future outbreak of this as well now that this is in the environment in other countries such as uganda and drc. We dont want this whole episode to result the next time that happens here we do know from those other countries that it can be controlled when there are measures in place to do so. The first pillar of the strategy is to focus on controlling the immediate epidemic and the immediate outbreak. The second pillar focuses on mitigating second order impact, things like food security, economic and political stability , and ensuring that as these countries struggle with the immediate outbreak, that we dont see second order impacts that are equal to if not greater than the outbreak itself in terms of human out human impact. The third pieces to coordinate an effective global and u. S. Government agency response. Coordination will be critical to the success of this, both at a country level and at a global level. There are many, many countries that are looking to play a role here, and in any major response that we undertake, there is a large coordination element, that hundreds and hundreds of ngos that famously showed up in haiti are a wellknown example of. In this case, its even more critical, because this is something that none of us have ever done on this scale before. Having cord did action is all the more important for that reason having coordinated action is all the more important for that reason. It is also critical because there is an ability to prevent future outbreaks of this magnitude. It is critical for the longterm future of these countries, but also critical in the immediate term that some of the neighbors do not see outbreaks on this scale. And i think the fact that cases have popped up in a few of the neighboring countries so far not triggering any major outbreaks is an indicator both of the risk but also of the potential to keep this managed with swift and decisive action. Just to speak briefly about usaids role. The office that i lead has the standing role in the federal government as the lead coordinator for International Disaster response. And so, in that capacity, we have sent a dart team to the region that has representation from across the interagency, works closely with the larger cdc team that is also there on the ground, also has cdc representation on the dart as well. The focus of the dart team is both to coordinate the agency input and also to deliver and execute on usaids pieces of the response. Our current focus, and i wont reiterate everything that president has already announced, but our current focus is along five lines of effort. The first being effective in country management and leadership of the response. We are very policed please to announce today that the Liberian National Emergency Operation center has opened officially. All of the elements of the liberian government coordination now sits under one roof after a great deal of u. S. Government support. The second element is to focus on scaling up isolation and treatment. So we are focusing heavily on getting etu set up and working closely with dod in that effort. The ebola treatment unit, excuse me if i use acronyms that you all dont recognize. Please just raise a hand. Its hard to think about. Fairly ingrained. The third piece of that is safe burial. We are on track to have we are on track i think thats one where weve seen the most rapid process. It is one of the more easily scalable pieces of this. We are on a good track there. The fourth element of this is Infection Control. More broadly within the country and a big piece of that will be the Community Care strategies that the president announced last tuesday. That will focus on beyond the etus, enabling communities and necessary households to safely isolate and provide care when etu treatment is not available, because that takes time to scale. The protective kits that tom referenced in the opening remarks are an important part of that approach and were happy to talk more about that. And then the fifth element is communications and social mobilization. This is a new disease in all of these countries. Theres a lot of misinformation and misunderstanding about it, and ensuring that theres accurate understanding, accurate information, and that people know the basics on how to protect themselves is a critical piece. Underpinning all of that is a huge logistical effort that both we and dod are working on very intensively to ensure both adequate procurement, adequate transport, as well as adequate supplies and supply Chain Management within the country, because the volume of personal protective equipment, chlorine and other supplies, that are required to run a medical operation on this scale is just enormous. So, thats a huge piece we are focusing on. Thanks. Tom . So, thanks very much for bringing us together and senator to senator coons office and to all of you for your interest. Ive been doing Public Health, running Public Health agencies for a few decades on a few continents and i became a doctor working in new york city in the 1980s where i cared for literally hundreds of people dying from aids with a limited ability to do much other than help them die comfortably. And that experience was searing for me personally, and ive never seen anything like that until i was in monrovia recently. And went during ebola treatment unit run by Doctors Without Borders who are working really with just incredible effort, their largest response ever, exceeding the capacity, stretching the limits of their operations. But we went into a treatment unit and we saw really a scene out of dante. It was patients who were in all stages of the disease, from those suspected but maybe didnt have it and maybe might get it there if they werent effectively separated from others. And our Lab Next Door was working more than 12 hours a day confirming within a few hours whether people had disease or not. People who were just getting in and being cared for and desperately needed rehydration to survive. Patients who were recovering, including one guy who was healthy enough to complain about the food. I thought he should probably be helping to make the food if he could complain about the food. [laughter] but also, tragically, three patients who had died in the past few hours, and the staff was so overwhelmed, they could not remove their bodies. And this is the facility in which there are 14 to 20 beds per tent. One person in one tent who had died was next to the other patients who were struggling to live. And that kind of situation is the real world example realworld exemplification of what it means to have an exponentially increasing outbreak. Its a very hard term for all of us, myself included, to get our minds around, that it is doubling in 20 to 30 days in the region. That facility had had 60 bodies removed that day. So, the situation right now in west africa is an absolute crisis. It is moving faster than it is easy to understand, particularly in liberia, and weve already seen exports to both senegal and nigeria. We now have a field team in rule cote divoire in rural cote divoire looking at cases there. If i were to just summarize for a minute, what we need is an Immediate Response that is sustained, and then make sure that this doesnt happen again. And if i can just outline those three concepts for a moment. Ive never seen a Public Health situation with this much need for immediacy. As ive explained to people, and an adequate response today is much better than a great response in a week. It is that urgent. And thats the case, really, in all three countries that