national regulation of insurance. a lot of countries do. we don't. reregulate insurance at the state level. this is insurance. it's going to be different in different places. what difference does the history of the state relationship between the state and federal government make? this whole thing is full of surprises. joslyn talked about the surprise in maryland. everything pointed to this being a huge success. it was a terrible failure in terms of the initial roll-out. why was that? maybe we don't know what points to a huge success. to answer all these questions, it's valuable to have people on the ground with serious knowledge of how their state operates. and what the ins and outs and peculiarities are.

people who have worked this the state know what's going on. then the challenge is to turn the knowledge into something more than interesting anecdotes of history of a particular state. but to figure out how we can learn to make the whole thing better. >> thank you very much, alice. you made a lot of key points about why we're here. i'm sure for people watching this and listening to it, it's a lot to take in. i have been over my career working with many people in this room and in the country on doing studies like this of new national policies. i have never seen a challenge as big as this one. i'm not a young guy. so we have, as alice said, a lot

to learn. it's hard to get your hands around it. i hope the program are has been helpful. the important thing is what tom said and what alice said. this is not going to happen next week or next month. this is a change of such magnitude that it is important to be able over a long period of time to look hard at what this law does in ways that go beyond what we can know at this time. some predictions are that it will take 10, 15 years, even longer before health care in america is affordably changed. its delivery has changed. the technology has changed. the treatment systems are changed. this law, it took us a long time. the last piece of the social

safety net in america took longer than in any other industrial country in the world. we now have a law that despite efforts to repeal it, a lot is happening. it is rolling out. it will roll out for years to come. in which people like the people you heard from today who are in communities, know the people there, know the politics there, know the history there. so what we hope is that this network, this implementation research network can add value, can contribute and produce what you might call the missing ingredient. over time because our field researchers are for real. i hope you have seen this. they are out there. they know the same. they are watching closely. they have written preliminary

papers. where are we now in the work. we have worked so far at the decisions made. the big challenge and the main purpose for us going forward is cross-cutting multi state studies. to use this network, to have the field researchers contribute to major analysis papers that the network will produce on things like what's the i.t. system. why does it work in places the technology not others. what are the economic effects of the new networks that insurance companies and health maintenance organizations are bargaining to set up and get customers. how competitive is this and does competition help people to make health care more affordable. to the keep people out of

hospitals. to keep people out of emergency rooms. these are really big things in everybody's life, in government and for the economy and for government finance. we are going to study outreach. you can't just do outreach to navigate and help people get signed up. you have to live with this. their address has changed. the family changed. the incomes change. can the new systems which didn't work in maryland and are working in a lot of places, bigger than amazon, bigger than getting an airplane reservation. is it going to bring the technology to the fore in health care in a way that makes health care more affordable, more accessible and makes systems work together better to do things that help people stay healthy and not just get treem

when they are sick. so this is, in my lengthening lifetime, as much fun as i have had doing research with the kinds of people you have heard from today. we have 61 people in 35 states working on this. we are adding some. indiana is going to join us and i would like other states. i would like to network to bring people in. indiana, as mike mentioned -- 'q)/kymñ mentioned it. very interesting. using this health savings accounts approach where you incent people who have money to make wise decisions because they have a financial stake. this is more than i could allude to in my time which is possibly

inspired? you say it's expired. >> thank you very much. let me remind everybody as you start thinking about what are the likely developments in the future that might affect this region. we are going to have an election which could mean changes in the senate. of course we are going to have are an election -- presidential election in 2016. i can announce here today the next president of the united states will not be barack obama. that's important in the sense that whoever is the next president doesn't have quite the same pride of authorship of the aca as the current administration. when you think about what happens it is important to realize there could be a different environment in washington with regard to the issues or the patterns that have been mentioned this afternoon. i want to make three points in

that regard as to how things might develop in this region and maybe further in the iw=÷futur. the first and chris and others maetd reference to this. you have seen a number of southern states that opposed the expansion of medicaid but have been very are interested in some private option that would have the functional equivalent of covering the same people. already states such uh as florida, south carolina, tennessee and texas have all expressed a great deal of interest in finding some form of private coverage through the exchanges using medicaid dollars. it's also been: mentioned that indiana, of course, as you mentioned, going down a similar road. so i think you could well see in the next few years a move towards making that more possible going back to those states and saying, well, what do you need to do to go down in this direction.

if you are not prepared to expand medicaid what can we do in terms of the law itself or administrative changes. it's possible, i think, if you look at a republican victory in the senate now this year and maybe in the presidential election. for this to move to a restructuring of medicaid itself. at least in part to a more cash-based private coverage system in the future. i think that's one thing to think about. it affects what you have heard. secondly as it's been said, again, the federal exchanges we have seen in many of the southern states are not a penalty. a slap across the wrist. but are really perhaps are seen as an alternative way of managing an exchange and that might develop further in the future of more customized federal exchanges at the state level, addressing some of the management issues and others that the states have raised.

it could be a resetting of what it means to have a federal exchange in those states such as you could see very active state engagement in the future. the third point i will make is that in 2017 when the next president takes office, another major provision of the affordable care act goes into place. the so-called white and brown provision which allows very wide changes, significant changes in the ability of states to propose a different approach to reaching the goals and objectives of the affordable care act. that provision would allow states that do get the agreement of federal government. you could see a raft of oh southern states and other states coming to the federal government

and saying we actually want to achieve the objectives you laid down in a different approach. different way. that reflects our situation, our particular circumstances, our politics and our philosophy. so come the end of 2017-18, you could see some very wide differences in the southern states and other regions that reflect what you have heard today in terms of why the states are passive or aggressive obstructionists to the current arrangement such that you could see the end result of getting people insured at a reasonable cost to those individuals and the federal government. kind of playing itself out in ways that reflect what youave heard today. >> okay. i don't think i could have picked a more intimidating group of people. i will keep my remarks brief. when i think about the future of

the affordable care act i have been reporting on it for four, five years now. it's almost two trends in tension with one another. one is the idea of experimentation and states. stuart was talking about really testing the limits of what the affordable care act looks like. when i look at what states have been doing with medicaid expansion they are seeing how far they can push the obama administration, republican states have a very important bargaining chip. they get to decide whether or not to expand medicaid. i think we have seen with arkansas and with indiana that the obama administration is willing to bend pretty far to get states into the fold. so i think we'll see more diversity as states learn from one another what the administration is okay with, if there is a new administration with different political leanings, whether it will approve different waivers. once we get to 2017, i think you will see lots of changes. i was in vermont. they planned to have a single

payer system. they want a single payer system in 2017. i think you will see a lot of variety on how states are handling the affordable care act. the trend i see in contrast to that is a little bit of a calming down controversy over the affordable care act. i feel i already see it in my job. a year ago it was easier. i worked at a newspaper then. it was easier to get a front page story on obamacare. now it's just not the political fight it used to be. it's still controversial. lots of fights. but my experience, i had one story that informs my experience on this is i spent time in the washington post archives. looking at the roll-out of medicare and medicaid in 1965. one of the things that struck he me is how skeptical seniors were of medicare. they profile add guy knocking door to door trying to sign up

for medicare getting the door slammed in his face, yelling, i don't want what you are selling. people were skeptical. when you go forward thousand you can't imagine seniors saying no to medicare. if we take the long view, it makes me think there will be convergence and variation in what the act looks like. >> i'm going to open it up to q&a for other people. the maryland experience is fascinating to me. i don't know whether maryland belongs in the southern state group. it is a good report are. we wanted to get out anyway. thank you. but it is interesting. you know, that maryland really does, just as joslyn pointed out, have all the ingredients of expecting a good implementation outcome. you know, they had the

leadership, resources, capacity, everything else going for them. but it didn't work. i'm sure they will get it to work at some point, at some level. i was wondering whether it might suggest something about this implementation task that's different from some of the implementation tasks of some previous programs we have dealt with. this program is trying to change the behavior of corporations, of individuals, in very complicated ways, often through indirect mechanisms through these exchanges through markets, et cetera. it's interesting that both oregon -- they did a lot of planning, support, and a lot of up front work. very comprehensive. it didn't work then either. kentucky though, as julia has pointed out, is really doing a lot of rapid cycle testing.

i'm sure they did a lot of planning, too. but i wonder whether in some ways given the fact that people don't know how these entities, individuals, corporations, et cetera, are going to react until they go out and try things whether this new public and cause for public administration is a little bit more experimental, incremental, monitoring what's happened in the short run and nation's capitals less adjustments. this is really a no end implementation situation. so that's a long comment from me. anybody can disagree or say that i'm smart. go ahead. >> i'm not sure what your question is, tom. >> different kind of

implementation problem. >> i think this is a very large implementation problem. but just the question of getting exchanges up and running, oregon and maryland are good examples of where there were high expectations and they failed. so was the federal government. i think the lesson is rather implementing large systems change is very, very hard. it's not peculiar to government. there have been many failurers in the private sector. unless you are prepared for failure and maybe that was maryland's problem that it wasn't. unless you are prepared for failurer and try again and try again and test again and so forth, you are very likely to have a disaster. whether you are a big corporation or a stater or oh whatever.

>> this is federalism in the internet age. this is immensely complicated. the systems are supposed to do. i was impressed with what julia did about kentucky with the point she made about how they made it user friendly. they didn't do the kind of things that some federal exchanges and some state exchanges did. but this is a way to illustrate where we are going and to keep making this point. michael spare, the director of the public health school at columbia university and larry brown, his colleague who used to be the director, are already in the field. they have been to maryland . they have been to massachusetts which is in the network. we are on the ground looking at, well, why did it work here? what did they learn from why it worked or didn't work there and maybe what julia learned and

what joslyn learned the hard way. the point is the kind of things we are going to need to know, the way stuart said it, are things that need to be known on the ground. sitting in washington in a think tank. you can't get the richness of what i hope is demonstrated today is what we can add. we are not trying to say other studies aren't important. we think the studies add. that's what we are already doing. we'll talk about it in october. >> richard is absolutely right on that. i think as you hinted, we really need to look at this as a process of experimentation. let's are remember that the redesigning the health care system in this country, that's for the entire economy. if the health care system was a separate economy it would be one of the sixths largest in the

world. the idea that we could get it right in one fell swoop just defies the capacity of the human mind. and also when you look at the highly complex changes, one of the you look at the highly complex changes, often where you think it's going to work, it backfires. often places where you think things are going to work give you clues. that is why what the process is to try things and to go back and say what have we learn and how can we then do the next phase. i think there is an opportunity here in terms of what we learned from the way the southern region is looking at the legislation and the ideas that are out there in terms of private options and how to look at the federal exchange differently. we have within this the capacity, the platform if you like, to tryout quite different

ways of reaching a common objective. of what the affordable care act sought to do. it is the perfect example and indeed it's the only way it can succeed in the future. >> i think i will leave it to the audience and ask them tougher questions. >> do we have any questions in the audience? yes?]jqqqqp over here. >> i'm clair and i'm an adhave voicate for people in long-term care in the state of maryland and i have been working in this field and interactioning with the department of health and mental hygiene. i have a question and a comment. my comment is that the district of columbia and maryland share a common border. a large proportion of the

employees of the federal government, upper level employees live in montgomery county, maryland. this had to have an effect on the people available from the state of maryland to work on a very complex it project. you can't have them doing both. they were trying to do it at the same time concurrently. i don't think that maryland was getting the resource s ths that needed. the question just went out of my head. i'm old. do you think that's a possible cause of this and the other piece of the comment they would offer to you is that upper level people are really not happy with what's going on with the program. they probably won't tell you, but they are telling me.

