[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]






                  FIGHTING EBOLA: A GROUND-LEVEL VIEW

=======================================================================

                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
                        GLOBAL HUMAN RIGHTS, AND
                      INTERNATIONAL ORGANIZATIONS

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           NOVEMBER 18, 2014

                               __________

                           Serial No. 113-229

                               __________

        Printed for the use of the Committee on Foreign Affairs

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                      COMMITTEE ON FOREIGN AFFAIRS

                 EDWARD R. ROYCE, California, Chairman
CHRISTOPHER H. SMITH, New Jersey     ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida         ENI F.H. FALEOMAVAEGA, American 
DANA ROHRABACHER, California             Samoa
STEVE CHABOT, Ohio                   BRAD SHERMAN, California
JOE WILSON, South Carolina           GREGORY W. MEEKS, New York
MICHAEL T. McCAUL, Texas             ALBIO SIRES, New Jersey
TED POE, Texas                       GERALD E. CONNOLLY, Virginia
MATT SALMON, Arizona                 THEODORE E. DEUTCH, Florida
TOM MARINO, Pennsylvania             BRIAN HIGGINS, New York
JEFF DUNCAN, South Carolina          KAREN BASS, California
ADAM KINZINGER, Illinois             WILLIAM KEATING, Massachusetts
MO BROOKS, Alabama                   DAVID CICILLINE, Rhode Island
TOM COTTON, Arkansas                 ALAN GRAYSON, Florida
PAUL COOK, California                JUAN VARGAS, California
GEORGE HOLDING, North Carolina       BRADLEY S. SCHNEIDER, Illinois
RANDY K. WEBER SR., Texas            JOSEPH P. KENNEDY III, 
SCOTT PERRY, Pennsylvania                Massachusetts
STEVE STOCKMAN, Texas                AMI BERA, California
RON DeSANTIS, Florida                ALAN S. LOWENTHAL, California
DOUG COLLINS, Georgia                GRACE MENG, New York
MARK MEADOWS, North Carolina         LOIS FRANKEL, Florida
TED S. YOHO, Florida                 TULSI GABBARD, Hawaii
SEAN DUFFY, Wisconsin                JOAQUIN CASTRO, Texas
CURT CLAWSON, Florida

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

               Jason Steinbaum, Democratic Staff Director
                                 ------                                

    Subcommittee on Africa, Global Health, Global Human Rights, and 
                      International Organizations

               CHRISTOPHER H. SMITH, New Jersey, Chairman
TOM MARINO, Pennsylvania             KAREN BASS, California
RANDY K. WEBER SR., Texas            DAVID CICILLINE, Rhode Island
STEVE STOCKMAN, Texas                AMI BERA, California
MARK MEADOWS, North Carolina
















                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

Mr. Rabih Torbay, senior vice president for international 
  operations, International Medical Corps........................     4
Mr. Brett Sedgewick, technical advisor for food security and 
  livelihoods, Global Communities................................    18
Darius Mans, Ph.D., president, Africare..........................    24

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Mr. Rabih Torbay: Prepared statement.............................     8
Mr. Brett Sedgewick: Prepared statement..........................    20
Darius Mans, Ph.D.: Prepared statement...........................    26

                                APPENDIX

Hearing notice...................................................    48
Hearing minutes..................................................    49

 
                  FIGHTING EBOLA: A GROUND-LEVEL VIEW

                              ----------                              


                       TUESDAY, NOVEMBER 18, 2014

                       House of Representatives,

                 Subcommittee on Africa, Global Health,

         Global Human Rights, and International Organizations,

                     Committee on Foreign Affairs,

                            Washington, DC.

    The subcommittee met, pursuant to notice, at 10:07 a.m., in 
room 2172, Rayburn House Office Building, Hon. Christopher H. 
Smith (chairman of the subcommittee) presiding.
    Mr. Smith. Subcommittee will come to order.
    The world community has known of the Ebola virus disease, 
more commonly called just Ebola, since it first appeared in a 
remote region near the Democratic Republic of the Congo in 
1976. In previous outbreaks, Ebola has been confined to remote 
areas in which there was little contact outside the villages at 
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 of 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 7 and then a followup on 
September 17, we heard about the worsening rates of infection 
and challenges in responding to this from government agencies, 
such as USAID and CDC, and NGOs operating on the ground, such 
as Samaritan's Purse and SIM.
    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 manifests the same symptoms as 
less-immediately deadly diseases, such as malaria, which means 
initial healthcare workers have been unprepared for the deadly 
nature of the disease that they have been asked to treat.
    This meant that too many healthcare workers, national and 
international, have been at risk in treating patients who 
themselves may not know they have Ebola. Hundreds of healthcare 
workers have been infected, and many have died, including some 
of top medical personnel in the three affected countries.
    What we found quite quickly was that the healthcare systems 
in these countries, despite heavy investment by the United 
States and other donors, remained weak. As it happens, 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 suffering and dead loved ones for safe burials, 
which places 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 6,500 Ebola cases officially recorded, probably 
a significant understatement. The number of infected and dead 
from Ebola could be as much as three times that of the official 
figure due to underreporting.
    Organizations operating on the ground have told us over the 
past 5 months that, despite the increasing reach of 
international and national efforts to contact those infected 
with Ebola, there remain 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 infection continues. Even 
when it looks like the battle is being won in one place, it 
increases in a neighboring country or region and then reignites 
in the areas that look to be successes.
    The United States is focusing on Liberia. The UK is 
focusing on Sierra Leone. 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 H.R. 
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 three countries.
    This includes recruiting and training healthcare personnel, 
establishing fully functional treatment centers, conducting 
education campaigns among populations in affected countries, 
and developing diagnostics, treatments, and vaccines.
    H.R. 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 to 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 Fiscal Year 2014 level to effectively support these 
anti-Ebola efforts.
    I would like to now turn to my friend and colleague, Ms. 
Bass, for any opening comments you might have.
    Ms. 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 
respective organizations continue to combat this deadly 
outbreak, what trends you are seeing, both positive and 
negative, and what additional support is needed as you 
coordinate with the governments of the impacted countries in 
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 
healthcare 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, 
also, 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.
    The 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 and 
attention to the fact that we are dealing with countries that 
could actually be moved quite a bit backward, especially 
countries that have recently gotten past civil war.
    So I look forward to your testimonies, and I am interested 
in hearing from you about what we can do to assist your 
efforts.
    Thank you.
    Mr. Smith. Thank you, Ms. Bass.
    I'd like to now welcome our three very distinguished 
witnesses who are extraordinarily effective and informed and 
will provide this subcommittee a real insight as to what has 
been happening and what needs to be done.
    Beginning with Mr. Rabih Torbay, who is the senior vice 
president for international operations and oversees 
International Medical Corps' global programs in 31 countries 
and 4 continents and its staff and 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 Leone, 
Iraq, Darfur, Liberia, Lebanon, Pakistan, Afghanistan, Haiti, 
Libya, and most recently Syria.
    As the organization's senior representative in Washington, 
DC, he serves as IMC's liaison with the United States 
Government.
    We will then hear from Mr. Brett Sedgewick, who is a 
technical advisor for food security and livelihoods for Global 
Communities. He previously served as vice president for the 
NASSCOM Foundation, for whom he built stakeholder relations 
with government entities, donors, and NGOs, and oversaw 
business development.
    Prior to that, he served as Liberia country director for 
CHF International, where he oversaw program design, 
implementation, and monitoring for a range of donors. He also 
served as Liberia technical advisor to Chemonics on a similar 
basis.
    We will then hear from Dr. Darius Mans, who is the 
president of Africare, where he is responsible for the 
leadership and growth of that organizations. 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 Africare.
    In these positions Dr. Mans was responsible for vast and 
diverse program portfolios in MCC compact 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 are joined by Mr. Weber, vice chairman of the 
subcommittee.
    Any opening comments?
    Mr. Weber. Thank you for being here. Let's go.
    Mr. Smith. Okay. Thank you.
    I turn to Mr. Torbay.

