report, found that the federal government continues to face cybersecurity challenges. including designing and implementing risk-based cybersecurity programs at federal agent situation. establishing and identifying standards for critical infrastructures, and detecting and responding to and mitigating cyber incidents. and since that report, we've got 28 gao additional recommendations. and i know that we've been talking about today in this hearing. in fact, gao has designated federal information security as a high-risk area in the federal government since 1997. and i think that there isn't anyone on this committee, or anyone in congress, or the public that doesn't think that more should be done. and in fact, that we embrace every potential positive, productive recommendation moving forward. so given that, ms. tavenner,

knowing that the upcoming november enrollment period is coming for millions of americans, who will be shopping on the exchanges, how prepared are you to take these 28 recommendations and others to assure protection? >> yes, ma'am. let me start with the 22 technical recommendations. 19 of those have been resolved or mitigated or will be further reviewed prior to open enrollment. so those will be handled. of the six other recommendations, we're in the process of either completing -- have completed those, or will complete those prior to open enrollment. >> and based on the 19 that you've identified, miss tavenner, and the remaining measures to implement, you are confident that not only are they implemented, but they're tested, and will have to the greatest degree -- i might disagree with some of my colleagues that we can do everything in our power,

and those hostile, those negative, those who intend us harm and intend to access that information for their own gain will find ways to do that. i want to make sure that we're doing everything that we know that mitigates and prevents and gives us the opportunity to also detect when there's been a problem. you're confident that these will be tested and in place by the open enrollment period? >> i am confident. but we will never quit continuing to try to improve the process. our work with the department of homeland security, our work with gao, org, will always be looking for improvements. >> i appreciate that. and given that we're working on another issue in my state, i appreciate your attention to that. and your coming. mr. chairman, we're working on a behavioral health issue. for me, it all ties to making sure that consumers have confidence, that they're protected in a way that cms is responsible to protect those citizens, that they are clear, that your responsibility and oversight is paramount to the

work that you do. and that the access to health care is only as good as making sure that the information and the protections that are required by law are in fact in place, and that they can go to cms when there's a problem and have that resolved objectively and appropriately. i really appreciate your attention to all those matters. >> thank you. >> i yield. >> miss tavenner, i just want to make sure that i understood what you just said. and i agree with every word that my colleague just said. but you're saying that there are six recommendations left, is that right? >> sorry. there were six major -- correct me if this is wrong -- there were six major recommendations. and we're in the process of completing those. and some of them are done. and the answer to those is, all of them will be done prior to open enrollment. >> and that starts when?

>> november 15th. >> would you let us know officially when they are done? >> yes, sir. >> because the chairman and myself -- i'd really appreciate that. >> if the gentlelady would yield. you didn't agree to all six, but three out of the six. you will now agree and complete all six? >> i think in some of them, we partially concurred. we're getting the work done. whether we totally agreed or not, i think there were some things, for instance, there was a different description of how we did security testing versus what gao wanted. that wasn't an action we would change, but we understand where they're coming from. we just have a different way of getting the security testing done. the rest of these things, such as the privacy impact statement, we will have that done. that was a documentation issue. the computer matching agreements with peace corps and opm, we'll

get that done before open enrollment. with equifax, we'll complete that. the 22 technical recommendations, 19, we've already done the others we're reviewing. i'll be happy to do something in writing back to the chairman, and to the -- >> i think we both would proesht it. gentleman from north carolina. >> i wanted to follow up on one thing, miss tavenner. it really, as we start to focus on some of these other issues, it takes our eyes off of the core issue, and that's what the ranking member is talking about, is providing health care, really, to the american public. and that's your primary responsibility. i can tell that you take that seriously. it is a distraction, to say the least, when we have a billion dollars spent on a website that doesn't work, security issues that are there. but along that same time, there was a rule that came out with

regards to medicare part "d" in january. that a rule that really would limit some of the options of our seniors. a rule that you came much to your credit and said, we're not going to do. and i want to say thank you for doing that on behalf of millions of senior citizens who would have seen choices limited. do i have your assurances here today that we are not going to put forth a rule that is similar in nature to that rule that was brought back? i very rarely have an opportunity to have you in a public forum under oath, so on behalf of millions of americans, do i have your assurances that we're not going to do it? i think you made a good decision. my mom who's a senior citizen thinks that you made a good

decision. so do i have your assurances that we will not see a similar rule? >> i'm not interested in bringing back the pieces that we pulled. >> that's a good almost answer. so do i have your assurances, yes or no? >> yes, my assurances i won't bring back the things i just pulled, how about that. >> or something similar. let me tell you the reason why. and it gets back to cbo indicates that much of the reason that it is working so well is the competitive nature that we have. i mean, that's what the study says. and yet we're going to limit competition. we're going to limit options for our seniors. some cancer, some antidepressants, some anti-epileptic. these are serious things. and so you and i can banter back and forth, but really, what i need is on behalf of the american people, your assurances

here today that that's not going to happen? >> now you're bringing in specifics. i'm not interested in bringing back the drug categories if that's the question. i am interested in promoting competition, promoting private market. and i think we've tried to do that with the marketplace rules as well. we would continue to work with that. >> we're not going to limit competition and we're not going to narrow what people can get? >> that would be my preference, yes, sir. >> that's your assurance? >> that's my assurance. >> all right. thank you. i yield back. >> could you yield to me? >> be glad to. >> briefly, item 4 from the gao says perform a comprehensive security assessment of the ffm, including the infrastructure platform and software elements. initially that was one you said no to. are you saying you will perform that full systemwide test and have it done by november 15th? because that's sort of the one that gao couldn't -- we can't

know what we don't know until you do that, right? >> the mic, please. >> we get into a discussion of style here. it is our intention, and we will complete a full end-to-end security assessment prior to open enrollment, yes, sir. that's scheduled for later this month, or october. i think where we got into a different kind of construction, it had to do with infrastructure and platform and our definitions. but i think our intentions are the same. >> why don't we let, greg, give us the rest of it. >> as long as the tests that they perform includes how the applications enter the phase of what the operating platforms and infrastructure, to look at it in totality is going to be critical. because certain vulnerabilities on certain layers of the security could affect the security of the other components of it. because there are a number of components involved with this

website and supporting systems, and a number of different entities involved with their operation. >> and so for the layperson out there, would it be fair to say that, for example, when software opens a portal on a particular piece of equipment, that that can create a vulnerability, and one type of hardware, that it wouldn't in another. that that's the type of thing that they actually have to look at the type of hardware they're using, what it interfaces with and so on, is that right? >> to include looking at the fire walls and routers and switches that support it, as well as the operating systems and how they're being configured, yes, sir. >> and i assume any remote access to devices, vpns, all of that would be part of it. as i understand it, one pc that has a vpn connection that isn't in the software, that once you put it in, it can create a separate vulnerability, right? so if i saw the heads nod, and i

like that, the two of you -- one of you is going to come back to the ranking member and myself if this agreement that you're going to do this by november 15th doesn't happen, is that right? maybe both of you? >> i would be willing to work with your staff to do follow-up. >> i think that's all that mr. cummings and i would like to know. since you're shaking your heads and now, if that stops between now and november 15th, one of you will tell us. >> yes, sir. >> mr. cummings? >> i'm going to encourage you to do that. just do it, please. >> we will do that. >> and i'm not trying to be smart. miss tavenner, i know -- and all of you, i know you're trying to do what's in the best interests of the american people. i understand that. but it seems as if what we want is the highest level of best practice. am i right, mr. chairman? >> absolutely.

