Transcripts For CSPAN West African Ebola Response 20141123

1976. In previous outbreaks, ebola has been confined to rural areas in which there was little contact outside the villages of which it appeared. Unfortunately, this outbreak now an epidemic spread from village to an International Center for regional trade, and spread into urban areas in guinea, sierra leone and liberia, that are crowded with limited medical services, and limited Resident Trust much government. The unprecedented west african ebola epidemic has not only killed more than 5,000 people, with more than 14,000 others known to be affected. This situation has skewed the planning for how to deal with the outbreak. In our two previous hearings on the ebola epidemic, an emergency hearing we held on august 7th, and then a followup on september 17th, we heard about the worsening rates of infection and challenges in responding to this forum from Government Agencies such as usaid and cdc and samaritans person. Todays hearing is intended to take testimony from nongovernmental organizations, providing services on the ground currently, in the affected countries, especially liberia, so we can better determine how proposed actions are being implemented. In its early stages ebola fan fests the same symptoms as less immediately deadly diseases such as malaria, which means initial Health Care Workers have been unprepared for the deadly nature of the disease that they have been asked to treat. This meant that too many Health Care Workers, national and international, have been at risk in treating patients who themselves may not know they have ebola. Hundreds of Health Care Workers have been infected, and many have died, including some of the top medical personnel in the three affected countries. What we found quite quickly was that the Health Care Systems in these countries, despite heavy investment by the United States and other donors, remain weak, as it happens there are these are three countries either coming out of very divisive civil conflict, or experiencing serious political divisions. Consequently, citizens have not been widely prepared to accept recommendations from their own governments. For quite some time, many people in all three countries would not accept that the ebola epidemic was real. Even now it is believed that despite the prevalence of burial teams throughout liberia, for example, some families are reluctant to identify their sufferings and dead loved ones for safe burials. Which places the family members and their neighbors at heightened risk of contracting this often fatal disease when patients are most contagious. The porous borders of these three countries have allowed people to cross between countries at will. This may facilitate commerce, which is a good thing, but it also allows for diseases to be transmitted regionally. As a result, the prevalence of ebola in these three countries has ebbed and flowed with the migration of people from one country to the other. Liberia remains the hardesthit of the three countries with more than 6500 ebola cases officially recorded. Probably a significant understatement. The number of infected and dead from ebola could be as much as three times, however, than official figure due to underreporting. Organizations operating on the ground have told us over the past five months that despite the increasing reach of international and National Efforts to contact those affected with ebola there remains many remote areas where it is still difficult to find residents or gain sufficient trust to obtain their cooperation. Consequently, the ebb and flow in infections continues. Even when it looks like the battle is being won in one place, it increases in a neighboring country, a region, and then reignites in the area that look to be successes. The United States is focusing on liberia. The uk is focusing on sierra leone, and france and the European Union are supposed to be focusing on guinea. In both sierra leone and guinea the antiebola efforts are behind the pace of those in liberia. This epidemic must be brought under control in all three if our efforts are to be successful. Last week, i along with congresswoman karen bass, and congressman mark meadows of this subcommittee introduced hr5710 the ebola Emergency Response act. This bill lays out steps that are needed for the u. S. Government to effectively help fight the west african ebola epidemic, especially in liberia. The worsthit of the throw countries. This krus recruiting and Training Health care personnel, establishing fully functional treatment centers, conducting education campaigns among populations in affected countries, and developing diagnostics, treatments and vaccines. Hr5710 confirms u. S. Policy in the antiebola fight, and provides necessary authorities for the administration to continue or expand anticipated actions in this regard. The bill encourages u. S. Collaboration with other donors. Mitigate the risk of economic collapse and civil unrest in the three affected countries. Furthermore the legislation authorizes funding of the International Disaster assistance account at the higher fy2014 level to effectively support these antiebola efforts. Id like to now turn to my friend and colleague miss bass. As always, thank you chairman smith for your leadership, and also for taking the lead on the legislation that we hope to have marked up soon. I also want to thank todays distinguished witnesses, and prominent ngo organizations. Providing critical medical, nutritional, and developmental assistance in the most adversely affected nations in west africa. I look forward to hearing your updates on how your respectively organizations continue to combat this deadly outbreak, what trends youre seeing both positive and negative, and what Additional Support is needed as you coordinate with the government the governments of the impacted countries and the international community. I appreciate your efforts and outreach to help Keep Congress informed of this evolving crisis. The current crisis, as has been stated, has been the largest and most widespread outbreak of the disease in history, creating a particular burden on the countries that are involved. Since the beginning of the outbreak, u. S. Based ngos have made a significant and sustained effort to support the three countries as they fought the disease. The United States has committed nearly 1 billion to build treatment centers, train Health Care Workers, and burial teams, supply hospitals with protective gear, and ensure the safety and humanitarian support. I would, in particular, like to hear from the witnesses what you think about the assistance that has been provided. And then i have a particular interest in your thoughts around when we are past this crisis what the u. S. Can leave in place. And your thoughts on how we move forward. So we know that the reason why this hit so badly is because of the Weak Health Infrastructure in these three countries. So out of this terrible crisis, is there a way for us to begin to think longterm about the future, how do we support the infrastructure of countries . And your thoughts on that would be appreciated. Ed administration has asked congress for over 6 billion in emergency funds in order to sustain the progress that has been made and to ensure an end to the crisis. This request will expand assistance to contain the epidemic, safeguard the American Public from further spread of the disease, and support the development of treatments. Sustained u. S. Financial support and involvement is essential to support the stable governance of these nations which is jeopardized by the current crisis. I also dont think that we have given much time to much time and attention to the fact that were dealing with countries that could actually be moved quite a bit backward, especially countries that have recently, you know, gotten past civil wars. So i look forward to your testimonies, and im interested in hearing from you about what we can do to assist your efforts. Thank you. Thank you. Id like to now welcome our three very distinguished witnesses who are extraordinaryly effective and informed and will provide this subcommittee i think a real insight as to what has been happening and what needs to be done. Beginning with mr. Rabih torbay, who is a Senior Vice President for the International Operations and oversees International Medical corps, Global Programs in 31 countries and four continents. And its staff and the staff volunteers numbering well over 8,000 people. He has personally supervised the expansion of imcs humanitarian and Development Programs into some of the Worlds Toughest working environments, including sierra lie yoen, iraq, darfur, liberia, lebanon, pakistan, afghanistan, haiti, libya and most recently syria. As the organizations senior