   STATEMENT OF MR. RABIH TORBAY, SENIOR VICE PRESIDENT FOR 
     INTERNATIONAL OPERATIONS, INTERNATIONAL MEDICAL CORPS

    Mr. Torbay. Chairman Smith, Ranking Member Bass, and 
distinguished members of this 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 10 recommendations for our Ebola 
response experience.
    International Medical Corps is a global humanitarian 
nonprofit organization dedicated to saving lives and relieving 
suffering through healthcare training and relief and 
development programs. We work in 31 countries around the world, 
and we have 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-fourths of all Ebola-related deaths have 
come from these two countries.
    By the end of this month, we anticipate having a total of 
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 the 
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 comprised 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 of 
Cuttington University in Bong County, 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 a 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, we have learned that 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 is no resurgence of this 
epidemic.
    The fight to contain Ebola and prevent future outbreaks 
will require a 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 in our Ebola treatment unit in 
Bong 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 testimony by offering 10 
recommendations for effective treatment and eradication of 
Ebola virus for the subcommittee's consideration.
    One, ensure the availability of an 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 
fits the local needs. The work must be well-coordinated and 
well-trained staff must be ready to work in each facility. We 
need to remain flexible and nimble and adapt quickly to 
changing demands to response to outbreaks in rural areas.
    Three, ensure that the necessary quantity and quality of 
personal protective equipment is available.
    Four, improve data collection, surveillance, and referral 
systems that will help individuals receive treatment faster.
    Five, ensure that clear and understandable 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 procedure to evacuate and treat expatriate 
health workers who might contract Ebola. We recommend that the 
systems being put in place now be institutionalized and made 
part of the global preparedness planning in the future for 
future epidemics.
    Seven, we recommend that commercial airspace over Ebola 
countries remain open so 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 
resources, proper training, and systems in place to respond 
themselves to possible future outbreak 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 are dying from malaria, they are 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.
    [The prepared statement of Mr. Torbay follows:]
    
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    Mr. Smith. Thank you very much, Mr. Torbay.
    Mr. Sedgewick, if you could proceed.

 STATEMENT OF MR. BRETT SEDGEWICK, TECHNICAL ADVISOR FOR FOOD 
          SECURITY AND LIVELIHOODS, GLOBAL COMMUNITIES

    Mr. Sedgewick. 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 subcommittee.
    My name is Brett Sedgewick, and I am technical advisor at 
Global Communities, formerly known as CHF International, and I 
am 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. 10 days ago after 
spending 3 weeks in Liberia helping to lead our response on the 
ground.
    Global Communities has worked in Liberia since 2004. In 
2010, we began a USAID-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, who 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 deceased to say goodbye through traditions that involve 
touching and washing the body. The CDC estimates that up to 70 
percent of Ebola infections are originating 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 backbreaking and 
heartbreaking. I have accompanied burial teams and seen the 
incredible professionalism with which they operate. These men 
and women work 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 for 
assuming great risk and social isolation in order to stop this 
epidemic. While risky, this work can be done safely. Not one of 
our more than 500 team members have contracted the virus.
    This work is not without challenges. Many resist 
identifying their dead as infected. They fear they will not be 
able to mourn their loved ones and they themselves will be 
stigmatized. This is why the work of safe burial goes hand in 
hand with community engagement. Many burial rites are safe, and 
the teams let communities safely and respectfully say goodbye 
to their loved ones.
    Another challenge is cremation. In Montserrado County, 
which contains Monrovia, cremation became official policy 
during the height of the outbreak. However, this practice is 
counter to traditional practices and is met with strong 
resistance.
    The idea of a deceased loved one being burned, in their 
vernacular, upset many and increased 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 Montserrado 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 Nimba Counties. By the first week of October, we had 
expanded to support teams in every county of Liberia. And last 
month they were able to collect 96 percent of bodies within 24 
hours.
    We were also able to directly reach over 1,500 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 has proven effective 
and 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.
    [The prepared statement of Mr. Sedgewick follows:]
    
    
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    Mr. Smith. 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 subcommittee.
    Dr. Mans, please proceed.

