is very limited data on this, it does come from cms, but when there is cms participation at the hearing, the reversal rate does go down. >> by how much? it was 6% almost over a few months of data that we had. i will get you the exact numbers but from about 46% down to about the percent. -- about 40%. ,s far as the reversal rates go i have that number now, which is on the dispositions. is overall favorable rate 35.2%. we had been doing a number of things which had been designed to bring our policy interpretations in line across all levels and develop some

consistency and adjudication. part of that is training. had approximately 20 training sessions delivered by cms, their doctors, their policy experts. to the administrative law judges since 2010. what you will see if you look at the historical data is the reversal rates have actually been going down. were at a high in 2010, 50 5.5% fully favorable and that is now down to 35.2%. to 35.2%. >> do you think there is a better quality of decision? the case is coming up to you. they either make better decisions at a lower level where there is something that has happened at the alj with better

training and you're making better decisions earlier in finding people fully favorable more often than what would be consistent with policy. >> or joint training leading to better consistency among different adjudication levels. say in herns if you training has fixed that, it was an issue at some point that we were doing too many fully favorable and partially favorable. >> i don't think i would go so far as to say it has fixed it, but i do believe it has improved it. out,e congresswoman points the goal is to have the case legalf it is a validly claim to have it paid as early in this process as possible to keep them from leaving that level. just want to touch on this. is the training coming from you back down to cms?

expo -- expecting that as a direct audit? i'm going to use an example in the orthotics industry were after an artificial limb is made and delivered to the patient, the claim is being denied by audits because the actual words, patient is an amputee does not appear the physician notes but patient requires artificial limb or prosthesis appears in the medicare history includes payment for the surgeon to conduct a limb amputation. and so, many of you denials could be eliminated in these are getting reversed at alj. is there feedback going back down to the cms saying just because the exact word does not appear in the surgeon's notes that the patient is an amputee does not mean that you deny these because if you look, it

says the physician is saying they need a prosthetic and we paid them to amputate a lamb. are you, cms, looking at different records? >> no. general rule, we review the same records. there are some exceptions to that. there is a cause exception allows additional evidence to be given at the alj level but we are supposed to be deciding at the same record. what changes is that we do have a hearing. at our level, we are able to question their providers, receive some explanation and then make a decision that becomes part of the evidence in front of us. my understanding is the auditors are not allowed to consider the notes but those notes are considered part of the physicians record and they show

up on the physicians record. the person who makes the notes, theyeg, his are not allowed to look at his notes, only the physician notes. but when you look at the physician notes you look at the thosety which includes notes. is there feedback coming from you to cms to allow the auditors and the lower level to say you at the prosthesis notes because you are pushing these people into the system and its ridiculous when it's something as simple as "patient is amputee" is missing from a record. we do have regular meetings with cms and with their appeals group within cms. i think does happen on a weekly basis? , we we identify a trend would bring that up at those

meetings or if it was a significant trend, i bring it up with marilyn. specificsware of the that you are describing. these who havein gone out of business waiting to be reimbursed and have gotten out of business. it's more than one. i'm sure we could get you a lot of those examples. >> as we become aware of them, that's part of the issue. our judges are individual adjudicators. we have to become aware that there is a trend. when we do, we have those feedback loops in place. we are able to do that. you spot a trend? do you have a system in place to analyze them? reiterate whatto the gentlewoman from illinois

was talking about. she's exactly right. this is not just unique to her group that has told her. we've got physicians who literally go through step one and step two who have complete records and it has to go to you before you look and say it's a complete record and they've waited how many months or years to find it? it is crazy stuff. got examples and after this last hearing, we started hearing from all over the country claims that were denied because the date instead of being at the top was at the bottom. signed hisician had name in this spot. i know we cannot fix stupid, but it seems like that's what we've got to do here. would doble person

this. you talk about trends. i don't know how you define trends because you have adjudicators adjudicating across the omaha system. what one adjudicator is seeing as a trend in his or her jurisdiction does not work. i appreciate the gentlewoman yielding and i yield back. i just have one final thing. go to meet with the newly confirmed secretary burwell, i was hoping that you would consider having a conversation with her about granting the same kind of relief from audits that were being granted the hospitals under part a to part b providers like those. if we're going to granted to those under part a, i think we need to consider granting it under part b especially since

there is a halt to the hearings at this point. thank you, mr. chairman. >> i will certainly convey that. >> did you want to jump in? >> at the risk of quite frankly piling on in the last couple of comments and statements, i have the same concern. you have introduced new initiative see your productivity is better but now we are minimizing, my information says, the average hearing is now at two hours. we have not talked about the complexities. we've talked about the easy stuff. i'm not sure this gets addressed. given that we now have an incredible backlog and we are struggling with this, it is time to do more than just figure out the steps and how we are cross communicating, with the training looks like. we have to maybe do something upfront.

nobody on this committee and i daresay no one in congress is willing to tolerate waste, fraud, and abuse. we want everyone on the system to do everything you can not just to minimize it but eradicated. these are clearly administrative issues. i expect providers to be as administratively competent as they can, i cannot with consistency -- and i'm a lawyer medicare form.e the form was updated this year and i have 200,000 forms from last year and instead of throwing those away, no one pays attention to that. the fact that we are doing this under waste, fraud, and abuse context, and i think that's important, we are closing these businesses who are not going to

be paid and there are a lot of small providers. i know you have heard all of this and i agree with my fairness., i want just because you are a big provider, i don't think a big hospital system should have to wait and be penalized in this fashion. what critical in a ruling state like mine, that means an entire community and a place wherein one of my district, in torrance county, there are no providers, no durable medical equipment providers, no small oncology providers. there is zero access. we don't even have the right tools or strategies to re-create these practices. i'm really interested as a result of understanding now the situations between how they are adjudicated, what your initiatives are, how you are trying to manage these cases. weeklyciate the meetings, but i would encourage you to go back to the secretary

and be a really clear with at least some of these comments. it seems to be there all the same. we've got a problem on the front end. we want updates about what you are doing on the back and -- back end. because people feel like it is cumbersome, they feel like they can win on an appeal even though there might be a material problem. have half a million cases coming to you on appeal, they are administrative issues that do not come anywhere close to fraud, waste, and abuse. we need to deal with that issue sooner rather than later. i expect my expectation is you will take this urgency back. with all of the work we've done to maximize access, this effort is minimizing it to the highest degree.