representative in washington, d. C. , he serves as imcs liaison with the United States government. Well then hear from mr. Brett sedgewick who is a technical adviser for Food Security and livelihoods for global communities. He previously served as Vice President for the nascom foundation for whom he built stakeholder relations with government entities, donors and ngos and oversaw business development. Prior to that he served as liberias country director for chf international where he oversaw programs designed, implementation and monitoring for a range of donors. He also served as technical adviser to on a similar basis. Well then hear from dr. Darius mans who is the president of africare where he is responsible for the leadership and growth of that organization. Previously he fulfilled a number of roles at the Millennium Challenge Corporation, including acting chief executive officer and Vice President of implementation and managing director for africa. In these positions dr. Mans was responsible for vast and Diverse Program portfolios in mcc, exact countries. He also has experience managing 45 country programs around the world, as director of the world bank institute, working as an economist, teaching economics, and serving as a consultant on Infrastructure Projects in latin america. Were joined by mr. Weber, vice chairman of the committee. Thank you for being here. Lets go. Thank you. Thank you i turn to mr. Torbay. Chairman smith, Ranking Member bass, and distinguished members of the subcommittee, on behalf of International Medical corps, i would like to thank you for inviting me to testify today to describe the ongoing fight against the ebola Virus Outbreak from the ground level. I have already submitted a lengthy written testimony to the subcommittee. My remarks this morning will highlight key observations, and offer ten recommendations for our Ebola Response experience. International medical corps is a global humanitarian Nonprofit Organization dedicated to saving lives, and relieving suffering through Health Care Training and relief and Development Programs. We work in 31 countries around the world, and weve been working in west africa since 1999. Our response to the Ebola Outbreak has been robust in both liberia, and sierra leone. More than two thirds of all ebola cases and over three quarters of all ebola related deaths have come from these two countries. By the end of this month, we anticipate having a total about 800 staff in those two countries, and by years end, we expect this number to exceed 1,000 working in four ebola treatment units, two in liberia and two in sierra leone. I would like to take this opportunity to acknowledge dedicated and Courageous International and African National staff working in our treatment centers. They are from liberia and sierra leone as well as many parts of the United States, europe and other states. Our staff is compromised of doctors, nurses, technicians, specialists in water sanitation and hygiene, logisticians, Mental Health professionals, custodial workers, and burial teams. In addition to the treatment units, we have established several services for groups just now arriving to combat the outbreak. One example is a Training Center on the ground in liberia. It will teach and train staff from all organizations engaged in the fight to contain ebola, and show them how to treat patients and stay safe in a potentially dangerous workplace. We are also responding to the upsurge of ebola cases in mali. We will be setting up an ebola treatment unit and developing Health Worker Training Program to help the country fight the outbreak. Our robust response to the Ebola Outbreak has one overriding objective. Contain the current outbreak at its source in west africa. To succeed several key factors must be in place. One of these is building and safely operating ebola treatment units, staffed by welltrained health professionals. Another key factor is using Training Programs to transfer into local hands the skills and knowledge necessary to respond effectively to the Ebola Outbreaks. We must also assure effective coordination among all actors involved in the fight to contain the virus, including the u. N. , international and national governments, and ngos. To turn the tide of this epidemic we must all Work Together to maximize the strength of all involved. Finally we need to conduct expansive Data Collection and rigorous Data Analysis to build an accurate picture of ebola containment, and spot any need for new responses. Once we succeed to contain the current outbreak, we must remain vigilant to assure that theres no resurgence of this epidemic. The fight to contain ebola and future and prevent future outbreaks will require substantial investment. I would like to thank the u. S. Agency for international development, particularly its office of foreign Disaster Assistance for the funding it has provided to International Medical corps for our Ebola Response, as well as the support of the u. S. Military, particularly in setting up a laboratory near our ebola treatment unit in bonn county. We welcome the president s emergency request to congress to combat ebola in west africa. And based on our ontheground experience in fighting this epidemic, we would recommend that the 1. 4 billion allocated for International Disaster assistance be increased by an additional 200 million to a total of 1. 6 billion. And we recommend that an additional 48 million be added to the Economic Support Fund for a total of 260 million. Mr. Chairman, i conclude my tell by offering ten recommendations for effective treatment and eradication of ebola virus. One, ensure the availability of adequate number of welltrained, well protected Health Workers. One of the most critical Lessons Learned from this response has been the importance of having sufficient Human Resources prepared to address an outbreak of Infectious Disease. Two, ensure that construction of new ebola treatment units fit the local loads. The work must be well coordinated and well trained staff ready to work in each facility. We need to remain flexible and nimble and adapt quickly to changing remand to response of breaks in rural areas. Three, ensure the necessary quantity and quality of personal protective equipment that is available. Four, improve Data Collection. Surveillance that will help individuals receive treatment faster. Five, ensure that fear and understand the lines of communications and divisions of responsibilities are established understood and maintained among coordinating bodies operating in the region. A smart and efficient coordination system at the National Level is critical for an effective response. Six, we welcome the advances made over the past few weeks in establishing procedures to evacuate and treat expatriate Health Workers who might contract ebola. We recommend that the systems be put in place now, be institutionalized and made part of the global preparedness planning future for future epidemics. Seven, we recommend that commercial air space over ebola countries remain open that personnel and resources can move quickly. Eight, accelerate and support the production of vaccines. Nine, invest in Emergency Preparedness in west african regions to ensure that these countries have the needed resource, proper training and systems in place to respond themselves to possible future outbreaks of Infectious Disease. And ten, finally, mr. Chairman, basic Health Services need to be reestablished in west africa. People are not just dying from ebola. Theyre dying from malaria. Theyre dying from waterborne diseases. Women are dying from the lack of facilities where they could go for Safe Delivery. And this needs to be done as soon as possible. We cannot wait until the Ebola Outbreak is done before we restart these activities. Thank you, mr. Chairman, and Ranking Member bass, for the opportunity to present this testimony to the committee. I would be glad to answer any questions you may have. Thank you very much, mr. Torbay. Mr. Sedgewick, if you would proceed. Chairman smith, Ranking Member bass, members of the subcommittee, thank you for the opportunity to testify today on the ways we are working to stop the ebola epidemic in west africa. The following is an abbreviated version of the written testimony provided to the committee. My name is Brett Sedgewick and im technical adviser at global communities formerly chf international and im currently on the ebola task force. From 2010 to 2011 i worked as global communities liberia country director and i returned to the u. S. Ten days ago after spending three weeks in liberia helping to lead our response on the ground. Global communities has worked in liberia since 2004. In 2010 we began a u. S. Aid funded water and sanitation project working closely with the ministry