      STATEMENT OF DARIUS MANS, PH.D., PRESIDENT, AFRICARE

    Mr. Mans. Thank you, Mr. Chairman.
    Let me start by thanking you and members of the committee 
for your 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 am honored to be here with them.
    If I may, I would 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 would 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 have shipped personal protection equipment and 
essential health supplies to all three affected countries 
through partnerships with Direct Relief and others. In 
addition, we have been helping frontline health workers do 
contact tracing.
    Throughout the crisis, we have been very focused on 
community mobilization and behavior change. That is 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 non-Ebola-
related diseases, and that includes safe deliveries of babies. 
We are taking into 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 real-
time information about what we are doing to contribute to the 
war against Ebola. And I should tell you we are doing all of 
this without any funding from the U.S. Government so far.
    But let me describe what we believe in addition needs to be 
done in the face of this challenge. Progress is being made, but 
much, much more needs to be done.
    We certainly strongly support the President's emergency 
request and hope the rest of the G20 countries will step up to 
the plate and do more. But it is not just more money that is 
needed. It is important how that money is used.
    There is a need for better coordination and planning of 
these emergency treatment centers. We believe we clearly don't 
need as many ETCs as were originally planned in Liberia, for 
example.
    Very important to take the efforts to control Ebola to the 
community level. That is 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 have seen as a rapidly evolving 
epidemic.
    And, in addition, very important, we believe that it is 
essential that civil society in the effected countries be given 
the support and space needed to help ensure the best use of an 
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 that 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 the health 
infrastructure that the 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 healthcare system.
    And, finally, Mr. Chairman, it is my hope that the 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 is needed to help these 
countries get back on the higher growth path that they were on 
before the Ebola crisis.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Mans follows:]
    