>> and miss tavenner, i couldn't help but -- when i was thanking you on behalf of my constituents, i could see a tear come up in your eye. you know, soh=k÷ often i think federal employees -- a lot of people don't realize that a lot of our employees, most of them are not in government for the money. they're in it -- and i have people coming to work for our committee all the time who are willing to take reduction of salaries from the private sector, because there's something about this that feeds their souls. something about lifting up the public, and making their lives better. so to all of you, and to all of the federal employees who may be listening out, and the ones behind you, miss tavenner, and all of those in the audience and up here, i just want to thank you very much. thank you. >> thank you. i understand the gentlelady from

new mexico, did you have any follow-up questions? >> mr. chairman, i don't. i was thanking you. i thank both the leadership that we get feedback, and they represented very effectively all of my concerns and points. so thank you very much for your leadership. >> thank you. i've got a couple very quick wrap-ups that came out of these. big smile, because we're nearing the end. there was a question about more people being insured. and i just have to ask, is medicaid insurance? >> in my opinion, medicaid is insurance, for sure. but that was not -- >> but the actual level of insurance under medicaid, that was talked about, it's medicaid insurance, that's what's lowering the number of uninsured is medicaid? >> plus the marketplace, lowering that number. >> which has been subsidies primarily?

the actual number of people who are receiving unsubsidized health care has gone down, is that right? >> you know, i don't have all the reports in front of me, but actually, the number of people insured off the exchange without subsidy is also rising. i don't have the latest private insurance -- private insurance had a negative trim going on for the last ten years. that seems to kind of stabilized out. if you add medicaid, and you add the marketplace exchange with or without subsidy, i think that's what you're seeing this falling -- >> the reason this question led to this sort of feeling that everything was better, but isn't it true that the medicare trustee, charles blahouse, he projected that by 2021, the impact of the affordable care act will be a 346 to $427 billion increase in the deficit.

essentially, because the government's going to pay that 100%, and then 90% for medicaid, the government is in fact the taxpayer, so the deficit will rise based on the money that buys that insurance, is that true? >> i'm not familiar with that report. >> okay. but the government is -- general tax revenues are in fact paying for these subsidies and medicaid, it doesn't come out of a trust fund. medicaid is ordinary income tax. is that correct? >> i'm sure that you know that, mr. chairman. i don't. >> for the record, medicaid is paid out of income tax, and much of medicare is paid out of income tax, that the trust fund, when we talk about it, only pays for a small part of what our seniors reflect. now, really, the final question, and it's one that deeply concerns me, and it wasn't the main topic today, but it's right in your lane. on may 15th, you projected 8

million as an enrollment number. august it's now 7.3. what happened to that 700,000 to 800,000 people? why was there such a precipitous drop? >> the 8 million individuals, and i think that number was after the end of open enrollment, had signed up. and i think during the course of the next several months, individuals may have either gotten employer sponsors insurance, they may have found other eligible for medicaid instead of the marketplace, and some individuals may have decided not to go forward and pay. i think there was always -- >> that's a great question. and the reason i ask that question is, people were asserting that signing up meant nothing, and paying meant everything. how much of that 700,000-plus drop were people who did not pay? or do you know?

>> i don't know that information. >> wouldn't it be all of those people did not pay? >> i don't think we'll know that until the end of the year. >> let me ask the question a different way. i'm an old businessman. people signed up, they were there for insurance, is that correct? they enrolled, they were insured. >> these were people who signed up for a plan. in order to get insured, you had to make a payment, right. >> no, they were insured right away, and then if they didn't make the payment, they went off. >> 90 days, right. >> they basically got a free ride, 700,000 people had a free ride. they had coverage. and if something catastrophic happened, they could make a payment. and if something catastrophic didn't happen, they could just let it drop. >> i don't think we know that information. >> no, but this is a structural question that i know you must know, or the technical people behind you must know. if 8 million people sign up,

let's just say 8 million people sign up and not the 700,000 who dropped, let's just say 50 people out of 8 million had a health event, and they weren't going to pay, they just signed up on a lark because it's a free ride to sign up. but then they had a health event, did they get to go to the doctor during that 90 days, because they had signed up and hadn't yet paid? >> yes. >> so the system as it is today is an incredibly easily gamed system, if i understand correctly? 316 million americans could all sign up, and get 90 days worth of free insurance, and if nothing happened, there's no down side, that they're just letting it lapse by not making a payment, is that right? you don't dunn them, you don't go after them, you don't sue them foreign the coverage they had, but never paid for, do you? >> which i think is why it's important to know that as of august, 7.3 million were still making their payments and were

still continuing the insurance. >> 7.3 million people may have made small payments because they were highly subsidized or larger payments because they weren't. are you prepared to release those figures anytime soon so we understand the 7.3 million, how many of them, if any, it would be some, were completely unsubsidized, how many were substantially subsidized? >> as soon as we have that information, we'll release it. >> estimate when? >> i don't have an estimate, but i'm happy to get that for you.÷ >> okay. being an old businessman, i must admit that giving people 90 days free, and no retrospective look to find out whether in fact they were maybe dual insuring, just signing up for a lark, to me

means people should be cynics and say, we don't know how many people have signed up, but next year, starting november 15th, i'm presuming that if gao is going to estimate the signups, they're going to be able to only use, that if you get 8 million again, they can assume 7.3 is the net number, right? >> 7.3 is a very strong number. i would remind you the people who sign up and get tax credits have a reconciliation process next april. >> yeah, we're looking forward to that part. this committee held a hearing, and on the issue of over $15 billion owed to the american people by the state of new york, for excess payments in violation of the law, in violation of cmx maximums, that falls under your watch. have you done anything to reclaim that $15 billion? >> yes, sir, we have. >> have you gotten any of it back? >> we recently initiated that.