they are being pushed to do and nobody know what is their job is. that's when government begins to come unravelled in my opinion. do you think it's possible? >> and the appropriations services will come to order. in march of this year, public health officials reported an outbreak in the west african country of guinea. unlike past outbreaks that have been efficiently and effectively stopped, this spread in ways that are potentially catastrophic to the world. due to the gravity of the situation and the danger it poses to the region and to our country. i have taken the step of calling this joint hearing of both the authorizing committee and i appropriations subcommittee which i also chair. we have coming to to learn what we can to work together

effectively to stop this deadly plague. the extent is tragic and grows more serious with each passing day. the death toll is far greater than other outbreaks combined. the world health organization estimates that 20,000 people may be affected by december. we know the mortality rate is close to 50%. we have other estimates that are higher. as this virus spreads, it can start to mutate and become more deadly or have other means of transmission other than through bodily fluids. ebola is one example and others include avian flu and the mideast respiratory syndrome or

mrs. i worked hard to strengthen in all of us both of these things. to strengthen investments preparedness and response capabilities at home. last year the bipartisan pandemic and all hazards prepared were signed into law. it came to this committee and the senator here who led a lot of effort on that on his side, senator alexander and senator casey all work very hard on this bill. it advances national health security by strengthening the response to capabilities and ensuring that the biomedical advance research has the authority it needs to support the development of critical treatments and vaccines. the appropriations committee, they worked to secure additional

funding at cdc to set up a network of disease detection centers across the globe. we now have ten including three in africa. we need in every country. it is centers that are deploying other staff to help in epidemic areas and those with high risk and we will have more discussion on that when we get to the witnesses with cdc. i hope and expect that and the senate will vote in favor of the millions of dollars that we work to secure in the continuing resolution to do just that. this is a crucial investment that enables 100 scientists to continue working in west africa and keep the z map and vaccine candidates moving quickly. as important as this is, it's a first step. i hate to say this, but ebola will not be conquered in the weeks of the continuing

resolution. the fight must continue to be an urgent priority. the subcommittee passed a bill that includes a $40 million health security initiative. we must maintain our commitment to the staff in the field. as this crisis illustrates, we must stop chasing diseases after the fact. start building public health systems around the globe capable of detecting and stopping diseases before they cross borders. last year with the help of senator moran, we were able to start a new initiative called the national public health institute to do just that. this program needs to be

expanded in light of this epidem epidemic. with these big things ahead of us, the hearing is critical. we have a group here to educate and advise us. i will turn to senator al zandor and moran and before that i request the record be kept open to commit statements and questions. >> thanks, mr. chairman and the witnesses for coming here today. we must take the dangerous threat of ebola as seriously as we take isis. let me say that again. we must take the dangerous threat of the ebola epidemic as sourcely as isis. i have a reputation of the senator and i don't believe that's an overstatement. the spread of this disease deserves a more urgent response from our country and other countries around the world. this is one of the most explosive deadly epidemics in modern time if we do not do what

we know thou do to control it. it will require a huge and immediate response. there is no known cure. there is no vaccine. half of those who get sick die. according to the center for disease control could infect 20 or more others including care giver, friends and family. samantha powers, the un ambassador said she is trying to get other countries to view this with the same urgency that we do. this is an instance that we should be running towards the burning flame with our suits on. ebola is killing people at alarming rates and picking up speed. it's hard to say what the number of cases is. there is an official number less than 5,000 ebola cases in guinea

and sierra leon. the worry is that one half of the cases were reported in the last three weeks. you don't have to know about math to know whatever the number if it doubles every three weeks, very soon we have an out of control epidemic. we can see it begins to infect others in the country. we said earlier and we will learn more about what we have to do and hear from a doctor who was here to talk about it. with global travel, you are one airplane ride away from a person

exposed and getting on the plane and becoming sick once they arrive. the mathematics could begin to develop in to country. the doctor who will testify here is an ebola patient working for samaritans. he would go on mission trips to help people who need help. i will support the administration's request for the $30 million they talked about for the $58 million for the advanced research and development for treatments. that should pass this week. that's a request to address $500 million of reprogramming.

they have to be involved if we want to deal with the problem. there is no way for the doctors and the nurses and the health care workers to deal with it. they are recognizing the severity and they are taking the lead and what we must do to control it. we must take the threat as seriously as we take isis.oóe; >> we appreciate your senator from tennessee to make certain that this takes place. park are it's discouraging to see what's taking place in africa. they have the ability to make a

difference in theó[ out come o what is occurring. sometimes we face problems and while i realize we have not discovered all the treatments, a lot can be done that will save people's lives and prevent the spread of e cola to other places around the globe. the encouraging thing is this is an example over congress can come and make a difference. something we ought to take satisfaction in to accomplish that. i appreciate the leadership here today. we need to declare a war. it's real and yet it's something that with that rule and campaign, we have the title change people's lives who are affected. diminish the number of lives affected in the future. this requires that global response in the united states needs to provide the necessary leadership to make certain that the war is won.

thank you very much. >> thank you, senator. we have a distinguished panel. i will introduce them with the statements. first of all, the director of the national center for emerging and infectious diseases at the centers for disease control and prevention. the doctor is responsible for the efforts and responding to a brought range of e merginging a and established threats. previously dr. bell served in leadership roles including during the response to the 2001 anthrax attacks and the influenza pandemic. a position that was held and

provided outstanding leadership. nih oversees a wide portfolio of basic and applied research. applying this knowledge to prevention and treatment strategies. the doctor serves as one of the key advisers to the white house and department of health and human services on initiatives to bolster preparedness against emerging infectious disease threats. that's the director of the advanced research authority. the office of the assisted secretary preparedness response with health and human services. that's innovative counts and drugs and diagnostic tools to protect against man made and naturally occurring health

threats. she played a key role against the research and development with the ebola treatments. thank you very much for being here. they will be made a part of the record in its entirety. you can give us a summary in five minutes or so. we have a lot of questions and you can sum up, i would appreciate it. >> i will. good afternoon. and moran and members of the committees. i am doctor beth bell, director for infectious diseases with the cdc. i appreciate the opportunity to discuss this and illustrate in a tragic way the need to strengthen global security. the doctor has sincere regret

for not being here. enabling us to build and sustain the capacity to respond to health threats like ebola. the epidemic is ferocious and spreading. the current outbreak is the first that has been recognized in west africa and the biggest and most complex epibemic ever documented. as of last week, the epidemic surpassed 4400 reported cases including nearly 2300 documented deaths, though we believe there is considerable under reporting and expect that the actual numbers would be two to three times higher. we have now seen cases imported into nigeria and senegal into the effected areas and others are at risk of exportations as the outbreak grows.

there is a need to help countries to better prepare for cases and strengthen the capabilities throughout africa. that includes the collapse of the systems, for example, an inability to increase the isolation of this. these are intensifying and not only signal a growing crisis, but have direct impacts on the ability to respond to the epidemic itself. there is a window of opportunity to control the spread of this disease, but that is closing. if we do not act now to stop ebola, we could be dealing with it for years to come affecting larger areas of africa.

the worst outbreak in history, but we have tools to stop it and response is urgently needed. the best way is to 1207 the outbreak in africa, but it is possible that an infected traveler might arrive in the u.s. should this occur, we are confident that the health care systems can prevent an outbreak here and recognize they put us in this strong position. many remain, particularly since there is no therapy or vaccine. we need to strengthen the response that requires close collaboration and insistence from partners and a strong and coordinated united states

government response. hundreds of additional staff are supporting this. they'll work with the partners across the government and elsewhere to focus on five pillars of response. and helping to promote burial practices and strengthening other elements of the health care systems and improving communication about the disease and thou can be contained. controlling the outbreak will be costly and requiring sustained effort by the u.s. and world community. the administration proposed that the congress provide 30 million dollars for the response during the continuing resolution period and for efforts to develop

counter measures that we will describe. the capabilities of the military will be engaged in this response. we are working across the united states government to access the full range of resources that can be used to change the trajectory of this epidemic. working with the partners, we have been able to stop every previous ebola outbreak and we are determined to stop this one. it will take meticulous work and we cannot take shortcuts. as cdc director noted, fighting ebola is like fighting a forest fire. one case undetected and the epidemic could reignite. it will take time and continued effort.

there is worldwide agreement and the ebola epidemic said there is much more to be done. any vulnerability can have impact if not stopped at the source. as you are aware, the fy 15 budget including an increase of $45 million to strengthen capacities around the globe. if these people and labs are battling ebola, they will not be today. stopping outbreaks where they occur is the most effective and least expensive way to protect people's health. many of you traveled to africa as have i. we am away with the challenges many people and challenges face. these have never been more evident. each day of the past several

months i have been in contact with the teams in the field. they e enforce the stories and faces on a tragedy. these stories enforce the role that cdc and the partners are playing and the sense that with an intensified focus you can make a real difference. thank you again for making cdc possible. >> members of the committee. i appreciate the opportunity to be able to speak to you about the role of the national institute of infectious diseases and research with the ebola disease. i have handouts that your staff put in front of you and it's on

divisionals there. the involvement of the nih and ni aid dates back to the tragic events of 9/11/2001 followed closely through the mail to letters to the united states senators as well as to members of the press because this led to a broad multiagency endeavor to develop what they called biodefense against threats not only deliberate threats, but unexpected naturally e merginging and reemerging threats. as you see on the right side of this, there was an agenda involving what we call category a agents. they are listed and familiar to you. the anthrax and botulism and the

bottom bullet. they see a category called the fever viruses which are ebola. these viruses were so important. they are so in need of counter measures that as you measured in the introductory remarks have the other senators, they have a high degree of lethality and infectivity. the therapy is essentially mostly supportive. without specific drugs directed into the microbes in question. this was a micrograph of the virus which is eye virus given the name because of the appearance it has when one looks at it. the nih's research and

development program is ongoing and has been for several years. before i even mention that, i wanted to underscore something that the doctor said. right now, today, the best way to contain this epidemic, this outbreak is by intensifying infection, control, capabilities. to protect the health care workers and development. the counter measures. the next couple of measures. it's important to supply the resources for the researches in industry to get to our end game which is better diagnostics and of course therapeutics and