    
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    Mr. Smith. Thank you. Dr. Mans, thank you very much for the 
extremely valuable work you are doing, but, also, the insight 
you provide our committee.
    Let me ask you a couple of questions, to all three of you.
    You mentioned, Dr. Mans, that you have 300 local volunteer 
community health workers that you have trained who, in turn, 
have educated some 150,000 Liberians about Ebola prevention, 
detection, and care.
    In your statement, Mr. Torbay, you talked about the need to 
ensure the availability of adequate, well-trained, well-
protected healthcare workers.
    How close are Liberia, Guinea, and Sierra Leone to having 
an optimum number of healthcare 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 are both from New Jersey. Welcome.
    You talked about how the safe body management is of the 
highest priority to stopping the spread of Ebola, and you 
mentioned the CDC number of up to 70 percent 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 you have very good information 
about your teams reaching 96 percent of bodies within 24 hours 
over the last month.
    How many of the folks that should be reached are not being 
reached, just to try 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. The church plays a key role, obviously, in funerals.
    What role are they playing from the pulpit and in any other 
way of getting that message out about the contagious nature of 
someone who is deceased from Ebola?
    With regard to personal protective equipment, Mr. Torbay, 
that is the third point that you made--how available is it, 
especially to those volunteers and those indigenous individuals 
who might not have access to it, as some of the NGOs do, going 
in? If you could just speak to that. Are we where we should be? 
Anywhere close to it? Because, obviously, that is one way of 
protecting.
    And then, Dr. Mans, you had mentioned, and rightfully so, 
the deep concern of President Sirleaf. When I spoke to her, she 
raised the concern, and you have echoed her concern here today, 
about other diseases that continue to have a devastating impact 
on people in the three affected countries, including Liberia.
    Congratulations and good work on the safe delivery aspect, 
to help both mother and baby have a venue where they can give 
birth as safely as possible. 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 will ask those first and then 
yield to my friend and colleague and then come back for a few 
others.
    Mr. Torbay. Thank you, Mr. Chairman, for your questions.
    I will start with the health workers gap. What we are doing 
at the International Medical Corps is focusing on training 
health workers that will be working in Ebola treatment units. 
That training is a 14-day intensive training that includes 
hands-on training actually treating patients in an Ebola 
treatment unit.
    As you probably know, when you work in an Ebola treatment 
unit, you cannot work for more than an hour or, maximum, 2 
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 are extremely 
careful about that.
    In terms of the healthcare gap, we are coordinating with 
agencies that are doing community work, such as, you know, 
Global Communities, Africare, 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 ratios. We are talking 1 doctor 
for 100,000 in Liberia, and that is before 324 health workers 
have died from Ebola. So you can just imagine the gap.
    One thing that is critical to the health gap, we cannot be 
only reactive. Anytime there is an outbreak, this is when we 
decide to train. We need to build a stronger healthcare system. 
We need to build a stronger preparedness system in all of these 
countries. And we need to focus on health workforce 
development.
    Again, it is not just the infectious diseases. It is the 
malaria. It is the safe delivery. It is diarrhea. It is 
vaccine-preventable diseases that children are dying from.
    I think we are on track in terms of training health workers 
for the Ebola response, but what we are doing in our 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 the sustainability aspect that we are 
encouraging all of our colleagues to look at, what comes beyond 
Ebola.
    Mr. Smith. Mr. Sedgewick.
    Mr. Sedgewick. Thank you for your question.
    To address your second question on unmet need, I would like 
to point out that the 96 percent of bodies that are collected 
within 24 hours, that is within 24 hours of the death of the 
individual, not of the phone call. So much of that 4 percent is 
because of a delay between the death and the phone call and the 
assignment of the team.
    That is a big effort that we are 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 are hearing about the status of the 
individual well before they pass.
    As much as possible, our success is made significantly 
easier by our colleagues, like IMC, running ETUs and having the 
volume and the beds available to treat those individuals. It is 
much better for the individual to first get community care and 
then get to the ETU, 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 is 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 is all anecdotal.
    I know that the African Union and the CDC have been working 
on doing some studies on this and they found limited volumes of 
people hiding, but any are devastating.
    So we are 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 have mobilized new teams 
within a day. So we are able to make sure that, as hot spots 
come up, the teams are positioned and available and responding 
immediately.
    On the second part of that question regarding clergy and 
faith-based leaders, they are a core part of how we interact 
with the communities. Our historical interactions in Liberia 
have been focused on Bong, Lofa, and Nimba Counties. And so we 
have really strong relationships not just with the religious 
leaders, but with the traditional leaders and with the 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 
is so-and-so and how is so-and-so's baby. They are 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 that we had to do really extensive 
interactions with religious, health, and traditional leaders, 
and they have been incredibly helpful in making sure that the 
communities know why we are there, that we are there for a good 
reason, that we are helping, and that we are able to do our 
work respectfully, closely, and rapidly. And so that has been a 
core part.
    The religious leaders have been really helpful, and the 
traditional leaders, who also serve very important roles at the 
community level, have been very important for making sure that 
our teams are able to operate rapidly and safely.
    Mr. Smith. Thank you.
    Mr. Mans. On personal protection equipment, no, 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 into 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 may 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 in building more and more of 
these maternal waiting homes and working with the private 
sector in Liberia to raise the money to do so. So far, I think 
we are up to about 20.
    And in these facilities, the point is to bring access to 
communities because women who were expecting were not able to 
get to these health facilities, which are so few and far 
between. And that is something we intend to continue to do 
post-crisis.
    Mr. Smith. Thank you.
    Ms. Bass.
    Ms. Bass. I again want to thank all of you for your 
testimony. I think it has been extremely helpful. And I have 
questions for each of you.
    Mr. Torbay, 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. You know, are you saying this in response to 
something that needs to be improved?
    Mr. Torbay. Thank you for your question. That is actually a 
very important question, and we have been discussing it over 
the past week.
    There had been plans to build a certain number of ETUs in 
every country based on findings that are about 2 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 are flexible enough so that if there 
is no need for an ETU, let's not even build that ETU.
    If there is a need for mobile teams that would go out and 
get patients to an Ebola treatment unit that has empty beds, 
let's do that, because we are seeing some Ebola treatment units 
that have an overflow of patients and some Ebola treatments 
units----
    Ms. Bass. They are empty.
    Mr. Torbay [continuing]. That actually have empty beds.
    Ms. Bass. Right.
    Mr. Torbay. And we need to make sure that we balance that.
    Ms. Bass. I heard about that, too, and I had thought that 
one of the reasons was because the population was, you know, 
afraid to come forward and the best case is that they are not 
needed, but that that wasn't the issue.
    So why do you have that discrepancy? And then I guess what 
you are saying is why Dr. Mans was saying that maybe ETUs is 
not the way to go right now.
    But I will come back to you, Dr. Mans.
    Mr. Torbay. Well, first of all, the virus is moving. It is 