of health and social welfare. Through this program we began to combat ebola in april by providing community education, protective equipment, and hygiene materials to communities at risk. In august we partnered with Usaids Office of foreign Disaster Assistance to have been excellent partners in this fight to scale up our response. Today we are also working in safe burial and body management, Contact Tracing, and ambulance services. Safe body management is of the highest priority in stopping the spread of ebola. The bodies of ebola victims are extremely contagious. In liberia it is often customary for the family of the diseased to say goodbye through traditions that involve touching and washing the body. The cdc estimates that up to 70 of ebola infections are originating from the from contact with the deceased. Global communities is working in every county of liberia, supporting 47 burial teams and 32 disinfection teams. We work in Close Partnership with the ministry of health. The ministry employ the burial Team Personnel and we provide training, vehicles, Logistical Support and equipment. The work of burial teams is both back breaking and heartbreaking. I have accompanied burial teams to and seen the incredible professionalism with which they operate. These men and women were covered in impermeable materials in high temperatures, hiking hours through thick jungle, taking canoes or assembling makeshift bridges over bodies of water. They enter communities stricken with grief and fear and carry out an incredibly Sensitive Task with the greatest care for their health, and for that of others. These men and women are heroes of this crisis that deserve our gratitude, and for assuming great risk and social isolation in order to stop this epidemic. While risky, this work can be done safely. Not once of our more than 500 team members, have contracted the virus. This work is not without challenges. Many resist identifying their dead as infected. They fear they will not be able to mourn their loved ones, and they themselves will be stigmatized. This is why the work of safe burial goes hand in hand with Community Engagement. Many burial rites are safe. And the teams let communities safely and respectfully say goodbye to their loved ones. Another challenge is cremation. In montserrato county which contains monrovia cremation became official policy during the height of the outbreak. However this practice is counter to traditional practices and has met with strong resistance. The idea of a deceased loved one being burned, in their vernacular, upset many, and increased the stigma and contributes to bodies being unsafely buried or the sick being hidden. To combat this, global communities, usaid and the liberian government, are exploring safe burials in montserrato through identifying land that can accommodate a large number of burials and has space for families to safely gather and mourn. Despite the challenges, safe burial is proving highly effective. We began burial team support in august for bong, lofa and mimba counties. By the first week of october we expanded to support teams in every county of liberia and last month they were able to collect 96 of bodies within 24 hours. We were also able to directly reach over 1500 communities through meeting and dialogue sessions. Bringing together senior government officials, county health teams, traditional chiefs, religious leaders, Community Health volunteers, and other local leaders. Indeed it is now being widely reported that we are seeing the rate of infection slow throughout liberia which is cause for optimism. However it is not yet time for celebration. We must maintain the level of vigilance that is proven effective in beginning to control the spread of the virus. Significant longerterm investments must be made in the Health Systems of the country. In closing, global communities would like to express profound gratitude for congress, particularly members of this committee for your continued support of this work. The worst Ebola Outbreak in history can be stopped, and will be stopped. I look forward to your questions. Mr. Sedgewick thank you very much for your testimony and your recommendations. And really some of the good news, at least somewhat optimistic perspective that you have provided the committee. Dr. Mans, please proceed. Thank you mr. Chairman. Let me start by thanking you and members of committee for you strong commitment to this issue. I also really want to applaud my colleagues here for the tireless work that they are doing on the ground. Im honored to be here with them. If i may, id like to start by describing what africare is doing on the ground in the fight against ebola. And then describe to you what we at africare believe are the most important steps that need to be taken in order to win this war. It will be won by africans on the ground who time and again have demonstrated that they can overcome disease and adversity. And finally id like to conclude with what we believe the United States can do to stop ebola in its tracks. When the ebola crisis began earlier this year, africare immediately swung into action. We mobilized more than 2 million in private donations to help break the chain of transmission. We shipped personal Protection Equipment and essential Health Supplies to all three affected countries through partnerships with direct relief and others. In addition, weve been help going front line Health Workers do Contact Tracing. Throughout the crisis, we have been very focused on Community Mobilization and behavior change. Thats at the heart of what africare does across the continent. We believe while aid from foreign governments and from organizations like ours is vitally important, it will be africans adopting changes in behavior that ultimately will win the war on the ground against ebola. So far, we have trained more than 300 local community Health Workers. They, in turn, have educated more than 150,000 liberians about ebola prevention, detection, and care. In addition, our team of nearly 100 staff on the ground, all liberian, are joined at the hip with liberias ministry of health to keep Health Facilities open, to treat nonebola related diseases. And that includes safe deliveries of babies. We are taking in to our maternal waiting homes women who have been turned away from hospitals, that are just overwhelmed by the ebola crisis. And since we believe that measurement is absolutely critical, we are also working with Technology Partners to find ways to embed data capture within our delivery systems. So that we can provide good metrics to gauge our performance, and realtime information about what were doing to contribute to the war against ebola. And i should tell you, were doing all of this without any funding from the u. S. Government so far. But let me describe what we believe, in addition, needs to be done in the face of this challenge. Progress is being made, but much, much more needs to be done. We certainly strongly support the president s emergency request and hope the rest of the g20 countries will step up to the plate and do more. But its not just more money that is needed. Its important how that money is used. Theres a need for better coordination and planning of these Emergency Treatment Centers. We believe we clearly dont need as many etcs as were morningally planned in liberia for example. Very important to take the efforts to control ebola to the Community Level. Thats where the bulk of care is provided by family members, by neighbors, by local Health Workers, who really are the First Responders in this crisis. We also hope that usaid will be given the flexibility to allocate its resources as needed to ensure there will be an agile response to what weve seen as a rapidly evolving epidemic. In addition, very important, we believe that its essential that Civil Society in the affected countries be given the support and space needed to help ensure the best use of, and accountability for ebola funding. Finally, mr. Chairman, let me say a few words about what more we believe the United States can do. One of the big lessons of this crisis is that donors need to move beyond the old approach of vertical programming, of targeting resources to specific diseases, like malaria, and hiv aids, as important as those are. We need to invest in strengthening public Health Systems, especially communitybased management of diseases. We also need to take advantage of this crisis to build a Health Infrastructure thats affected countries will need for the future. The investments being made now during the crisis need to help them build more robust and resilient Health Systems. As the liberian president has said, we must ensure that everything we do now is not just with the aim of ending the outbreak, but to ensure that we come out with