i don't think we've gotten any of this back yet. but we sent basically the request for recovery. >> you've made a request for recovery. >> we follow our normal process. >> do you have the authority to simply withhold as you would to a private entity? if i'm a doctor, and i overbill $15 billion, or maybe some minor amount less than that, if i'm less hard working, the first thing you would do is cut off payments for services, right? you simply wouldn't send them a penny. you're sending millions or billions of dollars to new york every month, aren't you? >> i can brief you or your team on this in some detail. whether it's a doctor or entity or whatever, we ask them how they would like to repay us. and we -- >> i wish that were true. i think too many health care entities who make it very clear, your people come in, you make a determination, the moment you make a determination, they

basically have to quit their practices and go into an appeal process. and in the meantime, they're not receiving a penny, and you claw back. you want to state that in a way that the private sector people don't call me up and say, how did you let her say that you give people lots of time and ask them how they'd like to repay it. >> i think you know i was on the private sector side for quite a period of time. if there's ever a question of overpayment, yes, cms will make you aware of an overpayment situation. >> and claw back real fast. >> dmls you want to pay them up front. >> if you're able to write a $15 billion check, they won't deduct from the revenue. >> right. >> is new york prepared to give you a $15 billion check? >> i can't speak for new york. >> but right now, new york, and perhaps others, owe the american people money from excess payments. and they're not being treated the way private sector is being treated. they're being treated a little bit with kid gloves. $15 billion is a lot of money. >> actually, we went through the first year and we made a request, or demand for the

money. and i'm happy to brief your staff on that. >> will the gentleman yield? >> of course. >> you have hit on an area that we have had a number of hearings already with regards to rack audits. i would implore you to treat new york the same way you're treating the constituents in my home state of north carolina. because very quickly, what you do is you put private companies out of business. you deny the claim, and you say, you either pay up or you go home. and if you're not going to treat new york the same way you treat north carolina, i've got a real issue with it, miss tavenner. >> we would treat new york the same way which treat every other state. >> no, i'm talking about government versus private. i'm not -- >> we would treat new york the same way we would treat anyone who owes these funds. new york, i just got this information from my staff, has appealed this decision, which is the same option that anyone has.

>> right. and a private company when they appeal, the answer is the same. pay up in five years or go out of business. >> i understand. >> the statute says, 60 months. i know it very well. >> i know. we have treated the states the same way we treat providers. i'm happy to get you the information. >> i yield back. thank you. >> i thank you both. we'll go to the ranking member. i appreciate your staff's assistance. although it's an issue that you know is never going away before this committee, it wasn't the main subject for today. mr. cummings? >> i want to go back to the 7.3 million people who paid their premiums. and i guess 700,000 who did not. there are all kinds of reasons, i guess, why people may not pay their premiums. and a lot of people in our society are still struggling with all kinds of things. you talked about a reconciliation process. can you talk about that for a

moment? >> the way that it works is individuals -- the 90-day grace period is set up to give individuals an opportunity to pay. at the same time, they start to receive tax credits. these tax credits are reconciled the next year on their income tax returns. if people have underpaid on their aptc, then they are likely to get a tax credit back. if they have over -- let's say they received a higher aptc, they may owe the federal government back. that's the partnership we have with the irs. i don't think that the 700,000 is -- in fact, i was very pleased to know we have payment levels at 90%. this is a brand-new program. this has never been done before. i think by the end of '14, and as we start to look back on '14,

we'll understand the circumstances. i expect in some cases they may have moved, they may have gotten married, they may have gotten insured, they may have lost their income and gone on medicaid or into the uninsureds ranks. we'll only know that as we look back. we're careful not to look back too early. >> these are not necessarily people trying to game the system. >> no, sir. >> i see folks every day that they're still being informed as to what the affordable care is all about -- the act is all about. and trying to make it one says, working nine to five just to stay alive. sometimes in my district it's working two jobs just to stay alive. they're struggling trying to manage all this information, trying to do the best they can to take care of their families and many of them going through very difficult circumstances. >> that's right. >> thank you very much. >> thank you. >> the gentleman from virginia,

normally the first to arrive, we just finished round three in the close. would the gentleman have some questions? >> i thank the chairman -- i was on the house foreign affairs committee with the secretary of state, forgive me for being late. >> i'm sure the questions there were provocative, so -- >> yes. welcome to the panel. mr. wilshusen, would it be unreasonable of us to suggest that no company, no government, no individual should feel entirely secure and safe in the digital age? >> i would say if you're referring to use of online transactions on the internet, and the like, that there are certainly risks associated with that. just given the weaknesses and the nature of the internet, as well as the competency and prevalence of hackers who might

wish to exploit those weaknesses. >> the issue of securing public and private information systems, i assume it's not something you need for the affordable care act implementation? >> no, it's an issue for any computer system operated by any agency, any organization. there's always a need to protect that information. and certainly, as we mentioned earlier, within the federal government, they've been identifying high-risk areas since 1997. >> right. since 1997. >> yes, sir. >> two administrations ago. >> probably. >> right. and welcome to our committee. >> thank you, sir. >> i think. it may not have been entirely

elicited at the beginning of the hearing, but i welcome you and thank you for your work. let me ask a question. one of the things we hear about the rollout of the website in retrospect is that the coordination of i.t. management is disparate, not always focused, and perhaps was seen as a technical issue while, you know, cms and the department of health and human services were focused on sort of the bigger picture and the reforms getting in place, and the pieces finally fitting into the mosaic, and maybe this got short shrift. it turned out to be the achilles heel. the whole enterprise was at risk because of this failure which was a technology issue. in looking back on it, what lessons did you learn as a manager, and is there some validity to that critique, from

your point of view? >> yes, sir, i think there's some validity to that critique. some of the lessons learned and changes that we've made early on in year one, and definitely year two, we needed a systems integrator. we needed a clear point of accountability. we needed better communication. and you're right, there was probably more time spent on the non-technical components and we didn't realize, as the technology was as difficult as it was. so those were lessons learned. i think we've put changes in place. we are very, very happy with the number who signed up. we have -- year two is going to be an equally hard year. it won't be perfection, it will be greatly improved, and we're looking forward to finding more uninsured and help people get coverage. >> thank you for that response.

finally, mr. wilshusen, are you familiar with the bill that the chairman and i have co-authored, called the federal information technology reform act, a month old? >> a little bit, sir. but not completely. >> well, that bill tries to get at how the federal government manages i.t. procurement, and acquisition, and it addresses interalia how the federal government is managed. and i think it's based on the conclusion that it's not well managed, and it's very inefficient, and there are too many people with the title cio, and what could go wrong with that. the estimate is the $82 billion we spend over the year is at least inefficiently used. sometimes downright unfortunately wasted. is it gao's position that we do

need some i.t. updates and reforms to kind of update on clinger cohen, which was almost 20 years ago in technology, that's light years. >> that's outside my particular area. i focus on information security and privacy issues. i can get that answer to you. >> that would be fine. but isn't information security related to how well we're managing our i.t. assets? >> oh, certainly. and certainly there is need for improvements in how i.t. is secured within the federal government. and by an implementation issue. we're also on record that the federal security management act that governs information across the government could also be updated and modified. >> again, i believe this committee and again the chairman, ranking member and i have been involved in that as well. but the house has certainly tried to address that. and with bipartisan common

ground on these issues, i urge you to look at the bill and see how it applies to your particular area. >> i will. >> i thank you. mr. chairman, thank you for allowing a shameless plug for our legislation one more time. >> well, in closing, it's not shameless, but it's a good plug. you know, i'll close because miss tavenner, we'll probably try to do everything without having you back. and i think we're on the right track. this is a committee that does legislation on a very bipartisan basis in most cases and it doesn't get reported. and then we have oversight, and perhaps it's not as bipartisan, and it often does get reported. i do think today's hearing was worthwhile. i believe that hopefully mr. cummings and i both expect that there will be a little bit more certainty as to the security that will come out of the website.