vaccines. the pipeline is not unidimensional. it's responsible for developing the early concepts and doing what you call preclinical studies and early clinical studies which i will mention in a moment. we partner with our colleagues that you mentioned to hand the baton over to industry tor commercial manufacturing with ultimate regulation and approval for the u.s. fda and other agencies. you will hear from dr. robinson shortly. let me spend a moment outlining some of the promising therapeutics. you mentioned and you heard of the pharmaceuticals. this is a combination of three artificially produced antibodies directed against the ebola virus that has been shown to be very promising in an animal model and as you adhere from the next

witnesses that this was given for the first time in humans. it is very, very important that we understand how well it works and is it safe. we have determined that it looks like on the circumstances it could be beneficial, but we don't know that. it's our job to prove it. it's among several interventions. by the company we are collaborating with which is one of several mofle drugs that interfered with the reproductive process of the virus and our department of defense was in collaboration with the company to get a drug which is actually a small molecule and again interfering with the virus. as i mentioned, it has been

administered to seven individuals. when you look at the animal model, it's a very encouraging result that you have seen with the animals. it can block the virus. then finally the issue of vaccines. this is something that traditionally has been the store of preventing and preventing people. we have been working for several years about a process we have improved upon. we have results in a model and the glaxo smithkline candidate which was developed at the nih

glaxo smithkline and looked good in a study. as i told you many times, the proof is in the pudding to show scientifically that it works. we have started that process. on september 2nd at the nih clinical center, and we started the phase one study aimed at vaccinating 20 normal volunteers. so far ten of the 20 volunteers have been vox nated and thus far have no flags. following this which will likely end ended end of november. we will expand to prove the fact that we have a safe and effective vaccine. so enclosing. i would like to reiterate. it comes from infectious disease. it's our responsibility to maintain a robust.

we have the other mandate to respond rapidly to the reemerging disease with the kinds of counter measures that would prevent morbidity and mortality and have our citizens feel both at home and abroad. ebola is one of the most daunting diseases. months and years to make sure we have the counter measures to address the problem. thank you very much. >> good afternoon. thank you, chairman. >> we thank you for the generous opportunities to speak with you about the response efforts.

florida. they are as prepared to act in 2006. is the agency responsible. the diagnostics for the entire future. they exist with the biothreats and infectious sdoezs. they supported the development from man made threats on a routine basis & the savian flu outbreak last year. today we face ebola which is a biothreat and material threat determination by the department of homeland security 2006 and an emerging disease.

when it comes to ebola, the best way to protect the country is to address the current epidemic, the worst in history. the federal part is with the early development at nih and department of fda approval. seven of these products got approval in the last two years. today we were transitioning seven promising vaccines and candidates from early developments under nih and dod support. we will ensure that we have counter measurements. over the past five years, as a

result, the improved framework has been afforded to federal and industry partners. we utilized this to manufacture tests and stockpiles in record time for the outbreaks in china. with the current response, we are working with a wider array in the uk and western african countries and the world health organization and the gates foundation and many others to make the candidates. they have established a counter measure infrastructure to assist on a daily basis and to respond immediately in a habitual health emergency. they have animal studies and the centers for innovation and

advanced development to expand production of ebola antibodies and the network to fill ebola vaccine products and the vials. additionally the consequences of man made threats on a routine basis is coordinating international and efforts on the current epidemic and impacts of the nonmedical and medical interventions. lastly they support a large production in the response measure for public health emergencies. and the outbreak in 2013, today the vaccine and therapeutic manufacturers, the scaled up manufacturing specifically supported the development and manufacture of antibody therapy for clinical studies of one manufacturing and additionally spanning overall manufacturing by listing the health of other

tobacco based manufacturers and seeking alternative candidates to expand the production capacity. additionally they are working with nih of pro promitwo promis candidates for next year. 2015 resolution and appropriations are needed now to fund investments of the candidates. florida faces challenges in the coming weeks and months with the counter measures. the bottom line with florida with the federal industry partners will use the collective bioterrorism going forward.

>> thank you very much and thank you all for the succinct summations. we have another event and we have a survivor. in western africa and i will start first with the doctor. these disease outbreaks seem to be more common because of the close proximity and humans and travel is common. that's the nonexistence of the countries. a couple of years ago in traveling and it occurred to me that in these countries they will have a cdc.

they need an entity that is sensitive and that involves people of that country that can detect them early. due to the work. last year the senator and i got the money in the bill to start expanding it, you speak to this and how important is it for these other countries to create their own version of the cdc. every country having their own cdc. >> thank you, senator. you make very important points. there fundamental capabilities that we at the cdc almost take

for granted. it's almost fundamental. the rapid response teams of what it is for an outbreak. that's what they need nord control and identify the outbreak. what they need are the fundamental capabilities. that's what the global agenda is about. they might give you an example by way of contrast. we are in the midst of the largest and extremely challenging outbreak. we have been investigating and stopping the ebola outbreaks in east africa for a long time. one of the countries is uganda.

if you look at the list some of the largest ones involving hundreds of people. with the ministry of health with the research to build capacity there. that allows them to do their own testing and detect the fevers, they have a transportation that allows them to move specimens and get them to the laboratory. that i have rapid response teams that know how to find ebola outbreaks and stop them. consequently what they have seen over the last few years is more outbreaks being detected. we know they are going on. they are much smaller. a year or two ago. the ebola was able to stop after

one person. this is an example of what building the capacity that you are talking about is a benefit to the country. it helps the country solve very fundamental problems that they have. this is an example that we agree with you and it needs to be built. that will really take this up. we spent lots of taxpayer dollars and military operations and people can defend themselves in terms of that. and yet on this one aspect, we have been inadequate like we expect our cdc to do everything. it can do a lots we have shown. we need the other cdcs in the country to think about them as forward outposts. where people can defend

themselves and in turn defend us from the rapid transmission of the fires. i thank you very much and i thank dr. friedman for the great leadership. i hope in the next few years, we can see it replicated. thank you, senator. >> doctor, you and the other witnesses have carefully explained that we know what to do about ebola and demonstrated that it can be controlled. however in talking with you, without putting words in your mouth, i can tell you feel like this is a very, very serious problem. we ought to jump all over it. i will try to put that into perspective. you said a few hundred cases would have been a big outbreak.

you said you identified less than 5,000 cases, correct? it might be higher, is that right? what are the chances that that is under reporting the cases? >> quite likely, senator. >> it's also true of those cases that you reported, half were reported in the last three weeks, is that correct? >> more or less, yes, sir. >> if the number were 10,000 or 15,000 instead of 5,000, perhaps half of those would be reported in the last three weeks. >> quite possibly. >> the danger is the rapid infection. why such a worry? is it that the infection spreads more rapidly? is that the concern? we had many epidemics, but why so grim about this epidemic? why does the cdc say it may be

the most dangerous of modern times? >> thank you, senator. as you heard, ebola is not easily transmitted. it is not transmitted through the air and it requires direct contact with body fluids with dead bodies. what we are seeing in this outbreak is because of right now, insufficient capacity to isolate patients with ebola. we are seeing the chains of transmission. you can imagine with the number of cases growing, the number of contacts for each case, these chains of transmission continue to propagate and that's how the number of cases grows and continues to grow faster as the number of cases increases. it's really a matter of arithmetic. it brings me to the point of what is the critical issue right

now, especially in liberia and really in all of these countries. that is that we must come up with ways to effectively isolate and treat ebola patients. right now -- >> first you have to find them. you have to chase down every infected person. right now there patients we know about and no treatment units in which to house them. yes, we must do meticulous tracing and identify all the potential cases. isolate them and make sure they are not infected.

>> the new cases double every three weeks and half of those infected die? >> it appears that's the mortality rate, that's right, sir. >> one question for you. dr. bell pointed out that you don't catch ebola by breathing on someone. it's bodily fluids when someone isuxaaaa: ñ infected and has sy someone is dead. those two are most of the infectio infections. you were quoted as saying it's not likely that ebola will change how it is transmitted, but it produces a more serious set of possibilities. are you tracking the virus in this outbreak as it affects more and more people? it is

they are not associated with the biological function. even though you see a lot of mutations, it is unlikely that there will be a change and the possibility there will be a change. usually with a change in function, it could get more or

less efficient. it's not impossible, but unlikely. we never take anything like that lightly. we follow it very, very carefully. in direct answer, we have the best sequencing groups in the world. in looking at the evolution of the mu takes to try to make sure that mu takes are not occurring that would have the biological function like transmissibility. the reason i made that comment siwanted to make sure that people understand that changing

transmissibility that can be transmitted by the respiratory route is something that can be a frightening thing. people understand we are watching that carefully and that's an unlikely event. not impossible, unlikely. what is likely is that if we don't do what we are doing now in the sense of a major ramping up of the control capabilities and including what we are hearing about getting the military involved with all the things they bring to the table. it is likely if we don't stop this epidemic, it will get worse and worse. getting it under control so you don't give it the opportunity to mutate anymore. a virus that doesn't replicate. we put the lid on this. that will be it. >> thank you.

i will recognize them next with the order of appearance i have here. senator warren and -- >> to you and doctor freed in. i have then at that point in time expressed my request that he expressed gratitude on behalf of me and all of us in this country for the efforts by the people who work here and are working globally and trying to contain and change lives. we are grateful for what you have undertaken. let me ask first a question that he just indicated about the

potential response and use of the military. is there something you all can say that, assures them that the military men and women. is it with the new task that i that are being asked to take? >> thank you, senator. thank you for the kind words about the cdc. we already have the cdc more than 100 people in the field. this question of safety and security of our own staff. any staff or any sort of members of the government. the safety and security is a lot of that. we have been paying attention to the issue starting with our own staff with making sure the staff understands and what the situation is like on the ground before they go. having them understand what are the interventions they need to

take and making sure they have the right equipment and that they understand the strategies in terms of distancing. i think the bottom line is it is a dire situation. we are taking that seriously and a lot of steps to do everything we can. it is a difficult situation there out there on the frontlines. >> let me extend gratitude to the organizations. and what education and training has taken place with regard to

the military. the preparation for the assignment. >> i don't have any specific information. we will be hosting in alabama at the fema facility. it's a three-day safety training for health care workers who are planning to deploy for a nongovernmental association. this is the colleague with doctors without borders. the precise purpose is to teach.

there is a mock facility there and we are hoping to actually have this course. the first is full and there is a lot of interest and this training is pivotal before americans deploy to work in treatment facilities and the region to your point to make sure they can care for the patients safely. how would you describe the best case nairio in regard to ebola in the spread and the worst case scenario and the difference, the item that makes the worst case scenario not happen and the best case scenario to occur.

we are able to effectivelies ailate and treat patients and are able to effectively trace all of the contacts and make sure they are all followed for 21 days. and we don't haves in the street and they can bury their dead and not put themselves at risk. over a period of the coming months we are able to interrupt the transmission and increase the cases that he was able to bend the curve. we continue to see the rise in cases that we are seeing.