are affected, even though liberia has, by far, the most out of control situation. But there are districts within liberia that are having relatively few cases. They have the opportunity to stop it before it spreads widely there. And where there are many cases, we are intensively trying to scale so we can reduce the spread. In sierra leone, where cases have not increased quite as quickly as in liberia, we have the opportunity to prevent a liberialike situation. In guinea, where cases have had three consecutive waves where it has expanded and been controlled, they have the potential of keeping it under control. The best analogy or the best metaphor is a forest fire. We see the forest fire raging in many districts of both sierra leone and liberia, especially that tricountry area. Theres a threeborder area where the three countries come together. It a deeply forest did deeply forested region. It has very poor infrastructure, has very poor relations with the rest of each of the countries but is the crucible of this epidemic. And other Capital Cities of freetown and monrovia which are the worlds first Extensive Urban spread of ebola in the context of the worlds ebola epidemic. So an Immediate Response is critically important and thats why president obamas announcement at the cdc last week is of critical importance that the department of defense is already on the ground. Usaid and the dart process is there. And the needs are extraordinarily large. And thats whats really hard to get our minds around because not only are the needs large today but they will be twice as large in less than one month. And if were going to be successful we have to build to where theyre going to be in a month. And were going to have to sustain this, because once we tamp it down controlling ebola is something that cdc has done for decades with who, with other countries. In 2012, in uganda where work on ebola many times, tragically a 12 Year Old Girl died from ebola. What was striking was that she was the only one who got ebola. Thats the only time in history weve seen a situation like that that im aware of, other than a laboratory incident, where there is someone who got it but people thought immediately, this might be ebola, they immediately isolated her, tested, and confirmed it was ebola. They confirmed that when she died she was safely buried and they ensure that any contacts were tracked. If they had gotten ill, they would not have spread it further. If that kind of core Public Health service, finding problems quickly, responding and preventing were possible, if that had been in place a year ago in these three countries, the world would be a very different place today. But the fact is we now have an outbreak that is likely to continue for a significant amount of time, and to protect other countries, we need to surge. So, when one individual went to lagos, city of 21 million people, about the same as the three cities in west africa the three countries in west africa, we got on the phone with the governor of lagos and Health Minister of nigeria. We sent a team of experts within 48 hours to be there. We brought in 40 people who we who were trained in the polio eradication effort and working effectively now they are not completely out of the woods but it does look like they have controlled the outbreak in both lagos and port harcourt. That involved more than 1000 Health Care Workers doing among other things more than 19,000 home visits to measure temperature of nearly 1000 made named contacts. That was to address one case of ebola. So, we need to have a response that is immediate, that is sustained, and that prevents future events like this. Because we could have prevented this in the first place. Sars cost the world 30 billion in just about three months. The economic implications of ebola in west africa, not just west africa, not just for africa, but for the world are quite substantial. Who, in the publication yesterday, raised the possibility of ebola becoming endemic in africa, and that would mean, for those of you who are not in the Public Health world, that it would continue on an ongoing low or medium level indefinitely. We think thats not inevitable. We think if that were to happen, it would be an enormous problem, not just for west africa and africa, but for the world, because we would always have to be thinking about the possibility of ebola. Anyone who had been in any region that might have a case of ebola i would reiterate the approach that president obama has outlined is exactly what we need , and we need to get to scale and speed that will match the exponential growth of the outbreak to ensure that we have an Immediate Response, sustained , and prevent this from happening both where it is not happening now and from happening again anywhere, whether it is ebola or any other health threat. Thank you. Thank you for the invitation to talk today. Let me start sorry. Let me start by saying i completely echo director friedens comments. We happened to see each other in sierra leone while he was there. Id like to preface my remarks with the fact with the understanding that i am mostly speaking from my experience in sierra leone and liberia. By remarks tend to be skewed towards those countries which are currently experiencing the worst parts of the outbreak. And when we say the situation is dire in sierra leone and liberia, we just cant emphasize that strongly enough. What we are facing is an end ofdays scenario locally, of biblical proportions. And the people of those countries largely feel abandoned by the International Community. However, that response is now starting to trickle in and there is hope, there is a light at the end of the tunnel, hopefully, although it is going to get worse before the its better. Id like you to keep in mind when were talking about at least those two countries, we are talking about two countries that have endured almost a decade of civil conflict. We are approximate 11 years out from the end of the civil conflict and considering build a Public Health care infrastructure in just 11 years is an enormous task. We were dealing with regions which are almost on the brink of not being able to offer sufficient health care on a normal day. What weve seen since the onset of the outbreak is a complete breakdown in the Public Health and the health care infrastructure. Schools are closed. Hospitals that havent even experienced ebola are closed. And i think from that we may never know the toll of deaths that resulted from nonebola cases, from very normative infections that occur every day in sierra leone. There was a headline today on cnn that you have ebola unless proven otherwise, and that is indeed the case. Before this outbreak i could argue the case would be you have malaria unless proven otherwise. We have complicating this factor that ebola is now occurring in the highly mobile environment, that is well connected by roads. We are dealing only with colonial borders. These are not tribal borders. The tribal languages amongst these three and four countries are all the same, so it is considered much as we would consider going to canada from the United States. It is a very easy and thorough transport through that region. We are still very much experiencing an upward trend in the number of cases in liberia especially, but also sierra leone, less so in sierra leone. And while i truly applaud the move i am sf to reach out to the United States military for , the building of Treatment Centers is something that i do not want us to put complete fed complete faith in stopping this