it has a chilling effect on our patient population. >> i will certainly take that back. that is is a positive coming out of this situation, i think it is that the department is viewing this workload more holistic lay. although there are three separate agencies, cms, omaha, and the appeals council that work with these workloads, the department is taking an active role in trying to resolve things . i will take your concerns back. i certainly share them. i would also say that i'm very pleased when i came here to omha be part of an agency that had, for the most hard, met the 90-day time frames. as an administrator myself, i find the delays very troubling and unacceptable. here abasically have

workload and capacity problem. >> can may get to that for a moment? we can sit here and complain for hours and nothing is going to change. of 17 new alj's, talk about the simple mouth that my good friend mr. meadows had referenced -- the simple math. be,000 appeals that will backlogged by the end of this year dividing that by 1220 working at optimal levels --and i don't know if you could do anymore than that and i don't know if we would want to so getting less than two hours to every case is probably unfair and sub-shot. that would mean we would need 410 new alj's to get rid of the backlog in one year. you have asekd 17 or have

been given 17. we basically saying to all of the providers that there to suck my language. that's basically what we are saying to them. to deal withlling in the reality that we are putting blinders on, add a few more, cross our fingers, and hope that with a few newer forms you put in place that it will work but it will not reduce it to the extent to which will not be back here next year with the same discussion. how would you comment that? >> there are several things. i'm sorry to interrupt. can you clear microphone a little closer to you? >> there are several funding issues here. in my mind, one of the primary

wants us to do with the recovery audit program and legislation. i think when congress passed the legislation of the program it was envisioned that it would be self funding out of recoveries that the legislation actually that the administrative cost of cms will be covered. the does not include administrative cost of omha or the appeals board. what we have basically had in that regard is a workload that came in on us that was basically unfunded. i think that's part of the problem. it's part of the problem that i think does have a solution. day, thatqueen for a would be one of the simple fixes that i think would be possible.

meaning what? >> to be able to properly fund sisternd a plug for my agency, the department of appeals board so those that come to the last two levels are asded out of the program they are at the lower two levels. that isere enough money to pay for all of the levels of appeals? >> yes, i think that there is. this is based on cms reports coming back from that program. think, ofe part, i the solution. there are some other things as

well. we are doing these id. pilots one involving alternative .djudication models if that pilot is successful, i think we need to look at some things like that as well. >> is that being piloted in a geographic location? >> at the office of medicare hearings and appeals. there is no geographic location. it's being done with part d claims right now. where we certain time are offering these facilitated settlement conferences. >> give us an example of what that means in real life terms. websites put on our june 30. it's a very new program and we are waiting to see how appellants respond to it. the theory is that an appellant will be able to come in and ask for a settlement conference with .n attorney who is at omha

cms would provide some on the settlement authority able to discuss merits of the claimant possibly resolve them short of having to stay in the queue to go to hearings. while that is going on, they do not lose their place in the hearing queue. allowhopeful this would us to resolve some of the pending claims. this is a two-part problem. there are also the receipts coming in. this piece of the solution is designed to deal with the pending cases that are already with us. >> is it your assumption that this will come to the signature in the wrong spot walking in and say it's not at the top but the bottom. is your assumption it will be the kind of stuff coming out you? are the settlements for a lesser paidt fully paid or fully

so a faster process to full payment? depends.k it like most settlement conferences, it's probably going to be a little bit of give and take. that would be my anticipation, but if it is something in the course of what is really a prehearing conference with an attorney, point out a simple technical error or something like that in the claims, it is potentially possible that they could be fully paid. we have to wait and see how that would work. >> the alternative resolution would be valuable to providers in particular if it was a decision that was going to be made swiftly. that becomes the appeal. no pun intended. >> we're trying to find ways of solving the claims within our pending workload more quickly

.han we can get them to an alj we're trying to do that given our current authority. right now the statutory scheme is structured, and appeal cannot get out of step three. cannot believe omha -- it cannot without action by ana alj. the agreement then becomes the resolution of the claim. chartthat listed in the that you gave us as dismissal? fully favorable, favorable? be a would probably dismissal but right now we are tracking them separately as a settlement resolution. the other alternative is this global settlement discussion concept which claimants with

very similar kinds of cases would all be invited to come in and participate in a global settlement but they could choose not to. is that correct? >> it's an initiative that is one of cms's. my knowledge on this is limited. that it understanding would be a global settlement. >> that would happen before it would even get to you. >> it also contemplates >> we haven't seen it operational you? >> no, we have not. it's an initiative. >> i know you're committed getting back and forth with cms and cms is part of the issue. i get that. that's not you. but you have these regular conversations. what we are getting to an attorney, help them try to do a

type of pre-settlement, that's something that they would have rather had with cms, face-to-face with someone there, resolve this or to get on the phone and everybody looks at the same document and tries to resolve this. it's a simple, straightforward cases. they just want this resolved. if they are a physical therapist that is shy to take care of its practice as will trying to do all the paperwork, he does not need one more thing to do. to try to chase all this stuff down. to be able to leave and to do hearing and be in the process to hire outside counsel as well beyond what they want to build to do. they just want resolution of simple things. how could a process work in a cms so it never gets to you? we are still can't figure out how do we prevent the backlog? >> right. i think amongst cms's initiatives you will see mention of a discussion period, particularly with regard to recovery audit. and i think that that could be helpful in resolving these

claims out of the lower level. >> but that's something they're discussing but that's not something that they do currently? >> i, i really can't speak to that. i don't know to what extent they have a discussion period right now. >> i am informed it is optional right now spent at the cms level they can do discussions as well? >> i think so but i will have to check on that. i would rather get back on of cms get back to you on this. >> i understand. we're just trying to do some fact gathering as well. again we come down to the issue of they just want resolution. once the contractor grabs it,

files it, lays it out, they lose contact another fight with someone else. they're fighting with the folks they can't get to anymore. because it's too late. that made the decision and have filed it and the opera is on to figure out, playing the percentages literate if they grabbed 10 or 15 they know they'll get three or four of these alleys, get paid a percentage of each of them. it's a whole different game for them. but for the provider, our issue all along is if it's fraud, it's fraud and we ought to bust them. if it's a good provider, there should not be -- these are the folks we need on our team and that the american people need rather than hurt. >> i fully agree. and i think that identifying not just medicare fraud but also improper payments is an important piece of this puzzle. but what we have done i guess

in the efforts to implement congress's intent in that regard it is gotten out of balance. what we need to do is restore that balance at this point between the fraud efforts and the appeal rights. and so i have spoken with the secretary on these issues and i know she is committed to restoring that balance. >> you know, i had an auditor in my district that was great a great deal of discomfort for one of the hospital providers in my district. and it was also a hospital those under and about the financial pressure coaches keep its doors open. my experience with that particular situation suggests that more than anything else, the provider wants to know what's going to be approved. they could, in fact, have been unbundling services that would allow for more reimbursement.

i don't remember the elements but sometimes the providers are in a bind and are looking for ways to up code or to unbundle services. so we need to be smart about this and not appear to be taking one side or another. everyone should be treated the same but it's so important for there to be some certainty and some finality and some timeliness in his to these decisions. and this backlog, i keep coming back to this backlog. we are not getting anywhere near addressing that even with all of these new proposals that haven't even been tested really. so i still think that whether we higher temporary aljs for a period of one year and deal with this backlog, otherwise we haven't really accomplished much

. >> and just to address that, there are very, very limited authorities for hiring temporary aljs. and its statutory under the administration's procedure act, really there are two ways. you can try to get a loan, a judge on loan from another agency. most agencies have their own backlogs and when we requested loaner judges and we did not get any. the other way is to our judges who have retired and they are called we hired senior aljs. those individuals are also on the list that is maintained by opm. they can be hired for a couple of years and then let go. beyond that an alj appointment is, you know, essentially a life appointment. except for removal for good cause after hearing before the board. >> how large is this list of retired aljs?