a stronger, efficient, health care system. And finally, mr. Chairman, its my hope that u. S. Government will commit to support longterm Economic Growth in the region. I hope you will join me in urging the Millennium Challenge Corporation to quickly finalize its programs in liberia and in sierra leone. Its significant investments in the key drivers for growth will be whats needed to help these countries get back on the higher growth path that they were on before the ebola crisis. Thank you, mr. Chairman. Doctor mans thank you very much again for your extremely valuable work youre doing but also the insights you provide our committee. Let me ask you a couple of questions, all three of you. You mentioned dr. Mans, that you have 300 local volunteer community Health Workers that youve trained who, in turn, have educated some 150,000 liberians about ebola prevention, detection and care. In your statement mr. Torbay you talk about to ensure the availability of adequate, well trained, well protected Health Care Workers. How close is liberia, guinea and sierra leone to having an optimum number of Health Care Workers who are adequately trained . What is the deficit . I mean this is excellent information and very encouraging information. Are you finding people have been scared away because of the fear of contracting it themselves . So if you could provide that information to us. Secondly, mr. Sedgewick, which i would point out parenthetically, were both from new jersey. Welcome. Let me just which is where im from. Let me just, you talked about the safe body management is of the highest priority to stopping the spread of ebola and you pointed out the cdc number of up to 70 of cases originating from contact from the deceased. I think a lot of people are not unaware but they have not known how stark the transmission is at that period of time when somebody has passed away. And yet you have very good information about your teams reaching 96 of bodies within 24 hours over the last month. How many of the folks that should be reached are not being reached . Just to fry to get a sense of the unmet need . And what is the role that clergy and church are playing . Obviously when somebody passes away, we all turn to our faith. You know, the church plays a key role, obviously, in funerals. What role are they playing from the pulpit . And any other way of getting that message out about the contagious nature of someone who is deceased from ebola . I also, with regards to personal protective equipment, mr. Torbay, thats your third point that you made, how available is it . Especially to those volunteers, and those indigenous individuals who might not have access to it like some of the ngos might going in . If you could just speak to that. Are we where we should be . Anywhere close to it . Because obviously thats one way of protecting. And then dr. Mans, you had mentioned, and rightfully so, the deep concern dr. Or president sirleaf spoke, her concern here today about other diseases that continue to take a devastating impact on people in three affected countries, including liberia, and congratulations and good work on the Safe Delivery aspect to help a mother and baby have a venue where they can give birth safely as possible and as, you know, if you might want to expand upon that, how many women are we talking about who have gotten help through your work . I have other questions but ill ask those first and then my friend and colleague and then come back for a few others. Thank you mr. Chairman for your questions. I will start with the Health Workers gap. What were doing at International Medical corps is focusing on Training Health workers that will be working in ebola treatment unit. And that training is a 14day intensive training that includes handson training, actually treating patients in an ebola treatment unit. And as you probably know, when you work in an ebola treatment unit you cannot work for more than an hour or maximum two before you get out, because of the heat, because of the pressure, because of the stress. And we want to make sure that those workers go out before they get tired and dehydrated because this is when mistakes happen. So were extremely careful about that. In terms of the health care gap, we coordinating with agencies that are doing community work, such as, you know, global communities, africare and other groups and samaritans purse and other groups as well. And the idea is to combine and coordinate the communitybased approach with the treatmentbased approach. Because one cannot work properly, or be effective, without the other. As you know, liberia and sierra leone even before ebola had very low doctor per patient ratio. Were talking about one for 100,000 in liberia. One doctor for 100,000 in liberia. And thats before 324 Health Workers have died from ebola. So you can just imagine the gap. One thing thats critical to the health gap, we cannot be only reactive. Any time theres an outbreak, this is when we decide to train. We need to build a Stronger Health care system. We need to build a stronger preparedness system. And all of these countries, and we need to focus on workforce, Health Workforce development. Because, again, its not just the Infectious Diseases. Its the malaria. Its the Safe Delivery. Its dee rhea. Its vac teen preventable diseases that children are dying from. I think were on track in terms of training Health Care Workers for the Ebola Response. But, what were doing in our ebola treatment or ebola Training Facilities is that we will be turning it in the next couple of months to an Infectious Disease academy. That covers much more beyond ebola. And this is a sustainability aspect that were encouraging all of our colleagues to look at. What comes beyond ebola. Thank you for your question. To address your second question on unmet need, id like to point out that the 96 of bodies that are collected within 24 hours, thats within 24 hours of the death of the individual. Not of the phone call. So much of that 4 is regards a delay between the death and the phone call. And the assignment of the team. And so thats thats a big effort that were working on in terms of our social mobilization and the social mobilization that all of the other partners are doing to ensure that that phone call happens very early on. Ideally were hearing about the status of the individual well before well before they pass. And as much as possible, our success is is made significantly easier by our colleagues like imc running etus and having the volume and the beds available to treat those individuals. Its much better for the individual to get to the etu, to get First Community care, and then get to the etu, and that make makes that allows our teams to do a lot less work which is a great situation to be in. In terms of the larger question of unmet need, its very difficult to understand. We do a lot of work with the communities trying to understand if there are people dying that are getting hidden. And its its all anecdotal. I know that the African Union and the cdc have been working on doing some studies on this. And theyve found limited volumes of people hiding. But any are devastating. So were really working on making sure that the stigma goes down which would encourage everyone to call, and to reduce that unmet need. In terms of volume we are completely mobilized. And we are able to respond very quickly. Weve mobilized new teams within a day. So were able to make sure that as hot spots come up, the teams are positioned and available, and responding immediately. On your second part of that question regarding clergy, and faith based leaders, theyre a core part of how we interact with the communities. Our kind of historical interactions in liberia have been focused on bonn and mimba counties. We have really strong relationships not just with the religious leaders but with the traditional leaders and health leaders. That made our initial entry with burial teams fairly straightforward. You cant drive one of our vehicles through those counties without getting stopped and having them ask how so and so, and whats the how is so and sos baby. And theyre so theyre so engaged there. That it made it very, very straightforward. When we moved to other counties, especially in the southeast where we have less of a historical presence, we very quickly realized we had to do extensive interactions with the religious health and traditional leaders. Theyve been incredibly helpful in making sure that the communities know why were there. That were there for a good reason, that were helping, and that were able to do our work respectfully and closely and rapidly. So thats been a core part. The religious leaders have been really helpful. And the traditional leaders who also serve very important roles in at the Community