and other people trained to work in this. this is a difficult task to get all of those people trained and over there and the volunteers, also. how many people have the time and interest to go and take care of patients who might look like this? these are very dangerous patients sometimes. it's stressful work and trying to do this and be in a situation if you are a doctor in the hospital in the united states and you tell your chief of staff i want to work in west africa for a little while they say who is covering your patients while you are gone? how is that working? your wife or husband may not be excited. we are adding 21 days where you are not working when you get back. the labor internationally and locally is a big challenge. so going out of order a little bit here.

and then i mentioned the 21 days added on, we need to fight against that and try to inject reasoning into that. the infrastructure, so i have been kind of not intentionally but finding myself playing a role of a spoiler in some of the meetings like this. not that i'm opposed. sometimes there are realistic expectations. these are the sorts of settings. this is an ebola treatment center, the upper one is in the creek and the epicenter of the outbreak. many other pictures, of course. these vary a lot. here is kind of something you might see in the beginning of an outbreak, very rustic settings. sometimes unfortunately the rustic settings what we have in west africa what we have with the capacity right now and some of these are really much less

treatment centers but places for someone to go and hopefully get more re-hydration solution, some tylenol and a lace to die out of circulation to not infect other people. when we have this sort of setting and then we contemplate something where we are going to do studies where we need to draw blood samples every four hours and have a cold chain and electrolytes. it's not that it can't be done but we need to be realistic about some of the challenges that are ahead of us. this is another photo. this is a treatment center. of course, not really -- i'm sorry. this is not how we would want this to be. we don't like to have all of these beds together. we like to have separate rooms but this is the sort of place where the nurses were going on strike frequently. we had a lot of health care

workers getting sick and dying in this area. we had times when we had 70 patients with ebola here and myself and one other health care worker to try to take care of them. when you talk about trying to do research and say we need to draw blood and monitor this or that, when you have this sort of setting very difficult. we need to increase the capacity. and it can be like this. this is a much more ordered setting. this was not from the present outbreak. this is the sort of thing that we like. of course, today we wouldn't like to have the beds all together but sometimes that's the only choice we have. a lot has been discussed about the personal protective equipment and leaving the safety issues and what's the right ppe aside no matter what you use this is very cumbersome work to do. so if you use this as the msf prescribed ppe that really you

can stay in for about an hour and a half until your core temperatures get up to potentially dangerous levels. this is closer to what would be advocated by w.h.o. we recently did a process at w.h.o. to have new guidelines on ppe that came out yesterday. of course, there is the obama challenge for ppe to try to really innovate into new things beyond that. regardless, this is not the sort of setting where you can just say let me go in and work for five hours at a time and take all the blood samples that i want. it is cumbersome work, stressful work and other issues are in place. on the laboratory side this is the mobile laboratory set up by the european union. this was in guinea. but these exist in a couple different places. cdc, european union, public health agency of canada set up mobile laboratories.

they are meant for diagnostic purposes. right now they have many, many samples coming in. not only sometimes the capacity of the treatment centers overrun but the capacity of the center as well. we have the same situation where we need to think can we dedicate them to the research and what are the priorities between research and the routine public health diagnostics that need to be done. also, just an example of trying to monitor and take some of these data in the laboratory. we were using this i stat device. turns out the device doesn't like the heat and humidity in west africa. we had a difficult time using this in most of the places. you can play with it and get it to work if you kind of put it on a bed of ice. how many beds of ice do you find

readily available in these places which don't routinely have this sort of thing and electricity is not a given. these things get set up by msf as the group used to doing it. it can be done by other groups, as well. it takes a lot of energy to get this together. we found that you put on a table top is a little better for this and not quite as sensitive to the heat and the humidity. and then data collection and transfer, of course, that is the whole point of doing research. when you are collecting data you have to have a way to get it outside the ward. you can't just -- gone are the days where i used to throw the patient charts out the window, spray them with bleach and then move on. i don't think we can do that anymore. we have to have ways a little bit higher tech ways. this can be done using cell

phone technology. there are many steps we need to go through and this is -- you can see the gloves that this person is wearing is not that easy to write all of this stuff down in the heat and all of the other things going on. this is an example where people are giving the information on the patients. they wrote it down inside and then they are recounting it across the fence to other people who can write it down and have it outside. there are ways to do this. and then ethical considerations. irb approvals and not only in this country but probably more challenging in the countries that we need to work in. they do have ethics committees or irbs but not necessarily ones that are used to expediting these things rapidly. it is being approached because what is going on. to placebo or not placebo is a huge contentious issue and trying to find the right balance

of what is research that we need to do. obviously talking about therapeutics and vaccines here. what is the research that we need to do to collect the information. clinical trials that are formally done so we come out of this with solid data. the expectations across west africa which were much more on compassionate use. we had a meeting a month and a half ago now at w.h.o. many representatives from west africa to try to figure out how we go forward with some of the use of potential therapeutics and vaccines. i can tell you all the people from west africa, i think the afternoon or evening when they got home from the meeting probably had a call from the minister of health and say which one did you choose and is your suitcase full? they are not really thinking so much clinical trial but where are the drugs to help people, an understandable way of thinking.

diversion of labor from outbreak response to patient care and research are a balance we would have to find. lots of logistics getting to the site. this takes a lot of veebhicles, lot of airplanes. this is using bicycles that were unloaded to do surveillance. that is one of the things mentioned is kind of the operational research that we need to include. surveillance is another area that needs to be approached. again, there is a strain on resources because this vehicle is needed for the surveillance but it is also needed really to get your research staff around and to do the different things on site. those are challenges. and then in many of the places the physical security. you have all read about this. there were some health care workers that were all killed in guinea last month. i can tell you some stories of some tense moments. i think everybody on site has a few of the stories.

especially when we have sometimes a resistant population, one of the ideas that's frequently spread around about that resistance is that we were there, ebola was created or intentionally introduced for people in authority from overseas, from foreigners to come in and do research on people. now when we are doing research on people how does that feed into it? we want to and will do ethical research but we have to be aware of the perception of that and there are some issues that we have been struggling against. what do you do if one of your research staff get sick? are they going to get evacuated to the united states? we can't necessarily send people into a battle zone and here and there somebody gets shot. you are ready for that.

i do think that the bpe can work but it is not the sort of thing that came in. the dallas hospital, it's not the sort of situation. here you have hours of training and then go. you have to set it up and think it through in advance. i mentioned this societal resistance. language barriers if you get off into very rural areas and some of your staff depending upon their training it is very common that people speak much more their local languages rather than even english even though english is the national language of the countries. i think i did it all in 15 minutes or close to it. so thank you very much.

so we have time for questions and discussion. and to engage our panel. there are microphones placed in key locations. please come forward. i wanted to start with a question and i'm kind of inspired by a couple of the presentations. what it has to do with is for the purposes of working on issues like personal protective equipment, disinfection, waste disposal, has any thought been given to what is an appropriate surrogate for the ebola virus in terms of its behavior and survival under various conditions. it does not require laboratory facilities in order to run experiments. do people have any ideas about

that? >> there's a species of ebola which is thought not to be pathogenic for humans and can be downgraded from four. in addition to that heinz feldman and colleagues have produced an ebola virus by genetic engineering. that is probably not pathogenic although i can't imagine any institution or review board giving permission to use it. >> other ideas about that? >> there are various viruses that could potentially be used. you do get into the question of you do those experiments and

then say is that really, does it act the same way as the real virus. that would be another idea. >> from the point of view of doing studies for ppe we would like a surrogate that fluress. >> ppe some of the surrogates that epa is using with waste which are bacteria must not be appropriate at all in terms of size and other characteristics. >> part of the problem is the surrogate needs to be selected for the type of experiments you want to do. if you want to look at persistence on environmental. if you want to look at how it interacts with bleach. if you want to look at thermal incineration you might look at a different one. it is difficult and not going to be one bug fits all. >> just to follow up on that.