>> it's probably around 100. it's not a tremendously long list. you know, but we do have that. we requested it in april because we do think that temporary capacity is a part of this solution to deal with the backlog. now, when you're talking about projective receipt levels i do think we need to be a properly staff for what we anticipate to be coming in. so i don't know if that's helpful, but aljs are non-probationary when you hire them under the aca. there's no probationary period. there are no performance reviews, and they can't receive awards. so those are kind of the things that make them different from other government employees.

>> if the gentleman would yield, i want to follow up because they're hitting on precisely the point, why it's so incredible important here today, that it really is about what's coming to you. and how do we address that. the bigger concern that i have is even when you're hired, 100 it will still be shy based on my simple math of what's going to happen. this doesn't stop today. it is growing exponentially every day. i think it's 1500 appeals at least a week. is that correct? >> it has been as high as 16,000 appeals a week. it has been down slightly at the beginning of this year to 11,000. we are trying to figure out where the plateau is going to be. >> well, i guess i was told by jonathan blum before he left that there was a policy change within cms that was initiated

and may be numerous policy changes but there was a policy change between 2011-2012 that dealt with the way that they start to refer these to you. part of it is rac, and he needed a legislative expect my question to him was, if there was a policy change why do you need a legislative fix? but what i'm concerned about is, is what changed in 2011 or 2012 to make this number grow that you are getting when we are not seeing payments, improper payments actually go down. so we have seen that progress in terms of improper payments and yet we have this huge problem on our hands and we are not saving any money. so what changed in 2011 or 2012? i'll yield back to the chairman.

>> well, the big thing was the recovery audit of course. we talked about that. that was initially a pilot program. we saw i think it was four -- that was an act of congress. he indicated it was a policy within their agency that, i don't know if -- >> and it's probably, i mean, there was, and he was probably around that time period where there was a focus on identifying improper payments. that's not tracked as part of our, we track the recovery audit separately, but cms' effort to identify improper payments, zone program integrity contractors, and others, you know, programs that were looking at fraud issues, and there was also a coding initiative and some other things like that. but any time there are efforts

at cms's level that result in denial of more claims, then at our level there's going to be an increase in appeal. >> that's my point. it didn't change the improper payment. they may have done that and it may been well-intentioned, but we are still actually increase, if you look at the numbers you can go on there. we had a hearing yesterday so that's fresh in my mind. but i will yield back but i want to thank the ranking member and the chair for their leadership on this. >> and if i -- could i go back to one issue you raised earlier, which i think i have finally kind of grasp what the question may have been. and that has to do with our appropriation and how that is handled. and, of course, as you pointed out the medicare modernization act did contain language which

would authorize the appropriated funds that would cover an increase. having said that though, that appropriation still has to be approved. and it does have to go through our department appropriations process. so i just wanted to point that out. i would also say with regard to our general appropriations that we do know we've been living in challenging budgetary times, and in the past five years the president's budget has actually only been approved for us in one of the five years. so requests that we have gone forward with, even though they would be somewhat modest, have really only been approved this year. so we appreciate that. we are trying to do what we can with the money has been appropriated to us.

>> and that was approved because it was part of the omnibus bill? >> oh, was it part -- >> why was approved this year? >> i don't know whether was part of this bill or what it was part of but i do know -- omnibus bill. >> is there any other statutory authority you think you need or could use? >> or solutions we have proposed? >> you know, i think that are a number of things that are going to be coming through the appropriate legislative process that we're looking at. i think the two that i have highlighted from our perspective will provide us with the greatest ability to handle our workload and to expand the we

adjuicate at omha. there are some additional things that are being considered through the departmental workgroup that i know will be coming up through the proper legislation channels. >> when will you evaluate the process? you obviously just started june 30. when is your target date? is it a year, six-month? >> we are looking at a six-month evaluation. >> can you put us on a calendar reminder six months and get to this committee as well? >> certainly. and we are tracking metrics with a from which we will judge the success of the program. we would be happy to include you. >> please do. this committee is obviously very interested in that. >> i don't have any further questions. i want to thank ms. griswold for being so attentive to her questions and for sitting around for an hour and half while we went and voted. and thank you for your service to our country. >> i thank you for your interest in this issue. it is certainly one near and dear to our hearts as well. >> it is near and dear to a lot

of people in our district. not only want to do with fraud and waste and improper payments which is a more direct one, but also to providers that absolutely firmly intensely hate the rac audit process. when they go through it and there's a signature in the wrong place or a date in the wrong spot and they just want to get it resolved, it now takes three years to get it resolved, tops. so it goes from their frustration from rac to frustration beginning an obvious solution. that doesn't help any of us. finding solutions to what you're proposing that they could go through the process, if you don't like it, if you don't like what happened in the summer but they still are in the queue to have it resolved, rv speak they are actually in the queue. there's nothing mandatory about that settlement process. at any point they can exit the process. >> they just want an answer. so that's -- >> they are entitled, i realize.

>> that's a key thing. if you are working on process to do that, thank you. continued to press. if there are ways we can help, because as ms. speier mentioned, bringing on more aljs is not going to solve this. there's no way you get 400 more aljs so there has to be another solution to this and determine how do they get answers. part of this we understand well is on cms. you should not have the numbers hidden from you. so if you have, and looking at these percentages and i know we've kicked around numbers but let me mention this one of a number. when i look at the percentages i pull out the remanded because those are coming back. that's a different number i pull out dismissed because they're not getting the. when i look at that fully favorable and partially credible just for part a, i don't know where the other numbers, showing 65% either fully favorable or

partially favorable resolution for them if they get to you. that's telling me the job is not getting done on the cms site. you should not have that high of a percentage of overturned getting to you. there is something being missed. so part of the issues we've got to press on cms to get things resolved before the every day to you so you don't have a backlog this high. just statisically you should not have a 65% overturn rate. to be able to get to you. so that's not on you but i'm just saying publicly there are issues on the previous to that we've got to get results. anymore comments? thing to for spending a day and we apologize for the long delay. with that we are dismissed. [captions copyright national cable satellite [captions copyright national cable satellite corp. 2014]