cms is critical to the american people. your role has been expanded perhaps more with the affordable care act than any item before. and mr. cummings often talks about the federal work force, and certainly about the good work that's being done. i want to close by saying, that just because we give you a hard time over item after item, just because a number of members asked about, what about these billions of dollars that were given to states for their failed websites, doesn't mean we think it's easy. just the opposite. we know it's hard. we want government to oversee itself, to the greatest extent possible. and it's the reason that we do appreciate and support the gao. we do appreciate and support the inspectors general. and that we try to be, if you will, their supporters in order to get the kinds of certainty and when necessary reforms that are necessary. so i want to thank you for being

here today. i think this was an informative hearing. and with that, mr. cummings gives me a yes, we stand adjourned. here's a look at tonight's primetime lineup on the c-span networks. on c-span, bill gates discusses the ebola outbreak in west africa. and his foundation's pledge to donate $50 million to fight the virus. on c-span2, the communicators, with federal trade commission member maureen ohlhausen, talking about privacy and data security. here on c-span3, a series of discussions on mars and science education, including a conversation with nasa administrator charld bolden on the difficulties nasa would face sending humans to mars. all tonight beginning at 8:00 p.m. eastern on the c-span networks. tomorrow, a hearing looking at the secret service's security

protocols, after an armed intruder entered the north portico of the white house. you can watch it live at 10:00 a.m. eastern on our companion network c-span. our campaign 2014 debate coverage continues on live on c-span 9:00 eastern tuesday, for the final texas governor debate between democrat wendy davis and state attorney general republican greg abbott, and live thursday night at 8:00 eastern, the oklahoma governor's debate between democrat joe dorman and incumbent governor mary fallin. watch the nebraska governor's debate between chuck hassebrook. the debate gor the control of congress. the head of the cdc, dr. tom

frieden, updated congress on the ebola outbreak in west africa. according to a new report from the cdc, there could be 1.4 million ebola cases in liberia and sierra leone by the end of january if the outbreak cannot be effectively controlled. this is 90 minutes. we are going to begin. as please come in, please grab your lunches. i'm the senior foreign policy adviser for senator kunz. i would just like to welcome everybody today. we have a remarkable panel. and we're very excited to have so many people interested, of course, in this critical, critical issue. i would like to thank anita for her effort to pull together this

event. thank you so much. i would also like to recognize the upmc center for health security for hosting this event. thank you for that. and i would like to turn it over to tom inglesby, our moderator today, who will introduce our distinguished panel. thank you. >> thank you, hailey, so much. and thank you to senator kunz, senator frank and to the senate foreign relations subcommittee on african affairs tor cohosting this event with us today. thank you to our distinguished guests whom i will introduce in a moment. and welcome, and thank you all for joining us today, for this very important discussion. we're very glad to have c-span here as well. so others can take part in this. for those of you who don't know, our center, the center for upmc are a nonprofit organization dedicated to protecting people's health from epidemics and

disasters. we're here today for a discussion of the urgent ebola crisis in west africa. there have been estimates in the last few days that project as many as 20,000 cases of ebola by november. and as many as 1.4 million cases of ebola by the end of january without an immediate and massive scaleup and successful response. there's terrible consequence and economic hardship on the ground. doctors and nurses have died in high numbers. and the health care systems have largely stopped functioning even for normal health care. ebola combines an extraordinary fatality rate with the capacity to spread by contact, and inability to treat with medicines or with vaccine, and doubling time as short as 20 days. there is no other infectious disease like this. a disease once relegated to remote villages is now threatening to take hold in

major cities in africa. but, there are also major new efforts under way by the u.s. government and by the w.h.o. and other governments in the world. cdc is making its largest international response in history. more than # 100 people on the ground in west africa, and atlanta providing expertise, tracing, et cetera, which we'll hear all about from dr. frieden. they're providing hundreds of thousands of home detection kits and people moving 100,000 units of epp to west africa. the u.s. department of defense is providing 3,000 u.s. forces for the response establishing a regional staging base to facilitate the arrival of the equipment and supplies, and building ebola treatment units and preparing to train hundreds of health care providers. we know w.h.o. has created a road map for response that's

providing expertise in west africa, and is seeking funding from governments around the world. and ngo is like doctors without borders, they're heroically leading the clinical effort on the ground. in our discussion today, we're going to hear about the situation on the ground in west africa, by people who have been there quite recently, and who are leading the effort. we're going to learn about what the u.s. government is doing in more detail, and perhaps most importantly, we're going to discuss measures we can take to end this crisis in the time ahead. each of our panelists will give opening remarks for about five minutes. after that, we'll have a panel discussion. and then turn to questions and answers from the audience, and from twitter. we have four speakers today. we're so fortunate to have given all that they're doing in this response. our first, jeremy konyndyk who is the director of the office of u.s. foreign disaster assistance. tom frieden, the director of the

centers for disease control and prevention. joseph fair, from the foundation of mario. and co-founder of the foundation. and andrew weber for chemical and biological programs. we have kejii fukada on the agenda, but 24 hours ago his boss w.h.o. director chan said she needed him in new york today. so with that, i'm going to turn to jeremy, and feel free to make your comments from there, or come to the podium. whatever you prefer. >> i'll just sit here, if that's all right. thank you very much. thank you for the opportunity to speak. it's great to see this level of interest here on the hill. this is a remarkable challenge. and i think it will take a whole -- it is taking a whole of

government, and it will take a whole of society response for us to fully support the liberia, sier ro leone governments in this. this is a crucial piece to our ultimate success. i will talk for just a few minutes about the overarching u.s. strategy that the president laid out last tuesday. and the specific pieces of that. and then turn it over to my colleagues to go into more depth on their agencies' respective pieces. on tuesday, we have a four pillar strategy that the u.s. government is pursuing across all of its many capacities. to try and control and ultimately defeat this outbreak. but also to look beyond the immediate outbreak as the longer term needs of health systems and the rel si yens of these

countries to what will be like "future outbreaks of this as well. now that this is in the environment as we've seen in other countries, such as uganda, it's likely to reoccur again. we obviously don't want this whole episode to result the next time that happens. we do know this can be controlled if there's plans put in place to do so. the first pillar of the strategy is to focus on controlling the immediate epidemic, the immediate outbreak. the second pillar focuses on mitigating second order impact. things like food security, economic stability, political stability, and ensuring that as these countries struggle with the immediate outbreak, that we don't see second order impacts that are equal to, if not greater than the outbreak itself, in terms of human impact. third piece is to coordinate an

effective global and effective u.s. intergovernment agency response. coordination will be critical to the success of this, both at a country level and global level. there are many, many countries looking to play a role here. and in any major response, that we under take, there is a large coordination element. the hundreds and hundreds of ngos that famously showed up in haiti are a well-known example of that. in this case it's even more critical, because this is something that none of us have ever done on this scale before. and so having coordinated action is all the more important for that reason. and the fourth pillar is fortifying the global health security infrastructure, such that in the future in these countries, and in the region, there's an ability to prevent future outbreaks of this magnitude. it's critical obviously for the long term future of these countries, but also critical in the immediate term that some of

the neighbors do not see outbreaks on this scale. and i think that the fact that cases have popped up in a few of the neighboring countries so far not triggering any major outbreaks is an indicator both of the risk, but also the potential to keep this managed with swift and decisive action. just to speak briefly about the office of foreign disaster assistance, has the standing role in the federal government as the read coordinator for national disaster response. in that capacity, we have sent a team to the region that has representation from across the interagency, works closely with the larger cdc team, that is also there on the ground. obviously has cdc representation there as well. we will coordinate the interagencies, and execute on usad's pieces of the response.