epidemic. This point in time we are over capacity for our Treatment Centers. You see horrific scenes. Almost a month ago, there was a situation being described where we had 10 persons that had passed. We had no body bags because flights had been stopped. As the director mentioned, as a patient you can imagine that you are trying to survive this disease and your mentality in trying to survive the disease is very important. However, you are looking to your side people who were lying next to you, alive just the day before, and you can only imagine you are going to be next. You can see why there is the tendency, which we have read about, of people fleeing, running, not coming into the Treatment Centers, and that is partially because Treatment Centers are considered a house of death. We are turning the corner in that opinion. Much of the messaging that we did early on in the epidemic, which was accurate, but not locally understood, was there is no licensed treatment for the ebola virus. What we had as a result of that is a large portion of the population did not believe in the virus, but why report to a treatment if there is no treatment . What they heard was there is no treatment for ebola, so that led to almost half the population to see cap traditional healers. A lot of that involves bloodletting, which is probably the worst thing you could do, and that is also greatly contributing to the spread of the forest. In my opinion, the priority has to be stopping transmission of the virus, and we are doing that with roots on the ground, with trained epidemiologists, and a sustained effort. As we saw in guinea, we thought the outbreak was over, but we missed two or three contacts. Concurrent with that is this construction of the Treatment Centers that are already infected, that speaking as a Public Health professional, our number one priority has to stop the transmission, save the people not yet infected, and also treat those that are currently infected. I want to caution that the phenomena that we have seen since the introduction of things like and the experimental vaccines, what that has resulted in is the belief that that is going to be the answer to the outbreak. Improving our Infection Control and Treatment Centers, and in the long term, at this will require is a rebuilding of the Public Health infrastructure of these countries. This has set these countries back in that regard five or six years. We are also going longterm dealing with the derivative effects of the Ebola Outbreak food security, airlines, and a lot of the commercial trade that those countries are doing, tankers, including oil tankers, have threatened to stop talking in sierra leone and iberia, and that would create another set of problems. Were still working on getting mobility and transport in place. Those are things we are going to have to deal with concurrently. Lastly, we are facing a unique situation, especially in sierra leone and light beer, this is the first time we have had an outbreak of fever in an area where we already have a lots of fever. Last week we are starting to enter the dry season. The areas which have been most affected, the areas of liberia that have been affect, those happen to be our areas for this fever. Very shortly, and we have already seen this, we are going to have multiple hemorrhaging fevers at the same time, and there is not a place to put all the ebola patients. That we will think about how we separate the fever patients in the ebola patients because that is not something we want to mix. The chances for surviving with the fever is much better than ebola. Those are my comments. Thank you. Thank you. Thank you, tom. Thank you for the center for Health Security and the senate for organizing this meeting. There is a lot of interest in this very important and urgent crisis. This is a National Security imperative. It is a human tragedy and an International Health emergency on a scale that we have not seen before. One thing i want to stress is that this team that you see her today, we did not just meet because of the ebola crisis. We have been working together on these issues, tom frieden and i, regularly for the last five years. We have a strong relationship between the department of defense and hhs and cdc that goes that many years. Dod is not new to global health. Going back to our tradition of walter reed and the work he did on the yellow fever virus. Last week we established Operation United assistance, which will be dods support to this global effort that is led by the United Nations and their special mission established this week, and we are in support of our civilian agency counterparts and working with allies, including the united kingdom, france, and others that have a lot of reach into the affected countries. Dod will focus our contribution on our strength, our unique capabilities and capacities, including command and control, logistics, training, and engineering support. We established the joint forces command under u. S. Africa command, and the Major General there is on the ground doing the assessment. He is also the commander of the u. S. Army africa, and the command headquarters is being established in monrovia, liberia, in addition to a regional intermediate staging base in dakar, senegal, which will provide support to ensure the flow of personnel and equipment and Material Supplies for this very, very large area of west africa. In addition, the United States will send this week two more diagnostic laboratories. Some of our best scientists and microbiologists from the Naval Medical Research Center will deploy with those units to liberia. One in monrovia, and one in another city, and they will be associated with ebola treatment units, so we can have rapid diagnostics. Department is providing a 25bed hospital that will be staffed by International Health workers and Public Health Service Medical personnel. The department of defense will not be involved in direct patient care as part of this patient care as part of this operation. To construct 17 100 bed ebola tradition ebola treatment units in liberia. And the planning and preparation contracting for that. That should start to show results on the ground in the next few weeks. These units will be staffed by local and International Health care providers. Department will not be engaged in direct patient care. But we will provide training based on the Infection Control training that msf has established in belgium and at the cdc has replicated in alabama at a facility there. We are going to establish a similar Training Center in liberia. And the focus of that will be on Infection Control. The department of defense is prepared and has requested support from congress for up to one 1 billion to commit to this ever. There are two major reprogramming actions that are pending here on the hill, and the nunnlugar cooperatives biological Engagement Program is also going to invest over 60 million in strengthening the global Health Security capacity and laboratory capacity, both in the affected countries and also in the neighboring countries. The department of defense through our Bio Defense Program has been involved for many years in the development of medical countermeasures, therapeutics, vaccines, as well as diagnostics, and we have sent over 10,000 diagnostic test kits for ebola to the affected countries as well as personal protective equipment. And i want to just note that in february, february 13 of this year come on the day the federal government was close, the u. S. Government launched a global effort called the global