as dr. howard pointed out, having some surrogate, testing the cleaning of an air purifying rubber is very different from thinking about how that could. the question of what you are trying to do with ppe testing, are you trying to evaluate whether the filtration effectiveness works or whether somebody who is doffing ppe contaminates their skin is a very different question. so thinking through what question you are asking requires defining what you want in a surrogate. >> they are commercially available florescent powders that are not visible to the eye until they are hit with uv light. it seems to me like that would

be very valuable to training people in doffing their gear if they put on their gear and have this powder applied and then they were fluresced after they got their gear off you can see where some of the breaks might occur. >> thank you for that. the first question at the microphone. if you can please identify yourself. the mic is a little bit high, isn't it? >> it's all right. i think it's fine. thank you. i'm the safety and health director. thanks for being here and your great presentations. the last presentation just really brought it all home in terms of the crisis that is being faced. i think one of the things that is really important as we are thinking about research in the same way that we are thinking

about how we stop the virus we have to look at africa and look first and foremost at africa for what other research needs, as well. one area that would be very helpful i think for us to focus on 527 health care workers who have gotten sick and the 250 who have died. do we have more information on those workers, who they were, what their occupations were, what the potential exposures? it does seem that is going to be at the heart of the response and the heart of protecting those people. finding out as much as we can about the exposures. and also go to the front line workers in africa and find out what do they need? what do they think the questions are that have to be answered for them to be able to do their jobs would be really critical as we are going forward as some of the immediate needs we need to

identify. thank you. >> great question. so looking at this we tried to investigate as intensively as we can in health care worker infections. in my time in africa when we have had health care workers i have gone to those people as awkward as it is and say what happened? can you identify anything? it's extremely rare that there is a discrete event. most times people have no idea how they got infected. they can say there was one small irregulari irregularity. one guy had to go to the bathroom and so he didn't recognize any real breach in protocol but he recognized that he did things very rapidly. we don't have an easy answer to that. very few people have something very discrete. we focus on the doffing part of this as it is probably the most

difficult although there is certainly the potential for infection and other parts of the whole process in the ward. there are also even though it seems logical to us and hard to believe, a lot of the health care workers do still do deliver care on a private basis on their homes and other places. there is the potential for infection unrelated to the ward. some of them are unrecognized chains of transmission elsewhere. i don't think we will have through existing data conclusive evidence for that. >> thank you. next question? >> lieutenant marcy wright. two questions first. i appreciate your comments regarding the need for what i consider applied bio safety research for waste decontamination systems.

how do you develop the risk assessment justification and explanation to the lay public on some of the technical nuances that we have in sterilization reduction versus decontamination reducing to an acceptable level et cetera as folks grapple with the fears of how well incineraters incinerate a virus for example. to follow on, dr. peters, how well developed are many genome systems and particle virus systems and other systems using ebola as a model in terms of pulling the work out of the bio safety level for containment in bio safety level too? >> well, i think the whole issue

of risk communication i didn't have it on my slide but i should have. it's a huge gap, i think, across the whole spectrum of everything especially on the waste management side. they have had to grapple with risk communication for years and years. i don't know that there is a magic bullet for that. but i think there's a definite need for us to be able to improve how we can take the scientific nuances and explain them to not just the general public. this is largely an interdisciplinary effort now that we are looking at it. you may have the jargon from one group of scientific experts who don't understand the jargon from another group. it goes way beyond just talking to the public.

>> can't agree more with that, actually. dr. peters. >> i guess virus like particles can be made with ebola and look like ebola and are the same size as ebola. they would be a possibility but they are not -- at this time they are not economically feasible. i don't know what it would cost to really scale up. in terms of risk communication, first of all, the public understands about as much about microbiology as they do about interval calculus. they can add well but i wouldn't go beyond that. what i have done is picked two or three reporters who seemed to be interested and more intelligent than average and

spent my time educating them and trying to use them as a mouth piece and trust in their abilities to translate what i say into real speech. >> i should say there are several reporters in the room, all of whom are above average. other comments? >> i wanted to ask, if this is a webinar going out to 700 people, let's say you were on one of the major news shows tonight and you had to explain in terms of this risk communication challenge that we all have the differences between the 21 day incubation period and a graph that says 42 days, how would you explain that to the general public? >> it's not a fair question. well, i think the data that i showed especially that curve pretty clearly demonstrates that

we can identify the vast majority but not all cases within 21 days. when we are talking declaring a country free of disease then twice that, 42 days, is the criteria w.h.o. used. intuitively you can run the graph out there and see there are no cases at the far end. it seems to me that additional safety precaution is there. >> thank you. one more response. >> so what would you say to that second little hump? when you looked at your very nice geometric distribution round about 14 days it looks like there was a small second peak. i wonder if an alert reporter were to ask you does that

suggest that the time should be later and the true doubling is to take care of unexpected unrecognized second outbreaks or is it really the doubling? >> that's a good observation. i think you need to just keep in mind that this is real data from the field. and the accuracy of the observations, you don't always know exactly when you were exposed just as dan was saying with the clinicians that became inf innected themselves. i think there will be using real data variability and assumptions we have to take into account. next question? >> good morning. aubrey miller, niehs. started to present some of the

work i was hoped dan could comment further about what he was able to accomplish in the sampling both in terms of human samplings and a little more for the group is what is the research concerning some of the understanding of viability and various fluids beyond -- i have seen evidence saying a blood sample may have it viable for up to 30 days. some comment about aerosols. thank you. >> so that study that we did after things calmed down a little bit and we were able to get patient care and public health response in reasonable order we went around and took convenient samples. whatever sample we could get from a patient that was ilustrative. we thought the virus was where

we thought it would be. unless somebody was sick that we could get it out of numerous different fluids. semen is one we know where the virus persistence is there for a couple of months afterwards. breast milk the latest we found it was eight days after on set of illness. it may be longer. we didn't necessarily have the fluids from people at every time point. an experiment that desperately needs to be done is a similar thing but much more prospective. this we were taking samples where we really need to get in there into an isolation ward and say let's take samples from blood, urine, sweat, vomit and really look at the excretion of this virus along those lines. so that's not technically particularly complicated. we can do it. we need to set up to get that

done. what we have now, for example, much has been made about virus and sweat. the only two studies that i know where the virus has been found in sweat we found it in the sweat of a sick patient with ebola and then port mortem studies found in sweat glands. those were really sick people. since we find it in sweat of the people who die of ebola the sweat is on the bowling ball or the chair on the subway in new york which is not necessarily true. on the environmental side it may not be completely ilustrative because that was a very clean ward when we did it so things were under control. i think if we had taken environmental samples perhaps in unclean wards in worst case scenario we might find more virus around. aerosol, it is hard to -- it just depends upon how you view the data.

it is very clear that most people get infected from direct contact with blood and bodily fluids. 15% of the people or some small percentage say i didn't have that direct contact. some say those were the 15% who had aerosol spread. if you say show me the data to back up your opinion they are not there which is why we are all here. >> one more comment. >> 20% of a recent new england journal paper patient coughed and one similar study in the 90s showed 20% of ebola patients coughed. there is one case report of likely air borne transmission. one of the lessons was that of super spreaders.

we don't know whether it is airway tract or liquidity. it is not that there isn't a reasonable scientific hypothesis to be asked. it's a reasonable question and warrants protection. >> i wanted to follow up that point. you sort of drop this interesting concept of these many transmissions that have occurred with 14,000 patients and the viral behavior. i thought you intimated the viral behavior in terms of transmission may have changed. did i misinterpret you? >> no. my point was that we don't know. we don't have data. we do know that this virus has been in human to human transmission for a very long time.

we do know that r&a viruses adapt to their hosts. those are scientific facts. we don't have detailed observations that allow us to associate any genetic change that may or may not happen because we don't have current genetic information on the viruses themselves and we don't have the detailed epidemiology background to put observations in the real world with the virus strains. we just don't know. i'm going to move to the next question. >> i'm from the office of science and technology policy. listening to the comments about specimens and about the availability of material to look at these important research questions, i'm asking the panel who might be able to facilitate sharing of specimens in access

to virus samples so that the world can make use of this material for research to inform the governments to develop better clinical management practices and research? >> does anybody know the answer to that? how that is being done? >> if there isn't should we be thinking about creating one? >> do you have thoughts? >> i go back to the analogous analogies with the sars outbreak. both cdc and w.h.o. led a very aggressive effort to make sure that the virus was available to the international scientific community for analysis. and that went very well.

i know i was at cdc then and a lot of time was spent packing up strains of sars to share with others. that worked very well. i don't know what the problems are now but i suspect it starts with the countries who have ownership of the material. it's more complex than that. i really don't have any answers. i'm going to move to the next question. >> thank you all for your work and your presentations. i wanted to also thank dr. bauch for bringing us back to the reality of the fact that it is in west africa and the bulk of the disease is in west africa. i spent a good part of seven years back and fourthrth.