we were concerned about as you can. how incredibly dangerous this would be. it was an enormous effort in order to get the situation to the point that it is today. while we are not out of the woods, we do not think there is uncontrolled transmission happening. hundreds of people working in the exportation that requires an enormous amount of work. as the outbreak spirals out of control, expect many more of the exportations. each one of those as i say requires a huge amount of work. we have no guarantee that we will be successful. you can imagine the outbreak

spread i spreading. >> what if someone in sneezes? >> there is no evidence over multiple outbreaks that respiratory spread occurs. it's rare. people in situations where that would have been noticed clearly indicate that is not the case. >> thank you for that.

one of the reasons it's so important is we have a large community. probably the largest in the united states. they are hardworking and concerned. i want to thank you because they participated. we have two doctors with the facul faculty. the doctor was in the country giving their skills and courageously working on behalf of the people of liberia. one other plan and this is something on the side, a number of those in rhode island are here on a status deferred enforced departure.

that status expires unless the president extends it. i would hope he would do so because to send people back to the danger. do you have a sense of how fast this could be deployed in west africa and have you reached a point where this is a huge risk and it has to be done even if you don't have the usual protocols completed? >> the standard way way of implementing a vaccine in the field is to go through a series of steps of what i just described phase one and is it safe or does it or does it not

induce unexpected reaction and hyper sensitivity. the right doses and does it have the right response. you go because now pretty sure it's safe in what's called a phase a or b. and depending on the disease if you can go out and test if it works. the worst thing you want is to have a vaccine that you're deploying that you think works, but it doesn't work or even one that would be even more terrible is a vaccine that makes things wor worse. you have to consider all of that. when you have an emergence situation like this, will you have the desire to get people prote protected if, in fact, the vaccine is protected. there are ways to get the ans r answers not as definitively if you do a pris tine type of a trial, but if you would them

employ the people who are needing the vaccine as part of the clinical trial where you compare one vaccine against another or one dose against another so you accomplish two things. you try and determine if it's safe and effective, even though it isn't as definitive as the pristine trial, but getting people in these trials, you make it available. so where we know what the dose is to have an expanded trial. more people would get the opportunity to be vaccinated. i might say that the target of the vaccinations is clearly directed among others to the health care workers. the people on the front line, the emergency responders, because those are the ones that put themselves at risk as did dr. brantley in taking care of individuals. >> if you can prove that it's

safe but you don't know if it's effective, you can try to prove its effective by inoculating health care workers and others. it's better than nothing, but it's not quite definitive. >> fully knowing you're not going to get an answer. when you're a situation, you what you have. >> further comments? clinical trials is we have to have the product there, the vaccines to be made available. part of that is taking these products that are in early development and making sure we can go to commercial scale and produce those in large quantities so these studies can be done and shown to be well tolerated that there's more vaccine availabtm% >> thank you all for your extraordinary work. thank your colleagues in the at risk. thank you. >> thank you very much.=8i senator burr?

>> mr. chairman, thank you to this panel and those who will be called into action over the next weeks and months and hopefully not years. you said if we don't act now, can you define now from a standpoint of a timeline? at what point will we have reached the point where we missed our opportunity? >> senator, i wish hi a crystal ball and could tell you precisely the answer to that, but the situation is quite fluid and i think it's quite hard to predict with any kind of precision. i certainly can say that speed and scale is of the essence. >> you used the term several times controlling the outbreak. is controlling the outbreak the same or do you use that the same way you do containment? >> yes, sir, more or less. >> how do you achieve containment on a disease that's broken the containment.

>> i think it's a matter you can think of this as bending a curve. a curve is going in one direction. we want to make it it go in the other direction. in order to do that we have to break these chains of transmission. and the way wi break the chains of transmission is by having a way -- effective ways to isolate patients so they can't transmit and to make sure there isn't ongoing transmission happening. for example, in health care facilities or from unsafe burial practices. >> liberia for example, we're surging through d.o.d. the capacity for 1,700 beds in a country that they have sozero n. my math is not great, but it says we're going to be behind the eight ball because we won't have enough beds. i'm told the most infectious method is the back of a cab where individuals ride with their family to find there are

no beds in the clinic and ride home. how long can the virus survive whether it's on a cab seat or sheet or table? how long can it infect somebody? >> there have not been definitive studies giving a timeframe. it's a fragile virus, but we do know that people get infected from touch iing the dead bodiesf people who have probably contaminated with blood or bodily fluids. that's when people have been documented to get infected. i don't think we could go beyond giving you days, weeks or whatever, but it clearly is not instantaneous where once the virus is out of the body it's gone, because we know people have been infected at funerals.

>> in previous outbreak, we have seen five generations of transmission. how many mutations are we seeing as the virus continues to spread with each chain of transmission? >> i can't give you a number on that. when you have an rna virus, it is notoriously is a bad producer. it makes mistakes. . when it makes mistakes, it mutates. most of the mutations don't mean anything. they are just irrelevant. sometimes it means it kills the virus. other times it may be modified some of the biological function. i can't tell you how many generations, but that could mathematically likely be figured out on the basis of a paper that just came out a couple weeks ago

from boston where they looked at 78 people and the virus taken from them. if you did a mathematical computerized, you'd be able to say how many replications. you can determine that. >> if you'd get that to us, i'm appreciate that. there have been reports we could see 28,000 cases a month and the outbreak may last 12 to 18 months, which would calculate to roughly 360,000 cases. again, i think we continue to be a step behind up until this point. on what projected number of cases and period of outbreak did the administration base its response strategy to date and the latest actions announced today? >> there have been a number of models out there, and we

ourselves have been working on a model. i think it is certainly true that a number of these models predict without intervention that we could see hundreds of thousands of cases. and so all of those modelling exerci exercises have been taken into account as we've been calling for additional interventions in these countries. i think the critical point here is that those models for the most part are based on not scaling up. and in addition to all the things that the u.s. government is doing to scale up including the announcements from the department of defense, there are also many other international partner who is are also scaling up. the world health organization, other countries p.

so there's also more financing that's become available from the world bank. the u.n. is becoming involved. so i think it's fair u to say that there is a general mobilization of forces here and what we're looking for is with that mobilization of forces these models what they are predicting is not what we're going to see happen. >> i appreciate that. and follow it very closely. i know the mobilization of most other countries in the united nations is not nearly the timeframe that ours is and that's why it scares me to death. mr. chairman, thank you for your generosity. let me say to dr. robinson, does barta have the resources it nee needs? >> yes, for this fall. we don't have going forward for ebola to produce more vaccines

and more therapeutics. we actually want to do more than just zmap. there are others we have under consideration. we and others will need more funding, there's no doubt about that. >> thank you very much to the panel and mr. chairman for having this hearing. i'm proud to represent a state that's producing truly incredible research in the biomedical field, including several ongoing studies and efforts aimed at curiing ebola. the geneva foundation, which is working on a treatment drug. they are looking at culturally appropriate ways to prevent further transmissions and the university of cats lab looking at vaccines and drug developments. we're doing a lot out there. the reality is that we all have to do more. and i think it's important to mention that one of the reasons i fought so hard to roll back

sequestration in the bipartisan budget act was to provide certainty for organizations like nih, which have had to deal with some steep and harmful budget cuts. i u believe it's going to be very critical that we continue to focus on rolling back this trend of disinvestment in research and development so we can ensure that our country continues to produce the kind of life saving, world changing research that we know we're capable of. i'm very concerned, i need to say this, that fiscal austerity and the return of sequestration next year is going to continue to weaken our ability to respond to needs like this. so while you're here, i wanted to ask you, can you talk a little bit about how the lack of budget certainty and sequestration and the budget fights over the last two years have really impacted the u.s.'s ability to respond to the ebola situation? >> i'd have to tell you honestly

it's been a significant impact on us, as you well know and you have been fighting for us for a long period of time. our budget has been flat since the end of the doubling in 2003 with the 2% inflation index that over a ten-year period we have lost about 22% in our purchasing power. that was the left hook, the right cross was the sequestration that came in and pulled out a significant amount of money. $1.5 billion which we gt reconstituted. we try to preserve the fundamental basic research of the investigators, the bright ideas that people have and if you want to preserve that, the money that you have for initiatives such as the development of vaccines and the development of drugs suffers because it's a balance. there's programmatic

initiatives. when you shrink the budget or don't give even an inflationary increase, all of that starts to whittle away and you get secondary effects like disincentives of getting bright people involved from your state or any state who feel that there's a disincentive to get involved. so it's been both in an acute and in a chronic insidious way eroded our ability to respond in the way that i and my colleagues would like to see it be able to respond to these emerging threats. in my institute particularly, that's responsible for responding on the dime to an emerging infectious disease threat. this is particularly damaging. >> i hope we all keep that in mind moving forward. again, i'm proud of the folks in my state, the gates foundation gave $50 million to scale up operations. the allen foundation opened

emergency operation sites in three of the most infected countries. dr. robinson, knowing that gates foundation have stepped up that way and the money included in the cr thank you to our appropriations chair sitting next to me is that enough money and global support to stop this outbreak? >> i'll answer for the cdc. we do appreciate the $30 million that's in the cr. that amount of money is enough to keep us operating through the end of the continuing resolution on december 11th. it allows us to keep our people in the field to pay for our staff and to begin to scale up in a way we think is necessary. we will be kind of considering over the time period of the cr what additional resources we will need for the rest of the fiscal year in order to fulfill our responsibilities and respond to the ebola outbreak in the way

we need to. >> the $58 million that we requested will get us through this fall. more therapeutics have to be funded to go forward. >> thank you, mr. chairman. >> senator harkin, senator alexander and senator reid about how proud we are of cdc. as one of the two senators, i want to add how proud we are at emory university and the staff there. dr. brantly would feel the same way. phoenix air, who was the contractor that brought the patients back from liberia to the united states. . for the committee's benefit, i was the only senator reachable by the press. the day was to come to emory

university. and the press looked for an ebola patient back to the united states and whether or not we had the capability of preventing the disease from spreading and emory university did a marvelous job of making those transfers seemless and complete and proving to the media that were trying their best to start a riot that it was going to be safely contained and they were in the best place in the world. so y'all deserve a tremendous amount of credit. i wanted to say that publicly to you. >> thank you, senator. >> you said this is by far the worst ebola outbreak you have ever seen. what was the next worse in terms of numbers? >> so that was about 400 in some cases. >> what makes this one so different? >> there are a number of factors, i think, senator that

has made this one quite a bit different. first of all, this is the first time we have seen ebola in a large urban setting. our previous experience with ebola has been primarily in rural areas. and there are many, many different sort of factors that come into play when you havet9ñ ebola in a situation with people packed very closely together in a large city. so that's one thing. another issue that has been