[captioning performed by national captioning institute] tonight, a live debate for the nebraska u.s. house second district. we will have been coverage beginning at 9:00 p.m. eastern on c-span. here are some of the candidates recent tv ads. 0 at one point in time, homeless veterans signed a contract with united states government that said we would go to battle and give our life if necessary. when you talk about homeless veterans, the va hospital, the veterans cemetery, you hear lee terry's name. thank you for giving us an opportunity to serve them. 0 i'm lee terry and i approve this message. a b 26 bomber on

d-day. he told me never to forget those who serve. my disagreements are not personal but his votes against veterans sure are. he defended his own pay and shut down the government while soldiers are on the battlefield. he's cutting veterans care. i'm brad ashburn. >> lee terry is fighting to keep our neighborhoods safe and strong securing grants to strengthen policing and fighting for the violence against women act, supporting new laws to crack down on human trafficking and he passed a law empowering a neighborhood activist to start a new radio station giving a voice to a community to stop street violence. lee terry working hard to keep us safe. i'm not running for congress

to represent any political party. i'm running to make a difference for nebraska. reducing partisanship is not one easy step or electing one new member. i'm going to work from day one to create a coalition who set aside partisanship and focus on solving problems. just like i've done for 16 years, i am brad ashford and i approve this message. 0 working together, changing congress. >> you can watch the televised debate in the congressional race here on c-span. watch more the campaign 2014 debates any time at c-span.org. >> this weekend on the c-span networks, friday night in primetime, the values voters tedit with texas senator

cruz and kentucky senator rand paul. saturday night at 8:00 p.m. eastern, a national town hall on the impact of voting. sunday on q and a, sally quentin. greenefore 930, daniel and william mullet, two operation iraqi freedom veterans talk about their experiences in iraq hama isis, and the use of american force. saturday night, pulitzer prize-winning reporter matt technology on society. the brooklyn book festival friday on american history tv on c-span three, former chief of staff and advisers talk about the relationship with the commander-in-chief and how he makes important decisions. author jonathan white on the role of the union army and abraham lincoln's 1864 reelection. exploringernoon,

first lady fashion. find our television schedule at www.c-span.org. let us know about the programs you're watching. call us at -- e-mail us at comments@c-span.org #comments.span join the conversation. like us on facebook. follow us on twitter. about 5800 illnesses and 2800 deaths have been documented since the first cases of ebola were reported six months ago. next, the centers for the disease control head takes a .ook at ebola this is hosted by the university of pittsburgh medical center. >> great, we are going to begin.

as people come in, please do grab your lunches. i'm the senior foreign-policy adviser for senator kuhn. i would just like to welcome everybody today. we have a remarkable panel and we are very excited to have so many people interested in this critical, critical issue. i would like to thank anita for her effort to pull together this event. thank you so much. i would also like to recognize the center for health security for hosting this event. i would like to turn it over to our moderator today who will introduce and distinguished panel. thank you. l. thank you. >> thank you, haley, and thank you to senator coons and the

senate foreign relations subcommittee on african affairs for cohosting this event with us today. welcome to our distinguished guests who i will introduce any moment and welcome and thank you all for joining us today for this very important discussion. we are so thankful to have c-span here for those who can take part in this. are those that don't know, the center or health security is a nonprofit organization dedicated to protecting people's health and epidemics and we are so pleased to be here today with you. there are as many as 20,000 cases of a bola projected and as many as 1.4 million cases of ebola by the end of january without an immediate and massive scale and successful response.

we have an economic hardship on the ground. doctors and nurses have died in high numbers. and the health care systems have largely stopped functioning. it is an extraordinarily hard disease to treatment and doubling time and shored as 20 days. there are no other infectious diseases like this. and it's now affecting to take hold in africa. but there are major new efforts under way by the u.s. government and other governments in the world, and the cdc is making its largest response in history. more than 100 people on the ground in west africa and hundreds of people in the cdc center in atlanta providing expertise that we will hear all about from doctor thomas frieden.

usaid is providing tons of training and information and its people are moving 100,000 units of pp to west africa and we are establishing a regional staging base to facilitate the arrival of equipment and supplies and preparing to train hundreds of health care providers. we know that who has created a world map for providing expertise and is seeking funding from governments around the world and ngos will of heroically led article efforts on the ground. in our discussion today, we are going to hear about the situation on the ground in west africa by people who have been there quite recently and those that are leading the effort now. we are going to learn what the u.s. government is doing in more detail and perhaps most importantly we are going to discuss measures that we can

take to end this crisis in the time ahead. each of our panelists will give opening remarks for about five minutes and then after that we will have a panel discussion and turn to questions to answer his from the audience and from twitter as well. the four speakers today we are so fortunate to have given all they are doing in this response. they are first, jeremy konyndyk, who is the director of the usaid office of assistance and tom frieden, the director of u.s. centers of disease control and joseph fair, who is adviser to sierra leone and the foundation they are they are. and andrew weber. we are very sorry not to have an extra guest. we thought we had him until 24 hours ago when his boss said she needed him in new york today.

and so it back among going to turn to jeremy. feel free to make your comments from there or come to the podium, whatever you feel like. >> thank you very much. and thank you for the opportunity to speak. it is great to see this level of interest here on the hill and this is a remarkable challenge and i think that it will take -- it will take the whole of society and government to fully supported the liberian government and the sierra leone government and the level of engagement is just a crucial piece to our ultimate success. i will talk for just a few minutes about the overarching u.s. strategy that was laid out last tuesday. and there are specific pieces of

that and i will turn it over to my colleagues go into more depth with these pieces. we have a four pillar strategy that the u.s. government is pursuing across all of its many capacities, to try and control and hopefully defeat this outbreak and look beyond the immediate outbreak as the longer-term needs of the health system and the resilience of these countries will be featured as well. now that this is as we have seen in other countries, it is likely to recur and we obviously don't want this whole episode to resolve the next time that happens. we do know that this can be controlled when we have the ability to do so. the first pillar of the strategy

is focused on controlling the immediate epidemic and outbreak. the second tour focuses on mitigating impact. that's things like economic stability, political stability. and ensuring that as we struggle with the immediate outbreak, that we don't see second-order impact than or equal to or not greater than the outbreak itself. and the third piece is to coordinate an effective u.s. government agency response and coordination would be critical to the success both at the country level and the global level and there are many countries that are looking to play a role here and in any major response that we undertake, there is an element with the hundreds of ngos and in this case it is even more

critical because this is something that none of us have ever done on a scale of our. so having coordinated action is all the more important for that reason and the fourth pillar is fortifying the global health security infrastructure such that in the future and in the region beyond there is an ability to prevent future outbreaks of this magnitude. but it's critical that the long-term future of these countries understand this and also with the immediate term that some of them do not see outbreaks on this scale. i think the fact that cases have popped up in a few neighboring countries, so far not triggering any major outbreaks, is indicated above the rest and the potential to keep this managed with swift and decisive action. so just to talk briefly about the role. it has the standing role in the federal government coordinated