not staying in one county. So you build an Ebola treatment unit 
in one county. You get it under control with the work between 
the community-based approach and the treatment approach.
    It is getting under control, but then it is appearing in 
another country----
    Ms. Bass. Right.
    Mr. Torbay [continuing]. In another county. So that is why 
there are large numbers in certain areas and lower numbers. And 
those need to be coordinated.
    And we support the community approach because, at the end 
of the day, Ebola started at the community level and this where 
it should die, at the community level.
    Ms. Bass. Right.
    Mr. Torbay. And we need to make sure that the community 
centers are well equipped and the staff are well trained to 
detect and isolate so they could refer to the treatment units 
for further treatments and those that are negative could be 
discharged back into the community. And this is what needs 
strengthening, and this is the work that is being done now on 
the ground.
    Ms. Bass. So you know how I said in my opening that I was 
interested to know if any of the things that we were building: 
Should they stay? I have not been inside an ETU. I have just 
seen them on TV.
    Is there any value to the ETUs that were being built being 
left there for either other infectious diseases or other health 
needs?
    Mr. Torbay. You know, some of those ETUs are not built to 
last----
    Ms. Bass. Okay.
    Mr. Torbay [continuing]. Which is fair enough. They are 
built with temporary material that would last for a few months, 
and that is good enough.
    But one of the approaches we are following is we are trying 
to build a more permanent structure that could be later on 
turned into something else. It could be turned into a training 
center or a clinic. And that is the sustainable aspect of it, 
and that is what we are encouraging.
    There will be a need for isolation wards or isolation units 
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, and there is a need for the facility as 
well as equipment and trained staff there.
    Ms. Bass. So it was the first time I have heard someone 
talk about that the only time a healthcare worker can be with a 
patient is 1 to 2 hours.
    Now, I have seen the equipment and I have seen the stories 
that talk about the heat, but that implies a large number of 
healthcare workers.
    So if you are only with the patient, you know, for an hour 
or 2 and you leave, then do you have relief? Do you understand 
what I am saying?
    Mr. Torbay. Absolutely.
    Ms. Bass. So how does it work?
    Mr. Torbay. In our Ebola treatment unit in Bong County in 
Liberia, it is a 70-bed treatment facility. We have 230 staff 
members working there.
    Ms. Bass. Wow. Okay.
    Mr. Torbay. We work around the clock. So it is by shifts.
    Ms. Bass. I got it.
    Mr. Torbay. When a doctor goes out, another one will be in 
to replace him.
    Ms. Bass. And so, when the person leaves after being there 
an hour or 2, they take a break of how long? And then I imagine 
they go back for----
    Mr. Torbay. Yes. It really depends on the level of 
exhaustion and dehydration. Usually, it is not less than 3 to 4 
hours. They need to recover before we bring them back in.
    Ms. Bass. Wow. Okay.
    And, Dr. Mans, maybe you could respond to this one if you 
wanted to add anything about the ETUs. But, also, I know that 
there was an issue around the healthcare workers at one point 
and them being paid and them wanting hazard pay, and I was 
wondering what the situation was with that, if that has 
improved.
    Mr. Mans. Sure. Thank you, ma'am.
    You know, I agree completely with what Rabih has just said 
about the ETCs as part of the strategy.
    Ms. Bass. ETCs.
    Mr. Mans. Emergency treatment centers. Sorry.
    And there are some certainly challenges around planning and 
coordination. For example, we have seen, you know, the United 
States Government construct a 100-bed emergency treatment 
center, you know, 3 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't get into any of those. So, 
again----
    Ms. Bass. So how does that happen?
    Mr. Mans [continuing]. The challenge of planning, 
coordination----
    Ms. Bass. How does that happen?
    Mr. Mans [continuing]. Is what is very important.
    Fundamentally, it is a responsibility of government.
    And so I think finding ways, again, as Rabih, I think, 
summed up so well, 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 Liberians about these big numbers that they hear 
that has been committed to Ebola and the actual response that 
is taking place on the ground.
    And 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 is about training, 
which was discussed earlier, which I think is extremely 
important. We think a lot about it; we work with community 
health workers and, of course, there is a big challenge.
    There are so few doctors in Liberia. Just take one example: 
4 million people, 425 doctors. But 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 could be done pretty quickly.
    And I think that there are institutions here in the United 
States that can provide the kind of support that is needed to 
ramp up pre-service training as well as supporting in-service 
training by institutions in the affected countries.
    Ms. Bass. Now, 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. And I wanted to know if maybe you could 
be specific about that.
    I certainly understand the community piece in terms of the 
contact tracing, identifying, people that are infected.
    And then what? If there are not ETCs, ETUs, whatever, then 
what? So you are taking it to the community, you have 
identified a person. Then what? You follow me?
    Mr. Torbay. I can try to answer that.
    The role of the community is critical. As you mentioned, 
contact tracing is critical. Informing the authorities is also 
very important, informing burial teams so they could remove the 
body.
    But 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 also they have at least 
gloves or things to protect themselves, but to make sure that 
they isolate and inform the different authorities, be it the 
health workers or the community 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. 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.
    Ms. Bass. So should there be smaller ETCs? Because I 
understand isolating the person. But 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 they are not needed. But in the places where 
they are not needed, then what happens to the person?
    Mr. Torbay. That is a very valid question.
    There are community care centers that are being 
established, which are like mini Ebola treatment centers.
    Ms. Bass. Okay.
    Mr. Torbay. And the idea is those patients will be taken 
there. They will be isolated. They will be cared for until the 
test is done. Then they are referred. So the important thing is 
for them to be taken out of their home.
    And 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 with 
USAID, about the need for Ebola treatment units and where they 
should be, we have seen that they have been extremely flexible 
and receptive.
    So if we tell them, ``Hey, there is no need for us to staff 
this one. Let's move it there,'' they have been extremely 
responsive to recommendations. And I would like to commend them 
for that.
    Ms. Bass. Okay. And, Mr. Sedgewick, you might want to 
respond, but I wanted to ask you a series of questions around 
cultural practices. But go ahead and respond.
    Mr. Sedgewick. Yeah. I would like to catch up a little bit 
and I would like to reiterate that flexibility on both the 
designation of where the ETUs are and, in general, that 
flexibility that, in particular, the USAID DART, and the 
general response has been really fantastic and it has allowed 
us to make sure that we are able to position resources as 
quickly as possible.
    On the issue of the community, we spend a lot of time and 
have spent a lot of time since April going over what the best 
way is to interact with the community, and that is a lot of 
these dialogue sessions that I have been talking about.
    It is really focused on making sure that we are not top-
down, we are not distributing leaflets and just doing radio 
shows, though we are doing that, but really making sure that 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.
    And that has 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 that 
they are making that phone call.
    Really, that phone call is the most important thing, making 
sure that that victim or suspected victim is isolated. Them 
making that phone call is really huge.
    In the long term, before we started, before this fire hit, 
we were doing these water and sanitation activities with the 
government and we were successful in working with over 350 
communities in Bong, Lofa, and Nimba on proper sanitation and 
proper hygiene. And that effort was incredibly successful.
    In all 350 communities, in Bong, Lofa, and Nimba, which are 
some of the hardest hit communities, none of them have been 