ten of our workers died because of lack of personal protective equipment. they didn't have it. one of my concerns in listening this morning is that we have had a few cases in the united states. at this point every hospital in the united states has bought personal protection equipment that they probably will never need which has made the pipeline to west africa dry up. we are about to send several teams to work on ebola in liberia and we are having trouble finding enough personal protective equipment to get there. i wanted to add that to the discussion because we need to think about where we need this equipment and make sure it gets there. the second thing i was thinking about is all of this information is wonderful research and i wonder how it will translate to places that yv spent time in

where we are lucky we can get bleach sometimes. if we can translate how we could safely dispose of waste, equipment, bodies on a much more simplified level because it is unlikely that we will have a lot of incineraters or auto claves in the next five or six years cropping up in places like liberia and guinea. i would be interested to hear how you think we can rapidly translate some of the information you have so eloquently presented in an immediate way to the countries that are suffering right now? >> just a reminder that today's work shop we are focused on the situation in the u.s. but i think you raised an important point which is the impact of preparedness efforts on the u.s. on the global supply chains for personal protective equipment and other things. i'm wondering if there is any

comment on that. i don't think we can delve into how should we be controlling the outbreak in africa because we haven't been composed to do that. >> first of all, thank you for all of your work in liberia. and i think the point that you are raising to me is the relationship between the u.s. and west africa in terms of the global supply chain of supplies. if you have every hospital in the united states prepared to take care of ebola patients you are exactly right the supply chain is going to dry up where you actually need it. so that's one of the logistical issues that i think this work shop needs to discuss. how can we make sure ppe protection for u.s. health care worker is proportionate to the prevalence, incidents and requirements and we don't choke off the supply chain to other countries in great need. i think that question is as

important a research question as some other issues that we are discussing. >> maybe just one more comment. i think i understand that we are trying to focus on the u.s. but it is definitely true that there is no way to not bring this back to west africa. that is our only choice regardless of if you are interested in american health or west african health. thank you for making that point. it is very difficult to just find the sweet spot of preparation without panic and without people going overboard. you are hearing that every hospital in the united states has to have their own ebola treatment unit and it's not realistic but every hospital needs to be prepared. that's the big struggle that we are having, how do we find the right place for preparation in the united states without overpreparation that not only is diverting our energies but resources from where they really

are most needed in west africa. i want to say i think we need to be very careful that we don't get the solutions to be so high tech that we price ourselves out of it and also just make them so logistically difficult that we can't implement them where they are most needed. our major problem is not environmental contamination. we don't have people that have come and we say we think they were infected from virus that has seeped into the ground water. i think that we really do need to focus on that person to person interaction where the money is and where we need to focus on. >> next question? >> i feel a little bit of a split personality here. i am the director for environmental health and safety and providing support to the unit at emory university.

i am also the co-chair for development for bio risk management. i was on the work shop agreement for bio risk management development over the last ten years. in addition i am the global director for a nonprofit who does work in africa and actually set up the nigeria setting up their response to the ebola team. so one of the concerns -- first of all, as a bio risk management geek i will have to say seeing this panel up here is just phenomenal. it is very exciting to see the efforts and the enthusiasm looking at some of the science and technology. former life i used to do pharmaceutical research so i have seen a lot of this science and technology which was eluded to and everything. there is one group that is not at the table and that is the

usda. if we look at our containment facilities for large animal research you do see a lot of this type of technology with personal protective equipment working around large animals that are in containment. that's a piece of the puzzle and a part of the team that needs to be brought to the table, as well. the africa issue it's not just africa, it is a lot of our developing countries, if we look at our developing countries we have spent a tremendous amount of resources, billions and billions of dollars on security. it is the global health security from the standpoint of containing from bio terrorist standpoint. we failed our global health security agenda is on international health. when we look at just these issues that we are dealing with, the dealing of looking at do we have the capacity to identify, contain, respond to a potential outbreak? whether or not it is a terrorist attack or a natural borne

outbreak. we need to start looking at that. i commend those who are in the front lines. as a bio safety professional it is an honor to be able to provide support to you. and whether it is here in the united states or not but one of the concerns that i have as we are developing some of these technologies and everything is just what was voiced earlier is how we relate it to developing countries. the other area i would say is from a bio risk management standpoint is we need to do a better job of risk assessment. the guide lines that came out from cdc, health care facilities what i'm finding is a lot of times they see those as law. those are risk assessments. i talked to the guys across the street as they were developing them. we need to have -- these are

guidelines. we need to be able to teach our staff and faculty and students as they are growing in their skill sets is how to do a risk assessment and equate that to the work place. how when all of a sudden the ppe line that you have depended upon dries up, what are you going to do next and have those contingency plans in place. and then there was also something that was interesting throughout our experiences was the nonhierarchy. if a nurse said to a physician stop they had to stop. in the beginning that was one of the things that wasn't necessarily thought of very positively but the success of our story was that anybody can stop a situation at any given

time. anybody could question and the decisions whether or not we scaled up or down in ppe was a team effort. and so i commend this panel for what you are doing and looking forward. and then also i ask how are you going to start rolling this out to not only health care facilities but research? the lack of ppe is going to impact research facilities here in the united states as well as abroad. >> so that was about six questions but i'm going to put them, summarized to the panel one at a time. i think starting with the first point of whether there is something to be learned from the practices that have been developed in the laboratories of the large animal laboratories. i know dr. peters you have been involved with outbreaks involving primates or large

animals. and some of you also have worked with animals even though we don't have usda at the table. is there any comment on that particular issue? >> we know that horses and goats are resistant to ebola because they were used to prepare antiserm. i think the expert here on setting up diagnostics on the ground is tom. >> very true. not the largest but certainly large. any other comment on that? if not i thought also the issue about use of risk assessment as opposed to protocols and if anybody may be more adaptive ways of doing preparedness in developing responses in am edical facilities as opposed to simply following guidelines?

i think that was the question. >>. >> just going to take the risk assessment question. it is a fundamental activity in occupational safety and health to assess the risk. often times a lot of our clinical infectious disease colleagues aren't quite as familiar but it is a fundamental principle. it does have an important role to play here when we are talking about equipment needs because you may be creating an inefficient situation if you are not assessing the risk properly. i think your comment about the health security i wanted to add is i said in the beginning i think this work shop is about ebola but the larger issues we are talking about -- i certainly hope the iom take this up, we are talking about international security. there are a lot of different viruses. there is a lot of very serious

issues out there with internationalization of travel and business et cetera. we are facing another work shop with a different name. so i think it is really important that we continue these discussions. >> just a little more detail. risk communication risk analysis, identifying the hazard and the degree of the hazard using humans as a surrogate, at what temperature? at what subjective feeling of illness do we think people start shedding the virus. is it 99.4? those are fundamental questions where we don't know the answer yet. we actually are given guidance. hazard assessment, risk analysis, at which point do we know what kind of ppe to use? we can study that in a formal way. unless the people who have to act on that are involved in thinking through questions and guidance they are not comfortable with the answers.

so involving health care workers in process strikes me as important. >> thank you. so the last one i'm going to pick off of that comment has to do with what one of the presenters called a nonhierarchal team approach. i know this has been a major concern for the institute of medicine in the provision of higher health care delivery they need to have changes in how members of health care wurbers interact around their own personal safety. and if there are further comments from the panel on that. >> well, the overlap of employee and patient safety has been in the air since i think the first joint conference of the veterans health administration, arc and

osha in 1998 in which the key note address was talked about. as we get to ebola where the source and the recipient are the same. for many diseases it's not as much of an issue but clearly this is the poster child for the overlap of patient and employee safety. seeing the pictures in liberia of those beds and tents was humbling as we think about the luxury of how we deal with patient safety here. clearly a huge, huge issue. >> next question? >> thank you. university of minnesota. i think if you did a poll of everybody in the room they would probably agree 15 to 20 weeks ago nobody here would think we would be here talking about a situation like this.

in some ways lack of imagination we will all go back and wonder why we didn't think about this possibility. when you look at the history of ebola in the human species there have been 24 documented transmissions, 2,400 cases, the most number of generations with ebola is five to seven. in many ways this virus has hardly pinged before now. some of us have written about the fact that the virus hadn't changed, africa changed and all about urbanization and crowding and lack of health infrastructure and poor response time. one of the things i think we are missing on is asking ourselves the hard question again, is there any difference in this potential virus whether it is an example of just a higher level

of irenia. there is such limited data to no data would that begin to change some of the possible conclusions we have had about past outbreaks. we have had other levels with certain other infections, we can see this same principles of transmission, but the rate of transmission is different. the dynamics is different in that regard. and i guess it would be interesting here for this meeting, because clearly we're making assumptions about all the previous outbreaks being the model for this outbreak. surely in the general trends, the question is, could it have changed, and it's not just the fact that it's crowding, that it's lack of medical services et cetera, that this is, for example, the higher viral loads that would result in different levels of transmission and we have seen in past outbreaks. i know gary will be covering some of this this afternoon. i guess i would ask the panel the implications for that. are we making a mistake by expecting this to be exactly like the past outbreaks with more people?