Health Security agenda, and that has grown. It was not in response to ebola, but we are glad we initiated that, and on friday the white house will be hosting an event of 44 countries at the ministerial level that is crosssectoral. We have Health Ministers, Home Affairs Ministers of defense ministers, crossing different sectors, which is necessary for the whole of government response that these types of events require, and the goal is to build those capacities which, had been in place in west africa, could have prevented this from becoming an epidemic. Those capacities are to prevent, detect, and respond to Infectious Disease outbreak as under the International Health regulations. Secretary hagel will participate in the global Health Security agenda event at the white house on friday, together with secretary burwell, secretary kerry, and that will be hosted by ambassador rice with the participation of president obama. Finally, i would just like to thank people like joseph and aid workers on the ground, 100 cdc experts on the ground, like jordan, who just returned from there, for their truly heroic efforts. We owe them a deep debt of gratitude for the heroic work they are doing on the ground every day in west africa. Thank you. Thank you, andy. Thank you all for really setting up this discussion and so much insight and information to start the discussion. We are going to now turn the discussion for those of you following along on the web or twitter, you can submit russians to the ebolaonthehill. Before we get too specific questions about the response, because people want to understand the new once as of the response from the leaders here, i want to ask one more question about the consequences if we get this wrong, if we do not rise to the occasion, and you begin to paint that ensure here of what is at stake, but we hear things in the media or along the way, along the lines of this country has enough on its plate, we are trying to deal with isis, we have National Security threats. Why is it important to invest so much of our time and talent on this problem, and what happens if we get this wrong . The usa today headline, could the ebola epidemic go on forever . What are the consequences for us for africa security, for health if we get this wrong . Early in my career, i spent three years living in guinea, working with refugees from sierra leone and liberia. And as joseph said, we are only about 11 years out from the end of the civil wars in these countries. The u. S. Invested large amounts of effort, political capital, resources to bring peace to these countries, particularly liberia, where we have strong historical ties. In this outbreak, if unchecked, could undo a huge amount of effort both in terms of strong investments the u. S. Has made, but at a human level as well. It is already devastating these countries, and there is a strong humanitarian impulse in the american body politic. It is the reason why we are a leader. I would say the Global Leader on International Humanitarian action and disaster response, and any time there is a disaster on this magnitude, the u. S. Is on the front lines. And this is for humanitarian reasons and for u. S. Interest reasons, an absolute National Security priority, and the president has articulated this. If you look at the interest level in the American Public and the media, there is a clear desire to beat this thing, and we know we can. I think the sad fact is that the worstcase scenarios are really bad. Yesterday cdc outlined in our report what would happen if the exponential growth were to continue at the rate it was going a few weeks ago. We do not think that will happen because of the response of the u. S. And others. But the worstcase scenario tops 1 million cases within a relatively short time, and not only would affect west africa, but would inevitably spread to other countries. We had two disease exportation events with the first couple thousand cases. How many events are we going to have if there are tens, or as the president said, potentially hundreds of thousands of cases . And whatever we may think, it is not possible to seal borders. It just does not happen in todays world. If it did, control of drugs and diamonds and people would be much easier, but it does not, and it is not going to here. And what that means is that we really are all connected. So while we do not think that if ebola continues to spread, as we believe it has been spreading all along, it will present a Significant Health risk to people in the u. S. It could absolutely change the way we work here and it could change the economy of the world. It could change the way we assess anyone who has traveled to anywhere that might have had ebola. We do not think that will happen. That is why president obama highlighted the whole of government response to each part of government intruding what they can do to stop this as quickly as possible among recognizing, as the doctor said, that it is going to get worse before it gets better. We have to recognize that although we have to work immediately, it is going to take time to show the around. But the other key findings of the report we released yesterday is progress is possible. When you isolate and of people, the disease begins to stop spreading, and then can decline in numbers almost as rapidly as that exponential growth we are seeing now. But what the model found that i found particularly striking was the mathematical documentation of the urgency we all feel, that even a delay of one month in scaling up the responsible result and a tripling of the size of the epidemic, and that kind of shocking increase is very hard, as i said, to really get our minds around and to act in a way that we are trying to make sure that we are anticipating what are likely to be the next problems, even though we recognize that the situation on the field is fluid almost beyond description. It changes day to day, but our response has to be with the urgency that will turn it around, and i think we can do so, the risks are not just west african africa, they are to the whole world. Sure. First of all, i would like to draw attention to something weve mentioned several times. There were two cases of exportation of a virus to other nations, nigeria and senegal, and we look at the response in those countries and how they contained it very quickly. We cannot ignore the fact that the gdp of nigeria is approximately 530 billion a year. The gdp of senegal is approximately 16 billion a year. You cannot ignore the fact that the socioeconomics of this disease, so like most tropical diseases, it is disproportionally affecting the poor. I would argue, as jeremy mentioned, that we are experiencing a level of mental and social trauma not seen since the civil conflict in this area. And a lot of us may question why we have never seen this run and clean mentality with the ebola. This is a direct result of this complex, because that was the mentality developed at those times, though the only way you are going to stay alive is to run, hide, to stay with her family, and that is what we are seeing right now. And i believe we are turning the corner in the psychology of that in convincing families that by hiding somebody, keeping them in your home, not only are you greatly increasing the chance that that person will pass, that you also will infect your whole family. That is unfortunately had to happen many, many times for that message to come through. We are likely to see major impact on the government of these countries. Just example, liberia. The president was