affected by Ebola.
    And it really goes to show that, if you make that long-term 
investment, if you prepare the communities before it hits, it 
has a huge impact and it really prevents that from happening. 
And I only wish that we were able to hit all the communities in 
Liberia before the virus hit.
    Ms. Bass. So I wanted to ask if you would expand a little 
bit more.
    You were talking about the cultural practices. And I do 
understand--first of all, it was really something when you said 
that 70 percent of the transmissions were due to contact with 
people who had passed away.
    How long is a body contagious?
    And then my colleague was asking about the role of the 
faith community. And I was just wondering if faith leaders--
since, obviously, the traditions are a part of people's faith, 
if they were taking the lead in getting people to deviate, to 
divert, from traditional practices. And I would imagine that 
would be really hard.
    You said that they have come up with ways to safely say 
goodbye, and I thought you said that they did that with all of 
the protective gear on. And I was wondering if that is what you 
meant.
    And then, finally, I want to know what happened to you. You 
were there. You came back. Did they hold you in a tent at the 
airport? I mean, I am glad they didn't, if they didn't. But how 
did you sneak back in?
    Mr. Sedgewick. Great. Well, thank you. And that is a series 
of great questions.
    I will answer the last one first. I was met at the airport. 
There was an ``X'' on my piece of paper as I was trying to get 
out----
    Ms. Bass. Seriously?
    Mr. Sedgewick [continuing]. You know, that pulled me over 
to the side. And so I conducted an interview with the CDC.
    Ms. Bass. What airport?
    Mr. Sedgewick. Dulles.
    And they were really great. They streamlined the process as 
quickly as possible, asked me about my potential level of 
exposure, which was very limited, and took my temperature.
    And, since then, I have been in daily contact with the DC 
Department of Health. I live in DC, so that I am in contact 
them every day. I self-monitor, take my temperature twice a 
day, and monitor any symptoms, of which I have none.
    But I would like to reiterate that they, the CDC and the DC 
Department of Health, are really focused on the partnership 
aspect of it and the fact that we are working together on this 
and that they understand why I am there and why I went and that 
it is not an antagonistic relationship, that we work together.
    And that allows not just me, but everyone coming back, to 
feel free and happy to discuss our health with the Department 
of Health and with the CDC, and that really opens up that 
dialogue. It makes it, I think, much more impactful in terms of 
a monitoring tool.
    On your question about safely saying goodbye, we don't 
allow the community members to don PPEs as a prevention tool 
because it requires a lot of training. We do actually, though, 
allow them to don some PPEs to make them feel better because, 
honestly, the burial teams are wearing full PPEs. It is fairly 
intimidating.
    And so, if it makes them feel better to wear some PPEs, we 
allow them to do that, but we don't allow them anywhere near 
the body. And they have to----
    Ms. Bass. So it was the burial teams you were describing?
    Mr. Sedgewick. Yeah. The burial teams are wearing the full 
PPEs. The community members are allowed to attend the burial 
and, if they want to, they can wear some limited PPEs, but, 
really, they are not allowed close.
    But that allows them to understand what is happening, where 
the burial is, to watch the process, which is incredibly 
important, to make sure that they are engaged and to make sure 
that the next time there is a victim, that they make that phone 
call.
    So that interaction really takes the bulk of the time. The 
way that the burial teams interact with the communities and 
make sure the burial is done in a respectful and dignified way 
is a huge part of their time.
    The other small item that I wanted to respond to was on the 
hazard pay, which is a really important aspect of the response, 
actually. Because these are really brave people doing really 
important work, but they do want to make sure that they are 
being compensated.
    And so that is a part of our efforts, is to make sure that 
that pay is happening on time and really working to ensure 
that. It is a small amount of money by our standards, but it is 
incredibly important to make sure that they understand that 
they are valued and that the work that they are doing is 
important.
    Ms. Bass. Just quickly to the two last questions, which 
were how long is a body contagious----
    Mr. Sedgewick. Oh. I'm sorry. Yes.
    Ms. Bass [continuing]. And then if somebody could address 
the abandoned children. Where are they? What is happening to 
them?
    Mr. Sedgewick. Sure.
    On the length of time that a body is contagious, we don't 
exactly know. And the CDC and the WHO are looking at this. And 
so that is why we are just focused on--it is a long time.
    It is on the order of weeks. And so that is why we make 
sure that the body is, you know, covered in chlorine, placed in 
a body bag, covered in chlorine again when it is buried.
    It is alternating soil and chlorine so that there is no 
risk. The virus doesn't last very long in water even. So it is 
very low risk to the water tables. But we also make sure that 
burials happen above the water table just to make sure.
    Ms. Bass. Thank you.
    Mr. Smith. Thank you.
    Just a few follow-up questions.
    At our September 17 hearing, Dr. Kent Brantly from 
Samaritan's Purse spoke at length about a number of things, 
having lived through it and having survived. One point that he 
made was that the 120-bed isolation unit at his hospital, ELWA, 
was turning away as many as 30 infectious individuals each day.
    And I am wondering, with the ETUs, has that changed or is 
the capacity growing? The military certainly is in the process, 
and you might give an update on how well you think the United 
States military is doing in creating that capacity.
    He also made a very strong point about those who will stay 
in their home and will be cared for by loved ones, husbands, 
wives, children. He said, ``If we do not provide education and 
protective equipment to caregivers, we will be condemning 
countless numbers of mothers, fathers, daughters, and sons to 
death simply because they chose not to let their loved ones die 
alone.''
    And I'm wondering, since, obviously, isolation is one of 
the keys to breaking the transmission chain and many of these 
infected people will stay at home, is the outreach to the 
individual caregivers as robust as it should be?
    Let me also ask, at the second hearing, Dr. Fauci from NIH 
used the word ``exponential'' time and time again during his 
testimony. We had a group of top people, including the head of 
USAID, at a hearing last week of the full committee, and that 
word wasn't uttered once. And I asked them, ``Are we seeing a 
turn?''
    You know, CDC had said that, if the rate of increase 
continues at the pace in September, there could be as many as 
1.4 million cases by late January. Where are we, in your view, 
in terms of the estimations of how large this epidemic may 
grow?
    Let me also ask you about one of the 10 points that you 
have suggested to us, Mr. Torbay, the importance of a capable 
ambulance network.
    And I am wondering, since so many people can't get to an 
ETU or any other kind of health facility, where is Liberia, and 
perhaps the other two countries as well, but I think you know 
more about Liberia, in terms of ambulance capacity?
    And, also, if I could, all of you might want to touch on 
this. You know, Dr. Brantly may have been helped by ZMapp. We 
still don't know. There are other drugs still in the pipeline, 
vaccines and curative potential drugs.
    I was amazed and positively shocked when you said, Mr. 
Torbay, that the rate of fatality at your Bong County Ebola 
unit in Liberia is approximately 26 percent. That is far lower 
than the average fatality rate in the three affected countries.
    And I am wondering, what is being done there to achieve 
those remarkable results in terms of mitigating fatality? So if 
you could speak to those issues.
    Mr. Torbay. Thank you, Mr. Chairman.
    I would like to start with the last question about the low 
fatality rate at our Ebola treatment unit in Bong.
    We are not using any miraculous drug or any testing drug 
there. What we are doing is working with the community to make 
sure that patients are referred to the Ebola treatment unit as 
soon as possible. That has been one of the major factors in 
lowering mortality rates.
    And as you have seen even here in the U.S., those that were 
caught early on and sent to the hospital, they survived, and 
those that were late did not make it, unfortunately. And, for 
us, that is extremely important.
    Our treatment is very basic. It is palliative care. It is 