>> anyone want that one? >> i can come in, i guess. certainly valid questions. my gut feeling is that the seeds of this are more related to the social and cultural factors and logistics of west africa and people going back and forth and all that. but i think we definitely need to be open to scientific inquiry. we have some of the beginning data. it just takes a long time to generate it. longer than we'd like. we have a sequence data, but that does not really tell us what we need to know. we need to put that into subculture, we need to put that into nonhuman primates, see if they have different manifestations, different viral loads. so i think those studies, i can't quote researchers, but i think those things are probably being done in various laboratories in the united states and elsewhere. it takes time to get those. and, of course, it takes time to

generate all of that data. if you think about just getting the samples and the logistics of import permits and getting somewhere where you can do those types of experiments, it is just a slower process than we would like to be, but it is a valid question that we need to be attuned to. >> dr. peters? >> i would not be surprised if we did not get an answer in the u.s. because in africa you are so pressured for time. there are so many people. so many different ways you can get ebola. but you plop somebody down in the middle of des moines and you may find out whether there's aerosol transmission that has evolved over a period of time. >> thank you. >> two at the mic and i think we have just enough time to take these last two questions. >> director of communicable disease control and prevention for the los angeles county

department of public health, also share of the infect shuz disease prevention and control for the national association of city and county health officials. again to dr. bausch, the realities and the needs on the ground in west africa, perhaps a domestic area research area that we could also put some priority to is ways we could more systematically improve the recruitment, as well as mobilization of health care workers, both public health and clinical to help in west africa. thank you. >> agreed, and i am open to any ideas you have to try to increase the numbers. >> all right. last question. >> on harrison, california department of public health. after the h1n1 pandemic, we did a series of studies with colleagues from niosh and several other states and actually went into about 15 hospitals in california. nationwide we have about 60.

in several other states. we asked how front-line health care workers perceive the use of ppe. we did some observation of donning and doving and we interviewed a whole series of staff in the hospitals, and i think we learned a great deal about the implementation of ppe on the ground, and i would put a plug in for putting that as a topic for research in terms of ebola. not necessarily now. i think that would be a hard lift to do it next week when our hospitals just are in the midst of figuring out how to even just purchase appropriate ppe. but sometime relatively soon while the memories are relatively fresh because we get a lot of questions at the state level about what exactly to buy and i wish, i would really like to know how people are using it. and what the experience of the front line health care workers are. so the model of more participatory research to help our public health at the local,

state, and federal levels really understand what we can learn six months or one year from now. >> thank you. >> i guess i will take this one. over the last two or three weeks w.h.o. has had a guidelines committee on ppe that i've chaired. and the guidelines just came out i think the day before yesterday. you can find those. they are, i think, helpful. we did do some surveillance of health care workers coming back from west africa and what they liked and disliked in order to inform those guidelines. i think they are valuable, but they suffer from what we desperately need and why we are here. we need some evidence base. it came down to one person saying we need this and another saying we need that. people can express what they like. but when we said this is what was really necessary it was all opinion.

>> we will take a last, last question. >> one small remark, rocky mountain labs, and i don't know if everybody knows, but because ebola select agent desat regulates experiments on this virus, and basically these regulations hamper me in actively respond fast to some of the research questions that you're asked here. and i think i want to put it out there that if i want to start doing something which, it will take me two years. >> could you identify yourself again? >> rocky mountain labs. >> rocky mountain labs. >> comment on that? it's probably true that the -- there are a lot of regulations that govern the ability to even initiate research in this area, and something to be aware of.

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when i'm home. it's the only station i have on most of the time. i think it's absolutely excellent. i watched all of the debates around the country. thank you for those -- the book talks, and for the history. i like all of it. and i am thankful that it's there and i use it in my classroom. i teach at a community college in connecticut. thank you very much. >> and continue to let us know what you think about the programs you're watching. call us at 202-626-3400. e-mail us at comments@c-span.org. or send us a tweet @c-span #comments. join the c-span conversation, like us on facebook, follow us on twitter. the 2015 c-span student cam video competition is under way. open to all middle and high school students to create a five to seven-minute documentary on the theme, the three branches and you. showing how a policy, law or action by the economicive,

legislative or judicial branch of the federal government has affected you or your community. there's 200 cash prizes for students and teachers totalling $100,000. for the list of rules and how to get started go to studentcam.org. awaiting the start of this hearing on the international response to ebola. representatives from several organizations, including doctors without borders, and international medical corps, will be updating a house foreign affairs subcommittee. and also focus on the need for trained health care workers in the outbreak zone. representative christopher smith chairs the subcommittee while representative eliot engel is the lead democrat on this panel. we expect it to start shortly, live here on c-span3. and more on ebola later today as dr. tom frieden and others update a house energy subcommittee. and the u.s. response to ebola. also at that hearing will be jeffrey gold, the chancellor of the university of nebraska medical center, where an ebola

patient died yesterday. that's scheduled to start live at 1:00 p.m. or later, depending on votes in the house of representatives. today in the senate members are scheduled to vote on a bill authorizing the keystone xl pipeline. their session just getting started now, with six hours of debate on the pipeline, and a vote for later this afternoon at approximately 6:15 p.m. the house passed its version of the bill last week, and president obama has threatened to veto the measure. coverage of the senate and that debate is live now on c-span2. you can participate by leaving your comments through twitter and on our facebook page. our question online today, should the senate approve the keystone xl pipeline? and following the senate vote early this evening we'll be asking you if you think president obama should veto the legislation. the hill's reporting that louisiana senator mary landrieu and other supporters of the

keystone xl oil pipeline are stuck at 59 votes. that's one vote shy of the supermajority they need to move their bill forward today. senator's carl levin and jay rockefeller said yesterday thad they would vote against moving forward with the legislation, making it unclear whether supporters had the path to the magic number of 60. every republican in the senate is expected to back the measure, and ten democrats have signed on to the legislation that landrieu is sponsoring. along with republican senator john hoeben of north dakota.

again, we're live on capitol hill waiting for this hearing to begin on the international response to ebola. more on the house work,

legislative work in the house begins at noon today with work expected ton a bill that changes the way members of the epa science advisory board are chos chosen. and house democrats are meeting this morning to elect new party leaders. we spoke with a capitol hill reporter about the leadership election. >> dan newhaasser a staff correspondent with national journal to talk about today's election. how does it work for these party elections for the house democrats? >> well, all the party elections essentially work the same way. everybody in the party will meet in a big room they have sort of an airing of the grievances, if you will. if there are any. and certainly there usually are. they will nominate each leader, you know, somebody will arrive and say i nominate "x" person, and then if there's opposition, someone will counterthat with another nomination.

and whoever gets the majority of the votes in the party wins the leadership election. >> okay. so, how many leadership positions are there? and what are they voting for today? >> well, there are several, you know, marginal ones. the big ones are, of course, you know, minority leader whip steny hoyer, and then you know, they can sort of -- clyburn is, you know, they created a position for him when they went into the minority. so, you know, but of course, the top billing ones, the ones that get the top belling are nancy pelosi, steny hoyer. >> will there be any new faces to this leadership team? >> not in the elected leadership. but there is a new face, interestingly enough, from new mexico is going to be the chairman of the democrats

campaign wing. he's succeeding steve israel of new york who had said before this cycle that he was going to -- that he was going to step down from that position. and they've created a position for israel to land and go to the head there -- in communications so that's interesting new face to the leadership position and a bit of a surprise actually. >> we're showing our viewers right now, congressman ben ray lujan, who is he and why did nancy pelosi decide to tap him for this post? >> he's a pretty relatively young 42, he's only been in the house since 2008. he comes from, you know, a prominent democratic family in new mexico. you know, ben lujan was once state speaker -- speaker of the state house, excuse me. you know, he -- he was -- he's in the congressional hispanic caucus. and you know, he says he wants to communicate the party's agenda in the house.