for international disaster response. in that capacity we have sent a team through the region and has representation from across the interagency and working closely with the larger team that is also there on the ground. and the focus of this team is both to coordinate the interagency and also to deliver and execute on the usaid pieces of the response. our current focus and i won't reiterate everything that we have already announced, but the current focus is along effort, the first being effective in countries management and leadership of the response and we are very pleased to announce that as of today. the liberian emergency center has opened officially and so all of the elements of the government's coronation assets

under one roof after a great deal of u.s. government support. the second element is to focus on scaling up isolation and treatment and we are focusing heavily on getting that set up and working closely with them in that effort, the ebola treatment unit, if i use ackermanacronymsy don't recognize, let me know. it's hard not to think of them. and so the third piece of that, we are on track and i think that is one of the things that we have seen for the most rapid progress. we are on a good track their and the fourth element is infection control within the country and a big piece of that will be the committee care strategy that the president announced last tuesday that will focus beyond this, and

enabling households to isolate and provide care to community members on the lawn treatment is not available. because that takes time. and so the opening remarks are an important part of that and we hope to talk more about that. if this element is communications and social mobilization. this is a new disease in all of these countries and there's a lot of misinformation and misunderstanding about it, ensuring that there is accurate understanding and accurate information and the people know the basics on how to protect themselves is so critical. underpinning that is a huge logistical effort to both we and the dod are working on very intensively to ensure that adequate procurement and transport as well as adequate supply chain management in the country because the volume of personal protective equipment and other supplies that are required to run on the scale is

just enormous. so that is a huge piece that we are referring to as well. >> thank you. >> thank you very much for bringing us together and to the senator's office as well for the interest. i have been doing public health and running public health agencies for a few decades now and on two continents and i became a doctor working in new york city in the 80s where i cared for hundreds of people dying from aids with a limited ability to do much other than help them die comfortably and that experience was searing for me personally. i have never seen anything like that until i was in monrovia recently. and i went to a ebola treatment unit run by msf. the doctors are working with

incredible effort and their largest response ever exceeding their capacity, stretching the limits of their operation. and we ran into a treatment unit and we saw a scene. it was patience in all stages of the disease, from those suspected that maybe didn't have it and maybe might get it if they were not effectively separated from others. in our lab next door was working more than 12 hours a day confirming within a few hours whether people have the disease or not. people who were just getting in and being cared for and desperately needed rehydration to survive in patients that were recovering, including one guy that was healthy enough to complain about the food. and i thought that he should

probably be helping to make the food if he could complain about the food. also tragically, three patients who had died in the past few hours and the staff was so overwhelmed that they could not remove their bodies. and the facility in which there are 14 to 20 beds per tent. one person in one tent that had died was next to the other patient that was struggling to live. that kind of situation is the real world exemplification of what it means to have an ax potentially increasing outbreak. it's a very hard term for all of us to wrap our minds around. but it doubles in 20 to 30 days in this region. and that facility had 60 bodies removed that day.

so the situation right now in west africa is an absolute crisis and it is moving faster than we need to understand particularly in liberia. and we have already seen experts to both cynical and nigeria and we now have the ability of looking at the possibility of cases they are. but if i were to summarize here for a minute, what we need is an immediate response that is sustained and then to make sure that this doesn't happen again. and if i can just outlined those three concepts for a moment, i have never seen a public-health situation with this much need for immediacy as i have explained to people, and adequate response today is much

better than a great response in a week. it is that urgent. and so that is the case in all three countries that are affected, even though liberia has the most out-of-control situation. but there are districts within liberia that have relatively few cases and they have the opportunity to stop it before it spreads. and where there are many cases, we are intensively trying to steal so we can reduce the spread and in sierra leone where cases have not increased quite as quickly as in liberia, we have the opportunity to present a liberia like situation for cases that have three consecutive waves and they have the potential of keeping it under control and the best analogy really with this metaphor is forest fire. we have teamed this region in

many districts to both sierra leone and liberia. especially the tri-country area and there is a border area where the three countries come together and it has very poor infrastructure and relationships with the countries, but it is the crucible epidemic and now the capital city in monrovia, which is experiencing the world's first extensive urban spread of ebola in the context of the world's first ebola epidemic. so an immediate response is critically important. and that is why president obama's announcement made last week is so particularly important that the department of defense is already on the ground and usaid is there as well and the needs are extraordinarily large. that is what is hard to get our minds around it. because not only are the needs lunch today but it will be twice as large in less than a month

and if we are going to be successful, we have to build where they are going to be in a month and we are going to have to sustain this. because once we camp it down, controlling ebola is something that the cdc has done for decades and in 2012 where we worked on it many times, tragically a 12-year-old girl died from it. and what was striking was that she was the only one who got ebola. and that's the only time in history we have seen a situation like that that i am aware of, where there is someone who immediately thought, oh, this might be it. they immediately confirmed it was ebola and they ensure that when she died that she was safely buried in nature than any contact -- that they would not have spread it further. if that kind of poor public

health service, the binding problem, if that was in place a year ago in these countries, the world would be a very different place today. but the fact is that we now have an outbreak that is likely to continue for a significant amount of time. and to protect other countries we need to surge forward. when one individual -- a city of 21 million people, about the same as africa, we immediately got on the phone with the governor of lagos and we sent a team of experts within 48 hours and we brought in 40 people whom we had trained as part of this in nigeria who had worked very effectively on that. and now they had not been completely out of the woods but it does look like they control the outbreak and that involved

more than a thousand health care workers, more than 19,000 home visits to measure temperature of nearly a thousand contacts and that was to address one case of ebola. so we need to have a response that is immediate and sustained and that prevents future events like this because we could have prevented this in the first place. sars cost the world $30 billion in just about three months. the implications not just for west africa but for the world are quite substantial. who has raised the possibility of ebola becoming a pandemic in africa and that would mean, for those of you who are not a public-health, that it would continue on an ongoing level indefinitely. and we think that that's not

inevitable. if that were to happen, it would be an enormous problem and we would always have to be thinking about the possibility of that and anyone who had been in any region may have had a case of ebola. so i would just reiterate that it's an approach that obama has outlined and it's exactly what we need. and we need to get the scale and the speed that will match the exponential growth of the outbreak to ensure that we have an immediate response that sustains and prevents this from happening again anywhere whether it is ebola or any other health threat. thank you. >> thank you. let me start by saying i completely echo the director's comments and we happen to see each other while we were there. i would like to preference my

remarks with the fact and understanding that i am mostly speaking from my own experience and my remarks tend to be skewed towards those countries which are currently experiencing worse part of the outbreak. so when we say that the situation is dire, we can't emphasize that strongly enough. what we are facing is a biblical proportion scenario. the people of those two countries largely feel abandoned by the international community, however that response starting to trickle in and there is a light at the end of that, although it is something that could become more so. and i'd like you to keep in mind as we talk about two countries that endured almost a decade of civil conflict. so we are approximately 11 years out from the civil conflict and considering building a public health care infrastructure in just 11 years, it's an enormous