hydration. It is balance of electrolytes. It is making sure 
that people actually are healthy enough for them to fight the 
virus on their own.
    One very critical component of, actually, our success has 
been the U.S. Navy lab that was set up right next to our Ebola 
treatment unit. It used to take us 5 to 7 days before we would 
get the test results for a suspect case. Now it takes us 5 to 7 
hours.
    So, basically, people are coming in. We are testing them. 
If they are positive, they are put in the treatment ward. If 
they are negative, they are sent home. And that cuts down on 
the potential exposure as well. This has been critical for us 
as well.
    Mr. Smith. Excuse me.
    That would be of people manifesting some symptom?
    Mr. Torbay. Correct.
    Mr. Smith. Okay.
    Mr. Torbay. Correct. They manifest symptoms. They are put 
as a suspect case until they are tested. Then we decide whether 
it is positive or negative.
    Mr. Smith. And if they are not manifesting a symptom, no 
testing is done?
    Mr. Torbay. No.
    Mr. Smith. Okay.
    Mr. Torbay. This actually ties into your question about the 
Ebola treatment unit capacity. Actually, the lab facilities are 
playing a critical role because the Ebola treatment units 
accept suspect cases. And that is why they were turning a lot 
of cases away, because they did not have the capacity to test a 
lot of those patients. They have to keep them there until they 
are tested.
    So with the additional number of labs that are being 
established in Liberia and Sierra Leone, that is helping out 
and it is no longer the case. Hardly any unit is actually 
pushing patients away. The situation in Liberia, and this is 
something that Dr. Shah, I think, mentioned here in his 
testimony, is looking better than it looked a couple of months 
ago. The numbers are lower. The new cases are lower than it was 
before. It is much better than what we estimated 2 months ago. 
And if we continue on the right track--and we have to continue 
with the same momentum, we cannot slow down--we will get it 
under control.
    And the same applies for the other countries. Liberia--now 
we see the numbers in Sierra Leone, actually, are increasing at 
a much faster rate than Liberia. So we need to work together--
community, the treatment, the host government, as well as 
donors and other governments and the military--to contain it. 
And Liberia could be a really good success story.
    Now, we shouldn't start celebrating yet. We have to be very 
careful. It is still not under control. It is looking positive. 
If we continue, we will get it under control, but it is too 
early to actually start celebrating.
    On the individual family protection, this is something that 
is definitely important. This goes back to educating the 
family, but also giving them basic protection equipment, 
gloves, mask.
    But at the same time, we do not want to give them a false 
sense of protection. We do not want them to think that, just 
because they have gloves and a mask, they are okay to be near a 
patient. We need to make sure that the education takes place 
properly and that they are very well aware of the risks even 
with the protection. And that is very critical.
    Ambulance network. That is very important in all three 
countries. And, you know, we turned pickup trucks into 
ambulances. We turned anything that we could get our hands on 
into ambulances. We are looking at different types of 
ambulances, including air ambulances that could take patients 
from faraway counties into our Ebola treatment units. It is 
much better and much cheaper than setting up another Ebola 
treatment unit in some of those counties.
    There is a need to increase that capacity, and there is 
also a need to train staff working in ambulances because that 
is a very risky job when you are in an ambulance. It seems that 
there is a move now to actually get ambulances in there. There 
are a lot of ambulances being donated. We are buying a lot of 
ambulances. Also, we look at alternative ways of 
transportation.
    Mr. Mans. Yes. If I may, I just wanted to add to Rabih's 
point about getting to that inflection point on the Ebola 
crisis.
    I think this combination of getting both the hardware right 
and the software right, hugely important. One, these ETCs and 
getting many ETCs out into communities, getting community care 
centers to improve access.
    On the other side is what I see happening on the technology 
front and very quickly so that we are in a position to do a 
better job of testing, tracking, and treating the virus.
    On the testing side, a number of rapid diagnostic tests are 
becoming available, being tested out on the ground in the next 
couple of months.
    A lot of work is being done with U.S.-based technology 
companies working with people on the ground to develop tools to 
automate contact tracing, to bring the power of technology into 
this to be able to do a much better job of tracking and doing 
surveillance.
    I think that, too, is coming in addition to what is 
happening on the treatment side. So like my colleagues, I am 
very hopeful, but we cannot be complacent or declare victory. 
There is still a lot of work to be done on all these fronts.
    Mr. Sedgewick. I would like to go through a few of your 
questions because I think they are really interesting and show 
the changes, especially in reference to Dr. Brantly's 
testimony.
    I believe there was sort of a vicious cycle that was going 
on at the early stages where there was not enough testing. So 
there were not enough beds. And so Ebola patients were being 
turned away from the ETUs both because of the lack of testing 
and just the simple lack of beds and healthcare workers.
    And so then the victims are turned away. They go back into 
their community and they infect others and they pass away. And 
the burial teams at that point were overstretched.
    And so both of those issues being addressed--the ETUs 
having the available beds and then the burial teams being able 
to collect all the bodies--really had a significant impact on 
lowering the rate of transmission.
    And then that cycle continued to bring down the number of 
Ebola victims going into the ETUs. So that has been one of the 
big flips that has happened since Dr. Brantly testified, which 
is, you know, wonderful to hear, obviously.
    And I would like to reiterate that, while the communities 
do need protective equipment and do need education about how to 
handle the sick, that risk of the false sense of prevention 
that Mr. Torbay brought up is something that we are very 
careful about, that just because they have got a mask and 
gloves doesn't mean that they are going to be able to safely 
handle victims.
    And, you know, the ETUs are not at all wasteful in terms of 
how they are put together. They are very straightforwardly put 
together. As he mentioned, most are temporary structures. And 
they are the fastest, lightest, high-quality treatment that you 
can get.
    And so, as you move down from that, you do incur some risk, 
in terms of the community care centers, that have to be looked 
at very carefully to make sure that the quality of care at 
those ETCs are very, very high.
    In terms of the projections that you mentioned, I think a 
lot of those projections were if nothing happened, if we don't 
do anything. So now that we are doing something--and I think we 
are doing a lot--that is bringing down a lot of those 
projections. And I think we will look forward to future 
projections as they come forward.
    On the ambulance network, it is something that we are 
involved in in responding to. And we got into a lot of the 
other activities that we are doing, such as contact tracing and 
ambulance work and the community engagement work in the 
southeast, because we are locating our teams at the county 
health team. So we have a significant relationship with every 
county health team.
    And we make sure that the burial teams are run out of that 
county health team. And so, when they say, ``Hey, our ambulance 
broke down. Can you help us out?,'' we are able to immediately 
respond and very, very quickly to make sure that they have 
another ambulance or that their ambulance gets repaired. That 
has allowed us to engage about 10 ambulances that are being run 
out of different county health teams as they have requested it 
from us.
    And I think that aspect of it--to make sure that we are 
hearing directly from the county health teams in some of these 
incredibly remote counties--some of them take 2 days to get to 
on a good, dry day--and we are able to hear from them 
immediately when they have these needs--allows us to respond 
very quickly.
    I know Ranking Member Bass stepped out. But I think, on the 
orphan issue, it is a pretty significant issue that is being 
looked at by a lot of different NGOs. The entire question of 
how you respond to the families that are affected--orphans, 
widows, widowers--is really significant, and it is one of the 
lasting effects of this virus.