Level, have been very important for making sure that our teams are able to operate rapidly and safely. On personal Protection Equipment, nowhere we are nowhere near where we need to be. There are shortages of all kinds of equipment. Including gloves for medical personnel to use. So what africare is doing is working with the private sector here in the United States. The big suppliers of equipment, like j j and so many others, to be sure that we can get a steady supply of consumables in to all Health Facilities in liberia, working with all of the ngo partners, because we are a big believer in collaboration. That no one of us can do this alone. And second on safe motherhood, you know know even before the ebola crisis, liberia had one of the highest rates of Maternal Mortality in the world. And headed in the wrong direction. Increasing. So a big focus for us has been developing more and more of these maternal waiting homes, working with the private sector in liberia, to raise the money to do so. And so far i think were up to about 20 and then these facilities that point us to bring access to communities, because women who were expecting were not able to get to these Health Facilities, which were so few and far between. And thats something we intend to do, continue to do postcrisis. Miss bass . I will, again, want to thank all of you for your testimony. I think its been extremely helpful, and i have questions for each of you. Mr. Torbay, pronounce that correct . In your recommendations, the second one says you wanted to make sure that the construction of the etus are appropriate for the needs of each country and so i was wondering if you find what is going on now is not appropriate . Are you saying this in response to something that needs to be improved . Thank you for your question. Thats actually very important question and weve been discussing it over the past week. There had been plans to build a certain number of etus in every country based on findings of that are about two months old. The situation is evolving rapidly. And we need to make sure that as it evolves we do not stick to the old plans that actually we adapt and were flexible enough to, if theres no need for an etu, lets not even build that etu. If theres a need for mobile teams that would go out and get patients to an ebola treatment unit hat that has empty beds, lets do that. Because weve seen weve see treatment units that have overflow of patients and some that have empty beds. We need to make sure we balance that. I heard about that, too. I thought one of the reasons was because the population was afraid to come forward. The best case is that they are not needed. That wasnt the issue. Why do you have that disprepancy . I guess you are saying maybe etus is not the way to go right now. I will go back to you. First of all, the virus is moving. It is not staying in one county. You built a treatment unit in one county and get it under control with the work between the Community Based approach and treatment approach. It is getting under control and then it is another county. So thats why there are large numbers in certain areas. Those need to be coordinated. At the end of the day ebola started at the Community Level and this is where it should die. We need to make sure that the Community Centers are well equipped and staff are well trained to detect and isolate so they can defer for further treatment. This is what needs strengthening and this is the work being done. You know how i said i was interested in the things we are building need to stay. Is there any value to the etus that were being built being left there for either other Infectious Diseases or other health needs . Some are not built to last which is fair enough. They are built with temporary material that would last for a few months and that is good enough. One of tpproaches we are following is we are trying to build a more permanent structure that could be turned into something else. It could be turned into a Training Center or clinic. That is the sustainable aspect of it. That is what we are encouraging. There will be a need for isolation wards in west africa that need to remain there even after we contain ebola because chances are there might be other diseases or ebola might resurface. There is a need for the facility as well as equipment and trained staff there. So it was first time i heard someone talk about the only Time Health Care worker can be with a patient is one to two hours. I have seen the equipment and the stories that talk about the heat, but that implies a large number of Health Care Workers. If you are only with the patient for an hour or two and you leave then do you have relief or you understand what im saying . Absolutely. How does it work . In our ebola treatment unit it is a 70bed treatment facility. We have 230 staff members. Wow. We work around the clock. Its by shifts. When the doctor goes out another one will be in to replace him. When the person leaves after being there an hour or two they take a break of how long . And then i imagine they go back. It depends on the level of exhaustion and hydration. They need to recover before we bring them back in. Wow. Okay. And maybe you can respond to this one if you wanted to add anything about the etus. I know that there was an issue around the Health Care Workers at one point and them being paid and them wanting hazard pay. I was wondering what the situation was with that, if that has improved. Thank you. I agree completely about the etcs. Emergency treatment centers. And there are certainly challenges around planning and coordination. For example, we have seen the United States government construct a 100bed Emergency Treatment Center three miles from where msf is operating one. The Chinese Government has built one in between and yet communities where there are hot spots not very far away but not accessible easily by road can get into any of those. The challenge of planning how does that happen . Fundamentally is the responsibility of government. And so i think finding ways, again making sure that there is a more mobile response to be able to get people into the facilities where they need support. Because what worries me in this is the gap that i see in talking to liberiaens about the big numbers that they hear that has been committed to ebola and the actual response taking place on the ground. So i think it is extremely important to be sure that the planning is done effectively, that that communication is out there so that citizens in these countries, expectations can be better managed. The other thing i just wanted to add about training which was discussed earlier which i think is extremely important, we think a lot about we work with community Health Workers. Of course, as a big challenge so few doctors in liberia. Take one example, 4 million people, 425 doctors, it is a big challenge, i think, to provide not just more training for medical personnel but some of this preservice training at the technical level is desperately needed and can be done pretty quickly. And i think that there are institutions here in the United States that can provide the kind of support thats needed to ramp up preservice training as well as supporting inservice training by institutions in the effected countries. Both of you or maybe all of you made reference to we need to take it to the community and have the community be involved. I wanted to know if maybe you could be specific about that. I certainly understand the Community Piece in terms of Contact Tracing and identifying the people infected. If there are not etcs then what . You are taking it to the community. You identified a person then what . You following me in. I can try to answer that m. The role is critical. Informing the authorities is also very important and forming burials teams and also very important is to educate the community about what to do if they see someone presenting with symptoms, how to isolate that person and make sure that they have at least gloves or things to protect themselves, but to make sure that they isolate and inform the different authorities, be it Health Workers. This is critical because what is happening is that there are people that have ebola that are staying in the same room with five other people. And that cannot happen. So the isolation is critical and this is where the education at the Community Level becomes very important because that is the only way we can contain it. Should there be smaller etcs . I understand isolating the person. If you isolate the person without treatment the person is just going to sit there and die. Then you said that the etcs are maybe in inappropriate places or maybe not needed. In the places they are not needed what happens to the person . That is a very valid question. There are Community Care