task. we were dealing with regions which were almost on the brink of not being able to offer sufficient health care on a normal day or it and what we have seen since the outbreak is a complete breakdown in the public health care infrastructure. schools are closed, hospitals would have an even experience this are closed and i think that from that we may never know the toll of death that resulted from non-ebola cases and normative infections that occur every day and the headline today ran on cnn do you have it unless proven otherwise and that is indeed the case. before this outbreak, i could argue that the case would be you have malaria unless proven otherwise. and we have complicated this factor that it is now occurring in highly mobile environments well-connected by roads and we are dealing only with colonial orders. the tribal languages amongst

these countries are all the same, so it's really considered much as we consider going to canada from the united states. through this region. and we are still very much experiencing upward trend in the number of cases especially in sierra leone. while i truly applaud the move by the msf to reach out for support, building of treatment centers is something that i don't want to talk about in stopping this academic. we could build them for the next several months, but at this time we are over task for treatment center. you can see horrific scenes i can tell you and i can tell you just in panama when we were in a situation much like was described where we had 10

persons and no body bags until approximately 10 bodies just outside of the treatment center and is the director mentioned come as a patient you can imagine that you are trying to survive this and your mentality is very important. however, you are lucky to see people they were there just hours or in all that you can imagine is you're going to be next. and so you can see why there is a tendency that we have all read about people fleeing and running and not coming into the treatment centers and that's because the treatment centers are considered a house of death. we are turning the corner, i think in that opinion. recently saw that was much of the messaging that we gave early on in this epidemic, which was

accurate but not locally understood, was that there is no licensed treatment for ebola. so what we have as a result is a large portion of the population, one that didn't believe in the ebola virus, but second, why should we report to a treatment center if there is no treatment for ebola. rather than hearing that this will increase your chances, what they heard was there is no treatment for it. and so that led almost half of the population to speak out and seek traditional healers and that involves blood letting a lot of times, which is probably the worst thing you can do and that is also greatly contributed to the spread of the virus as well. where we are today in going back to the treatment center, our priority has to be stopping transmission of the virus and we are going to do that with boots on the ground and epidemiologists with a very

sustained effort. as we saw in guinea, we thought that the outbreak was over. we miss two or three contacts and that is really all that it took to stop this largest outbreak in history. concurrent with that is construction of treatment centers for those that are already infected. but speaking as a public-health professional, i think our number one priority has to be to stop the transmission and save the people that are not infected and treat those that are currently infected. and i would like to caution that the phenomenon that we have seen since the introduction of things like z-mapp in the experimental vaccines is that that is going to be the answer for the outbreaks. and we have these miracle drugs and it's going to stop these outbreaks and that's how were going to halt the outbreak. and i go back to the number one

priority and we're going to stop it with the permission change and improving our control and treatment centers and the long-term will require almost rebuilding the infrastructure and setting that and we are all so going to be dealing with the derivative and most commercial airlines and so that was largely dependent on the cargo and a lot of the commercial trade that countries are doing, which have threatened to stop this and that would create another set of problems and so those are all things that we want to deal with concurrently and lastly i would say that we are facing a unique

situation especially in sierra leone and to a lesser extent in guinea. this is the first time that we have had an outbreak of this fever in an area where we already have a hyper epidemic as well. and so as of last week we are starting to enter the dry heat season. so the areas that have been most effective in panama and other areas, they have been effective in a happen to be our hyper endemic areas and celebrity status and we will have multiples presenting at the same time and right now there is not even a place to print all of the locations. so we have to think about how we separate the loss of patience from the ebola patients and we don't want to mix chances of survival with those of ebola and there is treatment for that.

so i will end my comments with that. >> thank you. thank you, tom for the center of health security and the u.s. senate for organizing this meeting and clearly there is a lot of interest in this important and urgent crisis. this is a national security imperative and a human tragedy and an international health emergency on a scale that we have not seen before. and so one thing i want to stress is that this team that you see today, we didn't disney because of the crisis, but we have been working together on these issues and tom and i

regularly for the last five years, we have a very strong partnership between the department of defense and the hhs elements and cdc that goes back many years. this is not new to global health and going back to our tradition of walter reed and the work that he did on yellow fever virus. last week we established operation united assistance which would either dod support to this global effort that is led by the united nations and the special mission was established this week in support of our civilian agency counterparts, working with allies, including the united kingdom and france and others that have reach into the affected countries. the dod will focus our

contribution on her strengths and our unique capabilities and capacities, including command and control and logistics and training, as well as engineering support. we established the joint forces command under the u.s. africa command and major general darrel williams has been on the ground since last week doing the assessment. he is also the commander of u.s. army africa. the command headquarters is being established in monrovia, in addition to a regional and intermediate staging in senegal that provides a lot of logistical support to ensure the flow of personnel, equipment, and material for this very large

area of west africa. and in addition the united states this week will send to more and diagnostic laboratories some of our best scientists and microbiologist from the medical research center will deploy with the units to liberia and one in liberia and they will be associated with ebola treatment unit so we can have the diagnostics. and the department is providing a hospital that will be staffed by international health workers and medical personnel. the department of defense will not be involved in direct patient care is a part of this.

we are going to construct 17100 bed ebola treatment units in liberia. and the planning and preparation and contrasting for that activity is under way. and that should start to show results on the ground in the next few weeks. and these units will be staffed by local and international health care providers. and again the department will provide training based on msf and what they have established in belgium and we are going to

establish a similar training center with the goal of training 500 health workers per week. and the focus of that will be on infection control. the department of defense is requesting support from congress for up to $1 billion to commit to this effort and they are pending here on the hill. and this includes the cooperative biological engagement program that is also going to invest over $60 million in strengthening global health security capacity and laboratory capacity of affected countries

and also the neighboring countries as well. in the department of defense program has been involved for many years in the development of therapeutic vaccines to the affected country as well as personal protective equipment. and so i'd like to note that the very 13th of this year, the u.s. government launched a global effort and that has grown and it wasn't in response to ebola, but the white house will be hosting an event of 44 countries at this

level and we have health ministers, defense ministers in different sectors which is necessary for the whole of government response and to build those that west africa could have prevented this from becoming an epidemic to prevent and detect and respond to infectious disease outbreaks as required under the international health regulations. secretary hagel will participate at the agenda on friday and secretary john kerry and it will be hosted by ambassador rice with the participation of

president obama. i would like to finally think people like joseph and the workers that are on the ground. those that are on the ground who have just returned from there for their truly heroic efforts and we owe them all a deep debt of gratitude for the work that they're doing on the ground every day in west africa. thank you. >> thank you, andy. and thank you all for setting up this discussion for so much insight and information to start the discussion. we are now going to turn the discussion for those of you following along. for those online, submit the questions to ebola on the hill. so before we get too specific questions about the response, because i think people really want to understand the nuances

