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S. HRG. 113–625 

THE EBOLA EPIDEMIC: THE KEYS TO SUCCESS 

FOR THE INTERNATIONAL RESPONSE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON AFRICAN AFFAIRS 

OF THE

COMMITTEE ON FOREIGN RELATIONS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

DECEMBER 10, 2014 

Printed for the use of the Committee on Foreign Relations 

( 

Available via the World Wide Web: http://www.gpo.gov/fdsys/ 

FOREI-43947 with DISTILLER

COMMITTEE ON FOREIGN RELATIONS

ROBERT MENENDEZ, New Jersey, Chairman

BARBARA BOXER, California 

BENJAMIN L. CARDIN, Maryland 

JEANNE SHAHEEN, New Hampshire 

CHRISTOPHER A. COONS, Delaware 

RICHARD J. DURBIN, Illinois 

TOM UDALL, New Mexico 

CHRISTOPHER MURPHY, Connecticut 

TIM KAINE, Virginia 

EDWARD J. MARKEY, Massachusetts 

BOB CORKER, Tennessee 

JAMES E. RISCH, Idaho 

MARCO RUBIO, Florida 

RON JOHNSON, Wisconsin 

JEFF FLAKE, Arizona 

JOHN McCAIN, Arizona 

JOHN BARRASSO, Wyoming 

RAND PAUL, Kentucky 

DANIEL E. O’BRIEN, Staff Director

LESTER E. MUNSON III, Republican Staff Director

——————

SUBCOMMITTEE ON AFRICAN AFFAIRS

CHRISTOPHER A. COONS, Delaware, Chairman

RICHARD J. DURBIN, Illinois 

BENJAMIN L. CARDIN, Maryland 

JEANNE SHAHEEN, New Hampshire 

TOM UDALL, New Mexico 

JEFF FLAKE, Arizona 

JOHN McCAIN, Arizona 

JOHN BARRASSO, Wyoming 

RAND PAUL, Kentucky 

(II)

FOREI-43947 with DISTILLER

C O N T E N T S 

Page 

Alvarez, Javier, senior team lead, Strategic Response and Global Emergencies, Mercy Corps, Portland, OR ................................................................... 31 

Prepared statement .......................................................................................... 33 

Coons, Hon. Christopher A., U.S. Senator from Delaware, opening statement . 1 

Farmer, Paul, M.D., cofounder, Partners in Health, Boston, MA ....................... 12 

Prepared statement .......................................................................................... 14 

Flake, Hon. Jeff, U.S. Senator from Arizona, opening statement ....................... 11 

Gaye, Pape, president and CEO, IntraHealth International, Chapel Hill, NC .. 25 

Prepared statement .......................................................................................... 27 

Peterson, E Anne, M.D., vice dean, Public Health Program, Ponce Health 

Sciences University, World Vision, Washington, DC ........................................ 17 

Prepared statement .......................................................................................... 19 

Sirleaf, Her Excellency Ellen Johnson, President, Republic of Liberia, Monrovia ...................................................................................................................... 2 

Prepared statement .......................................................................................... 5 

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

Catholic Relief Services, prepared statement ........................................................ 52 

Menendez, Hon. Robert, U.S. Senator from New Jersey, prepared statement .. 50 

Save the Children, prepared statement ................................................................. 51 

(III)

FOREI-43947 with DISTILLER

FOREI-43947 with DISTILLER

(1) 

THE EBOLA EPIDEMIC: THE KEYS TO SUCCESS FOR THE INTERNATIONAL RESPONSE 

WEDNESDAY, DECEMBER 10, 2014 

U.S. SENATE, SUBCOMMITTEE ON AFRICAN AFFAIRS, COMMITTEE ON FOREIGN RELATIONS, Washington, DC. 

The subcommittee met, pursuant to notice, at 10:35 a.m., in room 

SD–419, Dirksen Senate Office Building, Hon. Christopher Coons 

(chairman of the subcommittee) presiding. 

Present: Senators Coons, Durbin, Shaheen, and Flake. 

Also Present: Senators Markey and Murphy. 

OPENING STATEMENT OF HON. CHRISTOPHER A. COONS, 

U.S. SENATOR FROM DELAWARE 

Senator COONS. Good morning. This meeting of the Senate Foreign Relations Subcommittee on African Affairs will come to order. 

We are going to do things a little differently than usual today 

because of a rare honor for this subcommittee. Joining us from the 

Liberian capital of Monrovia today via video conference will be 

President Ellen Johnson Sirleaf, who will share with us her observations on the Ebola outbreak and its impact on her country. 

President Sirleaf is an extraordinary individual who has already 

once pulled her country back from the brink of collapse following 

Liberia’s long and destructive civil war. Her certainty of purpose, 

coupled with a vigorous commitment to reconciliation and economic 

recovery, make her the single best person to be leading Liberia 

through this very difficult time. 

President Sirleaf has shown extraordinary leadership for her 

country in this time of crisis and continues to be an example for 

all in public service. Winner of the Nobel Peace Prize and Africa’s 

first elected female head of state, President Sirleaf is an individual 

of exemplary character, fortitude, and compassion for her people. 

I would also like to take a moment to recognize Mr. Jeremiah 

Sulunteh, the Republic of Liberia’s Ambassador to the United 

States, who, like Madam President, has played a key role as a 

long-time servant to the Republic. 

It is an honor and a privilege to have you with us today. 

President Sirleaf has also volunteered to answer a few questions 

from members of the subcommittee following her remarks. It is a 

rare honor and an extraordinary opportunity to be joined by video 

conference by a sitting head of state, one for which my colleagues 

and I are grateful. 

Madam President. 

FOREI-43947 with DISTILLER

2 

STATEMENT OF HER EXCELLENCY ELLEN JOHNSON SIRLEAF, 

PRESIDENT, REPUBLIC OF LIBERIA, MONROVIA 

President SIRLEAF. Good morning. Thank you for inviting me to 

offer remarks at this hearing. 

I would like to start by extending warm and profound gratitude 

on behalf of the people and Government of Liberia to the American 

people, the U.S. Government, the many American institutions and 

faith-based organizations for the leadership your country has taken 

by joining us on the frontline of this battle to turn the tide against 

this unknown disease that has threatened our very way of life. 

My colleagues from Guinea and Sierra Leone, also victims of this 

disease, join me in these sentiments. 

Allow me to recognize also the extraordinary work of U.S. 

Ambassador Deborah Malac and the Embassy team. 

Chairman Coons and Ranking Member Flake, I would like to 

express my heartfelt thanks for the personal commitment demonstrated by you and other Members of Congress through your 

numerous phone calls and messages of support. 

We express appreciation to President Obama for the bold steps, 

including the work of Dr. Tom Frieden, director of the Centers for 

Disease Control, and Rajiv Shah, the Administrator of USAID, in 

coming to our aid. It was the United States that awakened the 

world to the scope and magnitude of the Ebola disease’s virulent 

spread in West Africa, that led to the extraordinary step to deploy 

the United States military to help Liberia. It was the leadership of 

the Obama administration, supported by Congress, that opened the 

space for the disease to stabilize in Liberia and encouraged the rest 

of the world to respond to this global crisis. It is a demonstration 

of leadership as important as the role to combat terrorism and 

other ills around the world. 

We applaud the construction of Ebola Treatment Units by the 

DOD and the establishment of the field hospital to treat health 

care personnel as a significant and timely response to our predicament. 

Today, our Armed Forces, which worked with the DOD, can 

boast of the capability to construct Treatment Units and other 

similar type of facilities. The Treatment Units send a powerful 

message to our people that Ebola is real, that it requires an overpowering response, and that the people of the United States stand 

by us. The units serve us well by ensuring that we can respond to 

continuing hotspots and possible recurrence. 

The fact that they are not full is a strong sign of their success 

and shows that by working together with overwhelming force, we 

have begun to push back on this unknown killer disease. 

Honorable Members of Congress, several of you may recall that 

on March 16, 2006, shortly after being elected President in Liberia’s first post-conflict elections, I had the honor to address a joint 

meeting of the U.S. Congress and said that we will pay any price 

to lay the foundation for durable peace. In 2013, we celebrated the 

10th year of peace that enabled us to achieve over 7 percent average annual economic growth, a 50-percent reduction in the infant 

mortality rate, 17 additional years in life expectancy, relief from a 

crippling external debt, and a restoration of economic and social 

infrastructure. Perhaps more importantly, we have established a 

FOREI-43947 with DISTILLER

3 

free and democratic society, thus reversing the many decades of authoritarian rule. 

This year incredibly changed everything. Like the rest of the 

world, we knew nothing about this disease. It sprung on us at the 

worst of times. Our subregion had just begun to recover from years 

of instability and commenced the process of regional integration. 

The three most affected countries have embarked on a path of 

democratic governance. As natural resource-rich countries, we were 

in the process of attracting investors, creating the conditions to 

accelerate growth with development. This has all been unimaginably reversed. 

Today, we are fighting to keep people alive, facing a faceless but 

deadly enemy. As I speak to you, the Ebola virus has caused a serious disruption of Liberia’s social, economic, and cultural fabric. It 

has destroyed many of our hard-fought development gains, 

wreaked havoc on our economy, exposed the weakness of our public 

health systems, interrupted our infrastructure development, closed 

schools, restrained travels, and shattered the lives of our people. 

The disease has subjected us to a stigma all over the world, creating a fear more destructive than Ebola itself. 

With the support of partners like you, we have made progress in 

containing the virus. Our 13 emergency treatment units, with a 

total of 840 beds, have only 136 patients. Our 70 burial teams have 

buried 23 persons per day across the country, compared to hundreds months ago. We have seen a drop from around 100 new cases 

per day at the peak of the epidemic to only 10 confirmed new cases 

per day over the past week. Our six active laboratories have tested 

60 samples a day but, on average, only find 8 new Ebola cases per 

day. The 4,000 contact tracers, which involve community workers, 

are following some 7,000 persons. Doctors, nurses, and other health 

care workers, some 174 of the over 3,000 who have died, are no 

longer at risk because quality treatment facilities are available to 

them. We are happy to say that 1,312 persons, including 345 children, many of them orphans, have walked away free from the 

disease. 

Can I profoundly say I am excited about this progress? Yes, I am. 

But I also know that more has to be done, as we are now in the 

most critical stage of response. At 10 new cases a day, the crisis 

is now manageable, but experts tell us that traveling that last mile 

to zero new cases will be much more difficult because the disease 

has retreated and must now be chased down in every corner. 

To illustrate this, consider the challenge of contact tracing. For 

each of the patients in the United States, there were around 40 

contacts that needed to be quarantined and monitored. The challenge in Liberia is greater, with thousands more contacts, often in 

villages which take hours to reach through densely forested terrain. This is one of the many reasons why your continued support 

and our joint collaboration is so important. Moreover, full eradication will not be secured until the whole region is freed from 

Ebola, until there is prevention against future possible outbreak, 

until we develop a medicine both preventive and curative to conquer this deadly disease. 

Yesterday, Liberia hosted a regional technical summit with 

Sierra Leone, Guinea, and Mali to share lessons and best practices. 