so, you know, you can't overlook the identity pockets of this. democrats are always looking to have new and more diverse faces at the leadership table. and they have been lacking a hispanic voice, and this is a cycle in 2016 where a lot of people believe that the hispanic vote is going to be very important. >> will there be any surprises at today's conference meeting with house democrats when they go to pick their leadership team? >> you know, i don't think so. i mean, there has been some griping, as there usually is, about pelosi, and about generally the age of all the leaders. they're all, 70 and that's something to which pelosi countered the other day saying it's sexist. nobody asks mitch mcconnell, oh, are you a little bit too old to be running the senate right now. so, you know, there are going to be voices in the democratic party who don't want to keep

pelosi. but there's just no other viable candidate. nobody who can unite the party. nobody who can raise the kind of money, so she ought to be handily re-elected. >> so before we let you go, i want to talk about also what's happening on the senate floor. there's going to be a vote today on keystone xl. when will that vote take place and what's it looking like? >> the world community has known of the ebola virus, or more commonly called just ebola, since it first appeared in a remote region near the democratic republic of congo in 1976. in previous outbreaks, ebola has been confined to rural areas in which there was little contact outside the villages of which it appeared. unfortunately, this outbreak now an epidemic spread from village to an international center for regional trade, and spread into urban areas in guinea, sierra leone and liberia, that are crowded with limited medical services, and limited resident trust much government.

the unprecedented west african ebola epidemic has not only killed more than 5,000 people, with more than 14,000 others known to be affected. this situation has skewed the planning for how to deal with the outbreak. in our two previous hearings on the ebola epidemic, an emergency hearing we held on august 7th, and then a follow-up on september 17th, we heard about the worsening rates of infection and challenges in responding to this forum from government agencies such as usaid and cdc and samaritans person. today's hearing is intended to take testimony from nongovernmental organizations, providing services on the ground currently, in the affected countries, especially liberia, so we can better determine how proposed actions are being implemented. in its early stages ebola fan fests the same symptoms as less immediately deadly diseases such

as malaria, which means initial health care workers have been unprepared for the deadly nature of the disease that they have been asked to treat. this meant that too many health care workers, national and international, have been at risk in treating patients who themselves may not know they have ebola. hundreds of health care workers have been infected, and many have died, including some of the top medical personnel in the three affected countries. what we found quite quickly was that the health care systems in these countries, despite heavy investment by the united states and other donors, remain weak, as it happens there are -- these are three countries either coming out of very divisive civil conflict, or experiencing serious political divisions. consequently, citizens have not been widely prepared to accept recommendations from their own governments. for quite some time, many people in all three countries would not accept that the ebola epidemic was real.

even now it is believed that despite the prevalence of burial teams throughout liberia, for example, some families are reluctant to identify their sufferings and dead loved ones for safe burials. which places the family members and their neighbors at heightened risk of contracting this often fatal disease when patients are most contagious. the porous borders of these three countries have allowed people to cross between countries at will. this may facilitate commerce, which is a good thing, but it also allows for diseases to be transmitted regionally. as a result, the prevalence of ebola in these three countries has ebbed and flowed with the migration of people from one country to the other. liberia remains the hardest-hit of the three countries with more than 6500 ebola cases officially recorded. probably a significant understatement. the number of infected and dead from ebola could be as much as three times, however, than official figure due to underreporting. organizations operating on the

ground have told us over the past five months that despite the increasing reach of international and national efforts to contact those affected with ebola there remains many remote areas where it is still difficult to find residents or gain sufficient trust to obtain their cooperation. consequently, the ebb and flow in infections continues. even when it looks like the battle is being won in one place, it increases in a neighboring country, a region, and then re-ignites in the area that look to be successes. the united states is focusing on liberia. the uk is focusing on sierra leone, and france and the european union are supposed to be focusing on guinea. in both sierra leone and guinea the anti-ebola efforts are behind the pace of those in liberia. this epidemic must be brought under control in all three if our efforts are to be successful. last week, i along with congresswoman karen bass, and congressman mark meadows of this subcommittee introduced hr-5710 the ebola emergency response

act. this bill lays out steps that are needed for the u.s. government to effectively help fight the west african ebola epidemic, especially in liberia. the worst-hit of the throw countries. this krus recruiting and training health care personnel, establishing fully functional treatment centers, conducting education campaigns among populations in affected countries, and developing diagnostics, treatments and vaccines. hr-5710 confirms u.s. policy in the anti-ebola fight, and provides necessary authorities for the administration to continue or expand anticipated actions in this regard. the bill encourages u.s. collaboration with other donors. mitigate the risk of economic collapse and civil unrest in the three affected countries. furthermore the legislation authorizes funding of the international disaster assistance account at the higher fy-2014 level to effectively

support these anti-ebola efforts. i'd like to now turn to my friend and colleague miss bass. >> as always, thank you chairman smith for your leadership, and also for taking the lead on the legislation that we hope to have marked up soon. i also want to thank today's distinguished witnesses, and prominent ngo organizations. providing critical medical, nutritional, and developmental assistance in the most adversely affected nations in west africa. i look forward to hearing your updates on how your respectively organizations continue to combat this deadly outbreak, what trends you're seeing both positive and negative, and what additional support is needed as you coordinate with the government -- the governments of the impacted countries and the international community. i appreciate your efforts and outreach to help keep congress informed of this evolving crisis. the current crisis, as has been stated, has been the largest and most widespread outbreak of the disease in history, creating a particular burden on the countries that are involved.

since the beginning of the outbreak, u.s.-based ngos have made a significant and sustained effort to support the three countries as they fought the disease. the united states has committed nearly $1 billion to build treatment centers, train health care workers, and burial teams, supply hospitals with protective gear, and ensure the safety and humanitarian support. i would, in particular, like to hear from the witnesses what you think about the assistance that has been provided. and then i have a particular interest in your thoughts around when we are past this crisis what the u.s. can leave in place. and your thoughts on how we move forward. so we know that the reason why this hit so badly is because of the weak health infrastructure in these three countries. so out of this terrible crisis, is there a way for us to begin to think long-term about the future, how do we support the

infrastructure of countries? and your thoughts on that would be appreciated. ed administration has asked congress for over $6 billion in emergency funds in order to sustain the progress that has been made and to ensure an end to the crisis. this request will expand assistance to contain the epidemic, safeguard the american public from further spread of the disease, and support the development of treatments. sustained u.s. financial support and involvement is essential to support the stable governance of these nations which is jeopardized by the current crisis. i also don't think that we have given much time to -- much time and attention to the fact that we're dealing with countries that could actually be moved quite a bit backward, especially countries that have recently, you know, gotten past civil wars. so i look forward to your testimonies, and i'm interested in hearing from you about what we can do to assist your efforts. thank you. >> thank you.

i'd like to now welcome our three very distinguished witnesses who are extraordinaryly effective and informed and will provide this subcommittee i think a real insight as to what has been happening and what needs to be done. beginning with mr. rabih torbay, who is a senior vice president for the international operations and oversees international medical corps, global programs in 31 countries and four continents. and its staff and the staff volunteers numbering well over 8,000 people. he has personally supervised the expansion of imc's humanitarian and development programs into some of the world's toughest working environments, including sierra lie yoen, iraq, darfur, liberia, lebanon, pakistan, afghanistan, haiti, libya and most recently syria. as the organization's senior representative in washington, d.c., he serves as imc's liaison with the united states government. we'll then hear from mr. brett sedgewick who is a technical adviser for food security and

livelihoods for global communities. he previously served as vice president for the nascom foundation for whom he built stakeholder relations with government entities, donors and ngos and oversaw business development. prior to that he served as liberia's country director for chf international where he oversaw programs designed, implementation and monitoring for a range of donors. he also served as technical adviser to -- on a similar basis. we'll then hear from dr. darius mans who is the president of africare where he is responsible for the leadership and growth of that organization. previously he fulfilled a number of roles at the millennium challenge corporation, including acting chief executive officer and vice president of implementation and managing director for africa. in these positions dr. mans was responsible for vast and diverse program portfolios in mcc, exact countries.