thl outbreak from the beginning. >> i have traveled extensively in west africa and i have seen firsthand -- there are almost bereft of health care facilities of anything we'd consider to be reasonable, which means when you described containment, you described a labor intensive process. you talked about people taking temperatu temperatures to see if somebody has been exposed or infected. you talked about isolating. we're sending 3,000 american troops to west africa. we have 100 cdc personnel. we have ngos and other volunteers, but it's going to take a lot bigger labor force to contain the disease at its current level, am i correct? >> yes, there's lots of different settings that we can talk about but for example, in

the ebola treatment units, 90% of the staff are local. i think it is important to remember that the governments, the people in the countries and the governments themselves are stepping up and with assistance from those of us that have the technical capabilities are really able to fill many of these roles and responsibilities. some of the work in the treatment units, much of this going out into communities every day and checking in with contacts to see how they are doing. these are roles that people themselves, the local people themselves in these countries can undertake with some technical guidance from some of us that have this experience. this is not to minimize the scale of the human resources that will be needed to contain this. but as i say, i think that there are many of these sorts of functions that we're already seeing the local people help

with and there are groups around the african union. many of our field training programs from around africa that are also stepping up. so it is an enormous job, but it's a job, as i say, where i think there are lots of different sectors and parts of the local community in addition to the international community that can work together to address this. >> i wanted to make a comment. the africa summit which was just about a month ago, i had the privilege of participating in a lot of that with a lot of the leaders, and i noted how they were begging -- not begging, but they were wanting so much american knowledge, cdc, nih, all the technology, but even the bordering countries seemed that they were willing to provide man power, but they badly needed leadership in terms of health care. is that correct? >> yes, sir, we have made quite a bit of progress over the last month or so and are working closely with the african union

to have them deploy staff to the area. >> thank you very much. >> before i recognize senator casey, you mentioned all these different entities now address ing this. we have cdc, state department, world health organization, doctors without borders, can you tell us who is in charge of coordinating our government's response effort in africa? >> yes, sir. in terms of the u.s. government in each of the countries, there is the disaster assistance response teams, the dart umbrella under which the government efforts are coordinates and we are quite well coordinated with the organizations. in the larger sort of undertaking, in each of these countries, people are getting organized generally speaking with the government.

>> they are in charge but overall who is in charge? >> the dart is actually the three countries together are all under the umbrella of the dart of the usaid dart. >> usaid? >> yes. >> i'm kind of startled to find that out. usaid would be -- >> it's a dar when the disaster is declared. i'm sure there will be other mechanisms to collaborate and coordinate with each other. but there's this kind of structure on the ground, which is meant to -- >> i think this requires further looking into by both these committees. senator casey? >> i would concur, mr. chairman.

>> mr. chairman, thank you very much. i want to thank the members of the panel for being here. i also want to note the good work that's been done by this committee and members of this committee for a lot of years. the chairman, grateful to work with them. senator burr, who has spent a lot of time on this and has become such a leading voice on this. i don't want to plow ground that's already been plowed through. i apologize for having to juggle to two hearings. i know that one of the fundamental questions you asked is the threat to the united states, if any, and how you articulate that. for purposes of process and the mechanics of confronting this kind of a threat, were it to

arise here, i'm just thinking about pick a town in pennsylvania, it won't opinion point one, but if there was someone in pennsylvania that was a patient at a hospital and they tested positive for ebola, what would be the steps that would be undertaken at that point. >> yes, thank you, senator. we have been working quite closely here in the united states to prepare for this sort of eventuality that you described. as we have mentioned, ebola is really not easily transmitted. and i think in terms of helping to understand the context to answering this question, i want to say a word or two about what a hospital in these countries in africa looks like as a way of contrasting. so when we think of a hospital, we think of a shiny, clean, lots

of equipment. most of the hospitals in this region, as many that you have travelled to this area are aware, often times there's no running water. there's no soap. there may not even be beds. there may be mattresses on the floor. every health care worker is care ing for a large number of patients. . there will be beds all around them. they may not have the appropriate protective equipment like gloves and gowns and masks. so that's the environment in africa where ebola is currently raging. in the united states by contrast, we have many, many protocols in place. and with these protocols, most hospitals that can isolate a patient in a private room with their own bathroom and can follow very strict and meticulous infection control practices, which have been outlined and health care workers are aware of can take care of ebola patients.

while we haven't taken care of any ebola patients prior to this outbreak here in the united states, we have safely cared for at least five patients with other fevers. so while this is certainty something to be taken quite seriously and we're doing a lot to educate health care workers, to educate laboratory workers and to answer peoples' questions to sensitize them to these issues, most hospitals in the united states with these sort of basic capabilities should be able to safely care for ebola patients. . >> i have limited time, but i want to ask one question. you noted in your testimony there are a number of ebola

therapeutics and vaccines in development. recognizing that all these products are still rather early in their development, do any of them have clear advantages or disadvantages over the others? can you make that assessment yet? >> i don't think honestly we can say that because a part from zmap and one other perhaps, they have not really been in humans. we have in the past have experience with things look really good in an animal and then when they get into the human for one reason or another it doesn't work or too toxic. it would be premature -- there are a&kç number of candidates t look favorable that we're enthusiastic about moving them into a phase one and beyond that. so there are a number of candidates that have a favorable profile in an animal model, but i think it would be unwise to

say this one looks a little better than this one because it's too premature to do that. >> i hope there's nothing that the congress has not been able to achieve that would be an impetment to answer that question down the road and to be able to make the progress that you want to make on these developments because we have an obligation, i believe, to fund a manner that leads to the research we hope. i say that for the record. thanks, doctor. >> thank you, we appreciate it very much, sir. >> senator? >> thank you, mr. chairman, and thank you for having this hearing. this is so important. we appreciate you being here, all of you have just excellent reputations and we appreciate the fact that you're working very hard to keep usñr safe.

from what i have read and the testimony, it seems like speed is important, education is ú i important. we have the cdc involved, we have the nih, we have the dod, we have the department of state, samantha powers is calling the security council for the first time ever for an event like this. ñqpo>cq&ge

coordinating from washington. it's really important that we draw on all of our assets from all of the different agencies working in our particular lanes and koocoordinating, as i say, altogether. there's very strong interagency coordination. the nsc is deeply involved in bringing the agencies together. and we take the lead in the public health aspect. >> i hope we get that worked out where we actually have somebody thatp@y we can point to a, an individual that's in charge. the same thing that's going on the ground that needs to be going on over there is simply not going to happen without that happening here.

one thing that's happened, there's an ebola outbreak going on in the democratic and republic of congo. is that related to this or is that all separate thing that we >> i will say something. this outbreak is not related to what we're seeing in west africa. as you çsay, senator, this are is an area in which we have seen many ebola outbreaks in the past. this outbreak is of the strain that's quite similar to those outbreaks. so while we are take iing it seriously and cdc have sent a team into that area, we don't think that outbreak is connected. we're actually aware of the individual case that began that outbreak and had no relationship to what's going on if west africa. >> you can actually -- and i agree that that will be

determined. the extraordinary ability to do rapt deep sequencing of the genome of these viruss can actually pinpoint whether or not they are related. it's very interesting that the study that was done and publi published very recently shows the exact point introducing as how it went from and it doesn't look like the strain that's in the democratic republic of the congo is in that lineage. >> dr. bell, can you reassure the -- i know the public is concerned about bringing it into the country. can you talk to us a little bit about the steps with helping those that are at the airports and identifying people that possibly have the virus? >> yes, senator, it's certainly quite understandable why people

would be concerned. the images are quite alarming. as you note, we have been working in the countries to improve their abilities to do exit screening. we have teams in each of the countries and we have really been able to help them improve their capability to do exit screening considerably over the last month or so. and are quite pleased with the progress in these countries. they have equipment, they understand what they are supposed to do, they have the protocols in place and they are really moving forward. in addition, i'll mention that we have been doing a lot of work with our own border agencies so with to train them so they understand what to look for and they understand when they need to call on us. cdc has quarantine stations so that they also are sensitized to what needs to be done.

we have done a lot of work here in the united states with health care providers. even with citizens so that they know what to look for, to remember to ask for a travel history. we have a number of our laboratory response network laboratories around the country who have the capacity to test for ebola. and then the health care facilities themselves are very tuned into the appropriate isolation methods that would be needed should they have a suspect patient. >> thank you, mr. chairman. >> thank you. senator bennett? >> thank you for holding this hearing. you mentioned in your opening comments the particular problem in liberia of there being a lack of isolation capacity. i wonder if you could describe for us, if everything worked the way it's supposed to work, make these fundings, first of all,

what the experience of somebody today who is infected with ebola if they don't have access to an isolation chamber. and second, what you would expect to be the progress points we need to see in order to know that we're actually creating an infrastructure that really can change the outcomes, the course of the disease. >> yes, thank you, senator. as you mentioned, there are not enough treatment facilities, isolation facilities in liberia right now to take care of all of the cases. and because of that, there's ongoing transmission that's occurring because we can't isolate them. we're working on this from a a number of fronts. first as a numb of the senators have mentioned, we will be building more treatment units. in addition a number of other entities including the government of liberia are also building ebola treatment units.

so there will be a scale-up. in the meantime -- >> go ahead. >> there are a number of measures that we're also going to be taking so that people can be isolated safely, not in a treatment unit. so there's a number of ways to approach that. there are community holding centers for lack of a better term where people can be isolated safely with one caregiver and that caregiver can be provided with the appropriate personal protective equipment that they need to prevent transmission to themselves. there's also some efforts to do that in households. so where households of a caregiver would be given a kit, which provided all the equipment that the person would need to protect themselves and also some of the medications, such as oral

rehydration, tylenol to help with fever that the patient themselves could use during their illness. so there's a numb of different kinds of interim measures that we're working to scale up now at the same time as we're working on building additional isolation facilities. . >>. how are you or with whom are you working to make sure that that work is actually happening rather than just being thought about? >> there's actually quite a bit going on right now. actually usaid has been working with a number of nongovernmental organizations including msf. they have actually produced tens of thousands of these kits and have a plan in place to scale them up to hundreds of thousands in the near future. >> thank you. and first question or one of the first questions the chairman talked about, maybe the need to have a cdc or something like it in every country. and that is something we shoulds

a fi a aspire to. i wonder if you could be talk about your efforts to make a network of realtime detection of diseases and collaboration among these various countries in our response. >> yes, part of our response here is to build up the basic capacities in these countries. in addition right now as an urgent matter, we're working to build up these capacities in the bordering countries. so emergency operations centers, prapd response teams, beginning planning on what they need to do in terms of ooislation should they need to do that. working on culturally appropriate burial practices. so in the bordering countries, that's an urgent priority for us. then across the rest of africa, we're working to kind of harden the country's ability to be able to recognize imported cases to

know who is the incident manager, how is the operation center going to work and what are the steps they are going to work to respond to an additional case. do they know how to do contact tracing. who would be responsible for the contact tracing. where would they isolate the patients. these are things we're working on in the context of this outbreak. . in a bigger picture kind of way, they are basic capabilities that the security agenda, for example, has been calling for and as you probably know, we have been working with a number of countries in a pilot kind of way over the last couple of fiscal years to show the proof of principle of what global health security can mean to detect to respond and to prevent these outbreaks with basic capabilities around capacity, around communication strategies, around emergency operations centers, basic epidemiology.