FOREI-43947 with DISTILLER

4 

The summit drove home the point that Ebola is not a Liberian 

issue or a West African issue. It is a global issue that we must all 

continue to confront. This is why continuing your assistance to the 

combined effort with our neighbors remains a priority. This is why 

the United States has been right to tackle it at the front line, here 

in West Africa. This is why Dr. Margaret Chan, Director General 

of WHO, was right when she noted that this is the greatest peacetime challenge the United Nations and its agencies have ever 

faced. 

In Liberia and in Sierra Leone and in Guinea, we continue to live 

this challenge. As our response evolves, we ask that partners continue to support our efforts. This calls for strengthening community 

ownership and responsibility for awareness and immediate 

response action through the Community Care Centers that are 

being established with the support of USAID. 

Here are a few statistics in this regard. Liberia has 218 medical 

doctors and 5,234 nurses to serve a 4.3 million population at 405 

public and 253 private health facilities. This means we have 1 doctor for 100,000 people, compared with 4 for 100,000 in Sierra 

Leone, 10 for 100,000 in Guinea, and 245 for 100,000 in the United 

States. As we speak, there are more Liberian doctors and medical 

professionals in the United States than at home. Most of them left 

during the war, and we were in the process of trying to get them 

back home with incentives that measure up to their qualifications. 

This disease has upset that effort. 

Clearly, we are far behind and can only sustain the progress and 

prevent a recurrence through better trained and better equipped 

health facilities, better diagnosis facilities for infectious diseases, 

better hospitals, better clinics. We have asked the 137 partners 

from some 26 countries who are with us in this fight to join us in 

this expanded effort. 

Above all, Liberia must get back on the path to growth. My government is preparing a comprehensive plan for Liberia’s post-Ebola 

economic recovery, accelerating our work in infrastructure, above 

all Roads to Health, electricity, and WATSAN operations. A major 

push in the agricultural sector, where most Liberians are 

employed, will enable us to generate jobs and restore livelihoods. 

The private sector will play a crucial role. In this regard, we commend the private sector organized under the Ebola Private Sector 

Mobilization Group with the efficacy of ECOWAS and the African 

Union for their support in making people and resources available 

to fight the disease. Their efforts will be even more critical in the 

building of post-Ebola economies, requiring from us commitment to 

create conducive conditions for private capital to succeed. 

Liberia is extremely proud that we achieved the MCC Compact 

eligibility in 2012 by passing 10 out of the 20 indicators, including 

control of corruption. Liberia again passed eligibility in 2014 by 

passing 10 of the 20 indicators. Liberia has surpassed the MCC’s 

Control of Corruption standard for seven straight years, one of the 

few developing countries to do so. An MCC grant would be a game 

changer for Liberia. It would facilitate our post-Ebola economic 

recovery and put our development momentum back on track, leading to substantial transformation of our economy. 

FOREI-43947 with DISTILLER

5 

I want to conclude by expressing our gratitude to you, the U.S. 

Congress, for the friendship and assistance, without which we 

would not have made the progress to date. 

There remains a lot to do to ensure the resources are properly 

deployed by the many institutions to which it is directly allocated 

to ensure that there is full accountability to you and to all our partners, and to the Liberian people. Our resolve to meet the challenge 

that confronts us is strong and unrelenting. We will win this battle. 

Once again, I want to thank you and the American people for the 

opportunity to be with you in this meeting today. 

[The prepared statement of President Sirleaf follows:] 

PREPARED STATEMENT OF HER EXCELLENCY ELLEN JOHNSON SIRLEAF

Chairman Coons, Ranking Member Flake, distinguished Members of the Senate 

Foreign Relations Subcommittee on African Affairs, Friends of Liberia, good morning. Thank you for inviting me to offer remarks at this hearing. 

I would like to start by extending warm greetings and profound gratitude of the 

people and Government of Liberia to the American people, the U.S. Government, the 

many American institutions, and faith-based organizations for the leadership your 

country has taken by joining us on the front line of this battle to turn the tide 

against this unknown disease that has threatened our very way of life. My colleagues from Guinea and Sierra Leone, also victims of this disease, join me in these 

sentiments. Allow me to recognize also the extraordinary work of U.S. Ambassador 

Deborah Malac and the Embassy team. 

Chairman Coons and Ranking Member Flake, I would like to express my heartfelt 

thanks for the personal commitment demonstrated by you and other Members of 

Congress through your numerous phone calls and messages of support. 

We want to express appreciation to President Obama for the bold steps, including 

the work of Tom Frieden, Director of the Centers for Disease Control, and Rajiv 

Shah, the Administrator of USAID in coming to our aid. It was the U.S. administration that awakened the world to the scope and magnitude of the Ebola disease’s virulent spread in West Africa; that took the extraordinary step to deploy the U.S. 

military to help Liberia. It was the leadership of the Obama administration supported by Congress that opened the space for the disease to stabilize in Liberia and 

encouraged the rest of the world to respond to this global crisis. It is a demonstration of leadership as important as the role to combat terrorism and other ills around 

the world. 

We applaud the construction of Treatment Units by the DOD and the establishment of the field hospital to treat health care personnel as a significant and timely 

response to our predicament. Today, our Armed Forces which worked with the DOD 

can boast of the capability to construct treatment units and other similar type of 

facilities. The treatment units send a powerful message to our people that Ebola is 

real that it requires an overpowering response and that the people of the United 

States stand by us. The units serve us well by ensuring that we can respond to continuing hotspots and possible recurrence. The fact that they are not full is a strong 

sign of their success and shows that by working together with overwhelming force 

we have begun to push back on this killer disease. 

Honorable Members of Congress: Several of you may recall that on March 16, 

2006, shortly after being elected President in Liberia’s first post-conflict elections, 

I had the honor to address a joint meeting of the U.S. Congress and said that we 

would pay any price to lay the foundation for durable peace. In 2013, we celebrated 

the 10th year of peace that enabled us to achieve over 7 percent average economic 

growth, a 50-percent reduction in the infant mortality rate; 17 additional years in 

life expectancy, relief from a crippling external debt, and a restoration of economic 

and social infrastructure. Perhaps more importantly we have established a free and 

democratic society thus reversing the many decades of authoritarian rule. 

This year changed everything. As the rest of the world, we knew nothing about 

this disease. It sprung on us at the worst of times. Our subregion had just begun 

to recover from years of instability and commenced the process of regional integration. The three most affected countries had emerged from the days of instability and 

embarked on a path of democratic governance. As natural resource rich countries, 

we were in the process of attracting investors, creating the conditions to accelerate 

growth with development. This has all been reversed. Today, we are fighting to keep 

people alive, facing a faceless but deadly enemy. 

FOREI-43947 with DISTILLER

6 

As I speak to you, the Ebola virus has caused a serious disruption of Liberia’s 

social, economic, and cultural fabric. It has destroyed many of our hard fought 

development gains, wreaked havoc on our economy, exposed the weakness of our 

public health systems, interrupted our infrastructure development, closed schools, 

restrained travel, and shattered the lives of our people. The disease has subjected 

us to a stigma all over the world, creating a fear more destructive than Ebola itself. 

With the support of partners, we have made progress in containing the virus. Our 

13 Emergency Treatment Units, with a total of 840 beds, has only 136 patients. Our 

70 burial teams have buried 23 persons per day across the country compared to 

hundreds, months ago. We have seen a drop from around 100 new cases per day 

at the peak of the epidemic, to only 8 confirmed new cases per day over the past 

week. Our six active laboratories have tested 60 samples a day, but on average only 

find 8 new Ebola cases per day. The 4,000 contact tracers which increasingly involve 

community workers are following some 7,000 persons. Doctors, nurses, and other 

health care workers, some 174 of whom died, are no longer at risk because quality 

treatment facilities are available to them. We are happy to say that 1,312 persons 

including 345 children, many of them orphaned, have walked away free from the 

disease. 

Am I excited about this progress? Yes, I am! But I also know that much more 

has to be done for we are now in the most critical stage of response. 

At 10 new cases a day, the crisis is now manageable; but experts tell us that traveling that last mile to zero new cases will be much more difficult, because the disease has retreated and must now be chased down in every corner. To illustrate this, 

consider the challenge of contact tracing. For each of the patients in the U.S., there 

were around 40 contacts that needed to be quarantined and monitored. The challenge in Liberia is greater, with thousands more contacts, often in villages which 

take hours to reach through dense bush. This is one of the many reasons why continuing support your support and our joint work together is so important. 

Moreover, full eradication will not be secured until the whole region is freed from 

Ebola; until there is prevention against future possible outbreak and until we 

develop a medicine, both preventive and curative to conquer this deadly disease. 

This is why securing our borders remains a priority requiring additional resources, 

as well as providing assistance to our neighbors. On yesterday, Liberia hosted a 

regional Technical summit with Sierra Leone, Guinea, and Mali to share lessons 

and best practices. The summit drove home the point that Ebola is not a Liberian 

issue or a West African issue. It is a global issue that we all must continue to confront. This is why the U.S. has been right to tackle it at the front line, here in West 

Africa. This is why Dr. Margaret Chan, Director General of WHO, was right when 

she noted that this is greatest peacetime challenge the United Nations and its agencies have ever faced.’’ In Liberia, and our Mano River Union neighbors of Sierra 

Leone and Guinea, we continue to live this challenge. 

As our response evolves we ask that partners continue to support our efforts. This 

calls for strengthening community ownership and responsibility for awareness and 

immediate response action, through the Community Care Centers that are being 

established with the support of USAID. Here are a few statistics in this regard. 

Liberia has 218 medical doctors and 5,234 nurses to serve 4.3 million population 

at 405 public and 253 private health facilities. This means we have 1 doctor for 

100,000 people, compared with 4 per 100,000 in Sierra Leone, 10 per 100,000 in 

Guinea and 245 per 100,000 in the United States. As we speak, there are more 

Liberian doctors and medical professionals in the United States than at home. Most 

of them left during the war and we were in the process of trying to get them back 

home, with incentives that measure up to their qualifications. This disease has 

upset all of this effort. 

Clearly we are far behind and can only sustain the progress and prevent a recurrence through better training and better equipped health facilities. We have asked 

the 137 partners from some 26 countries who are with us in this fight to join us 

in this expanded effort. 

Above all, Liberia must get back on the path to growth. My government is preparing a comprehensive plan for Liberia’s post-Ebola economic recovery, accelerating 

our work in infrastructure—above all Roads to Health, electricity and WATSAN 

operations. A major push in the agricultural sector, where most Liberians are 

employed, will enable us to generate jobs and restore livelihoods. The private sector 

will play a crucial role. 

In this regard, we commend the private sector organized under the Ebola Private 

Sector Mobilization Group (EPSMG), with the advocacy of ECOWAS and the African 

Union for their support in making people and resources available to fight the disease. Their efforts will be even more critical in the building of post-Ebola economies 

FOREI-43947 with DISTILLER

7 

requiring from us commitment to create conducive conditions for private capital to 

succeed. 

Liberia is extremely proud that we achieved MCC compact eligibility in 2012 by 

passing 10 out of 20 indicators, including control of corruption. Liberia again passed 

eligibility in 2014 by passing 10 out of 20 indicators. Liberia has surpassed the 

MCC’s control of corruption standard for 7 straight years, one of the few developing 

countries of the world to do so. 

An MCC grant would be a game changer for Liberia. It would facilitate our postEbola economic recovery and put our development momentum back on track leading 

to substantial transformation of our economy. 