centers being established which are like mini ebola treatment centers. The idea is those patients will be taken there, isolated and cared for until the test is done. I would just like to add one thing, as well, that you mentioned initially about the u. S. Government and the etcs. In our discussion with the u. S. Military as well as about the need for ebola treatment units and where they should be, we have seen that they have been extremely flexible. If we tell them there is no need to staff this one, lets move it there they have been extremely responsive to recommendations. You might want to respond but i wanted to ask you a series of questions around cultural practices but go ahead and respond. I would like to catch up a little bit. I would like to reiterate that flexibility on both the designation of where the etus are and in general that flexibility that in particularly the u. S. Aid, dart and general response has been really fantastic. It allowed us to be sure we are able to position resources as quickly as responsible. On the issue of the community, we spent a lot of time going over what the best way is to interact with the community. Thats a lot of these dialogue sessions that i have been talking about. Its really focused on making sure that we are not top down, we are not distributing leaflets and just doing radio shows but really making sure it is a conversation with the community about what ebola is and what it is not. And having them come up with their own solutions that we work through. Thats been able to allow us to make sure that the communities when they have a suspected case, that they put the Community Member in a separate location that the communities are doing a lot of their own monitoring and making sure they are making that phone call because really that phone call is the most important thing, making sure that that victim is or suspected victim is isolated and then making that phone call is really huge. In the long term before we started, before this virus hit, we were doing these water and sanitation activities with the government. And we were successful in working with over 350 communities on proper sanitation and proper hygiene. And that effort was incredibly successful. In all 350 communities which are some of the hardest hit counties, none of them have been effected by ebola. It really goes to show that if you make that long term investment, if you prepare the communities before it hits they have a huge it has a huge impact and prevents that from happening. I only wish we were able to hit all the communities in liberia before we were able before the virus hit. I wanted to ask if you would expand a little more. I understand it was something you said 70 of the transmissions were due to contact with people who had passed away. How long is a body contagious . My colleague was asking about the role of the faith community. I was wondering if faith leaders since the traditions are a part of peoples faith, if they were taking the lead in getting people to deviate and divert from traditional practices . You said they have come up with ways to safely say good bye. I thought you said they did that with all of the protective gear on. I was wondering if that is what you meant. I want to know what happened to you. Did they hold you in the airport . How did you sneak back in . Thank you. That is a series of great questions. I will answer the last one first. I was met at the airport. There was an x on my piece of paper. Seriously . That pulled me over to the side. So i conducted an interview with the cdc. What airport . Dulles. And they were really great and they treme lined the process as quickly as possible, asked me about my potential level of exposure which was very limited and took my temperature. Since then i have been in daily contact with the Dc Department of health. I live in dc. I am in contact with them every day. We discuss i selfmonitor, take my temperature twice a day and monitor any symptoms of which i have none. I would like to reiterate that they, the cdc and Dc Department of health are really focused on the partnership aspect of it and the fact that it is a that we are working together on this and that they understand why im there and why i went and that its not an antagonistic relationship. We Work Together. That allows me and everybody coming back to feel free and happy to discuss our health with the department of health and with the cdc. That really opens up that dialogue and makes it that much more impactful in terms of a monitoring tool. On your question about safely saying good bye, we dont allow the Community Members to don ppes as a prevention tool because it requires a lot of training. We do, actually, allow them to don some ppes to make them feel better because the burial teams are wearing full ppes. Its fairly intimidating. So if it makes them feel better to wear some ppes we alloy them to do that. We dont allow them near the body. The burial teams. The burial teams are wearing full ppes. The Community Members are allowed to attend the burial. If they want to they can wear limited ppes but really they are not allowed close. But that allows them to understand whats happening, where the burial is, to watch the process which is incredibly important to make sure that they are engaged and make sure the next time there is a victim, that they make that phone call. So that interaction really takes the bulk of the time, the way the burial teams interact with the communities and make sure the burial is done in a respectful and dignified way is a huge part of their time. There were a couple other small the other small item i wanted to respond to was on the hazard pay which is a really important aspect of the response actually because these are really brave people doing really important work, but they do want to make sure they are being compensated. That is a part of our efforts is to make sure that that pay is happening on time and really working to ensure that. Its a small amount of money by our standards but its incredibly important to make sure they understand they are valued and the work that they are doing is important. Just quickly to the two last questions which were how long is a body and then if somebody could address the abandoned children, where are they . Whats happening . Sure. On the length of time that a body is contagious, we dont exactly know. The cdc and w. H. O. Are looking at this. So thats why we are just focused on its a long time. Its on the order of weeks. And so thats why we make sure that the body is covered in chlorine, placed in a body bag, covered in chlorine again. Its alternating soil and chlorine. It is very low risk to the water tables but we also make sure that the burials happen above the water table to make sure. Thank you. Just a few follow up questions. In our september 17 hearing dr. Kent brantly spoke at length about a number of things having lived through it and having surviv survived. One point that he made was that the 120bed Isolation Unit at his hospital was turning away as many as 30 infectious individuals each day. Im wondering with etus, has that changed . Is the capacity growing . The military is in the process and creating that capacity. He made a strong point about those who will stay in their home and will be cared for by loved ones, husbands, wives, childr children. He said we will be condemning countless numbers of mothers, fathers, sons to death because they chose not to let their loved ones die alone. Im wondering since isolation is one of the keys to breaking the transmission chain in many of the infected people will stay at home, is the outreach to the individual caregivers as robust as it should be . Let me also ask at our hearing, the second hearing, dr. Fouchy used the word exponential time and time again during his testimony. We had a group of top people including the head of usaid at a hearing last week of the full committee. That word wasnt uttered once. And i asked them about are we seeing a turn . Cdc had said that if the rate of increase continues at the pace in september there could be as many as 1. 