with the leaders here. i just want to ask one more question about the consequences if we get this wrong and if we don't rise to the occasion and he began to paint the picture here about what is at stake. but we hear things in the media along the way in the long lines of this country has enough on its plate and we love our national security threats. why is it important to invest so much of our time and talent on this problem and what happens if we get this wrong. the usa today headline was that it could the ebola epidemic on forever, which i think is one way of saying pandemic, which was talked about. so what are the consequences for african security if they get the strong? >> earlier in my career i spent three years living in guinea, working with refugees from

liberia. and as joseph said we're only about 11 or so from the civil wars in this country. and the u.s. invested a large amount of effort and political capital and resources to bring peace to these countries and this outbreak is unchecked, if it is unchecked, it could undo a lot of effort in terms of strong investments that the u.s. has made for international interest reasons. but at a human level it threatens to devastate and it already is devastating in these countries and i think that there is a strong humanitarian impulse in the politics and it's the reason why we are a leader. and i would say the global leader on humanitarian action

and disaster response. and anytime there is a disaster on this magnitude, the u.s. is on the frontline and this is this is an absolute national security priority and the president has articulated it as such. and so i think if you look at the level of interest in the media, there is a clear desire to beat this thing and we know that we can. >> i think that the sad fact is that the worst-case scenario is really bad and yesterday the cdc outlined what would happen if the ex-potential growth were to continue at the rate that it was growing a few weeks ago.

we don't think that that will happen because of the response the u.s. and others that the worst-case scenario within a relatively short period of time, not only would affect one's africa but would inevitably spread to other countries, we have two disease exportation events with the first couple thousand cases. how many events will we have as the president said for hundreds of cases and whatever we may think, it is not possible to seal the borders. it just doesn't happen as it did in troll of drugs and diamonds of people and it just doesn't. and so what that means is that we really are all connected. and so while we do not think that they will continue to spread as we believe it has been

spreading it all along, it will present a significant health risk to people in the u.s. and it could change the way that we work and the economy of the world and the way that we assess anyone who has traveled anywhere that might've had ebola. that is why a president obama highlighted the whole of government response with what they can do to stop this as quickly as possible and recognizing as the president said that it's going to get worse before it gets better and we have to recognize that although we have to work immediately, it's going to take time as it comes around. and the other key findings was that progress is possible and when you isolate this, the disease stops spreading and can decline in numbers almost as

much as the numbers we're seeing now. but what we found particularly striking was the mathematical documentation of the urgency that we all feel even a delay of one month and scaling of the response resulting in a tripling of the epidemic and that kind of shocking increase is very hard, as i have said, to really get our minds around as we try to make sure that we are anticipating what is likely to be recognize the situation is fluid almost beyond description and it changes day to day. but the response has to be with the urgency that will turn around and i think that we can do so. but the risks are not just to west africa but the whole world.

>> sure. rst of all, i would like to draw attention to something we've mentioned several times. there were two other nations, nigeria and senegal. and we looked at the response in those countries and how they contained it very quickly and we can't ignore the fact that the gdp is approximately $503 million per year and when you compare that to the gdp of liberia, around 1.9 billion, you cannot ignore the fact that the socioeconomics of the disease are upsetting. so it disproportionately affects the poor. i would argue that we are experiencing a level of mental and social, not seen since the civil conflict and a lot of us may question the mentality with

ebola. and it's a direct result of the conflict at the time. the only way that you're going to talk about is to see live with live with her family in that sober talk about right now. we are turning the quarter convincing that bite keeping someone in their home, not only are you greatly increasing the chance of that person will be okay, but you could infect your family and that has happened many times for that message to come through and we are likely to see major impacts on the governments of these countries. for example, liberia. johnson was certainly one of the most popular presidents in africa until this epidemic and now you have seen a determinist of negativity flowing towards the current administration and we face a similar circumstance.

but the current episode, if you look at it, the book will divide is much like we have in the u.s., a two-party system. where the current epicenter occurs is the opposition party stronghold in this includes those that are all being used as political fodder in office in sierra leone even though they have greatly improved the conditions in the past 10 years. and i think everyone on this panel is familiar that we have spent much of the last 10 years focusing on bioterrorism since i'm 11 and another term which we use, bioerror. this is the worst case scenario that we have thousands of individuals with the ebola

virus. taken by technicians that are baseline phlebotomists and a lot of infections occur because of this and there are no good trappings for that. in addition, all of the clinical laboratory services that are needed with illyria, common infections of people have, it's understandable because when you receive this sample you assume that it is the ebola virus. so to echo this, i think were going to have a lot of long-term effects, which we are also going to have to address and to echo the previous comments, every single day we delay, we are experiencing an ex-potential increase in these number of cases.

>> opening it up to the audience or questions as well as online. but it relates to the pillars of response and we will need numbers of nurses that are not available now. there's an element of training going on in the planning and recruiting and so how do doctors and nurses get involved in this in our country and also in the world if they are willing? >> is a critically important question and prior to that there was no global reserve capacity in every previous response had been a relatively modest scale in comparison to this one. and so the global capacity to

treat this was premised on that sort of response and we are now faced in a situation where we need a response scale that involves funding institutions, organizations, and nonprofit, medical teams are able to come forward and it involves identifying this traffic and staff those and one thing i think is important to underscore is that the treatment unit model that is being widely applied, only five to 10% of the staff are professionals in the vast majority of the people who are taking a rest risk on putting themselves on want to control this are nationals of other countries and we are working seriously to set up training models and the world help organization has been

reorganizing training in the country itself as well. in working with, working with people to put them through this training, and the health organization recently opened with a large complement of the staff and we are looking for those to join in the response. and it is reachable from our webpage. were we are collecting contact information for people that are interested and we are making that information available to ngos and other partners who are looking for staff to step up their own responses. and it's a resource for them that they can draw on to help to

comput understaffing. >> there is a fear that ebola causes -- and the african union with the cdc and the department of state and they are now on the ground helping out providing care. and this is a great example and there are some barriers we need to break down and even for their own citizenship we have to help people in their habit. 90% of the staff or local staff intensively trained and willing to work in these areas.

in this week the cdc can see the first-ever training course outside of the nmfs model, now e have trained trainers and we're going to see the result. >> we will take questions from the audience. >> would you say your name and where you're from and ask your question? >> my understanding may not be accurate and that is roughly 75% of the current victims that are women and children. if that is true, what do you think the particular socioeconomic impact as in these countries and communities would be as a result and how does that change or alter your response? >> actually the publication from yesterday found that that although there was the female predominance which we have been

due to caregiving, we have seen like a 5050 response and children tend to be less affected directly because they don't tend to be caregivers. but we are seeing horrific implications of this and one i was thinking of one survivor and her nephew as their kind of bouncing off the walls. and they finally said that the neighbors don't let him go outside because they are so afraid of him. and the second is the young boy untrained girl whose parents died and we are seeing really horrific problems and i saw one who had done the post employment screening of the staff with one

of our staff described to try to save their child's life, hoping that someone else would help them and the implications are upsetting for themselves. >> in addition, once a person does survive the disease, there is a stigmatizing of them once they reenter the community much like he was talking about and as was said, the majority of caregiving is for women and we are experiencing around a 5050 split. considering the burden as caregivers, they are primarily

farmers with cassava being the main consumable and in addition to that, just touching on the point, we had entire families wiped out. but we have an untold number of orphans now coming into a system where the social map for things but orphans was already under developed until again, going back to this, we are seeing numbers now that are not exactly equivalent to what they saw during that content, but it's reaching that content with a number of orphans that we are seeing in the areas. >> very quickly to add to the second pillar, and there are

many effects that we are going to try to address. we are building on that as well. >> next question. thank you. i have a question about the evolution of the virus and the buyers has seen more human host than ever before and there was an article published at the end of august that documented the evolution of the virus through 99 human host and the question is what is the current and ongoing efforts to understand the direction. ..