I want to conclude by expressing our gratitude to you, the United States Congress, for the friendship and assistance, without which we would not have made the 

progress to date. There remains a lot to do—to ensure the resources are properly 

deployed by the many institutions to which it is directly allocated; to ensure that 

there is full accountability to you and all our partners and to the Liberian people. 

Our resolve to meet the challenge that confronts us is strong and unrelenting. We 

will win this battle. Once again, I want to thank you and the American people for 

the opportunity to address you today. 

Senator COONS. Thank you, Madam President. Thank you for 

your remarks with us today, and thank you for the opportunity for 

several of our members to ask a few questions. 

I might just begin with one question, and I think we might 

restrict ourselves to one question each, if we might. 

I want to make sure, Madam President, that we are providing 

the right resources both to meet the emergency that you so correctly point out is not over and we need to remain engaged on as 

an international community, the pressing and current emergency of 

Ebola. But I also am wondering if we are providing the right 

resources to rebuild your public health infrastructure and to overcome what you referenced, a stigma that is in some ways a fear of 

Ebola that is greater than Ebola itself in terms of long-term challenges for your economic recovery. 

Are we providing the right assistance, and are we helping you 

rebuild for the future in the right ways? 

President SIRLEAF. The resources to contain the virus are for the 

moment adequate to do so, as the progress has shown. However, 

there is always the chance of reoccurrence, as the history has 

shown in other countries that have been affected by the disease. 

This is why we must now move from containment, from treatment 

to prevention, and to do that means we will need the resources to 

rebuild, to strengthen our health care facilities, our hospitals, our 

clinics, through training, through better equipment, through better 

facilities. That way we can ensure that there will not be a reoccurrence, or in the event of a recurrence we will have the means to 

control it and to prevent its spread, not only within our country but 

as it spreads across borders. 

And that is why today we are working with our partners to get 

them to join us in this transition to prevention, working with our 

own people, our Community Care Workers, taking full responsibility by being trained to handle basic health care, particularly in 

our rural areas. 

Senator COONS. Thank you, Madam President. 

Senator Flake. 

Senator FLAKE. Thank you, Madam President. Thank you for 

appearing here today. I wanted to thank you for what you have 

done to rally the international community to join the effort to, as 

you say, stop the epidemic in West Africa. 

FOREI-43947 with DISTILLER

8 

We are pleased to hear the progress that Liberia is making, and 

our concern that similar progress has not been made in Sierra 

Leone. You mentioned that you have come together with leaders in 

other countries and public health officials. 

What are you doing to make sure that best practices are shared 

and that the progress that has been made in Liberia is replicated 

elsewhere? Can you give us some idea of what is going on there? 

President SIRLEAF. The coordinator of the President’s Advisory 

Ebola Committee is today on his way to start discussion that will 

put him in the position to become a general coordinator for the 

three countries, working with UNMEER, the U.N. coordinating 

agency that is based in Accra. At the meeting held yesterday, Liberia offered, and I had already obtained President Roman’s agreement to that, to send some of those nurses and doctors that we 

have over to Sierra Leone, with the agreement, of course, to be able 

to join the Sierra Leone forces in trying to expand their own capacity to deal with the disease. We expect that we will be looking at 

the results of yesterday’s meeting to see what else Liberia can do 

to be able to join Sierra Leone particularly because they seem to 

be right now the ones in most serious trouble. 

But we will do everything that we can, share every capacity that 

we have, every resource we have, to be able to work with them so 

that they can get the same progress. Because, like I say, until the 

other two countries are free, Liberia cannot be truly free. 

Senator COONS. Thank you, Madam President. 

Senator Durbin. 

Senator DURBIN. Madam President, thank you. Let me tell you 

that your statement about the number of doctors and medical professionals in Liberia is sobering and evidences a dramatic need for 

more medical resources in your country. 

Our immigration bill that we considered 2 years ago would have 

allowed, for example, Liberians practicing medicine in the United 

States to go back to Liberia and West Africa and to help on an 

emergency basis without jeopardizing their immigration status in 

the United States, and I hope we can return and pass something 

of that nature very quickly next year. 

But my specific question to you is this. The United States and 

President Obama are making substantial investments in West 

Africa to address Ebola. Many, many other countries are joining in 

that effort. I applaud all of their efforts. 

What is being done in Liberia to make certain that the investments that are being made are part of a transition in Liberia to 

a stronger public health system? The investments in equipment, in 

laboratories, in training of health care workers? Is Liberia working 

with these nations to make sure that there is a long-term commitment to strengthening the public health system in your country? 

President SIRLEAF. Congressman, first of all, I am so glad about 

the immigration law, and I wish it would be reintroduced and 

would pass to enable our Liberian doctors to come and work with 

us. 

I am so pleased that with the support of the Clinton initiative 

we had before Ebola worked on and finalized a 10-year health system improvement plan. That plan has in it the training of thousands of health care workers that would be placed throughout the 

FOREI-43947 with DISTILLER

9 

country, in all areas. It also has the upgrading of facilities by better equipment, better facilities. 

So this is our plan. We are now discussing that plan with the 

partners who are here working with us on Ebola and engaging 

them to start the transition from working on Ebola to support for 

our health care system, because that is the most lasting way to 

contain Ebola and to contain similar diseases such as malaria, on 

which we have made substantial progress and which could be 

reversed if we do not have the infection control system through a 

better health care delivery system. 

Senator DURBIN. Thank you. 

Senator COONS. Thank you, Madam President. 

Senator Shaheen. 

Senator SHAHEEN. Thank you very much, President Sirleaf, for 

your willingness to join us today and for your resolute leadership 

to address the Ebola crisis that has threatened not only Liberia but 

Guinea, Sierra Leone and other countries in Africa. 

As you know, one of the mandates of the U.N. mission for Ebola 

Emergency Response is to help work with the governments affected 

to reinforce the leadership of those countries, including Liberia, 

and I wonder if you could talk a little bit about how that part of 

the U.N. mission has been working and whether the cooperation is 

helpful, and are there other things that can be done to improve 

that cooperation. 

President SIRLEAF. The support has been most helpful to us. The 

mission works with us as we plan our responses not only for Ebola 

but responses in all of our development initiatives. There could be 

more coordination because we do have many partners that join us 

in this, and what we are doing is trying to ensure that we set up 

the mechanism that will enable us to be able to continue to monitor 

the progress that is being made, to continue to revise plans and to 

upgrade them to meet extenuating circumstances. 

So at this stage we are very pleased with the support of the mission, and when it comes to the USAID mission, I have to say that 

I cannot start saying so much for the Administrator, Rajiv Shah, 

who has just worked with us through all of this in so much, and 

has worked with so many of the other missions in the other countries that enable us to coordinate that, not only on a national basis 

but on a regional basis. 

Senator SHAHEEN. Thank you. 

Senator COONS. Thank you, Senators. 

Madam President, thank you so much for your remarks to us 

today, thank you for your leadership, and thank you for the opportunity to continue to work in partnership as we invest in sustaining the recovery of your nation, lay the foundation for a strong 

public health system, and work tirelessly together to ensure that 

this outbreak of Ebola is brought to an end. Thank you very much. 

President SIRLEAF. Chairman Coons, I thank you and all of you, 

the members of the subcommittee, for this opportunity, and thank 

you for the support that you continue to give to Liberia, not only 

in this fight but in our overall development effort. 

May I stay and listen to some of it? [Laughter.] 

Senator COONS. Absolutely, Madam President. You are the President. You can do what you want. [Laughter.] 

FOREI-43947 with DISTILLER

10 

Technically, what we are doing from a parliamentary procedural 

perspective is that we are now going to conclude what was a meeting of the subcommittee, and I will now gavel in a formal hearing 

of the Senate Foreign Relations Subcommittee on African Affairs, 

which is the final hearing of this subcommittee for the 113th 

Congress. 

And without objection, at the outset I would like to request the 

testimony from Save the Children and Catholic Relief Services be 

entered into the record. Additionally, I will request that a statement from the chairman of our full committee, Chairman Bob 

Menendez, be entered into the record. 

[EDITOR’S NOTE.—The articles mentioned above can be found in the 

‘‘Additional Material Submitted for the Record’’ section at the end 

of this hearing.] 

Senator COONS. I would like to invite our four witnesses for our 

next panel to come forward while I make some brief opening 

remarks. 

We plan to focus today on the factors that made it so easy for 

the Ebola virus to spread in West Africa and so difficult for it to 

be contained. It is by learning how we got here that I think we will 

be better able to prevent flareups and future outbreaks of Ebola 

and other highly infectious deadly diseases and reduce the likelihood that American and international intervention will again be 

necessary. 

Ebola to date, in this outbreak in three countries in West Africa 

and several others, has claimed the lives of more than 6,000 men, 

women and children that we know of, and has infected nearly three 

times that many, mostly in Guinea, Liberia, and Sierra Leone, and 

has claimed the lives of 330 health workers, who I was pleased to 

see earlier today were recognized by Time Magazine as person of 

the year. It is often the unsung, unheralded men and women who 

took to this challenge on the ground and from throughout the world 

who I think we should be lifting up and supporting in the weeks 

and months ahead. 

The international community, as we all know, was slow to 

respond to the outbreak and is still working to catch up, but the 

U.S. Government has already invested more than $780 million in 

the Ebola response effort, nearly twice the amount of the next largest donor, and I am grateful for the leadership actions of President 

Obama to ensure that members of our Armed Forces and the 

United States Uniform Public Health Service have been deployed 

and made available. 

My understanding is that as of this week, roughly 2,600 U.S. 

Armed Forces and public health personnel are deployed in West 

Africa. 

Our contributions are having a marked impact, as you heard 

from President Sirleaf. U.S. support for the establishment of Ebola 

treatment units and safe burial teams have contributed to a significant reduction in the rate of growth of the disease. However, our 

work is indeed far from done. Sierra Leone has seen a sharp rise 

in recent cases, and as cases continue to grow, Sierra Leone has 

surpassed Liberia, which previously for months had had the highest caseload. As we have heard from President Sirleaf, Liberia is 

FOREI-43947 with DISTILLER

11 

still wrestling with this virus but is making very hopeful progress. 

Mali also recently saw its first Ebola cases in October and now has 

eight. 

Ebola is a volatile virus with the potential to flare up at a 

moment’s notice, and we need to be able to react as quickly as possible to contain it. So I hope we will talk about how we work together with our partners to ensure that we are prepared for future 

outbreaks and that we build at the ground level the public health 

resources that we need. 

The U.S. Government was the first international governance 

institution to step in when the NGO community, which had been 

on the ground for months and truly led the response to Ebola, 

called for our response. It is because the United States stepped in, 

and at the scale we did, that progress has been made in combating 

this terrible disease. This is, as others have said, not just a matter 

of our national security, it is a matter of fundamental humanity. 

We cannot as a country go back to the sidelines and watch these 

already impoverished and unstable countries fall apart when we as 

a nation have the resources and the calling to help turn this crisis 

around. I am elated to have heard from Appropriations Committee 

leadership that $5.4 billion in emergency funding is included in the 

appropriations package that will be taken up and voted on this 

week by the Senate of the United States to contribute to the pace 

and scale and investment required to not just control this outbreak 

but to invest in preventing future outbreaks. 

The four witnesses who join us here today represent organizations that were fighting this Ebola outbreak far before headlines 

appeared here in the United States and have done heroic work for 

which all of us should be grateful. 