these are all fundamental capabilities that country by country we need to build if we want to prevent this kind of thing from happening in the future. >> thank you, appreciate that testimony. thank you. >> last year the appropriations committee put in $6 million to start this process of establishing cdcs in countries. i understand some time this fall cdc will announce those initial grants. we put $10 million in the appropriations bill this year to continue that effort. in light of the ebola outbreak and others i'm hopeful we can take a second look at this, if in fact we do have an appropriations bill that we can do that we might want to put some more in there. understanding you can't do it

all at once, but still know that the pipeline is there that we can start bringing people there to train them, train them in laboratory procedures, start buying the equipment they need to kind of get a jump start on even more countries next year. >> i appreciate that. i think there are a number of us that would love to work with you. >> we jeust need the money. >> senator whitehouse? >> two questions. i'm not an expert in epidemics, and i don't know if there are accepted stages in the acceleration of an epidemic when it goes from an outbreak to a raging occupant of control forest fire. if there are, what are the red flags that we should be looking for that this epidemic has gone

to the next stage in terms of the threat that it presents? >> there are some key indicators that we use that sort of depends on what the indicators are. in this situation, there are basic indicators like the number of cases and the number of cases per week as senator alexander has discussed. there are other indicators, for example, the number of cases in health care workers. we should not be seeing cases in health care workers. after that, i think that we are working to track things like whether patients that need to be isolated have a way to be appropriately isolated. whether we are not -- we stop seeing bodies that can't be picked up in a timely fashion and a number of different indicators like that that we use to help us understand if we're bending the curve and whether

it's going in the right direction. >> when you consider the existing effort, which has been heroic but measured against the threat has note not kept it from accelerating. how many multiples of the existing level of effort do you think are acquired to be able to get ahead of this and bring it back under control? ten times the effort? hundred times the effort? >> i would say a very large increase in the effort and also a very large increase in the effort with a sense of urgency so that the increase happens very quickly. it's hard to say, you know, how many multiples, but there needs to be -- and i think we can safely say -- >> we're not even close to meeting the threat right now. >> the sense of scale up that we have been hearing about in recent days is the sort of scale that we need in order to address this outbreak, this epidemic.

>> and is this a virus that's capable of being manipulated by humans? could one go into it if one had a sample of the ebola virus and meddle with a portion of the dna strain that relates to how it's transmitted? could somebody up to mischief try to make something that was more transmittable out of this existing virus? >>. theoretically, you can manipulate almost any virus to change it any way you want. so i mean that's a question that always raises red flags about it, but the fact is, yes, the only trouble is it wouldn't be easy for somebodyu>ñ to do that their laboratory backyard. they would probably kill themselves doing that. it would take a state type

thing. i don't know if you were here when i made my opening presentation, but. i mentioned that our getting involved in the fever viruss was part of a biodefense agenda because way back during the cold war, it was clear from intelligence and proven thatññ e soviets were stockpiling fever viruss for just the purpose that you make. so it would have to be a state thing. i don't think you're going to get some rogue person being able to do that. >> others would love to work with you on trying to explore that further. thank you very much. >> senator durbin? >> dr. bell, is cdc working with the world health organization? >> yes, we are, senator, very, very closely.y@s >> it's my understanding that the president submitted the name of dr. frieden from the cdc to be our representative to the

world health organization in july of[ç this year and it's stl lost somewhere in the united states senate. i would hope before this weekend's -- i would hope before this weekends and we return home that we might consider bringing this to the floor on a bipartisan basis and expedite the appointment of dr. frieden, who we know well and studied. we know his background, so he can be with the w.h.o. and not wait for two months or more for us to return and consider that nomination. i'd like to suggest that to the chairman and see if we can get that done. i'd like to ask a second question following up on what senator casey said. senator casey said i hope that there's nothing that's been done on a budgetary basis that slowed down the development of a vaccine that might be helpful. you talked about 22% decline in the funding in nih research and the impact of sequestration.

has there been, to your knowledge, any shortage of funds, which has led to a delay in testing or development of ebola vaccine? >> i think one could say honestly, senator, that everything really over the last several years with few exceptions has been at a level less productive than we would have been purely on the basis of significant constraints. i don't think we can say there's been a serious delay in this particular vaccine. that would be an overexaggeration. i would put it under the umbrella of the entire effort that we have been putting forth over the last several years have had to be muted somewhat by a budget that in real dollars is shrinking. >> it's my understanding based on statistics that i've read

about the physicians per capita that in my hometown of springfield, illinois, with a population of 100,000, there would be expected to be 240 physicians in sierra leone, two physicians for 100,000 people and in liberia one physician for 100,000 people. that's an indication, at least a few years ago, a snapshot of the scarcity of medical professionals at the highest level of doctors and such. i have been working and we included in the immigration bill, which passed the united states senate, a provision which provided in one respect if you are medically trained in africa and promised to serve in africa for a certain period of time before going anywhere else that we would honor that, respect that and not allow people to be recruited into the united states when they still have an obligation to their country.

secondly, that doctors in the united states would be able to serve in these crisis situations overseas without jeopardizing their immigration status. that passed the senate. that was in the immigration bill. it was never called for consideration in the house of representatives. speak to not just the terrible infrastructure when it comes to hospitals, but the medical professionals and health workers available in these countries that are facing this? >> yes, senator, you're right that the number of doctors in liberia and in sierra leone is extremely small. . liberia the number of doctors was in the hundreds, as you say. tragically, because of sort of the lack of infection control and the very, very poor conditions in the health care facilities and the inability of the health care workers to recognize ebola patients when they came with a fever, you

think it's malaria and turns out it's ebola and the health care workers are not able to protect themselves, tragically a lot of these sort of scarce health care workers have died in the context of the ebola outbreak. the rest of them, many of these facilities now that were rudimentary are closed and this is one of the things that we need to do is to train in infection control, provide appropriate personal protective equipment and get the facilities back up and running safely so that we don't sort of continue this spiral of not only the ebola outbreak, but also many other conditions that are not getting treated right now in the countries. >> we have learned the hard way that countries with very few medical resources can challenge are only a ten-hour plane ride away from the united states. thank you.

>> senator durbin, i must say when you talked about dr. frieden's nomination, i thought did we drop the ball on this? i just found out that it does not come to this committee but foreign relations committee. so hopefully -- >> mr. chairman, the information we have is the president didn't nominate him until the end of july. we were gone in august. the staff is meeting with him tomorrow. they are doing that in a bipartisan way. they could move him. i heard senator mcconnell say he supported president obama's proposals to deal with ebola. so i know of reason why the majority leader and whip couldn't work with senator mcconnell and bring it up before we leave. i would hope so, and i would be glad to support that as i imagine the chairman would. >> i'm not on the committee, but. one of those meetings in the back of the senate floor like we do all the time and get that job done in a hurry.

our wonderful chairman of the appropriations committee, senator mikulski? >> thank you very much, mr. chairman. first of all, thank you for organizing this hearing of both the authorizing and the appropriations committee and to my colleagues for such strong bipartisan participation in this. i want to, first of all, thank the people at the head table and all who work behind them for the outstanding job they are doing to organize the american government's response to this. and also to mr. charles, represe representative of the people who are really in africa trying to help people in this most horrific of challenges facing not only the countries, but the

people and particularly the workers who are there that must be facing just incredible stress. this is such a grim, horrific proportion and they are working 36-hour days, just as you are. so e we want to acknowledge that and thank them. mr. charles, it's wonderful to have you here. dr. brantly and mrs. brantly, good to see you. what's so great about seeing you, dr. brantly, is one, that you're well enough to be here. you were well enough to travel here and you're well enough that we're not afraid to have you here. and we can smile, but this is a stunning, stunning, stunning accomplishment. but again, we're glad to see you. mrs. brantly you look so much like samantha powers. i said what is she doing sitting next to dr. brantly? we could send you to the u.n. and have a lot to say that would

shake them up and help them to respond, so we're glad you're here. i want to make a couple comments and then a few questions, if i could. first of all on this issue of who is in charge that was raised by senator harkin and bozeman, usaid is in charge of responding in a disaster. an earthquake in haiti, the many disasters and they are to be acknowledged for their ability to do that. but the size and scope and multiple government agencies involved in this, i think needs a higher authority that actually can command personnel and organize working with us on bipartisan basis for the kind of resources to do this. because just listening to what we're doing today, we need the help, just go to the appropriations.

we're going to need foreign ops and we're going to need dod and within the labor hhs, it's cdc, it's fda. so i think, mr. chairman, working across the aisle, we should ask the president through whatever mechanism they are going to say, we need a point person in addition to omb, which will be here to do this. do you want to comment? >> i just wanted to make sure i didn't create a misconception in what i said about the dart. what i meant. is on the ground coordination in the middle of that area is coordinated. i take your point and -- >> here's my point. >> yes, ma'am. >> presuming there's a bipartisan group and there's the will here, we have one of the leaders within the republican

party, he's been one of the leading experts on pie yo hazards. if we wants to meet with the person in charge, what would be the person in charge? iad? frieden? dempsey? kerry? >> i take your point, senator. >> let's do that because we want to maximize and leverage everything we have. and also create that sense of urgency. now let's talk about resources. first of all, i'll be leaving shortly so if you see me go before you testify, it's because i'm going to work on the continuing resolution so we can have when the bipartisan basis pass that. but i'm looking ahead to december 11th and also the fiscal year for fiscal '16. so the cr is really a down

payment to keep your current response functioning, but it is not of the size and scope that you need to respond in africa and prevent it from spreading globally. am i correct in that? >> from cdc perspective, yes. it will allow us to continue or field operations through the end of the cr. but the situation is very fluid and we're assessing what we would need for the rest of the year. >> dr. bell, when did you have to submit to omb your fiscal '16 request? >> i'm sorry, senator, i don't know the answer to that question. >> let me tell you. >> i thought you might be able to. >> it was a few months ago. so whatever dr. frieden told omb in the white house that he needed for cdc it is really three to five months behind. so as we get ready to work,

we're encouraging omb -- this is our administration here, to go back and say, what is it that you need for the cr, which i hope we can achieve, but also a look ahead to fiscal '16 presuming we can find a way to cancel the sequester. so i would say to all the agencies involved, look at that and revisit that and it's our job to get omb to give you the latitude to come back because of this new need. wherever there's been an infectious disease crisis, you've been in the forefront of trying to find solutions for 30 years. we're so lucky to have you at all of these. but you spoke to us eloquently you a few years ago about a pandemic.

when you have a global infectious disease crisis, you need to have an infrastructure to be able to respond. am i correct? >> correct. >> now this is contained to one continent. do you think we're heading to a pandemic with this? >> no, i don't, senator mikulski because, as we have mentioned, the spread of this in the west african countries is really a reflection of the extraordinary disparity of lack of health care infrastructure to be able to handle an outbreak, to get the people isolated, taken care of, contact trace, so that you don't have essentially unfeddered spread. in a country like the united states and other developed countries that we may, and it's entirely conceivable, have someone get on a plane infected in a west african country, be

asymptomatic and land in paris or london or new york and get out of the plane sick and go to an emergency room and even infect a person or two because someone didn't take a travel history.history. but at that point once it's recognized, the kinds of capabilities we have would make it almost impossible to have the kind of outbreak that you're seeing in a country in which the outbreak is driven by a lack of ability to handle infection control. and we have that. >> well, then let's go to the disease. if this disease mutates, would mutation be of concern to you? and if it would mutate, do the current suggested treatments, possible treatments be ineffective because it's a new disease, and thn could it become a air bourn?