>> >>&yny than by genetic monitoring but they should go by hand in hand. >> i am from the senator's office. following up on your comments, with containment and response with the response potentially of the expansion of the virus. it is my understanding cdc

of a santry currently is passive surveillance. doctor, can you elaborate when the threshold from passive9&:ñ surveillance and what that looks like based on if that is coordinating training for cdc? >> i think of us as having three lines of defense against ebola and thinking carefully how to do that most effectively and practically. the first is to stop that in africa and we have been talking about that. that is the most effective way. and continuing for a while we need to do more of that. second is those that are departing the country to put

people in each of the airports with multiple temperature readings was well was of a questionnaire and they remove from the departure line anyone with a fever that may have ebola clearly that is not the perfect way to eliminate ebola because of somebody was just exposed land incubation period is between eight and 21 days. that doesn't mean we keep these people close. but it is a very important thing to do to keep travel safe and to keep those airlines flying because then expectation nobody will get very sick on the plane.

so we need to recognize it is not impossible someone will come into the hospital or health center with symptoms of ebola that may have that. 13 people have come on that were potentially consistent in the area the past 21 days. so we have ruled that out more than one dozen times. with12rt more than 100 health care facilitiesqhrj we put more then one dozen labs across the country. but in terms of border protection we have a close working relationship with the cdc and quarantine stations and we work very closely with porter

protocols that we follow someone would call in if it was consistent with ebola. we could respond effectively. one of the challenges is what we hope would be possible if somebody had ebola it is just not$ñ.6ñ possible. said to understand it is something we will dynamicallyyw; reassess with vhs and others. >> -- ada jazz and other. >> that was handed a microphone. >> we heard from our panelists that the effort to that not go had a hard over

three months than we are done but we heard about the u.s. response this is what you represent period"eñ including the $1 billion of sending that would cover six month period to build up the efforts. can you give us a sense of what you mean sustained by a length of time? and the response that you believe is needed from other countries besides the united states? because we're doing a lot but it needs to be a major international response. >> i will say a couple things. basically give them un number and the dates but not together. but we do know this sooner we get out there the sooner they will control it. so it is critically important.$uax

with of waterfall collaboration several parts of the department of defense and then i h them french in the italian all running laboratories but there has been a robust global response as with the peacekeepers is on the ground. there is a robust international response to have that unique ability to have those skills and scope

a french are increasing their involvement. it looks like other european partners will be going into guinea as well. the third pillar of the strategy, focusing on building international response to complement the u.s. -interagency response, is focused on that. is focused on that very question reno the u.s. government could carry this

entire response on its own with the u. k stepping up in a substantial way to mention the international partners stepping up doing regular calls. been passed have the day we have been on twice with the u. k and donor partners. that make intents -- intensified the efforts. >> international of reach is the area that president obama emphasized in his announcement in atlanta us cdc. the u.s. objectives is to mobilize the community to improve the of coordination among the international community. next week you k will host an event focused on sierra leone to coordinate contributions.

of the private partnerships for example, the gates foundation has pledged $60 million to this effort and others are contributing. the agenda we will leverage that the real commitments commitments, real commitments fraction of funding for in kind contributions for security around the world also specifically the current crisis. and does ambassador paul to lead this effort for the donor coordination the.

>> i forgot to mention the world bank. they have been terrific they have already put 100 people in the field. but they get not just the emergency or the immediate response but those laboratories that would have prevented that in the first place. and can prevent similar events in the future i will discuss at the white house on friday. >> i would like to add i don't want to speak to the timing. the with the decrease in number but for me sustainability so we can prevent this from happening again.

there will be medium term training and a long-term training coupled with investments and sustainable technologies. that will take time and effort and will continue to do so throughout the life span of the outbreak. but the african union secretary it all of them being extremely responsive and is coming together as far as governments. and the dates foundation all of them have started to contribute funds. when you look at the on the ground situation it is those bodies in the local population of government health care workers met that will be key to sustainability. >> the stakes for getting it

right are extremely high because even before we succeed in liberia or sierra leone it seems like a crucial element of the response. >> thank you. i am wondering as to evaluate the funding streams and the short-term time lines is their limitations to the current funding or those challenges? >> can i add on to that question? it would be great to hear from the panelist what they believe congress in particular could do since we are here today. bad is that that particular point what can they do to support this response. >> i will address cdc just

for the 11 weeks of the sea are cost $30 million we're grateful for congress to do advocate that just at the level we're going. that is no scale up that is just 11 weeks and it does not involve addressing other countries which may deal with large outbreaks to strengthen their resistance to surgeon in that area as well to produce the risk that would ignite forest fires elsewhere it does not deal with the medium long-term issues to make sure we have the technical capacity in the country to do that. we're working very closely with the world bank and others these are substantial and will continue for some time.

>> just as the panel reflects. and with those potential toecaps and with the prospective the highest priority with the programming request. with the overseas contingency operations. so immediate attention into those two will avoid any possible operations. >> from the usaid side one

of the top priorities is to ensure the dod reprogramming is improved because that will allow the large scale cooperation in the way that with this response just like any others that dod and aid worked extremely closely together where it works with dod to route those requirements that is well-suited. so having that resources available will turbocharge the type of scale of response that we absolutely need to mount. of the '80s side come as we

move into 2015 we have a better handle on what this will look like. but i don't want to get ahead. >> i think we have talked about the short-term financial needs i will speak more thinking about now as well as save holistic approach but in the medium term and long term objectives for sustainability, and to prevent this is we will require investment in infrastructure or laboratory setter permanently based you diagnose these log their own and investments of human capital with regards to new training and epidemiology and the laboratory. and another aspect is something that will be implemented is training of crisis management in the

emergency operations. prior to the outbreak they did not have to deal with acute humanitarian disasters. they were long-term but not acute. so that is the medium and long-term investments i argue to ensure this does not happen again. with the holistic aspect in addition to stopping the outbreak how do we deliver fuel to the area? and then to rebuild right before the outbreak and hopefully the silver lining they would have strengthened healthier systems.