our current focus, and i won't reiterate everything that the president's already announced, but our current focus is along five lines of effort. the first being effective in country management and leadership of the response. so we're very pleased to announced that as of today, the liberian national emergency operation center has opened officially. so all of the elements of the liberian government's coordination of this sits under one roof, after a great deal of u.s. government support. the second element is to focus on scaling up isolation and treatment. we are focusing heavily on getting etu set up and working with dod in that effort. some of these are acronyms that you don't recognize. the third piece of that is safe burial. we are on track to have -- i

think that's where we're seeing the most rapid progress, one of the more scaleable pieces of this. i think we're on a good track there. the fourth element of this is infection control, more broadly within the country, and a big piece of that will be the community care strategy that the president announced last tuesday. that will focus on beyond the etus, enabling communities, and when necessary, households to much more safely isolate and provide care to community members when full-on etu treatment is not available. because that takes time to scale. and the protective kits that tom referenced in the opening remarks are an important part of that approach. we're happy to talk more about and then the fifth element is communications. obviously this is a new disease in all these countries. there is a lot of misinformation and misunderstanding about it. and ensuring there is accurate

understanding, accurate information, and that the people know the correct way to protect themselves. underpinning on that is the huge logistical effort that we and dod are working on to ensure that both adequate procurement, as well as adequate transport and supply in the country, because the volume of protective equipment and other supplies that are required to run medical operations on this scale is just enormous. so that's a huge piece that we're focusing on as well. thank you. >> tom? >> so thanks very much for wringing us together and to senator kunz's office and all of your interest. i've been running public health agencies for a few decades on a few continents. i became the doctor working in new york city in the '80s where i cared for literally hundreds

of people dying from aids, with a limited ability to do much other than help them die comfortably. and that experience was searing for me personally. andpersonally. and i've never seen anything like that until i was in monrovia recently and went to an ebola treatment unit run by doctors without borders, nsf, who are working, really, with just incredible effort, their largest response ever, exceeding their capacity, stretching the limits of their operations. but we went into a treatment unit and we saw, really, a seen out of dante. it was patients wlor in all stages of the disease from those suspected but maybe didn't have it and maybe might get it there if they weren't effectively separated from others and our

lab next door was working more than 12 hours a day, confirming within a few hours whether people had disease or not. people who were just getting in and being cared for and desperately needed rehydration to survive. patients who were recovering, including one kbie who was healthy enough to complain about the food. i thought he should probably be helping to make the food if he could complain about the food. but, also, tragically, three patients who had died in the past few hours and the staff was so overwhelmed, they could not move their bodies. this is a facility in which there are 14-20 beds per tent. so one person in a tent who had

died was next to the other persons who were struggling to live. and that kind of thing is the example of what it is to have an exponentially increasing outbreak. it's doubling in 20-30 day ins the region. that facility had had 60 bodies removed that day. so the situation right now in west africa is an absolute crisis. it is moving faster than is easy to understand, particularly in liberia. we now have a field team looking at the possibility of cases in

another country. if i were to just summarize for a minute, what we need is an immediate response that is sustained and then make sure that this doesn't happen again. and if i can just outline those three concepts for a moment, i've never seen a public health situation with this much need for immediacy. as i've explained to people, an adequate response today is much greater than a response in a week. that's the case in all three countries that are affected. even though liberia has, by far, the most out-of-control situation. but there are districts in liberia that are having relatively few cases. they have the opportunity to stop it before it spreads widely there. and where there are many cases, we're intensively trying to scale so we can reduce the spread.

in siera leone, where cases have not spread quite as quickly, we have the opportunity to prevent a liberia-like situation. in guinea, where it's expanded and controlled, they have the potential of keeping it under control. the best analogy, really, is a forest fire. and we see many raging in liberia. especially that tri-country area. where the three countries come together. it's a deeply forested region. it has very poor infrastructure. it has very poor relations with the rest of the each of the countries, but it is the crucible of this epidemic. and the capital cities with the

first context of the world's first epidemic. so an immediate response is critically important. usad and their team is there. the need is extraordinarily large. that's what's hard to get our minds around. not only are the needs large today, but they're going to be twice as large in less than a month. and if we're going to be successful, we have to build to where they're going to be in a month. we're going to have to sustain this. in 2012, in uganda, where we've worked on ebola many times, tragically, a 12-year-old girl died from ebola. what was striking was that she was the only one who got ebola.

and that's the only time in history we've seen a situation like that that i'm aware of other than a laboratory incident where there's someone who got it but people thought immediately, this might be ewbola. they immediately tested. they con first named it was ewola. they confirmed when she died, she was safely buried and if any contacts were tracked. if that core public service had been in place a year ago in these three countries, the world would be a very different place today. but the fact is we now have an outbreak that's protected for a significant amount of time. so when one person went to the

city of lagos, we immediately got on the phone with the governor of lagos and sent the team of 10 cdc experts within 48 hours 20 be there. we brought in 40 people who we had trained to do contact tracing as part of the eradication work and had been working very effectively on that. now, they're not completely out of the woods. but it does look like they've controlled 2 outbreaks in both cities. that was to address one case of ebola. we need to have a response that's immediate, sustained and prevents cases like this.

the economic implications not just for west africa, not just for africa, but the world, are quite substantial. who and their publication yesterday has raised the possibility of ebola becoming endemic in africa. that would mean that it would continue on an on going low indefinitely. it would be an enormous problem because we would always have to be thinking about the possibility of ebola. anyone who had been in any region that might have had ebola. the approach that president obama has outlined is exactly what we need. we need to get the scale and the speed that will match the expone exponential growth of the outbreak to ensure that we have

an immediate response that sustained and prevents this from both happening where it ice not happ happening now and from happening again whether it's ebola or any other health threat. thank you. >> joseph? >> thank you. let me start by saying -- oh, sorry. i'd like to preface my remarks with the understanding that i'm speaking from my own experiences. so my remarks tend to be skewed from those countries which are currently experiencing the worst part of the outbreak. when we say the situation is dire in sierra leone and liberia, we just can't emphasize that strong enough.