one of the most popular president s in africa, and africa will altogether. Now you have seen a tremendous amount of negativity flowing towards the Current Administration. In sierra leone, we face a similar circumstance. Not widely publicized, but the current epicenters in sierra leone are in eastern sierra leone, and if you look at sierra leone, its political is divide is like it is in the u. S. , with a twoparty system, and where the current epicenters of the virus are currently occurring is the Opposition Party stronghold. The rate of infection, the percentage that is all being used as political fodder against the Current Administration and office desk in office and although they have improved conditions in sierra leone in the past 10 years. Everyone on this panel is at least familiar that we have spent much of the last 10 years focusing on bioterrorism since 9 11, and another term which we use, bioerror. This is somewhat of a worstcase scenario and the sense of we literally have thousands and thousands and thousands of samples of ebola virus. I did not have exact numbers on how many of those are positives, going into very low resource labs, taken by technicians that are baseline phlebotomists, so we have seen a number of infections occur just because of needle sticks, etc. , and there is no good tracking system for the samples. All the Clinical Laboratory services that are needed on a normal day in any of these countries for the typhoid, malaria, common infections people have all but stopped, and that is understandable because now as a lab tech mission, when you receive a sample, it is safe to assume it is ebola. To echo the comments of the panel, i think we are going to have a lot of longterm effects which we are also going to have to address and to echo dr. Friedens comments on every single day we delay we are potentially going to be seeing an exponential number of increased cases. You want to Say Something . One more question, and we will open it up to questions. If anyone has a question, on the webcast, and it relates to one of the pillars of the Response Rate it is clear we are going to need doctors and nurses in numbers that are not available now, and there is an element of training going on in the planning, and an element of her crew. How do doctors and nurses get involved in this, in our country and elsewhere in the world if they are willing . That is a critically important question, and it is that preoccupation of us now, because one of the things that has made this such a challenging response is that prior to this therell are was no standing global reserve capacity for largescale ebola response. It did not exist. He did not think it was modest scale at the time, but it was modest in terms of the swing, and contained rural settings. The global capacity to respond and treat ebola was premised on that sort of response scale. And we are now faced with a situation where we need a response scale that is orders of magnitude larger, and that involves finding institutions, organizations, nonprofits, medical teams who are able to come forward. It involves identifying staff who can identify ebola, and one thing that is important underscore is the treatment unit model is being widely applied, only 5 to 10 are professionals. The vast majority of the people who are taking the risks and putting themselves on the line to control this are nationals of countries. And we are working furiously to set up training models. Dod will have a role in this. Cdc in the World Health Organization are organizing training in the countries themselves. And working with ministries of health and local institutions to identify nationals of the country so we can put them through trainings. Institute, which was opened recently in monrovia, has a large, meant of train the library and staff. We are also looking for medical professionals to join in the response. A website has been set up, and it is reachable where we are collecting Contact Information of people who are interested who are volunteering to respond, and we are making that available to partners were looking for staff to step up their responses. As we are getting new grants out to ngos, this is a resource for them that they can draw on to help complement their staffing. There is a lot of interest in assisting, despite the fear that ebola natural causes. The african unit, with cdc in the department of the state, is now on the ground in the countries helping out and providing care. This is a great example of what is needed. There are some barriers that we need to break down some people are more willing to help. One of those is being able to go back to their home country, because some african countries have put up travel restrictions to those returning to the area, even from their own citizens, but we are seeing a lot of interest. As jeremy said, 90 plus our local staff, intensively trained, and willing to work in these areas, so the numbers become a little but more mens will when you think about it that way, but are still very large and needed very clearly. That is why actually this week cdc completed the first Training Course ever for ebola outside of the msf model, based on msf training, and that will train trainers and we will scale that up. Great. We will take russians from the audience. Dirksen questions already. I see some questions already. From the Foreign Relations committee. My understanding, that roughly 75 of the current victims are women and children. If that is true, what do you think the particular socioeconomic impacts are and psychological impact are in these communities would be as a result, and how does it change or alter your spots . The who response yesterday, said that although was an impression of a female predominance, what we have seen in the past, because females do more caregiving can we have seen a 5050 response in the data that the who published yesterday. Children tend to be less affected directly because they do not tend to be caregivers. But we are seeing just horrific implications of this. I will mention three four children. One, i was speaking with one survivor, a child was bouncing off the walls, and they said their neighbors do not let him go outside to play because they are afraid of him. The second one, i held a child, a survivor, her parents died. She is now with an aunt, but we are seeing horrific problems. And, three, i saw one of our staff at cdc who has done that postemployment screening of iron staff as they have come back, and a say the stories they tell are searing. For example, one of our staff described on the street seeing babies left by parents who were afraid of infecting them, so to try to save their childs life, they were abandoning their child hoping that someone would pick them up. The implications are enormous for the societies themselves. I would add to that that in addition, probably something you have read about them about once a person does show thrive, if they are fortunate enough to survive the disease, there is intense stigmatizing of them once they enter the community, even if they are allowed. As the director said, the majority of caregiving at the local setting is from women. Women are primary farmers for the region, with cassava the main consumable. Often, children have survived because parents were from them. We have untold numbers of orphans. Youre coming into a system where the social networking site people like orphans was already under developed. Again, going back to the civil conflict, we are seeing numbers now that are not exactly equivalent to what they saw