he also has experience managing 45 country programs around the world, as director of the world bank institute, working as an economist, teaching economics, and serving as a consultant on infrastructure projects in latin america. we're joined by mr. weber, vice chairman of the committee. >> thank you for being here. let's go. >> thank you. thank you i turn to mr. torbay. >> chairman smith, ranking member bass, and distinguished members of the subcommittee, on behalf of international medical corps, i would like to thank you for inviting me to testify today to describe the ongoing fight against the ebola virus outbreak from the ground level. i have already submitted a lengthy written testimony to the subcommittee. my remarks this morning will highlight key observations, and offer ten recommendations for our ebola response experience.

international medical corps is a global humanitarian nonprofit organization dedicated to saving lives, and relieving suffering through health care training and relief and development programs. we work in 31 countries around the world, and we've been working in west africa since 1999. our response to the ebola outbreak has been robust in both liberia, and sierra leone. more than two thirds of all ebola cases and over three quarters of all ebola related deaths have come from these two countries. by the end of this month, we anticipate having a total about 800 staff in those two countries, and by year's end, we expect this number to exceed 1,000 working in four ebola treatment units, two in liberia and two in sierra leone. i would like to take this opportunity to acknowledge dedicated and courageous international and african national staff working in our treatment centers. they are from liberia and sierra leone as well as many parts of the united states, europe and other states.

our staff is compromised of doctors, nurses, technicians, specialists in water sanitation and hygiene, logisticians, mental health professionals, custodial workers, and burial teams. in addition to the treatment units, we have established several services for groups just now arriving to combat the outbreak. one example is a training center on the ground in liberia. it will teach and train staff from all organizations engaged in the fight to contain ebola, and show them how to treat patients and stay safe in a potentially dangerous workplace. we are also responding to the upsurge of ebola cases in mali. we will be setting up an ebola treatment unit and developing health worker training program to help the country fight the outbreak. our robust response to the ebola outbreak has one overriding objective.

contain the current outbreak at its source in west africa. to succeed several key factors must be in place. one of these is building and safely operating ebola treatment units, staffed by well-trained health professionals. another key factor is using training programs to transfer into local hands the skills and knowledge necessary to respond effectively to the ebola outbreaks. we must also assure effective coordination among all actors involved in the fight to contain the virus, including the u.n., international and national governments, and ngos. to turn the tide of this epidemic we must all work together to maximize the strength of all involved. finally we need to conduct expansive data collection and rigorous data analysis to build an accurate picture of ebola containment, and spot any need for new responses. once we succeed to contain the current outbreak, we must remain

vigilant to assure that there's no resurgence of this epidemic. the fight to contain ebola and future -- and prevent future outbreaks will require substantial investment. i would like to thank the u.s. agency for international development, particularly its office of foreign disaster assistance for the funding it has provided to international medical corps for our ebola response, as well as the support of the u.s. military, particularly in setting up a laboratory near our ebola treatment unit in bonn county. we welcome the president's emergency request to congress to combat ebola in west africa. and based on our on-the-ground experience in fighting this epidemic, we would recommend that the 1.4 billion allocated for international disaster assistance be increased by an additional $200 million to a total of $1.6 billion. and we recommend that an additional $48 million be added to the economic support fund for a total of $260 million.

mr. chairman, i conclude my tell by offering ten recommendations for effective treatment and eradication of ebola virus. one, ensure the availability of adequate number of well-trained, well protected health workers. one of the most critical lessons learned from this response has been the importance of having sufficient human resources prepared to address an outbreak of infectious disease. two, ensure that construction of new ebola treatment units fit the local loads. the work must be well coordinated and well trained staff ready to work in each facility. we need to remain flexible and nimble and adapt quickly to changing remand to response of breaks in rural areas. three, ensure the necessary quantity and quality of personal protective equipment that is available. four, improve data collection.

surveillance that will help individuals receive treatment faster. five, ensure that fear and understand the lines of communications and divisions of responsibilities are established understood and maintained among coordinating bodies operating in the region. a smart and efficient coordination system at the national level is critical for an effective response. six, we welcome the advances made over the past few weeks in establishing procedures to evacuate and treat expatriate health workers who might contract ebola. we recommend that the systems be put in place now, be institutionalized and made part of the global preparedness planning future -- for future epidemics. seven, we recommend that commercial air space over ebola countries remain open that personnel and resources can move quickly. eight, accelerate and support the production of vaccines.

nine, invest in emergency preparedness in west african regions to ensure that these countries have the needed resource, proper training and systems in place to respond themselves to possible future outbreaks of infectious disease. and ten, finally, mr. chairman, basic health services need to be re-established in west africa. people are not just dying from ebola. they're dying from malaria. they're dying from water-borne diseases. women are dying from the lack of facilities where they could go for safe delivery. and this needs to be done as soon as possible. we cannot wait until the ebola outbreak is done before we restart these activities. thank you, mr. chairman, and ranking member bass, for the opportunity to present this testimony to the committee. i would be glad to answer any questions you may have. >> thank you very much, mr. torbay. mr. sedgewick, if you would proceed. >> chairman smith, ranking member bass, members of the subcommittee, thank you for the opportunity to testify today on

the ways we are working to stop the ebola epidemic in west africa. the following is an abbreviated version of the written testimony provided to the committee. my name is brett sedgewick and i'm technical adviser at global communities formerly chf international and i'm currently on the ebola task force. from 2010 to 2011 i worked as global communities liberia country director and i returned to the u.s. ten days ago after spending three weeks in liberia helping to lead our response on the ground. global communities has worked in liberia since 2004. in 2010 we began a u.s. aid funded water and sanitation project working closely with the ministry of health and social welfare. through this program we began to combat ebola in april by providing community education, protective equipment, and hygiene materials to communities at risk. in august we partnered with usaid's office of foreign disaster assistance to have been excellent partners in this fight

to scale up our response. today we are also working in safe burial and body management, contact tracing, and ambulance services. safe body management is of the highest priority in stopping the spread of ebola. the bodies of ebola victims are extremely contagious. in liberia it is often customary for the family of the diseased to say good-bye through traditions that involve touching and washing the body. the cdc estimates that up to 70% of ebola infections are originating from the -- from contact with the deceased. global communities is working in every county of liberia, supporting 47 burial teams and 32 disinfection teams. we work in close partnership with the ministry of health. the ministry employ the burial team personnel and we provide training, vehicles, logistical support and equipment. the work of burial teams is both back breaking and heartbreaking. i have accompanied burial teams

to -- and seen the incredible professionalism with which they operate. these men and women were covered in impermeable materials in high temperatures, hiking hours through thick jungle, taking canoes or assembling makeshift bridges over bodies of water. they enter communities stricken with grief and fear and carry out an incredibly sensitive task with the greatest care for their health, and for that of others. these men and women are heroes of this crisis that deserve our gratitude, and for assuming great risk and social isolation in order to stop this epidemic. while risky, this work can be done safely. not once of our more than 500 team members, have contracted the virus. this work is not without challenges. many resist identifying their dead as infected. they fear they will not be able to mourn their loved ones, and they themselves will be stigmatized. this is why the work of safe burial goes hand in hand with

community engagement. many burial rites are safe. and the teams let communities safely and respectfully say good-bye to their loved ones. another challenge is cremation. in montserrato county which contains monrovia cremation became official policy during the height of the outbreak. however this practice is counter to traditional practices and has met with strong resistance. the idea of a deceased loved one being burned, in their vernacular, upset many, and increased the stigma and contributes to bodies being unsafely buried or the sick being hidden. to combat this, global communities, usaid and the liberian government, are exploring safe burials in montserrato through identifying land that can accommodate a large number of burials and has space for families to safely gather and mourn. despite the challenges, safe burial is proving highly effective. we began burial team support in

august for bong, lofa and mimba counties. by the first week of october we expanded to support teams in every county of liberia and last month they were able to collect 96% of bodies within 24 hours. we were also able to directly reach over 1500 communities through meeting and dialogue sessions. bringing together senior government officials, county health teams, traditional chiefs, religious leaders, community health volunteers, and other local leaders. indeed it is now being widely reported that we are seeing the rate of infection slow throughout liberia which is cause for optimism. however it is not yet time for celebration. we must maintain the level of vigilance that is proven effective in beginning to control the spread of the virus. significant longer-term investments must be made in the health systems of the country. in closing, global communities would like to express profound gratitude for congress, particularly members of this committee for your continued support of this work.