>> any hypothetical is possible. did i think this was likely going to happen? no. you never rule anything out. you always keep an eye on it. we are following the genetic movability of this very carefully. when people ask us this question i say what i know will happen, not hypothetical, is unless we get control of this it will continue to not only devastate but it will be much more difficult to get in control. and so we always in the back of our mind are concerned about mutations, right now today in december of 2014 mutation st not the problem. the problem is the full court press by getting this under control in standard classical infections. >> which is a public health infrastructure in many this

country and helping other countries. >> quite correct. >> thank you very much, senator. i want to thank this panel. we're running very late. but it's been very informative. we thank you all very, very much for your great leadership. the record will remain open for ten days. i hope we can continue to call you for advice and consultation moving ahead on this. >> thank you very much. >> now we'll call our second panel. dr. kent brantly and ishmel. dr. brantly workeded in the liberyany factory. we're thankful he's recovered and feeling well enough to provide us his unique insight as both a are provider and a

patient. dr. brantly is joined today by his wife amber. we welcome you here also. dr. brantly, thank you for being here. and ishmel charles is a survivor of the sierra leone war. he manages all projects, including ebola awareness and prevention in 11 communities in the rural district of sierra leone. thank you also for being here today. we'll start with dr. brantly. dr. brantly, your statement will be made part of the record in its entirety, as will yours, mr. charles. and again, i apologize for the long period. you can tell the people here are very interested in what's

happening with ebola, and you bring a very unique perspective. you've had ebola. you are alive and well today. you are a provider. so dr. brantly welcome. and your statement is in the record in entirety. please proceed as you so desire. >> thank you very much, mr. chairman. chairman harkin, esteemed senators, guests of this committee, i'm grateful for the opportunity to testify before you today about the unprecedented ebola outbreak that's occurring in west africa. it's already claimed thousands of lives and there ettens to kill tens of thousands more. let me also take this opportunity to thank each and every one of you. i know many people, maybe some of you on this committee who helped bring a role in bringing me home when i was so sick, and i just want to say thank you. on october 16th, 2013, i moved to liberia with my family to serve as a medical missionary at

elau hospital in the capital city of morovia. i worked for a system to help the woefully inadequate health care system in a country still struggling to recover from a brutal civil war. in late march of this year we learned there were cases of ebola in our region, and we began preparing our staff as well as our facility to be ready to care for patients in the safest way possible, should that need arise. three months later in june, our hospital had the only available ebola treatment unit in southern liberia, and i was one of two physicians to treat the first infected individuals in that area. from june 11th when we received our first patient until july 20th, the number of cases continued to grow at an incredible rate. the disease was spiraling out of control, and it was clear we were not equipped to fight it effectively on our own. we began to call for more international assistance, but ore pleas appeared to fall on

deaf ears. as the ebola virus continued to consume my patients, i witnessed the horror this disease visits upon its victims. the intense pain and humiliation of those who suffer with it. the irrational fear and superstition that pervades communities. and the violent and unrest that now threatens entire nations. then on july 23rd i fell ill. three days later i learned i had tested positive for ebola virus disease, and i came to understand firsthand what my patients had suffered. i was isolated and unsure if i would ever see my family again. even though i knew most of my caregivers, i could see nothing but their eyes through their protective goggles when they came to treat me. i experienced the humiliation of losing control of my body functions, and i faced the horror of vomiting blood, a sign of the internal bleeding that could have led to my death.

i'm grateful to the team that worked tireless to keep me alive in liberia, and despite a severe lack of medical resources, they were courageous i was then evacuated to emery university hospital where i eventually became one of the few to recover from ebola. as a survivor, it's not only my privilege but it is my duty to speak out on behalf of the people of west africa who continue to face unspeakable devastation because of this horrific disease. this unprecedented outbreak received very little notice from the international community until the events of mid-july when nancy writebol and i became infected. since that time there's been intense media attention and increased awareness of the situation on the ground in west africa. the response to date, however, has remained sluggish and unacceptably out of step with

the scope and size of what is before us. the united states government has been closely following the events in west africa since that time if not before. and only now are we seeing a significant commitment to a solution. i had the privilege and honor of meeting with president obama this morning, and we discussed his equipment of more military and medical resources to fight this epidemic. he has also requested increased funding for the cdc. i thanked him for entering into this battle with us in a larger. and now it is imperative that these words are backed up by immediate action. to control this outbreak and save the lives of thousands of west africans and possibly many americans, we need the promised ebola treatment units. the surge in health care workers. the u.s. military regional command and control center and we need it immediately. we also need the 400,000 home treatment kits that have been committed to be sent without

delay. there's no time to waste if we are to contain ebola and adequately care for the thousands of people that ep d m just weeks. we must have personnel and medical supplies and to continue bringing in more resources in the future. we cannot turn the tide of this disease without regular flights of personnels and large cargo loads of equipment and supplies. i'm grateful to the president for his decision to send tens and thousands of test kits to the region. but these will only be helpful if we also deploy all available mobile laboratories and increase funding for more to built as quickly as possible. during my time in liberia, the laboratory we used to confirm ebola virus innext in patients was 45 minutes away from the hospital and inadequately

staffed. the turnaround time to positively identify an ebola case was anywhere from 12 to 36 hours after the blood was drawn. if a patient is not infected with the virus, that can be a life threatening delay. more kits are not effective unless we have the facilities and the staffing to use them. as the first human being to use the experimental drug, i'm a strong advocate if for the cdc and nih as they research vaccines and drugs that we've just heard about, and these drugs can give patients hope for recove recovery. i'm deeply grateful to the personnel who before this outbreak dedicated their lives to combatting ebola. we cannot wait, however, for a magic bullet to halt the spread of this virus in west africa. the current epidemic is beyond anything we have seen before, and it's time to think outside the box.

i realize that home health care interventio interventions can be controversial, hour we knwever, many ebola positive people are staying home and hiding because of fear and superstition their families either abandon them or lovingly care for them in ways that always result in infection of the caregivers. this is a major contributor to the spread of ebola and we cannot con train the disease without addressing this problem head on. caregivers must be trained in safety measures and supplied with basic protective equipment so they can care for their loved ones while protecting themes. as the number of survivors increases, these individuals should be mobilized. they would be a powerful witness the disease is not 100% fatal and they could provide much needed support for those trying to do the best for their family members.

in the home it's impossible to administer iv fluids and other supportive medical interventions, however, there are not enough beds in the ebola treatment units right now and many are choosing to suffer and die at home. the least we can do is try to give their caregivers the information and resources we need to protect themselves from this deadly virus. all of these interventions that are needed to stop this horrendous transnational outbreak require significant funding and budgets must be adjusted appropriately. this is not simply a matter of providing humanitarian aid, it's very much a national security concern. one of my patients in liberia was a man named francis. like most patients, at first he was fearful. but eventually he shared the story of how he contracted the disease. he said to me, doc, i remember who the man was he got this

infection from. he was sick at home and his condition worsened and when he began vomiting blood everyone around him fled, but his wife was determined to get him to the hospital. since no one was around to help, francis went to this man's help and helped carry him out of the the house and put him in a taxi. on the way to the hospital that man died. if someone had come alongside francis and given him a little bit of education and provided him with the personal protective equipment he needed, his family would still have tear father and their son and their brother and the world might still have this good samaritan. but unfortunately francis fell victim to ebola and died. many, including one of the senators today used the analogy of a fire burning out of control to describe this unprecedented outbreak.

indeed it is a fire. it is a fire straight from the pit of hell. we cannot fool ourselves into thinking the vast mote of the atlantic ocean will protect us from the flames of this fire. instead we must move quickly and immediately to deliver the promises made and to be open to practical innovative interventions. this is the only way to keep entire nations from being reduced to ashes. thank you very much, mr. chairman. >> thank you, dr. brantly. thank you for your courage and for being here, your example. but mr. charles, welcome and please proceed. >> thank you very much. chairman harkin, senators, dr. brantly and fellow guests of this committee, thank you for the opportunity to allow me to

come all the way from west africa and testify in front of you today. my name is ishmel alfred charles from sierra leone. i'm married. i'm a father of two children. nine months and 5 years. i arrived yesterday around 2:00 a.m. to share with you what my country is currently dealing with on a daily basis with the current ebola outbreak. while still trying to rebuild from the bruised civil war, unlike the civil war, sierra leone outbreaks creating more fear to the entire population. that's one goal. in the civil war it was a time the population would be afraid of the attack.

today the general atmosphere in my country and among all africans within the west african region are afraid of fear. the biggest crisis that we've ever faced. bigger than even the civil war. as a former child soldier, i was able to survive the war. but i fear that this is going to be worse than the war. the foundation based in new jersey supports the rebuilding of health care services in sierra leone and provided relief and a lot of support to war torn countries like sierra leone, and they have been working in sierra leone for more than 12 years. the foundation's mission is to invest and support families affected by disaster, war, adverse social economic conditions. through the delivery of health

care, food, and training and other kinds of programs. hence the money to power committees and build the capacity to become self sustained. the foundation partners with the free town. of which i am placed with. and they run all the foundation projects in sierra leone. the mission is to eradicate poverty, corruption, injustice, improve equality, advance good governing and empower women and the disabled. as a spokesperson for the healing and national relief foundation in sierra leone, i feel privileged to share with you our experience on the ground in the war fronts.