that response is starting to trickle in. there is light at the end of the tunnel, hopefully, but it is going to get worse before it becomes better. i'd like to keep in mind we're talking about two countries that endured almost a decade of civil conflict. so we're approximately 11 years out from the end of that civil conflict. and consider this enormous task, we're dealing with almost on the brink of not being able to deal with a normal day. from that, we may never know the toll of deaths that resulted

from non-ebola cases. there was a headline today on cnn that you have ebola unless proven otherwise. and that is, indeed, the case. before this outbreak, i could argue the case you would have malaria unless proven otherwise. it is well-connected by roads. we're dealing only with colonial borders. these are not tribal borders. we're still very much experiencing an upper trend, but less so in sierra leone. and while i truly applaud the move by nsf to reach out to the

united states military for support, the building of treatment centers is something that i don't want to put complete faith in. almost a month ago, we were in a situation where we had ten persons that had passed. we had no body bags because nearly all flights had stopped so that our delivery of ppe in body bags. as director friedman mentioned, you're trying to survive this disease and it's very important. however, you're looking just to your side at people that were lying next to you just the day before, just hours before and

looking at 10 bodies stacked up. and you can see why there's the tendency which we all read about. people fleeing running, not coming into the treatment center. it's large bhi because they're considered a house of death. i think we are turning the concern erp in that kind of opinion. and the reason that we saw that early on was part of the messaging. there was noo licensed treatment. what we have is a result of that of one large population that didn't believe in ebola virus, to start. so rather than hearing that supportive care will increase your chances, what they heard was there's no treatment for ebola. population to really seek out

where we are today, our number one treatment has to be stopping the vie ris. weapon're going to do that with boots on the ground. as we saw in guinea, we almost thought the out break was over. we were 2-3 dafs from thinking it was completely over. we missed two or three outbreaks and that's all it took. speaking as a public health professional, i think our number one priority has to be stop the transition, save the people that are not yet infected and treat those that are currently

infected. and i want to caution the phenomenon that we've seen since the introduction of z-map and the introductions of the experimental vaccines, what that has resulted in local ly is tha is going to be the answer to the outbreak. again, i go back to the number one priority which is epidemiology. we're going to stop the outbreak by stopping the transition chains and improving our protection control. and long term, food security, most commercial airlines with the exception of one have

stopped flying to these areas. it would create a whole set of problems with the fuel for the cars. those are all thing that is we're going to have to deal with. we're facing a very unique situati situation. >> this is the first time we've had an outbreak of hemorrhagic fever in an area where we already have an area of hyperendemic. as of last week, we're starting to enter the dry season of sierra leonne.

>> very shortly, and we've already seen this, we're going to have multiple hemorrhagic people. >> thank you. thank you, tom, and the u.s. senate for organizing this meeting today. clearly, there's a lot of interest in this very important and urgent crisis.

this is a national security imperative. one thing i want to stress is that this team that we've met here today, we didn't just meet. we've been working on these issues. tom friedman and i, regularly, for the last five years, have a very strong partnership. we, last week established operation united assistance

which will be dod's global support. and we're in support of our civilian including the united kingdom, france and others that have a lot of reach into the affected countries. dod will focus on our strengths, our unique capableties and capacities. including control, engineering support. we established the joint forces command under u.s. africa command.

the command headquarters is being established in monrovia. liberia, in addition to a regional interimmediate yat staging base in the logistical support to ensure the flow of personnel and equipment and material supplies for this very, very large area of west africa. some of our best scientists will deploy with those units to liberia, one in monrovia, and one in bong, liberia.

they will be associated with ebola treatment unit sos we can have rapid diagnostics. >> the department is providing a 25-bed hospital that will be staffed with medical department personnel. the department of defense will not be involved in direct patient care as a part of this operation. we are going to process 17 treatment facility ins liberia. activity is underway and that

should start to show results on the ground in the next few weeks. again, the didn't will not be engaged in direct patient care. but we will provide a training based on the infection control training that msf has established in bell yum and cdc has replicated at a fema facility there. up to $1 billion to commit to this effort.

they're going to invest 60 million tlarsz in strepgtenning the laboratory capacity both in the affected countries and also in the neighboring countries. the department of defense has been involved for many years in the department of developmental counter measures, back scenes as well as diagnostics. we've sent over 10,000 diagnostic test kits to the countries as well as perm protective e kwichment.

i want to just note in february, february 13th of this year, the day that the federal government was closed, the u.s. laurjed a global effort call it had global health skurpt agenda. and that has grown. it wasn't in response to ebola. >> we have health ministers, defense ministers, crossing different sec tors which is necessary for the whole of government response that these types of events require. the goal is to build us capacities preventing this from becoming an epidemic in the first place.

>> secretary hegel will participate in the global health jurat agenda together with secretary virwell and caroty. that will be hosted by ambassador rice. finally, i'd like to mention the workers on the ground, a hundred cdc experts on the ground like jordan who just returned from there. for their truly heroic efforts. we all owe them gratitude for the would recollect they're doing on the ground every day in west africa. thank you.

>>. >> thank you, andy. thank you all. we're going to turn the discussion to ebola on the hill. before we get to specific -- specific questions about the response, because i think people really want to understand the nuances of their response from the leaders here chlts i just want to ask one more question if we get this wrong. you're beginning to paint the picture here. why is it important for us to invest so much of our time andal ent on this problem.

and what happens if we get this wrong? usa today, their headline the other day was could the ebola epidemic go on forever: what are the consequences if we get this wrong? >> earlier in my career, i spent three month ins guinea working with preferences from liberia. we're only actbout 11 years out. this outbreak, if it is unek

which 7d could undo a huge amount of effort. but at a human level, as well, it just threatens to devastate. it already is devastating these countries. any time there is a disaster on this magnitude, the u.s. is on the front lines. for u.s. interest reasons, the president has very explicitly articulated it as such.

i think if you look at the level of interest, as well, there is a clear desire to beat this thing and we know we can. >> welt, i think the sad fact is that the worst case scenarios are really bad. yesterday, cdc outlined what would happen if the exponential growth were to continue at the rate it was going a few weeks ago. we don't think that will happen because of the u.s. response aened others. not only would it affect west africa, but would ineftblely spread to other countries. we had two exportation, disease-exporation e vebts. how many events are we going to have if there are tens or as the president said, hundreds of

thousands of cases. whatever we may think, it's just not possible to secure borders. control of drugs and diamonds and and people would be a lot easier. but it doesn't. what that means is that we really are all connected. it will present a significant health risk to people in the u.s. it could absolutely change the way we work here. it could change the economy of the world. we don't don't think that will happen.

>> recognizing that the president said we have to work immediately. it's going to take time to turn it around. but the other key findings of the mmwr we released yesterday was that progress is possible. when you isolate nuch people, the disease begins to stop spreading and can decline. but what the model found that i found particular pli striking was that the mathematical documentation of the urgency we all feel that even a delay of where you know month will result in a tripling in a size of the epidemic. and that kind of shocking increase is very hard, as i said, to really get our minds

around and to act in a way that we're trying to ensure that we're anticipating what we like will be our next problems. the situation is fluid almost beyond description. but our response has to be to the risks that we turn around. >> we can't ignore the fact that the gdp is approximately $530 million a year.

when you compare that to the cdc, it's like most tropical diseases. disproportionately affecting the poor. and i would argue, as jeremy mentioned, that we are experiencing a level of social conflict that has not been seen in this level in this area. this is a direct result of those conflicts. it's exact lip what we're seeing right now. and i believe we are turning the corner and the psychology of that in convincing families that by hiding someone and keeping them in your home, not only are you greatly increasing the chance that that person will pass, but that you will also infect your whole family.

that's had to happen many, many times for that message to come through. now uf seen a tremendous amount of negativity. we face a very similar circumstance. not widely publicized, but if you look at sierra leonne, it's politicized like in the u.s. and where the current ep centers of the virus are currently occurring is the opposition stronghold. the rate that is all being used against the current administration and office in sierra leonne, and then lastly,

i think impb on this panel, at least, is familiar that we have spent much of the last ten years focusing on bioterrorism. so this is somewhat of a worst case scenario in the sense that we have literally thu sabds and thousands of samples of ebola virus. i don't know how many of those are positive. there is no good tracking system for those samples. in addition, all the clinical laboratory services are needed.