the worst ebola outbreak in history can be stopped, and will be stopped. i look forward to your questions. >> mr. sedgewick thank you very much for your testimony and your recommendations. and really some of the good news, at least somewhat optimistic perspective that you have provided the committee. dr. mans, please proceed. >> thank you mr. chairman. let me start by thanking you and members of committee for you strong commitment to this issue. i also really want to applaud my colleagues here for the tireless work that they are doing on the ground. i'm honored to be here with them. if i may, i'd like to start by describing what africare is doing on the ground in the fight against ebola. and then describe to you what we at africare believe are the most important steps that need to be taken in order to win this war. it will be won by africans on the ground who time and again have demonstrated that they can overcome disease and adversity.

and finally i'd like to conclude with what we believe the united states can do to stop ebola in its tracks. when the ebola crisis began earlier this year, africare immediately swung into action. we mobilized more than $2 million in private donations to help break the chain of transmission. we shipped personal protection equipment and essential health supplies to all three affected countries through partnerships with direct relief and others. in addition, we've been help going front line health workers do contact tracing. throughout the crisis, we have been very focused on community mobilization and behavior change. that's at the heart of what africare does across the continent. we believe while aid from foreign governments and from organizations like ours is vitally important, it will be africans adopting changes in behavior that ultimately will win the war on the ground against ebola. so far, we have trained more than 300 local community health

workers. they, in turn, have educated more than 150,000 liberians about ebola prevention, detection, and care. in addition, our team of nearly 100 staff on the ground, all liberian, are joined at the hip with liberia's ministry of health to keep health facilities open, to treat nonebola related diseases. and that includes safe deliveries of babies. we are taking in to our maternal waiting homes women who have been turned away from hospitals, that are just overwhelmed by the ebola crisis. and since we believe that measurement is absolutely critical, we are also working with technology partners to find ways to embed data capture within our delivery systems. so that we can provide good metrics to gauge our performance, and realtime information about what we're doing to contribute to the war against ebola. and i should tell you, we're doing all of this without any funding from the u.s. government

so far. but let me describe what we believe, in addition, needs to be done in the face of this challenge. progress is being made, but much, much more needs to be done. we certainly strongly support the president's emergency request and hope the rest of the g-20 countries will step up to the plate and do more. but it's not just more money that is needed. it's important how that money is used. there's a need for better coordination and planning of these emergency treatment centers. we believe we clearly don't need as many etcs as were morningally planned in liberia for example. very important to take the efforts to control ebola to the community level. that's where the bulk of care is provided by family members, by neighbors, by local health workers, who really are the first responders in this crisis. we also hope that usaid will be given the flexibility to allocate its resources as needed

to ensure there will be an agile response to what we've seen as a rapidly evolving epidemic. in addition, very important, we believe that it's essential that civil society in the affected countries be given the support and space needed to help ensure the best use of, and accountability for ebola funding. finally, mr. chairman, let me say a few words about what more we believe the united states can do. one of the big lessons of this crisis is that donors need to move beyond the old approach of vertical programming, of targeting resources to specific diseases, like malaria, and hiv/aids, as important as those are. we need to invest in strengthening public health systems, especially community-based management of diseases. we also need to take advantage of this crisis to build a health infrastructure thats affected countries will need for the future. the investments being made now

during the crisis need to help them build more robust and resilient health systems. as the liberian president has said, we must ensure that everything we do now is not just with the aim of ending the outbreak, but to ensure that we come out with a stronger, efficient, health care system. and finally, mr. chairman, it's my hope that u.s. government will commit to support long-term economic growth in the region. i hope you will join me in urging the millennium challenge corporation to quickly finalize its programs in liberia and in sierra leone. its significant investments in the key drivers for growth will be what's needed to help these countries get back on the higher growth path that they were on before the ebola crisis. thank you, mr. chairman. >> doctor mans thank you very much again for your extremely valuable work you're doing but also the insights you provide our committee. let me ask you a couple of

questions, all three of you. you mentioned dr. mans, that you have 300 local volunteer community health workers that you've trained who, in turn, have educated some 150,000 liberians about ebola prevention, detection and care. in your statement mr. torbay you talk about to ensure the availability of adequate, well trained, well protected health care workers. how close is liberia, guinea and sierra leone to having an optimum number of health care workers who are adequately trained? what is the deficit? i mean this is excellent information and very encouraging information. are you finding people have been scared away because of the fear of contracting it themselves? so if you could provide that information to us. secondly, mr. sedgewick, which i would point out parenthetically, we're both from new jersey. welcome.

let me just -- which is where i'm from. let me just, you talked about the safe body management is of the highest priority to stopping the spread of ebola and you pointed out the cdc number of up to 70% of cases originating from contact from the deceased. i think a lot of people are not unaware but they have not known how stark the transmission is at that period of time when somebody has passed away. and yet you have very good information about your teams reaching 96% of bodies within 24 hours over the last month. how many of the folks that should be reached are not being reached? just to fry to get a sense of the unmet need? and what is the role that clergy and church are playing? obviously when somebody passes away, we all turn to our faith. you know, the church plays a key role, obviously, in funerals.

what role are they playing from the pulpit? and any other way of getting that message out about the contagious nature of someone who is deceased from ebola? i also, with regards to personal protective equipment, mr. torbay, that's your third point that you made, how available is it? especially to those volunteers, and those indigenous individuals who might not have access to it like some of the ngos might going in? if you could just speak to that. are we where we should be? anywhere close to it? because obviously that's one way of protecting. and then dr. mans, you had mentioned, and rightfully so, the deep concern dr. or president sirleaf spoke, her concern here today about other diseases that continue to take a devastating impact on people in

three affected countries, including liberia, and congratulations and good work on the safe delivery aspect to help a mother and baby have a venue where they can give birth safely as possible and as, you know, if you might want to expand upon that, how many women are we talking about who have gotten help through your work? i have other questions but i'll ask those first and then my friend and colleague and then come back for a few others. >> thank you mr. chairman for your questions. i will start with the health workers gap. what we're doing at international medical corps is focusing on training health workers that will be working in ebola treatment unit. and that training is a 14-day intensive training that includes hands-on training, actually treating patients in an ebola treatment unit. and as you probably know, when

you work in an ebola treatment unit you cannot work for more than an hour or maximum two before you get out, because of the heat, because of the pressure, because of the stress. and we want to make sure that those workers go out before they get tired and dehydrated because this is when mistakes happen. so we're extremely careful about that. in terms of the health care gap, we're coordinating with agencies that are doing community work, such as, you know, global communities, africare and other groups and samaritan's purse and other groups as well. and the idea is to combine and coordinate the community-based approach with the treatment-based approach. because one cannot work properly, or be effective, without the other. as you know, liberia and sierra leone even before ebola had very low doctor per patient ratio. we're talking about one for 100,000 in liberia. one doctor for 100,000 in

liberia. and that's before 324 health workers have died from ebola. so you can just imagine the gap. one thing that's critical to the health gap, we cannot be only reactive. any time there's an outbreak, this is when we decide to train. we need to build a stronger health care system. we need to build a stronger preparedness system. and all of these countries, and we need to focus on workforce, health workforce development. because, again, it's not just the infectious diseases. it's the malaria. it's the safe delivery. it's dee rhea. it's vac teen preventable diseases that children are dying from. i think we're on track in terms of training health care workers for the ebola response. but, what we're doing in our ebola treatment or ebola training facilities is that we will be turning it in the next couple of months to an infectious disease academy. that covers much more beyond ebola. and this is a sustainability aspect that we're encouraging all of our colleagues to look at. what comes beyond ebola.