4 million cases by late january. Where are we in your view in terms of the estimations of how large this epidemic may grow . Let me also ask you one of the ten points that you have suggested to us is the importance of a capable Ambulance Network. Since so many people cant get to an etu or Health Facility where is liberia . I think you know more about liberia in terms of capacity and also, if i could, all of you might want to touch on this. Dr. Brantly may have been helped by z matt. There are other drugs still in the pipeline, vaccines and curative potential drugs. I was amazed and positively shocked when you said that the rate of fatality at your ebola unit in liberia is approximately 26 . That is far lower than the average fatality rate in the three effected countries. What is being done there to achieve those remarkable results in terms of mitigating fatality . So if you could speak to those issues. Thank you, mr. Chairman. I would like to talk with the last question about the low fatality rate of the ebola treatment unit. We are not using any miraculous drug or any testing drug there. What we are doing is working with the community to make sure that patients are referred to the ebola treatment unit as soon as possible. That has been one of the major factors in lowering mortality rates. As you have seen here in the u. S. Those that were caught early on and sent to the hospital survived and those that were late did not make it, unfortunately. Our treatment is basic, balance of electrolytes, making sure people are healthy enough for them to fight the virus on their own. One very critical component of success is the u. S. Navy lab set up next to the treatment unit. It used to take us five to seven days before we get the test result for suspect case. Now it takes us five to seven hours. So basically people are coming in, we are testing them. If they are positive they are put in the treatment ward. If they are negative they are sent home. That cuts down on the potential exposure, as well. This has been critical for us, as well. That would be if people manifesting some symptom . Correct. This actually ties into your question about the ebola treatment unit capacity. The Lab Facilities are playing a critical role. The ebola treatment units accept suspect cases. They were turning a lot of cases away because they did not have the capacity to test those patients. So with the additional number of labs that are being established in liberia that is helping out a lot. It is no longer the case, hardly any unit is pushing patients away. The situation in liberia and this is something that was mentioned here, its looking better than it looked a couple of months ago. The numbers are lower. The new cases are lower than it was before. It is much better than what we estimated two months ago. If we continue on the right track and we have to continue with the same momentum, we cannot slow down, we will get it under control. And the same applied for the other countries. We see the numbers increasing at a much faster rate than liberia. We need to Work Together, community, treatment, the government, the host government as well as donors and other governments in the military to contain it. Liberia could be a really good success story. We shouldnt start celebrating yet. It is still not under control. It is looking positive. If we continue we will get it under control but it is too early to start celebrating. On the individual protection, this is something that is definitely important. This goes back to educating the family but also giving them basic protection, gloves, masks. At the same time we do not want to give a false sense of protection. We do not want them to think that just because they have gloves and a mask they are okay to be near our patient. We need to be sure education takes place properly and they are very well aware of the risks even with protection. That is very critical. Ambulance network is very important in all countries. We turn pickup trucks into ambulances. We turn anything we can get our hands on into ambulances. We are looking at different types that can take patients from far away counties into our ebola treatment units. It is better and cheaper than setting up in some of those counties. There is a need to increase that capacity and a need to train staff working in ambulances. That is a very risky job when you are in an ambulance. It seems there is a move now to actually get ambulances in there. A lot of being donated. Also, we look at alternative way of transportation. I wanted to add to the point about getting to that Inflection Point on the ebola crisis. I think this combination of getting both hardware right and software right are hugely important. These etcs and getting many out into communities, getting Community Care centers to improve access. On the other side is what i see happening on the Technology Front and very quickly both so that we are in a position to do a better job of testing, tracking and treating the virus. On the testing side a number of rapid diagnostic tests are coming available, being tested out on the ground in the next couple of months. A lot of work is being done with u. S. Based Technology Companies working with people on the ground to develop tools to automate Contact Tracing, to bring the power of technology into this, to be able to do a much better job of tracking and doing surveillance. I think that, too, is coming in addition to what is happening on the treatment side. Like my colleagues i am very hopeful but we cannot be complacent or declare victory. There is still work to be done on all of these fronts. And i would like to go through a few of your questions because i think they are really interesting and show the changes especially in reference to mr. Bradleys testimony. I believe there was a sort of vicious cycle going on at the early stages where there was not enough testing so there were not enough beds and so ebola patients were being turned rai from the etus both because of the lack of testing and just the simple lack of beds and Health Care Workers. And so then the victims are turned away. They go back into their community and they infect others and they pass away and the burial teams at that point were overstretched. And so that both of those issues being addressed, the etus having the available beds and then the burial teams being able to collect the bodies really had a Significant Impact on lowering the rate of transmission and then the cycle continued to bring down the number of ebola victims going into the etus. That has been one of the flips that happened since dr. Bradley testified which is wonderful to hear. And i would like to reiterate that while the communities do need protective equipment and do need education about how to handle the sick, that risk of the false sense of prevention is something that we are very careful about that just because they have a mask and gloves doesnt mean they are able to safely handle victims. The etus are not at all wasteful in terms of how they are put together. They are very straightforwardly put together. Most are temporary structures. And they are the fastest lightest high quality treatment that you can get. And so as you move down from that you do incur some risks in terms of the Community Care centers that have to be looked at carefully to make sure that the quality of care is very, very high. In terms of the projections that you mentioned, i think a lot of the projections were if nothing happened, if we didnt do anything. Now that we are doing something and i think we are doing a lot, that is bringing down a lot of the projections i think we will look forward to future projections. On the Ambulance Network it is something that we are involved in and responding to and we got into a lot of the other activities that we are doing such as Contact Tracing and ambulance work and the Community Engagement work in the southeast because we are locating our teams at the county health team. So we have a significant relationship with every county health team and we make sure that the burial teams are run out of that county health team. So when they say our ambulance broke down, can you help us out, we are able to immediately respond and very, very quickly to make sure they have another ambulance or that it gets repaired. Thats allowed us to engage about ten ambulances that are being run out of different county health teams as they have requested it from us. I think that aspect of it to make sure that we are hearing directly from the county health teams in some of the remote counties, some take two days to get to on a good, dry day. And we are able to hear from them immediately and allows us to respond very quickly. And i think on the orphan issue it is a pretty significant issue that is being looked at by a lot of different ngos. The entire question of how you respond to the families that are infected, orphans, widowers is significant. It is a lasting effect that is going to have on this virus. Who is really in charge . Is it the ministry of health . We know that w. H. O. Came under some withering criticism in mid october from a report about how they had missed it and had inadequate staffing. Im wondering who is truly in charge . What role do they play . We know cdc is playing a very significant advisory and leadership role. Secondly, on the issue of training Health Care Workers, community Health Care Workers, could you give a sense what their ages are. Are they older, more experienced . People