Before I turn this over to my friend and distinguished ranking 

member, I just wanted to note what a pleasure it has been for me 

to chair this subcommittee these last 4 years. I have had the honor 

of sharing this dais over many hearings with two wonderful ranking members, Senator Isakson of Georgia and Senator Flake of 

Arizona, who care deeply and passionately about Africa and with 

whom it has been a true joy to work. 

Senator Flake. 

OPENING STATEMENT OF HON. JEFF FLAKE, 

U.S. SENATOR FROM ARIZONA 

Senator FLAKE. Thank you, Senator Coons, and let me just 

return the sentiment. It is wonderful to work with a chairman who 

not only cares deeply about the continent but has so much experience and firsthand knowledge and a desire to learn more all the 

time, and it has truly been a pleasure working with you, and I look 

forward to a long-time partnership on these issues. I want to thank 

you for calling this hearing as well, and for your response on this 

issue early on and encouraging a more robust response from the 

United States. I think the response that we have seen is, in large 

measure, due to your efforts. So, thank you for that, and thanks 

for this hearing. 

I appreciate the witnesses being here and look forward to hearing what you have to say. As Senator Coons mentioned, there is 

a significant investment that has been made by the United States 

FOREI-43947 with DISTILLER

12 

and the taxpayers, and we represent them. We want to make sure 

that the hard-earned funds that are being spent here are done so 

wisely. So that is why we are so anxious to hear from you on what 

we need to do, one, for the current crisis, and moving ahead what 

we need to do to make sure that we do not have flareups as well. 

So, thank you for being here, look forward to the testimony. 

Senator COONS. Thank you, Senator Flake. 

I would now like to turn it over to our witnesses to make opening 

statements, and I will offer a brief introduction of each of you in 

turn. 

First is Dr. Paul Farmer, one of the founders of Partners in 

Health. Dr. Farmer has been a revolutionary voice in public health 

globally and in working to build and sustain community-based 

health care institutions since the 1980s. He heads the Department 

of Global Health and Social Medicine at Harvard Medical School. 

Partners in Health had a footprint in West Africa prior to this outbreak, and Dr. Farmer has been on the front lines of soliciting 

international support for the Ebola response effort, and I am grateful for his passionate voice around the questions of equity and 

access to health care globally. 

Dr. Anne Peterson is the vice dean of the Public Health Program 

at Ponce Health Services University and is former director of 

Global Health for World Vision and former USAID Assistant 

Administrator for the Bureau of Global Health. Dr. Peterson 

recently returned from Liberia and Sierra Leone, where she was 

working through World Vision to identify gaps in response efforts 

and evaluating how stakeholders have been coordinating efforts on 

the ground. 

Mr. Pape Gaye is the president and CEO of IntraHealth International, which is focused on strengthening health systems by 

training health care workers in developing countries at the community level. A native of Senegal, Mr. Gaye has been a lifelong advocate of health systems strengthening in developing countries and 

now more than ever can speak to the needs in these crisis-stricken 

countries. 

And last but certainly not least, Javier Alvarez is the Liberia 

country director for Mercy Corps, with more than 15 years of experience at UNDP and UNICEF, and he is an expert on humanitarian emergency response and wrote Mercy Corps’ most recent 

report on the economic impact of Ebola in Liberia. 

Thank you, all of you, for your service, for your time, for your 

advice, and we look forward to your input. 

Dr. Farmer. 

STATEMENT OF PAUL FARMER, M.D., COFOUNDER, 

PARTNERS IN HEALTH, BOSTON, MA 

Dr. FARMER. Thank you, Mr. Chairman. Thank you, Senators. 

And greetings, Madam President. It is wonderful to see you, and 

thank you for the warm welcome that you have showed our teams 

in Liberia, and the leadership that you have shown in responding. 

I am making just very brief and illustrative comments and will 

submit a more extensive written comment to the record, if that is 

acceptable to you, Senator. 

Senator COONS. Without objection. 

FOREI-43947 with DISTILLER

13 

Dr. FARMER. I just wanted to—and I apologize for obliterating it. 

I do not know if there is an image that comes up. I would rather 

look at the President myself. But just as a reminder, the matter 

of zoonoses—that is, diseases that leap from animals to humans— 

is an important one. It will remain important. In the 1960s and 

1970s and 1980s, some of these hemorrhagic fevers were first 

described, and remember HIV shortly thereafter, also a zoonosis 

which spread into a global pandemic. I believe this is what we are 

here to avert with a much more rapid, clinically rapid pathogen, 

Ebola. 

Now, one of the questions that I was asked to address was how 

did this disease spread quickly. Every time there is an epidemic, 

there are explanatory voids where lots of assertions are made, and 

we heard in this example a great deal about bush meat and other 

exotic modes of transmission. We should be very clear that the 

rapid spread of Ebola is not due to 15,000 episodes of bush meat 

eating frenzy but rather to person-to-person transmission in a setting of weak health care infrastructure. So the diagnosis, speaking 

as a physician, is that it is critical that we understand that. So, 

weak health systems are responsible for the spread. 

In interviewing survivors—these are three young people from 

Sierra Leone, but it is not a different story elsewhere in the 

region—there are very few mysteries. These are people who are 

looking after members of their families—their family members— 

while they are sick or after they have died. As in every culture in 

the world, we respect the dead, we bury the dead. That is actually 

in my faith tradition one of the corporeal works of mercy, if I get 

my Sunday school memory back, bury the dead. Of course, this is 

not something that can be easily wished away, that people stop revering those who have passed away and honoring them. So these 

are, as has been said, in a way, the heroes of the epidemic. 

Now, what I hope we will be able to focus on in the hearing is 

what usually does not happen with emergency responses. The last 

time I was in this room was shortly after the earthquake in Haiti, 

making these very same points, and yet President Sirleaf has made 

them more effectively. We need to address the human resources for 

health crises. We need to build local capacity, local systems, and 

local health care infrastructure. That is how we will avert the next 

disaster. 

This has gone under the unglamorous name of health systems 

strengthening. I think we need a consultant to help us think of 

something—you know, we all of us talk that language, but we need 

a little help from you. These are substantial resources you have 

requested, and we are thrilled to see that many of them will go into 

health systems strengthening that has a significant component 

focused on building local capacity in places that include Liberia, 

Sierra Leone, and Guinea. 

I would like to just close by saying I personally am proud, as an 

American, of the CDC’s role, the NIH, other American institutions 

that have stepped up. I think I am very grateful for my colleagues 

who are physicians and nurses from the states you represent and 

all across the country who have gone in to serve Partners in 

Health, who is proud to be part of this coalition. We will seek to 

promote health systems strengthening while we are looking for the 

FOREI-43947 with DISTILLER

14 

new and sexier term and to open with our colleagues in the public 

health sector in Liberia and Sierra Leone—and we hope one day 

Guinea—many clinical units able to take care of people sick with 

Ebola. 

But also, as noted, and maybe I skipped over this, the largest 

number of Ebola victims will not have Ebola. They will have 

malaria, they will have obstructive labor, they will have minor 

injuries that, because there is no health care system, will fester 

and take their lives or maim them in other ways. 

So we are looking forward to responding over the course of the 

coming years and again are grateful to the President for being here 

with us today, but also for being such a welcoming host. Thank 

you. 

[The prepared statement in the form of slides of Dr. Farmer 

follows:] 

FOREI-43947 with DISTILLER

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FOREI-43947 with DISTILLER

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FOREI-43947 with DISTILLER

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Senator COONS. Thank you, Dr. Farmer. 

For several members of the subcommittee who have joined us, 

the President of Liberia made remarks previously and has graciously agreed to stay and to hear from our witnesses. 

Dr. Anne Peterson. 

Dr. Peterson. 

STATEMENT OF E ANNE PETERSON, M.D., VICE DEAN, PUBLIC 

HEALTH PROGRAM, PONCE HEALTH SCIENCES UNIVERSITY, 

WORLD VISION, WASHINGTON, DC 

Dr. PETERSON. Thank you, Chairman Coons and Ranking Member Flake, and subcommittee members as well; and thank you for 

having this hearing and for inviting me to be here. 

I went to Liberia and Sierra Leone not so much to look at what 

was being done well—and I will say many things are being done 

very well in all of the countries, and especially in the United States 

response—but my terms of reference as I went with World Vision 

was to look at what are the gaps, what are the gaps between what 

the faith communities are doing or could be doing and how well are 

they working together with the U.S. Government. 

So I will try to focus my remarks on six areas where I think we 

could do a little better than we have. Three of them are in areas 

of ongoing effort, and the first is in the need for cross-cutting 

coordination. 

If you talk to anyone who is working on the ground, they will tell 

you there is a lot of coordination happening. There are meetings 

and meetings and pillar meetings and coordination meetings. But 

they are all focused in their more narrow vertical programming. 

We have seen this all along in health development. Vertical programs, vertical efforts can be very, very effective. But when you do 

that, you do not build an intact health system. So as I went and 

looked across the pillars, across government agencies and NGOs 

and faith-based organizations, as I looked at the difference between 

what was happening in Liberia and Sierra Leone, in fact there 

FOREI-43947 with DISTILLER

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were a number of places where it was clear that if we had had a 

bigger view, a cross-cutting collaboration and coordination, we 

would have had economies of scale, we would have had reduced 

duplication, and some of the gaps in what needs to have been done 

would not have been missed. 

So my first call was outlined in the Institute of Medicine report 

that was published this summer, ‘‘Investing in Global Health Systems: Sustaining Gains and Transforming Lives,’’ that I was honored to cochair with Ambassador John Lang. We talked about this 

need to go from vertical focus to a broad health systems approach, 

and the same thing is happening right now in Ebola response, and 

we can do better than that. 

The next is to invest sustainably. Very rightly, investments that 

the U.S. Government and others are putting in are focused on stopping Ebola. Stopping Ebola is absolutely essential. But we are also 

setting it up in such a way that the ground is being cleared, the 

tents are being put up, the labs are set, the foreign doctors and 

health care workers are coming in, and when Ebola is done, my 

desperate fear is that the tents will be rolled up and the expats will 

go home, and what will be left will be the previous health system 

that is only more broken than before Ebola came. 

So as we are doing just what we should be doing in addressing 

Ebola, if we could focus on investing it so that it will make permanent improvements in the health systems; to be, in fact, training 

and building health worker capacity even as we deal with the 

Ebola epidemic itself. 

My third ‘‘do it better’’ comment is in the area of listening to 

communities. Communities are part of the health system. If, in 

fact, we do not hear their needs and address their needs, they do 

not respond to our behavior change messages. So we heard from 

President Sirleaf that people heard messages that this is a terrible 

disease, it is a fatal disease. Well, if that is so, then why would you 

send your child to disappear into an Ebola treatment unit and 

never come home? Instead, we should be looking at what can be 

done, celebrating survivors, knowing that people can protect themselves, protect their families. By going in sooner when they have 

Ebola, they can prevent transmission to their families. 

So I would ask that all of the communities and the collaboration 

that is going on, do not just talk to one another. Remember to go 

in and talk to the people of communities. Some of the best messages I heard were talking to mothers in the slum communities in 

Monrovia and Freetown, and I will tell you I am not surprised that 

in Freetown, in Sierra Leone, cases are going up. It is exactly what 

I expected as I looked at both the economic issues and the behavioral issues and Ebola approaching those slum dwellings. 