>> thank you for your question. to address your second question on unmet need, i'd like to point out that the 96% of bodies that are collected within 24 hours, that's within 24 hours of the death of the individual. not of the phone call. so much of that 4% is regards a delay between the death and the phone call. and the assignment of the team. and so that's -- that's a big effort that we're working on in terms of our social mobilization and the social mobilization that all of the other partners are doing to ensure that that phone call happens very early on. ideally we're hearing about the status of the individual well before -- well before they pass. and as much as possible, our

success is -- is made significantly easier by our colleagues like imc running etus and having the volume and the beds available to treat those individuals. it's much better for the individual to get to the etu, to get first community care, and then get to the etu, and that make makes that allows our teams to do a lot less work which is a great situation to be in. in terms of the larger question of unmet need, it's very difficult to understand. we do a lot of work with the communities trying to understand if there are people dying that are getting hidden. and it's -- it's all anecdotal. i know that the african union and the cdc have been working on

doing some studies on this. and they've found limited volumes of people hiding. but any are devastating. so we're really working on making sure that the stigma goes down which would encourage everyone to call, and to reduce that unmet need. in terms of volume we are completely mobilized. and we are able to respond very quickly. we've mobilized new teams within a day. so we're able to make sure that as hot spots come up, the teams are positioned and available, and responding immediately. on your second part of that question regarding clergy, and faith based leaders, they're a

core part of how we interact with the communities. our kind of historical interactions in liberia have been focused on bonn and mimba counties. we have really strong relationships not just with the religious leaders but with the traditional leaders and health leaders. that made our initial entry with burial teams fairly straightforward. you can't drive one of our vehicles through those counties without getting stopped and having them ask how so and so, and what's the -- how is so and so's baby. and they're so -- they're so engaged there. that it made it very, very straightforward. when we moved to other counties, especially in the southeast where we have less of a historical presence, we very quickly realized we had to do extensive interactions with the religious health and traditional leaders. they've been incredibly helpful in making sure that the

communities know why we're there. that we're there for a good reason, that we're helping, and that we're able to do our work respectfully and closely and rapidly. so that's been a core part. the religious leaders have been really helpful. and the traditional leaders who also serve very important roles in -- at the community level, have been very important for making sure that our teams are able to operate rapidly and safely. >> on personal protection equipment, nowhere we are nowhere near where we need to be. there are shortages of all kinds of equipment. including gloves for medical personnel to use. so what africare is doing is working with the private sector here in the united states. the big suppliers of equipment, like j&j and so many others, to be sure that we can get a steady

supply of consumables in to all health facilities in liberia, working with all of the ngo partners, because we are a big believer in collaboration. that no one of us can do this alone. and second on safe motherhood, you know know even before the ebola crisis, liberia had one of the highest rates of maternal mortality in the world. and headed in the wrong direction. increasing. so a big focus for us has been developing more and more of these maternal waiting homes, working with the private sector in liberia, to raise the money to do so. and so far i think we're up to about 20 and then these facilities that point us to bring access to communities, because women who were expecting were not able to get to these health facilities, which were so few and far between. and that's something we intend to do, continue to do post-crisis.

>> miss bass? >> i will, again, want to thank all of you for your testimony. i think it's been extremely helpful, and i have questions for each of you. mr. torbay, pronounce that correct? in your recommendations, the second one says you wanted to make sure that the construction of the etus are appropriate for the needs of each country and so i was wondering if you find what is going on now is not appropriate? are you saying this in response to something that needs to be improved? >> thank you for your question. that's actually very important question and we've been discussing it over the past week. there had been plans to build a certain number of etus in every country based on findings of -- that are about two months old. the situation is evolving rapidly. and we need to make sure that as it evolves we do not stick to the old plans that actually we adapt and we're flexible enough

to, if there's no need for an etu, let's not even build that etu. if there's a need for mobile teams that would go out and get patients to an ebola treatment unit hat that has empty beds, let's do that. because we've seen -- we've see treatment units that have overflow of patients and some that have empty beds. we need to make sure we balance that. >> i heard about that, too. i thought one of the reasons was because the population was afraid to come forward. the best case is that they are not needed. that wasn't the issue. why do you have that disprepancy? i guess you are saying maybe etus is not the way to go right now. i will go back to you. >> first of all, the virus is moving. it is not staying in one county. you built a treatment unit in one county and get it under control with the work between the community based approach and treatment approach. it is getting under control and

then it is another county. so that's why there are large numbers in certain areas. those need to be coordinated. at the end of the day ebola started at the community level and this is where it should die. we need to make sure that the community centers are well equipped and staff are well trained to detect and isolate so they can defer for further treatment. this is what needs strengthening and this is the work being done. >> you know how i said i was interested in the things we are building need to stay. is there any value to the etus that were being built being left there for either other infectious diseases or other health needs? >> some are not built to last

which is fair enough. they are built with temporary material that would last for a few months and that is good enough. one of the approaches we are following is we are trying to build a more permanent structure that could be turned into something else. it could be turned into a training center or clinic. that is the sustainable aspect of it. that is what we are encouraging. there will be a need for isolation wards in west africa that need to remain there even after we contain ebola because chances are there might be other diseases or ebola might resurface. there is a need for the facility as well as equipment and trained staff there. >> so it was first time i heard someone talk about the only time health care worker can be with a patient is one to two hours. i have seen the equipment and the stories that talk about the heat, but that implies a large number of health care workers.

if you are only with the patient for an hour or two and you leave then do you have relief or -- you understand what i'm saying? >> absolutely. >> how does it work? >> in our ebola treatment unit it is a 70-bed treatment facility. we have 230 staff members. >> wow. >> we work around the clock. it's by shifts. when the doctor goes out another one will be in to replace him. >> when the person leaves after being there an hour or two they take a break of how long? and then i imagine they go back. >> it depends on the level of exhaustion and hydration. they need to recover before we bring them back in. >> wow. okay. and maybe you can respond to this one if you wanted to add anything about the etus. i know that there was an issue around the health care workers at one point and them being paid and them wanting hazard pay.

i was wondering what the situation was with that, if that has improved. >> thank you. i agree completely about the etcs. emergency treatment centers. and there are certainly challenges around planning and coordination. for example, we have seen the united states government construct a 100-bed emergency treatment center three miles from where msf is operating one. the chinese government has built one in between and yet communities where there are hot spots not very far away but not accessible easily by road can get into any of those. the challenge of planning -- >> how does that happen? >> fundamentally is the responsibility of government.

and so i think finding ways, again making sure that there is a more mobile response to be able to get people into the facilities where they need support. because what worries me in this is the gap that i see in talking to liberiaens about the big numbers that they hear that has been committed to ebola and the actual response taking place on the ground. so i think it is extremely important to be sure that the planning is done effectively, that that communication is out there so that citizens in these countries, expectations can be better managed. the other thing i just wanted to add about training which was discussed earlier which i think is extremely important, we think a lot about we work with

community health workers. of course, as a big challenge so few doctors in liberia. take one example, 4 million people, 425 doctors, it is a big challenge, i think, to provide not just more training for medical personnel but some of this pre-service training at the technical level is desperately needed and can be done pretty quickly. and i think that there are institutions here in the united states that can provide the kind of support that's needed to ramp up pre-service training as well as supporting in-service training by institutions in the effected countries. >> both of you or maybe all of you made reference to we need to take it to the community and have the community be involved. i wanted to know if maybe you could be specific about that. i certainly understand the community piece in terms of

contact tracing and identifying the people infected. if there are not etcs then what? you are taking it to the community. you identified a person then what? you following me in. >> i can try to answer that m. >> the role is critical. informing the authorities is also very important and forming burials teams and also very important is to educate the community about what to do if they see someone presenting with symptoms, how to isolate that person and make sure that they have at least gloves or things to protect themselves, but to make sure that they isolate and inform the different authorities, be it health workers. this is critical because what is happening is that there are people that have ebola that are

staying in the same room with five other people. and that cannot happen. so the isolation is critical and this is where the education at the community level becomes very important because that is the only way we can contain it. >> should there be smaller etcs? i understand isolating the person. if you isolate the person without treatment the person is just going to sit there and die. then you said that the etcs are maybe in inappropriate places or maybe not needed. in the places they are not needed what happens to the person? >> that is a very valid question. there are community care centers being established which are like mini ebola treatment centers. the idea is those patients will be taken there, isolated and cared for until the test is done. i would just like to add one thing, as well, that you mentioned initially about the u.s. government and the etcs.

in our discussion with the u.s. military as well as about the need for ebola treatment units and where they should be, we have seen that they have been extremely flexible. if we tell them there is no need to staff this one, let's move it there they have been extremely responsive to recommendations. >> you might want to respond but i wanted to ask you a series of questions around cultural practices but go ahead and respond. >> i would like to catch up a little bit. i would like to reiterate that flexibility on both the designation of where the etus are and in general that flexibility that in particularly the u.s. aid, dart and general response has been really fantastic. it allowed us to be sure we are able to position resources as quickly as responsible. on the issue of the community,

we spent a lot of time going over what the best way is to interact with the community. that's a lot of these dialogue sessions that i have been talking about. it's really focused on making sure that we are not top down, we are not distributing leaflets and just doing radio shows but really making sure it is a conversation with the community about what ebola is and what it is not. and having them come up with their own solutions that we work through. that's been able to allow us to make sure that the communities when they have a suspected case, that they put the community member in a separate location that the communities are doing a lot of their own monitoring and making sure they are making that phone call because really that phone call is the mostm