who have come back into the system . Are they young people who are stepping up to the plate . What does it look like . Does the usaid provide salary support . We know in catastrophic situations very often that subsidy can be provided. I remember being in sri lanka after the tsunami issue and we were paying salaries to individuals to do work, to do cleanup, not only was motivating, it stopped them from they were actively doing the cleanup of their own homes and communities but there was that significant subsidy to help them get money in their pocket, to get their businesses going locally. Im wondering if usaid or any other entity is providing salary support. The liberia government is in charge and they should be in charge. At the end of the day its their country and we are just guests there. We only work through them and with them. I dont think any of those countries were prepared for such an outbreak, especially countries like liberia that have suffered from a long civil war and trying to recover from that. In addition to other systemic issues there. The world health organization, cdc, ngos work to support the liberia mintry of health and social work. They have a body that coordin e coordinates the Ebola Response. One thing going back to your question about what needs to be done, we cannot afford to go back to where we were before the Ebola Outbreak. We need to build the systems better than they were before because we saw they werent that effective one way to do it is to support the government, the ministers of health, build their systems, train their staff, give them all the support that they need to move things forward. And they are doing what they can given the limited capacity and capabilities that they have. Amir is playing a more robust role than a while ago. There still needs to be clarification in terms of who is responsible for what and who is coordinating what. That is very important. I think as discussions take place on the ground that should be clarified. I will answer briefly about the Health Workers that im sure my colleagues will give you a homo detailed answer. Most of them, the majority of them are younger. They are college kids or people who went to school or work in the market. They are younger. Those are the ones that have been working with us mostly. In terms of usaid support they have been very generous with us and others working on the ground. Whatever we ask them for including salary for staff working in the community there hasnt been hesitation. I dont know what has been going on in terms of support for the libeeria government. They have been extremely generous and effective and pragmatic in their approach. I would like to reiterate that the Liberia Ministry of health is leading the effort. And the assistant minister of health has been leading the Incident Management System has been a really great coordinator of the effort. Those meetings which happen about three times a week, make sure everyone is on the same page. And thats allowed us to thats been our approach to make sure we are leveraging the resources they have and supplementing what they have to make sure we are successful and that they are successful. Doing so has allowed us to move very, very quickly and be very responsive as i mentioned before. That said, the other actors especially u. S. A has been responsive and excellent at coordinator their efforts. The dart has been really incredible partners for us to make sure that as the situation changes on the gruound we are able to move very, very quickly. On the community Health Workers the system in liberia that existed before was for all the community Health Workers to actually be Community Health volunteers so they were unpaid volunteers that received supplemental support in some way or another. I believe that depending on what the activity is they are getting some limited level of support certainly from our side when we do activities they do get incentive payments. If they are able to achieve certain deliverables then we get them some payments occasionally. I dont know if they are receiving large scale salary from ministry of health at this point during the emergency. The only thing i would add is the great frustration that exists within liberia. The crisis and the gap between the people perceive is actually happening on the ground. These are big numbers that the public hears about. The government, the president in particular has been very forceful in demanding that the government be very focused on this agenda. As you may know she just had a shakeup in the cabinet. She replaced the minister of health to be sure she has the leadership in that ministry to see this thing through. There is no sense of complacency, quite the opposite. They are leading and working very hard to ensure that there was a joined up government approach on their side just as United States government is taking a joined up government approach. Just to conclude, i mentioned in the outset that we just introduced hr 5710, the ebola Emergency Response act. Many of you provided insights as to what ought to be in there. I ask you to take a look at it to see if it covers all the bases, if you will. And if you can see your way clear after you look at it and perhaps support it. I do think we are talking about a sustainable problem that needs a sustainable response. And the good work that our House Appropriations and Senate Appropriations committees have done particularly when the d. O. D. Asked for a reprogramming request that was huge was done without the slightest bit of hesitation. We need to have the authorizers make sure we leave no stone unturned in mitigating this crisis. Please take a look at this legislation. Anything you would like to say before we conclude . I would just like to thank you for your leadership and the leadership of the u. S. Government. We are very proud of what has been achieved so far and the continuous focus on resolving this issue. Again, thank you for having us here today. I would like to reiterate the efforts that you see on the ground in liberia in particular are really incredible and a large volume of that is due to the leadership of the u. S. Government and the leadership of this subcommittee to make sure it happens. It is truly inspiring seeing the response happen and seeing the impact that we are all having. Thank you. And i want to thank you for your continued leadership long after the headlines fade and they will to be sure that everybody is focused on how to rebuild in liberia and get these countries back on track. Thank you for your leadership. Thank you so very much. Again, i want to thank you for your expertise, your tremendous leadership, the three of you. It next, a house hearing looks at the problem with unaccompanied migrant children. Your calls and comments at 7 00 on washington journal. The week on cspan it, we will have interviews with retiring at members of congress. Tom p we will talk with etri. Mccarthy has served nine terms of the house. She called on younger members of the party to move up the caucus latter. Currently does need to know when its time to move on. We have a lot of talented younger members. Its not just mrs. Pelosi feared i think shes been a great leader. She is good at raising money. That is not one of my fortes. I was never good at that. They have to start training younger people and bring younger people into the caucus. They will become the future leaders. Of the things that i believe with all my heart and soul, you have to know when to leave. Nancy does not feel that this is the time to leave. Stayin fort she might this coming year and turn the reins over to someone else. When i look around, is anybody ready to replace her . Its a hard job. I give her a lot of credit for what she has been able to do. Leaders start the looking at who is going to fill my spot. We are all replaceable. There might be some bumps in the road, i do believe that its time for younger people to take our spots. I see nothing wrong with that, thats progression up. Thats a normal progression. Interviews retiring congress members. Monday at 8 00 on cspan. On tuesday, the House Foreign Affairs subcommittee held a hearing on unaccompanied children at the southern u. S. Border. This is about an hour and a half. I yield myself as much time as i may consume to present my opening statement. Good afternoon and welcome to this, the second hearing that ive convened on the humanitarian crisis that resulted from thousands of unaccompanied minors showing up at our southern border. Ive been engaged on this issue from the beginning, not only as the chairman of this subcommittee, but also as a member of the Speakers Working Group on the unaccompanied alien child crisis. I traveled with several of my colleagues to the region and saw first hand the insecurity and