just to echo already, i think we're going to have a lot of long term effects. and just to echo dr. friedman's comments, every single day we delay, we are experiencing an exponential increase in potential number of cases. >> it ice clear that we're going to need doctors and nurses in number that is are not available now. and there's an element of training going on in the planning. and there's an element 06 recruiting.

how do doctors and nurses get involved in this. prior, there was no standing capacity for a large scale ebola virus. it just did not exist. so the global capacity to respond and treat ebola was premised on that sort of response. we are now faced with a situation where we need a response scale that is magnitude or larger and that involves finding institutions, organizations, nonprofits.

who are able to come over. the treatment model, only 5-10% of the staff are trained professionals. the mass of the people are nationals of the countries. and we are working furiously to set up training models. and, as you said, dod will have a role in this. you said cdc and the world hemt organization are orging training in the countries themselves. working with ministries of health department to put through those trainings the institute -- the new treatment unit that the world health organization recently opened in monrovia. but we are looking for international medical

professionals to join us we are collecting contact information of people who are interested in vol untiering to the response. and we are making that information available to ngos and other participanter ins for staff. this list is at a resource on them to help draw to compliment their staffing. >> i would just add to that that there is a lot of interest in assisting, despite the fear that ebola actually causes. the department of state has supported and department of state and eu dollars 1 now on the ground in the countries helping out and providing care. this is a great example of what's needed.

there are some barriers that we need to break down so that people are more willing to help. one of those is being able to go back to their own country. but we are seeing a lot of interest. 90% plus are local staff intensively trained and willing to work in these areas. so the numbers become a little more manageable when you think about it that way.

we've seen more like a 50/50 response. children tend to be less affected directly. they don't tend to be care givers. but we're seeing just horrible imply cases of this. i was speaking with one survivor in her home. her nephew was there kind of bouncing off the wallsment and

they finally said the neighbors don't let him go outside to play because they're so afraid of him. i held a survivor whose both parents died. and, three, i saw one of our staff at cdc who has done the post agreement of all of our staff. the stories they tell are really sering. for example, one of the staff described on the street saying babies lift. trying to save their child's life hoping somebody else would pick them up. the implications for society are enormous. >> i would just like to add, in addition, probably something that you've read about. but once a person does survive,

there is an intense stigmatizing if they re-enter the community. the majority of care giving is from women. they are the primary farmers for the region. oftentimes, the parents were survived. we have an untold number of orphans now. you're coming into a system where they were already

under-developed. they're not exactly equivalent to what they saw in that conflict. but it else reaching that catego category. >> very quickly, just to add to that, that is an element of exactly that and that's why we're focusing on that. we notify that the immediate outbreak under control from a public health perspective, there are going to be many income-on and o effects to address. i had a question about the evolution of the virus. it documented the evolution of the viruss through 99 hosts, human hosts. the question is what is the current and on going efforts to

understand the direction this viem rus is going to evolve. >> we've seen less than 25% genetic change, which is relatively small for moat pathogens. i think the facts that we've seen now, 10, 20 different generations and we're seeing it in thousands of people does put us in a different environment. woe eve had some groups looking at this. there is the need to track the genetic virus over time. and there are tuxs working to do that. >> there's also the need to track the epidemiology. we're more likely to pick up a change by that core, public

health department meeting. >> just following up on your comments, it's my understanding that dhs is working with cdsc on development of surveillance and passive surveillance. can you elaborate when you see a threshold of el vating from pace v to active surveillance.

>> i think about three lines of defense and thinking carefully and how do do that most effectively and most prablgtically. the first is to stop it at the source. and that's going to be the effective way of doing immaterial. obviously, it's going to be continuing for a while. we need to do more than that. the second is stopping people who may have ebola from departing the country. there we've surged and they're removing from the departure line anyone with a fever or who may have ebola. that clearly does not -- is not a perfect way of eliminating ebola because someone could have just been exposed. and the incubation period is usually 8-10 days, but can be as

lopg long as 21 days. it's one of the important things to do to keep travel safe. the third area is within our country. and we really do need to recognize that with ebola spreading this widely, it is not impossible that someone will come in to one of our hospitals or health centers with symptoms of ebola who may actually have ebola. we've had 13 people come in with symptoms that were considered potentially consistent with ebola that from the area, they've all been tested and been negative.

we've ruled it outs more than a dozen times. in terms of border protection, we have a very close-working relationship. anyone with suspected disease, whether ebola or otherwise, we work very closely. we've worked with border protection on protocols if someone were to come in with symptoms close to ebola, we would be able to respond effectively. >> understanding what is best done is something that we will always consider to dynamically

reassess with dhs and others. >> question. i've got the microphone. i'm sorry, i was handed a microphone. >> go ahead. >> logical purpose. richard fieldhouse with the armed services committee in the senate. we heard from our panelists, that the effort, the response will need to be sustained. this is not just a brief, you know, let's go at it hard for three months and we're done chlt chltsd. >> we heard a lot about the u.s. response. that's covering a six-month period to build up the effort. can you give us a sense of what you mean by sustained in terms of length of time? and the response that you believe is needed from other countries, besides the united states, because, obviously, we're doing a whole lot. but this needs to be a major,

international response. thanks. >> so maybe i'll say a couple things, then, jeremy. basically, give a number or a date and hold them together. we know that the sooner we get out there, the sooner we're going to control it. woe know that the penalties for delay are critically important. i will say we've seen a wonderful global collaboration here. if you just take laboratory services, we've got several parts of the department of defense running labs. there really has been a kind of robust, global response: it's already on the ground and helping. there is a robust international response.

but the u.s. has unique capableties in terms of speed, kills and scope. >> just expand a bit on the international piece. the worst-affected countries are as you're all aware, sierr sierra leonne and liberia. guinea has a stronger health system to begin with. the u.k. is stepping up now. they're taking the role of the foundational principle in the way that we are doing in liberia. in guinea, there is not.

the french are increasing their involvement. it looks like other european partners will be going as well. where he know we know that the u.s. government can't and shouldn't have to do this on its own. many other partners are also stepping uch. we're doing very regular calls with international counter parts. just in the past half a day, i've been to two. >> if i could add, the international out reach is an area that president obama

emphasized in his announcemented in atlanta and cdc. that one of the u.s. objectives is to help mobilize the international community and impruf the coordination among the international community. ner next week, the u.k. will focus on an event focused on sier sierra leonne to coordinate the contributions. public partnerships with many other ngos around the world are contributing. there's a lot of out reach this week in new york. and, as i mentioned in my opening remarks, this friday, the global health security agenda, we're going to leverage that to get real commitments, real commitmenteds for action, for funding, for kind

contributions to global health security around the world, but, also, specifically for the current crisis in west africa. and the state department has named ambassador nancy pow to india to hope lead this effort for internartional outreach and donor coordination. >> i forgot to mention the world bank. they've been trif ek. they've leaned forward enormously. they really understand putting into place emergency response capacities that would have prevented in the first place that can prevent similar efferents in the viewture and will be discussed on friday.