So there are now three game changers, and I am almost out of 

time. You probably have not heard about rapid diagnostic tests as 

a major game changer. I will tell you that if we could distinguish 

between who has Ebola and who does not have Ebola, you would 

change how many people are in the Ebola units, and you would be 

able to remove those from risk who do not have Ebola, the malarias 

that look like Ebola. You would change the ability of health care 

workers to go in and man the regular outpatient departments so 

we could begin to address the indirect impacts and profound health 

FOREI-43947 with DISTILLER

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impacts of other diseases, and we would change what happens in 

burials. 

Maybe up to 70 percent of community transmission is now happening in funerals and burials. If people knew when someone died 

whether they truly were an Ebola patient or not, we would then 

have fewer Ebola burials. We would not be doing Ebola burials 

with destruction of homes for those who are not Ebola patients. So 

for me, the rapid diagnostic test is a profound game changer in 

almost every aspect, and it would stop a lot of transmission. 

The last and probably most important, if we are going to listen 

to communities and learn from them, we need to work with the 

faith-based sector. They are the link between our governments, our 

NGOs, and the communities. They know where the orphans are, 

they know where the people in need are, and they are an incredible 

vehicle. There are starting to be quite a number of things. World 

Vision is doing safe burials, but dignified and safe burials, meeting 

the cultural needs of the people. 

In closing, I will just say that I would suggest that we need to 

focus on listening better, building back better, partnering with the 

communities and the faith-based organizations; and I, like Dr. 

Farmer, am very pleased and very proud of the work that the U.S. 

Government has been doing in West Africa. 

Thank you. 

[The prepared statement of Dr. Peterson follows:] 

PREPARED STATEMENT OF DR. E ANNE PETERSON

Chairman Coons, Ranking Member Flake, and subcommittee members, thank you 

for conducting this hearing on what remains a critical issue to Americans and to 

the people of West Africa. Thank you also for the honor of being able to speak with 

you about Ebola. I have spoken before this committee previously when I was Assistant Administrator for Global Health at USAID, but now hopefully will bring a civil 

society and on the ground perspective on what is and could be done to address Ebola 

in the affected countries. 

Recently, I spent most of a month first in Liberia and then in Sierra Leone as 

a consultant to World Vision. My terms of reference for that consultancy were very 

similar to the questions to be discussed in this hearing. I was to assess what was 

being done, what could be done better and what additional capacity was needed to 

meet the gaps. The focus of the assessment was on what the faith sector was contributing to the response. My broad terms of reference connected me with a variety 

of government agencies (U.S. Ambassador in Liberia, CDC, USAID, DFID, and both 

national Ministry of Heath representatives) as well as a myriad of NGO, FBOs, and 

individual faith leaders. We were able to see an incredible amount of what was happening in response to Ebola could spend time with people in communities in both 

the countries we visited. This gave us a big picture view of the response but also 

gave us access to the community perspective that highlighted strengths, weaknesses, gaps and growing needs that had not been addressed yet. 

I would like to focus my testimony on three areas of current work that I believe 

could be enhanced, three ‘‘game changers’’ and then some suggestions about how 

future USG investments might be prioritized to speed ending the Ebola crisis, mitigate the suffering of the countries most impacted and help rebuild the health system so that Ebola or other similar crises never take hold again at this level. Let 

me say first and strongly, that the emphasis on stopping Ebola is the correct focus 

and there is a great effort to achieve that end, but there is room to work smarter 

and to greater effect. The international aid community is fully aware of the need 

for coordination, correct messaging and need to build health care capacity but the 

workload and vertical pillar approach have limited the perspective and effectiveness 

in each of these areas. With some new perspectives the current work could be significantly more effective. Some of these needed changes were beginning to happen 

as I left Africa but clarity and encouragement to continue those improvements will 

maximize impact and the usefulness of the U.S. investments in Ebola. The three 

game changers would be (1) engagement and mobilization of the faith community; 

FOREI-43947 with DISTILLER

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(2) availability of a rapid Ebola test; and (3) addressing now the massive indirect 

impacts of Ebola on the economy, society, and health of the impacted countries. 

Each of these ‘‘game changers’’ would significantly help reduce transmission of 

Ebola and mitigate the immediate and long term harm of the epidemic, beginning 

to reestablish a stable, functional system. 

ACHIEVING GREATER IMPACT IN OUR CURRENT EFFORTS

There are several ways that the current Ebola epidemic response could be improved to achieve greater impact, both in the immediate and the long term. 

First, there is a need for cross-cutting coordination. Coordination of effort is essential and a great deal of time and energy is appropriately being expended on coordination with national government and collaborating aid agencies. While the current 

coordination is essential the intensity of the response work and the narrow focus 

of work within each of the coordinating pillars leaves little time for collaborating 

across pillars, agencies or even learning lessons from nearby affected countries. 

Opportunities for synergy are lost, unnecessary duplication of effort is inevitable. 

These are predictably inefficiencies and like vertical programming of the past 

measureable and laudable progress might be happening in a certain ‘‘pillar’’ of the 

response, but the disconnected pillars do not build a coherent health system. The 

gaps between the vertical pillars are no one’s responsibility and go unnoticed until 

they reach harmful levels. The recent Institute of Medicine (IOM) report that I was 

honored to cochair with Ambassador John Lange, ‘‘Investing in Global Health Systems: Sustaining Gains, Transforming Lives,’’ speaks about the limitation of the 

piecemeal approach to health and cites this Ebola outbreak as an example of what 

happens without a strong and intact health system. Our Ebola response is falling 

into a similar vertical, piecemeal set of actions. 

Invest sustainably. The U.S. is investing heavily in the Ebola response and doing 

good Ebola control response with the invested funds. It is probably necessary, at 

least for patient care, that there is a parallel Ebola system in addition to the regular 

health care infrastructure. We do want to separate Ebola patients from other 

patients to prevent transmission. We are clearing land, putting up tents, and manning Ebola units primarily with foreign medical personnel. While this is due in part 

to an existing lack of health care workforce exacerbated by the epidemic, it is not 

an approach that will help build national capacity, either in health facilities or 

workforce. When Ebola has been halted, the tents will be rolled up and removed, 

the foreign workers will return home. The other preventable health problems that 

have been ignored and neglected by a health system either shut down or diverted 

to Ebola will be of far larger proportions than before Ebola emerged. And unless 

we do our current work differently, the health system which has lost so much manpower will be weaker than before Ebola while forced to address greater and ongoing 

health challenges. It is possible, to address the urgent Ebola scale-up needs in a 

way that contributes to a stronger and sustainable health system. If we plan and 

invest only in the short-term control of Ebola, we will miss a great opportunity to 

strengthen national health systems to build their capacity to address the already 

prevalent preventable maternal and child deaths or to avert or respond to the next 

major health crisis. 

Listen to the communities. There are so many meetings and long conversations 

among all the Ebola response agencies that it isn’t obvious initially that conversations are primarily between foreign aid workers and the government officials and 

rarely do we hear the voice of community members. Decisions and activities in the 

Ebola response have in some cases led to distrust and anger in communities, messages on the seriousness of Ebola have been scoffed at as unreal by some and taken 

fatalistically by others. In many instances, well intentioned scientifically based messages just haven’t elicited the behavioral responses from the communities that were 

desired and transmission of Ebola therefore continues. The only way to develop 

effective behavior change programs and messages is to know and address the issues 

of the community from their perspective, addressing the fears and beliefs that have 

hindered the response effort. Listening before messaging is the key. Listening to the 

concerns of community members, the mothers with young children as well as leaders who might be at the decision tables will lead to a better understanding of what 

is needed to change behaviors and reduce Ebola transmission. 

GAME CHANGER: ENGAGING WITH THE FAITH COMMUNITY

If most Ebola transmission is happening in communities, as it is, and if we 

acknowledge it is hard for foreign aid agencies to link directly to communities, then 

an interface or intervening organization is needed. Far better than secular NGOs, 

faith-based NGOs or FBOs and church or Muslim associations are deeply embedded 

FOREI-43947 with DISTILLER

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and knowledgeable about their communities and can link the voices and views of 

the communities to the Ebola response. 

The U.S. Government has long worked with faith-based organizations. Engaging 

with FBOs was critical in the war against AIDS and rose to some prominence in 

the implementation of PEPFAR. Longer ago than PEPFAR, local churches were instrumental in the small pox eradication efforts in the same West African settings 

now beset by Ebola. Yet, USG engagement with FBOs or mobilization of the faith 

networks has not been a core part of the Ebola response to date. 

A core focus of my work in Liberia and Sierra Leone was to conduct a qualitative 

assessment for World Vision of the roles of faith-based organizations (FBOs), 

churches and faith leaders in the Ebola response; what were they doing, what could 

they be doing and how could they be better integrated with the U.S. Government 

Ebola response. Granted, there are fewer FBOs who work in disaster humanitarian 

operations type settings, but there are some FBOs experienced, willing or active, 

such as Samaritan’s Purse work in Liberia that responded early and at great cost 

in establishing Ebola treatment centers. Medical Teams International is providing 

training in infection control. Catholic Relief Services, CAFOD (another Catholic 

FBO), Catholic Medical Mission Board, MAP international, IMA World Health and 

World Vision all are participating in different places and ways. 

I’ll use World Vision as just one example of what FBOs can contribute to the fight 

against Ebola. World Vision works primarily in Sierra Leone and has taken on unusual leadership roles in addressing Ebola, such as efforts to improve safe and dignified burials, training pastors and imams on Ebola prevention and stigma reduction, and addressing the indirect consequences of Ebola (including food insecurity, 

livelihoods, care of orphans and survivors, and educating children while they are out 

of school). 

The first and perhaps most urgent FBO coalition activity was taking on safe and 

dignified burials. The World Vision coalition in Sierra Leone, with Catholic and 

Muslims partners, has taken on managing, training, and paying burial teams in 12 

of the14 districts. They are making sure the Ministry of Health burial teams are 

actually paid for their gruesome work, using their financial management expertise. 

As result of this effort, there are fewer burial team strikes and great progress has 

been made toward responding and conducting all burials within 24 hours. 

The added value of the FBO rather than secular coalition is that they have added 

a strong emphasis on how to convert safe but offensive burial practices (mass unmarked graves, no markers, no prayers or family attendance) into safe but dignified 

burials acceptable to the communities. As burials become ‘‘dignified’’ and faithful to 

spiritual traditions, families will no longer need to conduct the high risk transmission secret burials of Ebola deaths that are occurring now. 

But the issue isn’t just what are international FBOs doing but what are the faith 

leaders and local churches doing and what part could they play in the Ebola response in their communities. In Liberia, there was more vigorous infection control 

but less visible coordination among the faith community. The reverse was true in 

Sierra Leone, where infection control practices were more lax but there was more 

action and greater coordination among the local faith community. 