as it is today sierra leone is considereded to be a war front, and so is guinea and other west african countries. since the outbreak, we have the ebola outbreak projects in the districts. we work closely with the administration of health and sanitation. this shows that smaller organizations with lower human capacity and budgets are able to make impacts at the lowest level because they live within the community and they understand the reality on the ground. as part of this project we have been working with a number of communities in the western districts and about 219,000 people raising awareness, providing chlorine to kill the

virus. soap and buckets to police stations and police posts. in addition, we have strong national media in clab rax with other regions of the country. the growing number of cases are recalled on a daily basis has made the situation in sierra leone very scary. each day the situation becomes worse and the effects of ebola cannot be overemphasized as dr. brantly painted a picture very clearly for you to see. when i was about to leave, my 10-year-old daughter asked me, she said dad are you going to leave us in this country and go to america where there is no ebola? i said to her for a minute and said ma, as i call her, my trip

is for general good of the family. and for your future. i will be back in two weeks. and she said again, are you sure? because every day flights have been canceled. as i speak there are only two flights going to sierra leone, liberia. similarly, my wife said, dear, the morning you leave normally when you travel is not going to be enough this time around because the prize of commodities have tripled. what i'm trying to say in essence the situation in sierra leone is getting very difficult every day. and so it is in other countries that have been faced with the current outbreak challenge hean

the economic burden is getting very heavy on a number of people. as i was about to leave my biggest concern was the situation if anyone get sick behind me, the health system is not functional. when you go to a hospital the doctors are not there anymore. and they are there they deny they are not doctors because they're afraid they might be infected. they're not sure what sort of sickness a patient might have come in with. the ebola phobia is increasing. even people who do not have ebola are being stigmatized. we have suffered. now let's talk about those who have tested positive. -- the to call the it ebola response. people are losing their confidence every day. the ebola cry sus has escalated

into a wide economic situation and has damaged further the health care systems which are not prepared to manage such a difficult situation. harvest has been canceled because too many farmers are dying. in the capital free town, hotels have very few number of guests. a very big hotel who may have the capacity to house 300 guests may have 4 guests or even less. and the hotels keep dropping their staff every day because they don't have the money, the resources to take care of this stuff. and these are parents that have families they need to take care of. in a country with 70% illiteracy, schools have been closed indefinitely because of ebola. we have no idea when we're going to reopen the schools.

our country has high orphan population, and ebola is increasing that on a daily basis. there the foundation we were able to make donations to the ministry of social welfare and support the ministry of social welfare who are currently taking care of the ebola offense. we're also very careful this will be stigmatized and could be positive. it's a very bad situation. people do not have the free will to bury their loved ones anymore and show the compassion and care and emotional love, which normally helps people to recover very fast when you know that you have support around you. flights have been canceled. the commission situation is getting worse every day. as a result, households are struggling. not just the ebola killing

people in sierra leone. poverty, hunger lack of medical facilities. families go hungry when breadwinner dies or gets sick or loses their job. which is happening on a daily basis. with @ support of the united states, the international community and the spirits of sierra leone, we believe we will put ebola at our back. however, a decade of progress will be lost. especially so when already the health facilities were in bad shape before the outbreak. i plead to this house and to the united states and international communities not to leave sierra

leone when the outbreak might subside. we will need to help invest in sierra leone so we can be able to be self reliant again. we will not need to continue to rely on international support. if we are self sustainable we will be able to have had a cdc report that the doctor spoke about. she gave a number of incidents or instances specifically talking about liberia. every picture that she painted is equally as devastating in sierra leone. and probably even worse. the numbers that the government gives on a daily basis of infections, of infected people is definitely way less than what is really happening on the ground. for various reasons. and the health facilities, all

the support that we have currently does not mean much with the number of professionals that we have. lastly, i want to thank this house for listening to me. and please, we will look forward to the continued support of the the united states in sierra leone. i thank you very much for your attention and if for the privilege you give me in listening to me. thank you. >> well, thank you mr. charles, and both of you. it's always important to put a human face on matters like this. i think people read about it. you get the numbers. you say it's horrible. but again you have to understand the human impact and what this is going to your families in your country, in liberia, and

other countries. and the nature that i'm now beginning to understand of how if we don't get it controlled soon, it will spiral out of control and it will have the devastating effects that mr. charles is talking about. business will end. the whole economy will start grinding to a halt. dr. brantly, first of all, i'm sure i can speak for many americans around the world when i say thank you. thank you for being such an example for all of us on how to serve others. we regularly thank our soldiers for marching into harm's way. rightfully so. let me say this is no different. you and others like you run towards the risk to help those

standing in the path of this terrible disease. so i want to include you and others like you in that pantheon of american heros. you do us proud. real proud. i just -- i have so many questions, but i know we're running out of time. but i guess, dr. brantly, what i would probably ask you first is with all that you know, and you've been there with your family. you know what the situation is like. give me, one, two, three, what's the most important thing we can do now? what's the most important response that we can do now? >> thank you, mr. chairman. >> if the you were in charge and you had a magic wand, what would you do with it? >> i think one of the the most important points is in your very question. we have to do it now.

this has been in the eye of the government for months. we can't afford to wait months or even weeks to take action. to put people on the ground to begin opening the logistical bridges and pathways, to begin going out into the communes and educate i educating caregivers. it's not that we're trying to keep people at home. but we need to increase the capacity to care for them. and that means not only creating more beds but having the staff to care for them in the beds. putting them in a bed may keep them in giving the disease to somebody else. it does nothing to improve their chances of survival unless they're receiving good, quality support of care. so we need more capacity in ebola treatment units, but we must have the staff for them as well. and we need to start educating people right now in their communities about how to safely care for their family members

who are hiding at home dying from ebola and ashamed or scared of their own situation. >> you must have a -- you have to have a valuable perspective on liberian culture and societying having been there. we send in a lot of people. they don't understand the situation. and the people actually become more afraid of the workers we send in if they're not adequately trained and equipped. >> i think that's a very real possibility, mr. chairman. i think, yes, liberia's civil war ended ten years ago. but think about the situation in the united states ten years after our own civil war. there was still a lot of tension. and in liberia there's still a

lot of tension. and there's a sense of distrust. distrust of government, distrust of foreigners. so yes, people will be resistant to health. but i think because of the devastation of this outbreak, even those people who have been resistant to help are starting to see the need for some assistance, and i think that's why it's important we don't just march in with the military and take over, but we partner with the ngos, like doctors without borders and samaritan's purse and the administrative health of liberia so that it's a partnership and we're using people like the survivors from ebola. there are being more and more survivors every day in places where they can get good, supportive care. and those survivors are the ones who can go out in what you refer to as a culturely appropriate way, educate and support their communities and distribute the needed personal protective equipment to protect those home care providers.

and i think that is very much an important part of the strategy. but again it has to start now. it has to start in a matter of days. from the time i fell sick, just less than two months ago, the death toll has tripled. if we take two months to get our response up and going, even if we only maintained that rate of growth, we're looking at thousands and tens of thousands and in nine months down the road we're looking at hundreds of thousands, of not only cases of ebola but deaths. and we can't afford that. >> that's where i hope our military air lift capability will come in and start moving material and personnel over there. senator alexander? >> dr. brantly, mr. charles. thank you both. mr. charles, thank you for your work in prevention and bringing awareness here and drchl brantly, thanks for being a good

samaritan and we greatly admire what you've done. you're a survivor of ebola. is it like cancer that is in remission? are you cured? or do you know? >> thank you, senator? i'm cured from ebola. >> so it's gone from you. >> yes, when a person survivors ebola, when they recover, they're not a carrier of the virus. the dr. at emery university was very clear to say we pose no public health risk. so there's no risk to the public from a survivor. there's a lot of stigma attached to being a survivor of ebola. but we could -- >> can an ebola survivor become infected once again? or are you then immune from ebola? >> in theory, and i think in

practice, i am immune to the strain of ebola that i was infected with. but there are five different strains of ebola. if i went to the democratic republic of con go, i may not be immune to the strain causing outbreak there. >> you talked about you treated a lot of patients. would you say it's accurate that about half the patients who are infected die, or is it higher or lower than that? >> unfortunately, senator, in my experience we did not have a 50% mortality rate or survivor rate in our facility. as we saw patients early on in the outbreak, they were usually showing up very lace in the course. and in the month and a half that i treated patients we had one survivor. >> from the time you discover an infection until death, how long is that typically? >> it varies greatly depending on how early the person seeks

care. we had people that came and died within a matter of hours and we had others who were under our care for a matter of days, four or five or six days before they passed away. >> but it's not months? >> no, the illness is generally two weeks. by the end of two weeks the person has either died or they're on the road to recovery. >> that's one thing it's such a concern is because it's so explosive and moves so rapidly, is that right? i hear you talking about a lot of people at home sick for a variety of reasons. we don't know about them. we've heard the official statistics say less than 5,000 infections. sounds to me like there might be many more. >> i think that's very accurate, sir. as many of the witnesses said, those numbers are based on the cases we have tested and identified but there are many more at home.

>> so there's many more and the course may last a couple of weeks and you're either dead or a survivor in that point in time. in your experience all but one died, and the others, they say half. the official statistics say the cases double. the official cases have doubled over the last three weeks, so you don't have to do much math to see that the numbers are, as you say, can quickly go to tens of thousands, hundreds of thousands if we don't get control. am i correct the home health kits are primarily for the benefit of the caregivers? to keep the infection from spread sng does it make the home sort of a hospice for the infected person with ebola? >> i think that's a fair way to look at it. as i said, you can't carry out complicated medical interventions in a home, but you can give people oral rehydration

solution. you can give them tylenol to help with the fever and pain. but the most important part of that kit is the part that offers protection to the caregiver. because without that we're not stopping transmission. and that's what has to happen to control the the epidemic. is to strap top the transmissio this disease. >> you took a great risk in going there and it's obvious from the testimony of you and mr. charles and others that we'll need hundreds, thousands of people, in addition to the soldiers who are going. what would you say to others, people like yourself. we have a tradition in this country of doctors without borders, samaritan's purse, of which you were a part. what would you say to americans who are seeing this and trying to decide whether to go to west

africa to help control this disease? >> thank you, mr. senator. this is a topic very dear to my heart. i think the international president of doctors without borders said it very well in a recent article. she said, comparing ebola to a fire, this is not the time to run away. this is the time to put on our protective gear and run into the burning building. the physicians and health care proegsales even if just symbolic have taken an oath. in many institutions they still take the hippocratic oath, and that oath is to the service of mankind. and i think if we can help people overcome the fear of facing a deadly disease and

remember this is not just a disease. these are people who need help. these are societies collapsing because of the weight of this burden. we just need people to go help. >> well, this was -- oh, i'm sorry. >> thank you, mr. chairman. dr. brantly, mr. charles, thank you for being here. mr. charles, when you go back and see those girls, your daughters, i hope you'll share with them that the purpose of this committee is to try to make sure we can process enough fact to make sure that we can provide what's needed from a standpoint of the resources.

there are other pieces of government that has the responsibility to get them there, to train, to equip. but we have to make sure that we have the resources. and what you have shared with us, both of us, is invaluable from a standpoint of how we look at it. and as both senators said, to see the human face behind the issue is absolutely crucial to those of us who sit on this committee and in this institution and ask taxpayers to fund things from people that they'll never meet. but i do have a couple of questions. dr. brantly, are you convinced that it played a role