during that conflict, but is reaching that category of a number of orphans we are seeing, especially in the most affected areas. Very quickly to add, the second pillar of u. S. Strategy, focusing on the second order impacts, is exactly that. That is an element of exactly that, and that is why we are focusing on that, because we know that even getting impact, the immediate outbreak under control, there are going to be many knock on social and economic effects that are going to take years to address. So we are building that from the beginning. Next question. Mri global. I had a question about the evolution of the virus. The virus has seen more human hosts than ever before. There was an article published at the end of august that documented the evolution of the forest to 99 human hosts. The question is, what is the current and ongoing effort to understand the direction in which this virus is going to evolve now that it has seen more hosts than ever before . As you point out, we are in an unprecedented situation. We have tracked the genome of ebola for 40 years, and we have seen less than 5 genetic change, which is small for most pathogens. I think the fact that we have seen now, 10, 20 different generations, and were seeing it in thousands of people, does put us in a different environment than before. We have had groups looking at this, and there is the need to track the genetic changes in the virus over time, and there are institutions working on doing that. There is also a need to try to track the epidemiology over time, because we know so little about the genome and what the different expressions are, that we are more likely to pick up the change by that court Public Health epidemiological monitoring that should be going hand in hand. I am gary, from senator rob portmans office. Following up on your comments about containment and response and the response to a potential expansion of the virus, it is my understanding that cdc is working with dhs on development of surveillance for points of entry, and currently that it is past the surveillance. Dr. Frieden, can you elaborate when you see elevating the threshold for surpassing the surveillance, and how that does correlate for training to cdc officers at point of entry . I think of us and having three lines of defense against ebola, and thinking carefully about how to do that most effectively and most practical. The first is to try to stop it at the source in africa, and we have been talking about that, and that is going to be the most effective way of doing it, but it will be continuing for a while, so we need to do more than that. The second is stopping people who may have ebola from departing the country. And there we have searched and have put people in each of the airports in each of the affected countries, and they are doing multiple temperature readings on every person boarding a plane leaving, as well as a questionnaire, and they are removing from the departure line anyone with a fever or who may have ebola. That clearly is not a perfect way of eliminating ebola, because someone could have just been exposed, and the incubation period is usually eight to 10 days, but can be as long as 21 days. That does not mean we will keep you ball in these countries because people travel over land, as the individual who went to senegal to come in because there may be an incubation period, but it is an important thing to do to keep the travel safe, and one of the things that has kept some of the airlines that have kept flying flying, because they have been having a reasonable expectation that nobody is going to get very sick on a plane. The third area is within our country and we really need to recognize that with ebola spreading this widely, it is not impossible that someone will come in to one of our hospitals or Health Centers with symptoms of ebola who may actually have ebola. We have already had 13 people come in symptoms that were considered potentially consistent with ebola, who were from the area in the past 21 days, they have been tested, and they have all been negative or ebola. We have rolled it out more than a dozen times. We have had inquiries from close to 100 Different Health care facilities that we have been able to assess, and we have provided more than a dozen labs around the country with the ability to test for ebola so that Public Health labs can do that quickly. In terms of border protection, we have a very close working relationship at cdc. We have staff in quarantine stations throughout the u. S. Anyone with suspected disease, ebola or otherwise, we work very closely. We have worked with order production of protocols we would follow if someone were to come in with symptoms that might be consistent with ebola. So that we would be able to respond effectively. One of the challenges is that what we might hope would be possible, magically knowing that somebody has ebola, it is just not possible. So understanding what is best done and how we can manage more effectively is something that weve always consider and continue to dynamically reassess at dhs and others. I have a microphone. Sorry, i was handed a microphone, so i assumed it was the logical purpose. Im here with the Armed Services committee in the senate. We heard from panelists at the effort that the response will need to be sustained. It is not a brief go at it hard for three months and we are done. We heard a lot about the u. S. Response, which is what youre representing largely today, including the billion dollars of the Defense Department funding, but my understanding is that is intended to cover up about a sixmonth period to build up the effort. Can you give us a sense of what you mean by a sustained come in terms of length of time, and the response that you believe is needed from other countries, besides the United States, because obviously we are doing a whole life, but this needs to be major International Response . Thanks. I will say a couple of things, jeremy. Basically, give them a number and we will give it a date, but do not give them both together. We do not know what the future is going to hold. You know the sooner we get out there, the sooner we are going to control it, and the penalties for delays are extraordinary. So surging now is critically important. I will say we have seen a wonderful global collaboration here, and just take laboratory services. We have got several parts of the department of defense running labs. We have nih, cdc, the south africans, netherlands, chinese, russians, french, and italians all running laboratories in these regions. There has been a robust mobile response. The African Union, a Health Keepers resource, is already on the ground. There is a robust capacity on the ground, but the u. S. Has unique capabilities in terms of speed, skills, and scope. On international piece, the worst affected countries are sierra leone and liberia. The u. K. Is stepping up now in sierra leone in a similar manner to what the u. S. Is doing in liberia. They are taking the role of the foundational or principal donor partner to the sierra leone government in a way we are doing in liberia. In guinea, there is not a single lead donor there, but it is a smaller outbreak. The french are increasing their involvement. It looks like other European Partners will be going in a larger way into guinea as well. The third pillar of the strategy that i mentioned focusing on building the coherent International Response to complement the u. S. Interagency response is focused on that very question, because we know that the u. S. Government