    Mr. Smith. Just let me conclude with these following 
questions.
    Who is really in charge, like in Liberia? Is it the 
Ministry of Health? We know that WHO came under some withering 
criticism in mid-October from a report about how they had 
missed it and had inadequate staffing. I am just wondering, who 
is truly in charge? UNMEER, what role do they play? We know CDC 
is playing a very significant advisory and leadership role.
    And, secondly, on the issue of training community 
healthcare workers, could you just give a sense what their ages 
are. Are they older, more experienced people who have come back 
into the system? Are they young people who are stepping up to 
the plate? I mean, what does that look like? And does USAID 
provide any kind of salary support?
    We know that, in catastrophic situations, very often that 
kind of subsidy can be provided. I remember being in Sri Lanka 
after the tsunami, and we were paying salaries to individuals 
to do work, to do cleanup. And it not only was motivating, but 
they were actively doing the cleanup of their own homes and 
communities, and there was that significant subsidy to help 
them get money in their pocket to get their businesses going 
locally. And I am wondering if USAID or any other entity in 
government is providing any salary support.
    Mr. Torbay. The Liberian Government is in charge, and they 
should be in charge. At the end of the day, that is their 
country and we are just guests there. And we only work through 
them and with them. And I don't think any of those countries 
were prepared for such an outbreak and especially countries 
like Liberia and Sierra Leone that have suffered from a long 
civil war and they were trying to recover from that and they 
still haven't fully recovered, in addition to the other 
systemic issues within the health systems there.
    The World Health Organization, CDC, and NGOs work to 
support the Liberian Minister of Health and Social Welfare, and 
they have people seconded to them. They have a body that 
coordinates the Ebola response, and they have people from 
different agencies supporting them.
    One thing that we definitely--going back to your initial 
question about what needs to be done to make sure that we do 
not go back there, we cannot afford to go back to where we were 
before the Ebola outbreak in terms of systems in those 
governments. We need to build the systems much better than they 
were before because, as we saw, they weren't that effective.
    One way to do it is actually to support the Liberian, 
Sierra Leonean, or the Guinean Government, the Ministries of 
Health, build their systems, train their staff, give them all 
the support that they need to move things forward. You know, 
they are doing what they can, given the limited capacity and 
capabilities that they have.
    UNMEER is now playing a more robust role than they did a 
while ago. As I mentioned in my testimony, there still needs to 
be clarification in terms of who is responsible for what and 
who is coordinating what. That is very important. And I think, 
as discussions take place on the ground, that should be 
clarified.
    I will answer briefly about the health workers. And I am 
sure my colleagues here would give you a more detailed answer.
    Most of our health workers that are working with us, the 
majority of them are younger. They are college kids or people 
who went to school or are working in the market, but they are 
younger. And those are the ones that have been working with us 
mostly.
    In terms of USAID support, USAID has been very generous 
with us and other NGOs working on the ground. Whatever we ask 
them for, including salaries for staff working at the community 
or at the Ebola treatment units, there hasn't been any 
hesitation.
    I do not know what is going on in terms of support for the 
Liberian Government, who should be paying--or who is paying the 
incentives. But as far as we are concerned, they have been 
extremely generous and effective and very pragmatic in their 
approach.
    Mr. Sedgewick. I would like to reiterate that the 
Government of Liberia, in general, is leading the effort and 
the Ministry of Health and Social Welfare in particular.
    Tolbert Nyenswah, who is the Assistant Minister of Health 
and has been leading the incident management system, has been a 
really great coordinator of the effort in those meetings, which 
happen, I think, about three times a week, makes sure that 
everyone is on the same page.
    That has been our approach, is to make sure that we are 
leveraging the resources that they have and supplementing what 
they have to make sure that we are successful and that they are 
successful. And doing so has allowed us to move very, very 
quickly and be very responsive, as I mentioned before.
    That said, the other actors, especially the USAID DART, 
have been incredibly responsive and excellent at coordinating 
their efforts and their various arms. The DART has been a 
really incredible partner for us to make sure that, as the 
situation changes on the ground, we are able to move very, very 
quickly.
    On the community health workers, the system in Liberia that 
existed before was for all the community health workers to 
actually be community health volunteers. So they were unpaid 
volunteers that received supplemental support in some way or 
other occasionally. And I believe that, depending on what the 
activity is, they are getting some limited level of support.
    Certainly from our side, when we do activities, they do get 
some incentive payments. If they are able to bring--if they are 
able to achieve certain deliverables, then we do give them some 
payments occasionally. I don't know if they are receiving 
large-scale salary from the Ministry of Health at this point 
during the emergency.
    Mr. Mans. The only thing I would add, again, as I said 
earlier, is the great frustration that exists within Liberia, 
this crisis and the gap between what people perceive is 
actually happening on the ground and these very big numbers 
that the public hears about.
    The Government, the President in particular, has been very 
forceful in demanding that the Government be very focused on 
this agenda. As you may know, she just had a shakeup in the 
cabinet. She replaced the Minister of Health to be sure that 
she has the leadership in that ministry to see this thing 
through.
    So there is no sense of complacency. Quite the opposite. 
They are leading and working very hard to ensure that there is 
a joined-up government approach on their side, just as the 
United States Government has taken a joined-up whole-of-
government approach.
    Mr. Smith. Thank you.
    Just to conclude, I mentioned in the outset that we had 
just introduced H.R. 5710, the Ebola Emergency Response Act, 
and many of you have provided insights as to what ought to be 
in there.
    I would ask you to take a look at it to see if it covers 
all the bases, if you will, and if you could see your way 
clear, after you look at it, you know, to perhaps support it, 
because I do think we are talking about a sustainable problem 
that needs a sustainable response.
    And, you know, the good work that our House Appropriations 
and Senate Appropriations Committees have done, particularly 
when the DOD asked for a reprogramming request that was huge, 
it was done without the slightest bit of hesitation.
    But we need to have the authorizers, I think, as well 
making sure that we leave no stone unturned as well in 
mitigating and, hopefully, ending this crisis. So please take a 
look at the legislation, if you would.
    Anything you would like to say before we conclude?
    Mr. Torbay. I would just like to thank you for your 
leadership and the leadership of the U.S. Government. We are 
very proud of what has been achieved so far and the continuous 
focus on resolving this issue. And, again, thank you for having 
us here today.
    Mr. Smith. Thank you.
    Mr. Sedgewick. I would like to reiterate that thanks.
    And the efforts that you see on the ground in Liberia in 
particular are really incredible, and a large volume of that is 
due to the leadership of the U.S. Government and the leadership 
of the subcommittee to make sure that it happens.
    So it is truly inspiring when you are in Liberia seeing the 
response happen and seeing the effort, the impact that we are 
all having. So thank you.
    Mr. Mans. And I want to thank you for your continued 
leadership long after these headlines fade, and they will, to 
be sure that everybody is focused on how to rebuild in Liberia 
the health sector and get these countries back on track. So 
thank you for your leadership, sir.
    Mr. Smith. Thank you so very much.
    And, again, I want to thank you for your expertise, your 
tremendous leadership, the three of you. It is just remarkable.
    And, that said, the hearing is adjourned.
    [Whereupon, at 11:32 a.m., the subcommittee was adjourned.]
                                     

                                     

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