>> i don't want to speak to the timing of sustainability. we start seeing a decrease in number. but, for me, sustainability is going to equal human and technical capacity so that we prevent this from happening again. that's going to take time and effort of the outbreak. the governments, the african union, all of them have been extremely spops i have and all of them have started to come together. as secretary webber mentioned,

the ngo, all of though have started to contribute funds to doing this. when you look on the ground, it's the government health care workers, et cetera, that are going to be key of the effort. >> just to put an exclamation point on that, getting back to your earlier kmernts, international coordination are extremely high. >> thank you. i'm wondering, as you evalwait the funding streams and some of the short term timelines, if you identify any of the limitations to the current funding or any challenges that you've

identified that we can play a role in? in particular, it was, i think, a question at that particular point, what is it that congress can do to support this response so that they are not already doing. >> i'll just start with -- address cdc. it costs us $30 million and we're very grateful for congress allocating that just to keep our operationings going at the level we're going. that doesn't involve addressing other countries which may be dealing with large outbreaks or strejtsenning their fire resistance. we're beginning to surge in that area as well with forest fires

elsewhere and it ducht address any of the medium or long term issues of putting in place those efforts and making sure that we have the technical capacity in country to do that. we're working very closely with the world bank. the needs are substantial and they're going to continue for some time. >> just as this panel reflects a whole of government effort, up here, on capital hill, this spans across many different committees. so we would you describe ask that you work closely together with each other to avoid the potential gaps in seems. and from the dod perspective, our highest priority is getting approval of of the two pending $500 million reprogramming requests from overseas

contingency operations funds to overseas humanitarian disaster and civic aid funding. immediate attention to those actions will avoid any pause in our operations. >> from the usa i.d. side i would say one of our top priorities is to ensure the reprogramming is approved because that will allow a very large scale cooperation between d.o.d. and a.i.d. the way we operate in the field in this response is like we do in any response as we did for example in the philippines working extremely closely together where it identifies and validates needs and works to then route to d.o.d. those requirements that it is

particularly well suited to. and so getting as andy laid out in the beginning those are substantial. so having that resource available will really turbo charge the type of scale of response that tom has eloquently laid out we need to mount. on the i.d. side i think we are as we move into 2015 getting a better handle on what this is going to look like but i don't want to get ahead of the budget process on that. >> if i may i will add one comment to that, as well. i think we talked enough about this short term financial needs so i will speak more to medium and long term needs that we will have to start thinking about now as well as holistic approach to this. in the medium and long term objectives for sustainability as we were talking about earlier and to prevent this from happening again is that we are going to require investments in

foreign infrastructure, laboratories that are going to be permanently based there and able to diagnose and detect these diseases on their own, investments in human capital in those countries especially with regards to training and clinical care and laboratory. another aspect that we have talked about and something that is going to be implemented is training in crisis management and emergency operations. prior to this outbreak the countries have never had to really deal with an acute humanitarian disaster. they have had long-term disasters which they dealt with but it was never acute and had to be responded to exactly right then. those are the medium and long term investments that i would argue that we are going to have to be prepared to make sure they never happen again. in addition to thinking about just stopping the outbreak we

are going to start talk about the food security and how to deliver fuel to the area. in the long term we have to start thinking about aid packages for those countries to help them rebuild to where they were before the outbreak and hopefully afterwards they will have strengthened health care systems. >> next question. >> thank you very much. sarah williams with the alliance for bio security. a couple of you mentioned sort of the issues with messaging and misinformation that we have seen throughout the outbreak so far. i am curious about the level of local government engagement and sort of trying to fix that problem and address those concerns about, you know, getting the correct messaging in an understandable way to the affected communities. what is the level of engagement and how are those relationships

going? and, secondly, how critical is it that that is done correctly this time and in this timeframe for success in the overall mission? thank you. >> so with regards to the messaging i think the most important thing to remember is that there have been conflicting messages sometimes coming internally from within the governments and deal like other governments do. there are opposition parties. i think we are seeing a turn in that because the presidents of at least liberia have done a great deal to rein in those individuals within the political consortium that are giving conflicting messages or maybe not so accurate information. we are still dealing with messages from groups that you may not immediately expect such as evangelicals coming in from nigeria offering hope through

prayer. that is something that we are trying to fight against right now because that messaging is not always correct. that being said it is absolutely essential that we work through religious leaders in the area because you are facing an armageddon-like situation so many people are flocking to the religious community now. a large focus is on the religious community. it was misportrayed as a lo lockdo lockdown. it was a three-day stay at home social mobilization campaign of what ebola actually is, how you can identify it, at least symptomatically and what you can do as well as possibly identifying potential cases in the home. i feel the messaging is taking shape. people are starting to listen to it more. you have much less denial than the earlier days of the epidemic. i feel like we are turning the corner.

the messaging does need to be concise and the same from everyone. >> i think the key here is organization. now each of the three countries has an incident manager who is the point person for the country. they report directly to each of the three presidents. our role at cdc and d.o.d. and throughout u.s. government is to support their entity. jeremy noted that the liberia group is moving into the building found by the government and regulated by coalition. in guinea the incident manager this week moved in and within the incident within the management system there is a communications lead. instead of anyone doing their thing the goal is to have clear evidence based strategic objectives for each aspect of the response including communication and base that on

information coming back, very interesting household survey done by others showed a surprisingly high level of awareness of some of the key messages emphasizing the need to go from what people know to what they do in terms of our communication. that involves getting the logistics out so people can take someone sick in to be cared for where they can have a higher likelihood of surviving and lower likelihood of infecting others. >> good afternoon. you had spoken about the history of the region going through about a decade of civil war. how do you think the reaction will be with the u.s. military showing up when they have had such a traumatic past dealing with their own military? and then also their mistrust of the services that have been provided prior to this again going back to the rumors that there is no care or that we

can't provide care? what is the military doing to address the psychological impact of a pretty large force showing up on their door step? >> i believe that the involvement of the department of defense and global effort will actually build confidence in the local population in the governments in the region and that resources commensurate with the scale of the challenge are coming from around the world to support the response. >> there was a fervent desire on the part of the government and

people to see a massive scale of the response, the report backs that we were getting from our teams out there and the arrival and announcement of u.s. military resources has been well received. i think that people can easily distinguish between what the u.s. military is coming in to do and the sorts of conflict that they have in their history. >> if i may i will add that especially in liberia it will not be the first time that they have experienced u.s. troops on their soil. we had a fairly large contingent stationed there which has been training over the past four or five years. and much of the same through international assistance programs where the u.s. governments have been training militaries of those countries. in liberia it happens to be one of our most staunch allies and

voted with the united states on almost every resolution. they are ecstatic that the u.s. is coming in. i think adding to that was the request by msf that the d.o.d. do participate. and the reason for that in my opinion was that msf despite being a humanitarian organization operates much like a military. it is disciplined and logistics that they use to be so effective on the ground. so i think the military is widely known for having both of those qualities. i think that is very welcome to everyone on the ground including the local population. >> next question. >> thanks for being here. two quick things. one, in your meetings abroad when you are traveling to the region, what kind of role are front line health workers using?