cannot and should not have to carry this entire response on its own. With u. K. Setting up in a very substantial way, that is a huge piece of that. As tom mentioned, many other International Partners are stepping up. We are doing very regular calls. In the past half a day i have been on ones with u. K. And other International Partners. That is an important part of the effort. International outreach is a big part of this ever. Is a part that president obama emphasized in his announcement in atlanta at cdc. One of the u. S. Objectives is held mobilize the International Community and improve the coordination among the International Community. Next week the u. K. Will host an event focused on sierra leone, to coordinate donor contributions. The publicprivate partnerships are a big part of this. The bill and Melinda Gates foundation has pledged initially 50 million to this ever, and many other ngos around the world our country. There is a lot of outreach this week in new york, and as i mentioned in my opening remarks, this friday the global Health Security agenda, we are going to leverage that to get real commitments, real commitments for action for funding, for inkind contributions, to global Health Security around the world, but also specifically for the Current Crisis in west africa. And the state department as named ambassador nancy powell, former head ambassador to india, to help lead this effort for International Outreach and owner coordination. I forgot to mention the world bank, and i would not want to leave them out. They have been terrific. They have leaned forward in a receipt. They have already put over 100 million in the field. There is more than 100 million theyre put into the field, and they not just get the Emergency Response, but put into place the laboratories, disease detectives, and Emergency Response capacities that would have prevented it in the first place, that can prevent similar events in the future, and that will be discussed in the white house of friday on global Health Security, which has been a top priority for us at cdc. I would like at i do not what want to speak the timing of sustainability. That is dependent on how fast we get a handle on the outbreak and we start seeing a decrease in numbers. But for me, sustainability is going to equal building human and technical capacity so that we prevent this from happening again. That will take time. There is going to be shortterm term training, mediumterm training, and theres going to be longterm training coupled with investments and locally sustainable technologies, and that will take time and effort, and it is things we are currently introducing and will continue to introduce throughout the lifespan of the outbreak. Regarding the International Coordination, i think the governments, the African Union they are going to be the key to the sustainability of his effort. Doing that your earlier comments, the state with International Coordination has become extremely high. Even if we fully succeed in liberia and sierra leone, for like that is ams crucial element of the response. And . Thank you. My name is eli greenspan. I am wondering, as you evaluate the funding streams with shortterm timelines, if you have identified any limitations to the current funding or any challenges that you have identified identify the week and play with. Adding to that question, since we are on that topic, it would be great to hear from the panelists if they could tell us what they believed congress could do in particular today. What is it that congress can do to support this response that they are not already doing . Cdc, justdressing the for the 11 weeks of the cr it costs us 30 million and we are rate for the congress for allocating that just to keep operations going at the level we are going. That is 11 weeks. That doesnt involve addressing other countries, which may be dealing with large outbreaks or strengthening their file resistance. We are surging in that area now as well so that we can reduce the spark from forest fires elsewhere. It doesnt address the medium or longterm issues of putting in place those efforts and making sure that we have the technical capacity to do that. We are working closely with the , but theks and others needs are substantial and are going to continue for some time. Just as this panel reflects the whole of the government hillt, a peer on capitol this spans across many different committees. We would ask that you work closely together with each other to avoid the potential gaps and seems. From the dod perspective, our highest irony is getting the approval of the two pending 500 fromon programming request a Contingency Operations funds to receive the louver cooperation threat funding. Immediate attention to those actions will avoid any pausing in the operation. From the usaid side, i would say that one of our Top Priorities as well is to ensure that the programming is approved , because that will allow a very large scale of cooperation. The way that we operate in the field is like we do with any response. Like we did in the philippines. They worked extremely closely together where they identified to validate the needs of the dod in order to turn out the requirements that they were particularly wellsuited to. As and he laid out at the beginning, those are substantial. Having that resource available will really turbocharge the type of the scale of the response. We absolutely need to mount. I think that as we move into 2015 we are getting a better handle on what this is going to look like. If i could add one comment to that, we have talked about the shortterm financial needs, so i will speak more to the medium and longterm needs that we need to speak about now, as well as the holistic approach. The mediumterm and longterm objectives for sustainability, to prevent it from happening again we are going to require investments in foreign infrastructure, laboratories that will be based there permanently, able to diagnose these diseases on their own. Investments in Human Capital with regards to training and , another aspect that we have all talked about is essentially training in Crisis Management and operations. Prior to this outbreak the countries have never had to deal with an acute humanitarian disaster. They have have longterm disasters over 10 years, but it was never acute and had to be responded to exactly like this. Those are the medium and longterm investment that i would argue that we are going to have to be able to be prepared to make to make sure this does not happen again. In addition to stopping the outbreak, we will have to Start Talking about different security for the area if the tankers stop. In the longterm we will have to fork about aid packages those who were there before the outbreak and hopefully a Silver Lining will be the health care system. Next question . Thank you very much. A couple of you mentioned the misinformation we have seen so far. I am curious about the level of local government engagement and trying to fix the problem. Attempting to address the concerns in an understandable ,ay to the affected communities first off what is the level of engagement . How is the relationship going . How critical is it that it is done correctly this time in this of theme for the success Overall Mission . Thank you. I would be happy to talk to that. With regards to the messaging, the most important thing to remember is that there have been messages sometimes coming internally from within the governments. There are political aspirations, etc. But i think we are seeing a turn in that. They