The church, as has been true in past epidemics like AIDS, has been mixed in their 

response. There are many examples of churches being helpful and others that 

spread messages and practices contrary to helping control the spread of infection 

and discourage stigma. The situation is improving over time as the stark reality of 

Ebola hits congregations directly. Most churches have stopped the practice of greeting one another with handshakes or kisses or ‘‘laying on of hands’’ in prayer for the 

sick. Many, but not all, churches and mosques now have chlorine and hand-washing 

stations set up before people enter the church though sometimes the chlorine is 

missing and the water bucket is dry. A brave few churches were venturing out from 

their church buildings to conduct services right outside the doors of Ebola treatment 

units so patients can hear that others are praying for them. Others are beginning 

to note and address the needs of widows and orphans, or provide trauma counseling 

for devastated families. Support and reassurance from faith leaders is essential also 

in helping the transition to safe and dignified burials be acceptable to their communities. If faith leaders are engaged and informed they can even pave the way for 

acceptance of new tools, like an Ebola vaccine or rapid diagnostic test once they are 

available. 

The faith community has a clear command to meet the needs of their people, but 

as the epidemic has spread, the desire for reliable information has grown but many 

churches and mosques do not have reliable ways to learn about Ebola to correctly 

guide their congregations. Some have welcomed scientists from the CDC to their 

services to learn about Ebola. In addition to information from the government and 

CDC, there is a need to frame the science of Ebola response into the more familiar 

FOREI-43947 with DISTILLER

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faith language of the Christians and Muslims. World Vision is leading another consortium, working with CRS and the Muslim organization Focus 1000, on the production of a toolkit on Ebola messaging to be disseminated through the leaders of each 

faith group. World Vision is combining the available scientific information on Ebola 

with the faith oriented tool kit into a reflective and action oriented training for a 

wide array of faith leaders, Muslim and Christian, through its Channels of Hope 

program which had previously been developed and used for training in HIV/AIDS. 

Through this tool, faith leaders can reduce negative messages and enhance positive ones, such as that reporting in to Ebola centers as soon as the disease is suspected protects their families from harm. Rather than preaching fear, faith leaders 

can affirm that God works through His people to meet the needs of the sick, widows, 

and orphans. Framing the stigma being experienced by families of victims and survivors in parallel to biblical example of reaching out and caring for lepers and outcasts can be particularly helpful in reducing stigma faced by survivors. Correct 

information, in the hands of faith leaders, harmonized and expressed in their faith 

language, can overcome widespread mistrust of the government and by extension 

the Ebola response. FBOs and faith leaders can encourage the people of Liberia, 

Sierra Leone, and Guinea not only to respond more appropriately to Ebola but to 

be active agents to stop the spread of Ebola and mitigate the enormous personal, 

spiritual, and societal impacts of Ebola on their people. 

But the impact of Ebola and the opportunities for faith leaders and FBOs to mitigate the impact of Ebola goes far beyond stopping Ebola infections. Food insecurity 

is increasing as prices rise and farmers are not planting crops. Attention is also 

diverted from other health issues. Most deaths in Ebola-affected countries are not 

Ebola deaths. The even larger epidemic of deaths is from pneumonia, childbirth, 

malaria, and diarrhea due to the Ebola epidemic’s impact on the health care system, 

lack of preventive services and broken societal and economic structures. Addressing 

these issues cannot wait for the end of the Ebola outbreak and the global health 

community, FBOs and faith leaders know how to prevent these deaths. It is the 

kind of work they are already called to do. They just need encouragement and 

resources to take on the daunting devastation of the impact of Ebola on these 

countries. 

GAME CHANGER: RAPID DIAGNOSTIC TEST FOR EBOLA

Ebola symptoms are similar initially to many other diseases. This nonspecificity 

of symptoms has profound impacts on health care worker risk and on patient care 

seeking behavior. I would argue that not being able to know promptly whether a 

patient (or body) has Ebola or not is a major driver of continued Ebola transmission 

and the cause of the collapse of almost all other health services, leading to 

unmeasured numbers of non-Ebola deaths indirectly caused by Ebola. A rapid diagnostic test would have a dramatic impact on both health care workers and patients 

Most of the recent health care worker infections have not occurred in Ebola treatment centers but in settings where they thought they were treating illnesses other 

than Ebola. A doctor was infected and died after delivering a baby. Forty-two health 

workers were infected by one Ebola patient, a friend who claimed initially only to 

have an ulcer. Twenty one of those health workers died. Each time a health care 

worker in a non-Ebola center is infected and diagnosed as an Ebola patient, all his 

or her health care worker colleagues become contacts, must be quarantined and 

often the care center closes until the 21-day quarantine is completed. Perhaps as 

much as two-thirds of the regular health system is closed and once closed, it is very 

hard for health care workers to return to take on again the risks of caring for 

patients who are not supposed to have Ebola but might. 

Patients, just like doctors, can’t tell the initial Ebola symptoms apart from many 

other common diseases. Unless they have had significant exposure to a sick or dead 

Ebola patient, most of the symptoms will be due to malaria, diarrhea, typhoid fever, 

lassa fever or the number one child killer, pneumonia. These very common illnesses, 

have only become more common as the immunization programs, malaria prevention 

programs, outpatient treatment centers have closed in mass. Mothers, in poor slum 

areas have stated emphatically, that if they or their child was sick with a fever or 

a stomach ache or diarrhea they would not bring them in to a treatment center. 

They know these symptoms could be Ebola, but they believe sometimes rightly and 

sometimes with wishful thinking, that it is far more likely to not be Ebola than to 

be Ebola. They don’t want to risk ‘‘disappearing into an Ebola’’ center never to return. When someone becomes sick they are rightly afraid to come in for care. If their 

symptoms could at all be like Ebola, as is true of many common illnesses, they know 

they will be held in Ebola observation until the test result is known 2–3 or more 

days later. They also know that staying in these holding centers with suspected 

FOREI-43947 with DISTILLER

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Ebola cases puts them at high risk of being infected with Ebola while seeking care 

for another health problem. Very logically they stay home until it is clear they have 

Ebola. They would rather risk their child dying at home of malaria than risk getting 

Ebola and dying far away. 

But if in fact, the sick person has Ebola the delay in accessing care has impact 

on more than just that one individual. We have learned in this epidemic that Ebola 

is both more infectious as the disease progresses and that infectivity is dose dependent. The sicker and longer an Ebola patient stays in the home the greater the likelihood of transmission to family and friends. 

But if we had a rapid Ebola test at the triage of all non-Ebola centers and maybe 

even available for community health workers, all of these scenarios are changed. 

Health care workers could safely go back to work and families could safely bring 

their sick family members in for diagnosis and treatment. Communities, families, 

and patients would know only non-Ebola patients would be in the regular health 

centers and Ebola patients would be referred to now much less crowded Ebola centers. This would decrease transmission of Ebola in communities because families 

would be less likely to delay. It would decrease transmission within holding and 

quarantine centers. Patients could safely seek treatment for malaria and the increasing common diseases caused directly by the diversion of care to Ebola and halting of preventive and curative services other than Ebola. It would even reduce 

transmission in Ebola centers where uninfected suspect cases were previously being 

exposed to Ebola. Health care workers, both national and international volunteers, 

who are not ready to treat Ebola but do want to assist with the devastating health 

needs in the impacted countries could safely return to work. We could begin to rebuild the broken health system that allow the Ebola rampage to begin and continue 

unchecked. 

Community Ebola burials have been a source of anger and sometimes violence, 

especially if it turns out the death was not an Ebola death. A rapid test would contribute rebuilding of relationships with the community and to decreasing transmission since only the fewer and proven Ebola burials would need Ebola burials. 

If secret burials were thereby avoided, we would begin to get more accurate death 

reporting, surveillance, and referral. It would also help ensure when there is a nonEbola death that homes and possessions aren’t destroyed unnecessarily. A rapid 

diagnostic test would facilitate more rapid access to care for family contacts, less 

breaking of quarantine and fewer contacts lost to followup. All of these impacts will 

lead to better data on deaths, reduced burial transmission and better relationships 

with community members, which directly or indirectly enhances Ebola infection 

control. 

GAME CHANGER: ADDRESS THE INDIRECT IMPACTS OF EBOLA

The massive indirect impacts of Ebola on the economy, education, social structures and health of the impacted countries are much greater and long-lasting than 

the impact of the Ebola epidemic itself. The plight of children demonstrates just a 

portion of this impact. WHO estimate of the number of orphans from October 29 

for the three countries was 10,395 single orphans and 4,455 double orphans. These 

numbers corrected for underreporting (CDC uses 2.5 fold multiplier, which has been 

verified in an active surveillance activity in November) would make the estimated 

total orphans 25,986. Because of the previous civil war, there were many single parented homes in both Liberia and Sierra Leone. When Ebola hits these vulnerable 

homes, with perhaps greater adult vulnerability to Ebola than children, there are 

a disproportionate number of double orphans which is unprecedented even in Africa. 

In Sierra Leone, 42 percent of the orphans are double orphans and in some districts 

there were more double orphans (both parents dead) than single orphans. This was 

unheard of even in the height of the AIDS epidemic. 

Life is difficult in Sierra Leone and Liberia, even before Ebola. There are high 

child and maternal mortality rates and poverty in both countries, which was just 

beginning to improve after the civil war of a decade ago. Now, ALL children are impacted by Ebola. Most are out of school for the entire year, with some radio broadcast classes as their only educational input. About 50 percent of parents have been 

keeping their children home—all the time—no friends, no family gatherings, so they 

aren’t exposed to Ebola. Most of the regular health care facilities are closed for any 

usual illnesses—malaria, diarrhea, pneumonia. Children (all children but even more 

so for orphans) are less well-nourished because of increasing poverty and food insecurity, they are also no longer receiving preventive services like Vitamin A or routine vaccinations. Therefore disease rates are escalating just as access to all health 

services, except Ebola services, are decreasing. 

FOREI-43947 with DISTILLER

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Stigma is a debilitating reality for children, adult survivors, and families of Ebola 

victims even if they never had Ebola. People are afraid of the children as potential 

vectors of Ebola but also don’t trust that the children won’t bring Ebola into their 

home, even after a 21 day quarantine. Unlike other orphan situations in Africa, the 

extended family is very reluctant to take the children in. Even those who would, 

usually can’t afford to take in extra children. The economy is so hard hit with so 

many businesses and schools closed that there is little income. Families in poor 

urban areas have gone from two meals a day to one meal a day for their own children and just can’t feed anymore. In rural areas, between stigma and lack of crops, 

orphaned children are abandoned in large numbers. People are also afraid of survivors, especially since even when a survivor is no longer infectious they often have 

continued symptoms of migratory joint and muscle pain—which people misinterpret 

as still sick with Ebola. Survivors often move across the country to avoid anyone 

knowing they were sick with Ebola even if they are fully recovered. 

Often survivors also have no home to return to or family members have no home 

to stay in. When a sick person or body is picked up the house must be decontaminated, this may destroy much of the household belongings and the house itself is 

stigmatized as an Ebola house. It may in fact be infectious for a few days so care 

and decontamination is needed. But the process leads to further impoverishment 

and stigmatizing of those who have just been through the horrific experience of 

being sick with Ebola. 

The indirect impacts of Ebola need immediate and long term response. Without 

food and financial support food insecurity now, is likely to evolve into something 

closer to famine in a few months. WFP, UNICEF, and some NGOs, like World 

Vision, are beginning to partner with faith leaders and communities to identify hard 

hit communities, orphans and other vulnerable children (OVC) and survivors to 

begin to provide child protection, food, and safe places to live. 