have done a great deal to rein in those individuals within political consortiums that are giving come get giving conflicting if not so accurate information. We are still dealing with the groups that you may not offering hopepect from prayer and money through churches. We need to work through the religious leaders in the area. Many people are flocking to the religious community now. What it is and how you can identify it and thematically and what you can do in the case that you do have it as well as identifying potential cases within the home. I feel that the messaging is taking shape and people are starting to listen more, with less denial than we had in earlier days of the epidemic, i feel that we are turning the corner and the messaging needs to be concise and needs to be the same message from everyone. The key here is organization. They report directly to each of the respective president s. They are moving into their new incident management building. Others,g the dart and the Incident Manager this week moved into his new building and within the system there is a new lead. The goal is to have clear evidencebased instructions on every aspect of it. A very interesting Household Survey was done early on and it showed a surprisingly high level of awareness of some of the messages. Going from what they know to what they do, that involves getting the logistics out. That way they can have a higher likelihood of surviving in a lower likelihood of affecting others. Time for a few more. You had spoken about the history of the region. They had gone through about one decade of civil war. How do you think the reaction will be with the u. S. Military showing up after such a traumatic past of dealing with their own military and their mistrust of the Services Provided prior to this, going back to the rumors that there is no care or that we cannot provide care . What is the military going to do to address the psychological impact of a pretty large force showing up on their doorstep . I believe that the involvement of the department of defense in this global effort confidencely build in the local population. That resource is with the scale are coming from around the world to support the response. Thats excellently right. When we were out there a few there was a fervent desire on the part of the liberian government and the people to see a massive scale up we wereesponse that getting from the teams out there. I think that people can easily between what the u. S. Military has been coming to do and the processes they have in their history. It will not be the first time, contingentirly large over the last four or five years. We had much the same and sierra leone. The u. S. And u. K. Government seven training those two countries. In liberia in particular it happens to be one of our most staunch allies. The reason for that, in my opinion, is that the msf operated much like a military, discipline and logistics. They are widely known for having both of these qualities and it is welcome to those on the ground in the local population. Good morning. In your meetings abroad when you travel to the region, what kind of a role our frontline Health Workers using . How are they being perceived in the local community . A group of staffers and myself are recently at the headquarters and were able to meet with routine combating and one of the things we heard was when it aimed to Public Infrastructure the Health Ministers dont always get as much attention as the other ministers. How is this changing the environment . Most people Pay Attention in the middle of an epidemic or outbreak. Within countries you will find that Health Ministries are generally weak compared to others and that the Public Health aspect is particularly weak. Initiative tonal establish Public Health institutes, they would be able and it is very important. It would be tragic if it didnt also putat we didnt in place the kinds of systems that allow the next outbreak from getting out of hand as this has. An enormous challenge is an enormous risk. One of the sometimes overlooked the ones working in the Mental Health system. The someone presents facility with the systems it does not necessarily have the needs of the person with the training that they need. As joseph has referent referenced, these are countries with extremely weak Health Systems. Note are traditionally fantastic Infection Prevention systems within the health system. The Community Care program was announced last tuesday. It will be there to provide training and protective equipment so that that health upe workers can help to set workers for already popping up set upf organizing to care centers, they are just not getting any support. This will provide a degree of support, training, and oversight so that the facilities will have for the people infected, rather than having to keep them in the health center. I am going to give a minute to the doctor from the cdc, he was just in liberia and he has some valuable final comments about the situation. Anything that you heard today that you would like to emphasize . Thank you for the opportunity. I am more than happy to talk to people afterwards. That theto reiterate Health Care Workers on the front liberian been largely and guinean. They took a tremendous toll through the early days of the epidemic. We know how to deal with it and deal with it lately. We have been working in the space for decades. The support that we can give to try to provide Community Care to theyenter as far as how are built is critical. Is most critical element what Family Member takes care of their loved one in these facilities. Those who leave the hospitalss to work in his Community Care centers, making sure that they receive the best opportunities to bridge the gap to when we actually have the units with the support of the of the and others. The most compelling reason for moving in this direction has been moving through the front lines. They just want to be trained. The facilities, the personal for theve treatment practices in the program will have longterm benefits in the program. It will decrease all kinds of possible at wired infections as well. I will be happy to take questions. I know it is 1 30, but i will stick around to talk you about my personal experience and other things. Many of us in this room have friends and colleagues working on the frontline in west africa. It struck us that there has not been an easy way for people to be sharing realtime information and learning. That is being built into the system. We are trying an experiment at our center. It is called a Knowledge Forum for doctors and nurses to be able to put online First Impressions that could eventually make their way into formal guidance through organizations like the cdc if they proved to be useful. It is now two minutes past time. I want to thank all of our distinguished analysts today for the time in service for this country and for west africa with a special thank you to andrea, matt, anita, maria, and jason. They all really worked in the last few weeks to put this together. I want to thank the panelists altogether for their work. [applause] [no audio] and keep up the good work on the hill. Thank you. [captioning performed by national captioning institute] [captions Copyright National cable satellite corp. 2014] here are just a few of the comments we have recently received from our viewers. Be veryd cspan to educational for me in regards to whats currently going on with disease and climate and conflict in our global society. 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