These devastating impacts of Ebola warrant attention in their own right. These 

are illnesses and deaths we know well how to prevent. But ignoring them also impacts Ebola prevention efforts. Sick and malnourished children maybe more vulnerable to Ebola but certainly will add to the case load of an already overburdened 

health system. Every malaria case prevented is one less diagnostic dilemma that 

complicates isolation of suspected Ebola patients. When hunger, illness, or economic 

necessity compel someone to break quarantine more Ebola transmission is possible. 

When these other concerns loom so large and compromise life and health, Ebola precautions fall in relative importance and increased transmission becomes more likely. 

We cannot wait until the end of the Ebola outbreak massive indirect impacts of 

Ebola on West African society. Again, in Sierra Leone World Vision is ahead of the 

game in commissioning a rapid assessment of these indirect impacts of Ebola. They 

will use the information to help them reprogram their own funds but I believe this 

information will also provide desperately needed data for advocacy and prioritization of the global efforts. 

What could/should the USG do? 

• Stop Ebola by enlisting the assistance of those who care even more than we 

do—the people of Liberia, Sierra Leone, and Guinea. Work with trusted faith 

leaders to empower communities: listening to their concerns and potential solutions. 

• Rebuild better not separate and temporary. The incredibly weak heath system, 

lack of surveillance systems, labs, inadequate workforce are the things that 

allowed the Ebola outbreak to reach such epic proportions. Instead of building 

a parallel system, in tents and manned by foreign health care workers, we 

should be ‘‘building back better’’ in ways that last; upgrading permanent facilities, building communications systems, training all cadres of health workers in 

infection control and disease treatment with a strong emphasis on preventive 

medicine, public health and community-based interventions and disease prevention. It would have been far easier to identify the first cases of Ebola if they 

were not lost among the many sick from diseases we know how to prevent. 

• Don’t wait. The indirect impacts of Ebola on the people of each of these countries are enormous. As poverty, malnutrition, lack of school and work and preventable diseases increase, Ebola control will fall lower on the population’s priority list. If you can’t feed your child, the ‘‘far away’’ risk of getting Ebola 

becomes much less important. 

• Listen well, address their fears, give messages of hope, celebrate survivors, and 

empower parents, families and communities to protect themselves and assist in 

the response. 

• Message at home. Stopping Ebola in Africa is the best protection for Americans 

and celebrate those willing to serve in Africa. Healthy people don’t transmit 

FOREI-43947 with DISTILLER

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Ebola. Health care workers are not a danger to Americans just because they 

have worked in West Africa. We need to encourage American volunteers who 

want to help to be able to go and to be able to return home without stigma, 

shunning and exclusion from normal American work and society. The inappropriate level of fear is hindering the flow of aid workers needed to stop this 

Ebola epidemic there and increasing the risk of spread here. 

CONCLUSION

I am very proud of my country for its extraordinary efforts to address Ebola. The 

investments by the U.S. to address the Ebola outbreak in West Africa are critical 

and are the best way to protect the American people. We have learned an immense 

amount in this current epidemic, that we couldn’t have learned from previous 

smaller outbreaks. But we must continue to learn and to apply the lessons learned, 

to improving our medical and the nonmedical programs, addressing the urgent demands of stemming the spread of Ebola and addressing the urgent life needs of communities devastated by the presence of Ebola in their country We are doing well 

but we can do even better by investing in the right interventions, focusing on longterm sustainability and engaging the right stakeholders. We can stop the Ebola 

epidemic and leave behind a health system and developed infrastructure wellpositioned to respond to future crises. 

Senator COONS. Thank you, Dr. Peterson. 

Mr. Gaye. 

STATEMENT OF PAPE GAYE, PRESIDENT AND CEO, 

INTRAHEALTH INTERNATIONAL, CHAPEL HILL, NC 

Mr. GAYE. Chairman Coons, Ranking Member Flake, and other 

distinguished members of the subcommittee, on behalf of IntraHealth International, I thank you for inviting me to testify today 

on this issue of paramount importance to our friends in West 

Africa and to us here in the United States. 

I ask that my full written testimony be submitted for the record. 

Senator COONS. Without objection. 

Mr. GAYE. In my native Senegal, there is a Wolof proverb: ‘‘Nit, 

nit ay garabam.’’ It means ‘‘the best medicine for a person is another person.’’ I am fortunate to lead an organization, IntraHealth 

International, that for 35 years has been a firsthand witness to this 

proverb in action through our support to frontline health workers 

in 100 countries around the world, including all the Ebola-affected 

countries. 

Tragically, however, far too many people in the West Africa 

region I hold dear did not have access to that person, that health 

worker, who could have prevented Ebola from decimating their 

communities and threatening the well-being and security of their 

countries, their region, and the world. 

As this Ebola outbreak has already started to fade from the consciousness of some, one of the crucial underlying conditions that 

helped the virus spread remains the absence of a sustainable and 

resilient health workforce in the region. Let there be no misunderstanding: if health workforce does not get the high-level political 

attention it sorely needs, workforce deficiencies will continue to 

threaten global health security, and threaten the tremendous 

progress made in saving women and children’s lives, fighting diseases like HIV/AIDS, and all the great work accomplished by 

USAID. 

As shared by President Sirleaf, Liberia, Sierra Leone, and 

Guinea all had fewer than three doctors, nurses, and midwives per 

10,000 people, even before the Ebola epidemic began. But these 

FOREI-43947 with DISTILLER

26 

countries are hardly alone. The World Health Organization last 

year estimated that 83 countries in the world are below the minimum threshold of health workers needed to provide essential services to everyone. 

Last year, at a major conference in Brazil, Guinea and Liberia 

were among 57 countries that made health workforce commitments. Guinea’s commitment highlighted two rural provinces 

where frontline health workers were largely absent, and one of 

those regions is where ‘‘Patient Zero’’ of the Ebola epidemic was 

believed to be infected less than a month later. 

Let me be clear: because of the generosity of the American people 

and the know-how and innovations of implementing partners like 

IntraHealth, the United States Government has maintained global 

health leadership, and no one on this Earth will dispute that the 

mantle of that leadership rests and will continue to rest on the 

shoulders of the United States. 

For example, IntraHealth and UNICEF are currently working 

with the Liberian government on a tool called mHero to allow the 

Ministry of Health and health workers to instantly communicate 

critical information. The USAID-supported, open-source, online personnel management system, called iHRIS, will save low-income 

countries about $232 million, and data using the tool has already 

been used to drive additional domestic investment for health workers. In the next 5 years, iHRIS is expected to save the Liberian 

Government, the equivalent amount of money as the salaries of 317 

Liberian nurses. That number of nurses could serve 634,000 Liberians. 

These innovations supported by American foreign assistance are 

critical to addressing some health workforce challenges, but certainly not all of them. The Frontline Health Workers Coalition, an 

alliance of 41 U.S.-based public and private organizations, with a 

Secretariat housed in our offices at IntraHealth, last month 

released recommendations for how the United States can lead 

on these issues. I have included them in an addendum to my 

testimony. 

In brief, there must be a more concerted effort to address the 

needs of local health workers in West Africa, such as ensuring 

timely delivery of hazard pay and personal protective equipment. 

This support to local health workers must be backed by an equally 

fervent political push for addressing the most critical health workforce gaps globally. A 2010 report estimated that by 2020, the 

United States needs to invest at least $5.5 billion in health workforce strengthening to achieve its global health goals. Investment 

must be guided by a cross-agency strategy that sends an unequivocal message that America is committed to this issue, and we expect 

others to respond in kind. I also believe all global health procurements should be required to show how they will help strengthen 

the health workforce and systems. 

I would like to close by asking each of us to think about what 

it would be like to wake up tomorrow morning infected with Ebola 

and not have a single person in your community to turn to for care, 

or to have your infant child this evening show signs of malaria and 

have nowhere to take them. This is the reality for far too many, 

and it must be changed now. We would be doing a great disservice 

FOREI-43947 with DISTILLER

27 

to the 346 health workers who, as of the end of November, have 

given their lives to help turn the tide on this Ebola epidemic if we 

did not focus on their colleagues’ immediate needs, while working 

fervently to ensure we never again have a crisis of this scale in 

public health. 

I thank you very much, and I look forward to answering your 

questions. 

[The prepared statement of Mr. Gaye follows:] 

PREPARED STATEMENT OF PAPE GAYE

Chairman Coons, Ranking Member Flake, and other distinguished members of 

the subcommittee, on behalf of IntraHealth International, I would like to thank you 

for the honor of inviting me to testify today on this issue of paramount importance 

to the security and well-being of our friends in West Africa, as well as to us here 

in the United States. I ask that my full written testimony be submitted for the 

record. 

In my native Senegal, there is a Wolof proverb, ‘‘Nit, nit ay garabam.’’ It means 

‘‘the best medicine for a person is another person.’’ 

I am fortunate to lead an organization, IntraHealth International, which, for 35 

years, has been a firsthand witness to this proverb in action through the awe-inspiring efforts of frontline health workers we have supported in 100 countries around 

the world, including all the Ebola-affected countries. 

Tragically, however, far too many people in my native West Africa have not had 

access to that person—that health worker—who has the training and support necessary to prevent the Ebola virus from desolating their communities and threatening the well-being and security of their countries, their region, and the world. 

Stories from this epidemic—such as the five Liberian children who were left at 

home with the corpses of their Ebola-infected parents for three days because of overwhelmed ambulance services—make us sick to our stomachs and heighten our resolve to end the crisis as soon as possible. The heroic efforts of health workers on 

the front lines of the epidemic have given us hope that, if our resolve to support 

them does not waiver, that day is coming soon. 

But as this Ebola epidemic has already started to fade from the consciousness of 

some, one of the crucial underlying conditions that helps the virus spread remains: 

the absence of a sustainable and resilient global health workforce to both stop 

threats like Ebola in their tracks and complete the daily work of saving and making 

lives healthier in every community. 

Let there be no misunderstanding: if health workforce deficiencies do not get the 

high-level political attention the issue sorely needs and it continues to languish as 

a global health policy afterthought, it will continue to threaten both global health 

security and the tremendous progress the United States has helped to lead in saving 

women’s and children’s lives and fighting diseases such as HIV/AIDS and tuberculosis. 

Liberia, Sierra Leone, and Guinea all had fewer than three doctors, nurses, and 

midwives per 10,000 people even before the Ebola outbreak began. More people 

could very well die due to Ebola’s impact on such fragile workforces and systems 

than directly from the Ebola virus itself. Yet, these countries are hardly alone. The 

World Health Organization last year estimated 83 countries are below the minimum 

threshold of 22.8 doctors, nurses, and midwives per 10,000 people needed to provide 

essential services to a population. 

The countries that have the most acute workforce crises—the Ebola-affected countries in West Africa among them—have long recognized the gravity of inaction on 

health workforce strengthening for their communities, and they have been committed to action. Unfortunately, chronic lack of attention and significant reduction 

of formal development assistance to the West Africa region as a whole has exacerbated the problem. 

Last year, I had the pleasure of speaking to government and civil society leaders 

and health workers at the Third Global Forum on Human Resources for Health in 

Recife, Brazil. At this forum, 57 countries—including Liberia and Guinea—made 

specific health workforce commitments, for several of which IntraHealth provided 

technical guidance in crafting. Guinea’s commitment focused on its desire to get 

more frontline health workers to two rural provinces where they were largely 

absent. One of those regions, N’Zerekore, is the same region where ‘‘patient zero’’ 

of the current Ebola epidemic was believed to be infected—less than a month after 

Guinea made this commitment. Yet as many African countries stood up to make 

FOREI-43947 with DISTILLER

28 

their commitments clear in Recife, only one donor commitment to health workforce 

strengthening was made. That financial commitment was made by Ireland. 

Let me be clear: because of the generosity of the American people and the knowhow and innovations of implementing partners such as IntraHealth, the United 

States government has made huge inroads in helping countries improve the numbers, the competencies, and the support for health workers in West Africa and 

around the world. 

For example, a major issue Liberia now faces is the need to quickly get the latest 

information to its health workers. IntraHealth and UNICEF are currently working 

with the Liberian Government on a tool called mHero to allow the Ministry of 

Health and health workers to instantly communicate critical information to one another. The USAID-supported, open source, online personnel management system 

IntraHealth is using for this effort, called iHRIS, has already saved our low-income 

country partners approximately $232 million in 20 countries around the world—and 

many of these countries are using iHRIS data to successfully drive more domestic 

investment in health workers. 

In Liberia, more than 8,000 health workers are registered in iHRIS. This open 

source system will save Liberia more than $3.1 million in proprietary fees over the 

next 5 years—equivalent to the annual salaries of 317 Liberian nurses for 5 years. 

These nurses could provide 634,000 Liberians access to lifesaving services. 

Innovations such as iHRIS that are supported by American foreign assistance are 

critical to addressing some specific workforce challenges, but certainly not all of 

them. I believe if you asked any administration official to articulate the United 

States strategy or its cumulative results across agencies in assisting partner countries in strengthening their health workforce, they could not tell you. 

The Frontline Health Workers Coalition, an alliance of 41 U.S.-based public- and 

private-sector organizations and of which IntraHealth is proud to host the Secretariat and help lead, last month released recommendations for how the United 

States can lead in helping the countries of West Africa and other low-income country partners build the resilient and sustainable workforce we need for the 21st 

century. 

I’ve included our full recommendations as an addendum to my testimony. In brief, 

there must be a more concerted effort to address the needs of local health workers 

in Liberia, Sierra Leone, and Guinea. This includes ensuring timely delivery of hazard pay, ensuring an effective and efficient supply chain management system that 

provides personal protective equipment and other necessary supplies with requisite 

training, creating supply outposts for local health workers, making psychosocial support available, addressing Ebola-related stigma that has arisen, and increasing the 

authority of local management of health workers. 

This support to local workers—a critical first step to rebuilding the health systems of these countries—must be backed by an equally fervent political push for 

global action to meaningfully address the most critical deficiencies of the global 

frontline health workforce. A 2010 IntraHealth report estimated that by 2020, the 

United States needs to invest at least $5.5 billion in health workforce strengthening 

to achieve the global health goals and targets to which it has committed. 

The robust bipartisan support for global health must also continue to ensure 

Ebola does not set back the extraordinary progress we’ve made in the last decade. 

And I believe each procurement for those investments should be required to show 

how it will help strengthen health workforces and systems. 

U.S. health workforce investments must be guided by a multiyear, costed, crossagency strategy with an implementation plan that sends an unequivocal message 

to our developing country partners: that America is committed to this issue and we 

expect others to respond in kind. This clear sign of commitment would go a long 

way in helping to ensure a serious and coordinated effort by all governments for a 

financed global health workforce strategy with specific timelines and targets. 

I would like to close by asking each of us to pause and think about what it would 

be like to wake up tomorrow morning infected with Ebola and not have a single person to turn to for health care. Or to have your infant child this evening show signs 

of malaria, and have nowhere to take her. This is reality for far too many—and it 

must be changed now. 

Frontline health workers have started to turn the tide on Ebola at great risk to 

their own lives—WHO reports as of November 30, 622 health workers have been 

infected during the epidemic, 346 of whom have died. We would be doing a great 

disservice to health workers’ sacrifices if we didn’t focus on their immediate needs 

and at the same time work just as fervently to ensure we never again have a crisis 

of this scale in public health. 

Thank you very much, and I look forward to answering your questions. 

FOREI-43947 with DISTILLER

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ATTACHMENT 

INTRAHEALTH INTERNATIONAL—BUILDING A RESILIENT, SUSTAINABLE HEALTH

WORKFORCE TO RESPOND TO EBOLA AND OTHER FUTURE THREATS

FRONTLINE HEALTH WORKERS COALITION POLICY RECOMMENDATIONS—NOVEMBER 2014

The Ebola virus disease epidemic in West Africa has highlighted the urgent need 

for increased support for frontline health workers and the systems that support 

them in the region and around the world. The World Health Organization (WHO) 

reports that as of Nov. 2, 2014, 546 health workers have been infected with Ebola 

since the onset of the epidemic, and 310 of them have died caring for the more than 

13,000 people confirmed or suspected to be infected with the virus. 

Nearly all of these lives have been lost in three countries—Guinea, Liberia, and 

Sierra Leone—that have some of the lowest numbers of health workers per capita 

in the world. These three countries all had less than three doctors, nurses or midwives per every 10,000 people before the Ebola epidemic even took hold, far less 

than the 22.8 per 10,000 ratio WHO says is the minimum needed to deliver basic 

health services. 

Access to competent and supported health workers can no longer be allowed to 

languish as a global health policy afterthought. The heroic sacrifices of frontline 

health workers must be met with honor, compassion, and support for their efforts. 

Investments must be made in equipment, supplies, training, effective management 

and financial support for the retention of health workers to ensure that every community has the workforce needed to save lives, and the robust systems to support 

those workers in detecting, analyzing and responding to new and emerging public 

health threats like Ebola. 

The Frontline Health Workers Coalition recommends that the U.S. Government 

and its partners address this public health emergency and help build a sustainable 

response to future emergencies by taking the following actions: 

In Guinea, Liberia, and Sierra Leone 

• Increase support for local health workers on the frontlines of the Ebola fight: 

Working with health ministries, professional associations, local governments 

and communities, and nongovernmental organizations (NGOs), the U.S. can 

support local health workers by: 

Æ Supporting the financing and timely delivery of hazardous duty pay and 

death and insurance benefits for local health workers during the period of 

active crisis; 

Æ Ensuring personal protective equipment (PPE) and infection control supplies are provided to health workers with the requisite training and supervision for safe and consistent use; 

Æ Ensuring the availability of psychosocial support for health workers and 

specific treatment units or centers dedicated to health workers who become 

infected with Ebola; 

Æ Creating supply outposts for health workers to collect food, clean water and 

basic supplies; 

Æ Improving data collection and dissemination efforts about the epidemic, including data on the health workforce, patient tracking and supply chain; 

Æ Supporting the recruitment of health workers from the region to respond 

to the epidemic and assist in bringing routine health services back to 

normal; 

Æ Increasing capacity and authority for local management of health workers. 

• Build a responsive and sustainable supply-chain management system: Health 

workers’ ability to continue fighting Ebola depends on having adequate equipment, supplies, and medicines. The U.S. should work to ensure that both local 

and international health workers have the supplies they need through a responsive and sustainable supply chain management system. 

• Ensure a sustainable frontline health workforce by supporting training programs: The World Bank estimates that at least 5,000 additional health workers 

are needed to respond to the current epidemic. Maintaining and scaling up educational and training programs, such as medical and nursing schools for new 

health workers, is critical to building a sustainable response. The U.S. should: 

Æ Support scale-up of enrollment of students from rural communities into 

health professional schools and community health worker training programs; 

Æ Ensure educational programs for health workers are open and adequately 

staffed and funded to meet local health labor market demand. Liberia’s 

FOREI-43947 with DISTILLER

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health professional schools are currently closed, and they must be assisted 

to reopen; Æ Ensure all health worker training programs provide adequate infection control information on Ebola and other transmissible agents. 

• Address stigma: 

Æ Frontline health workers and their families have been attacked, stigmatized and even thrown out of their homes and communities while risking 

their lives to care for those infected with Ebola. The U.S. should work with 

partners to ensure health workers are protected and honored for their 

work. Æ The U.S. should work with partners and communities to leverage media 

and communications channels to promote messages about protecting health 

workers as a national and community asset. Community members and 

health workers should to be encouraged to share their stories to directly 

address stigma and psychosocial issues. 

Worldwide 

• Provide new investments that could help: 

Æ Jumpstart U.S. partner country efforts to strengthen their health workforce’s capacity to quell Ebola and other public health emergencies as part 

of the Global Health Security Agenda. The United Nations estimated that 

it will cost at least $600 million to halt the current Ebola epidemic in West 

Africa. Æ Build a sustainable frontline health workforce in partner countries to 

achieve the U.S. Government’s core global health priorities (ensuring global 

health security, ending preventable child and maternal deaths, and achieving an AIDS-free generation). A report from FHWC member IntraHealth 

International estimated that the U.S. should invest at least $5.5 billion by 

2020 1 to help strengthen the health workforce to achieve USG global 

health goals. 

• Ensure through continued robust investments across global health that Ebola 

does not set back the extraordinary progress of recent decades in saving lives 

and preventing the spread of diseases. • Release a multiyear, costed, cross-agency health workforce strategy with an implementation plan that sends an unequivocal message about how the United 

States will support partner countries to ensure that communities have access 

to health workers who are supported and equipped to save lives and stop public 

health threats. This strategy should include concrete targets and benchmarks 

and have clear mechanisms for monitoring progress. • Provide specific targets that include key cadres of health workers, necessary 

financing and an implementation timeline for the following goal of the Global 

Health Security Agenda: 

Æ ‘‘The United States will also support countries in substantially accomplishing: A workforce including physicians, veterinarians, biostatisticians, 

laboratory scientists, and at least 1 trained field epidemiologist per 200,000 

population, who can systematically cooperate to meet relevant IHR and 

PVS core competencies.’’ 

• Advocate strongly for the World Health Organization to adopt at the 2016 

World Health Assembly a financed global health workforce strategy that sets 

specific targets, timelines, and commitments for ensuring that by 2030: 

Æ All communities will have access to competent health workers, trained and 

supported to save lives and improve health; Æ All countries will have the health workforce and systems needed to stop 

Ebola and other existing and emerging public health threats. 

———————— 

End Note 

1The IntraHealth International report Saving Lives, Ensuring a Legacy (2010) recommends the U.S. Government invest at least $5.5 billion by 2020 dedicated to strengthening health 

workforce in partner countries to address severe shortages and human resources for health 

(HRH) deficiencies in U.S. Government partner countries. As of November 2014, the U.S. Government currently does not have mandated funding allocations for health workforce. A detailed 

explanation of the methodology used for this estimate is available in the report: http:// 

www.intrahealth.org/files/media/saving-lives-ensuring-a-legacy-a-health-workforce-strategy-forthe-global-health-initiative/IntraHealthlPolicylPaperl1.pdf. 

Senator COONS. Thank you, Mr. Gaye. 

Mr. Alvarez. 

FOREI-43947 with DISTILLER

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STATEMENT OF JAVIER ALVAREZ, SENIOR TEAM LEAD, STRATEGIC RESPONSE AND GLOBAL EMERGENCIES, MERCY 

CORPS, PORTLAND, OR 

Mr. ALVAREZ. Mr. Chairman Coons, Ranking Member Flake, and 

members of the committee, Your Excellency President, I would like 

to take the opportunity again to meet you. We met a couple of 

weeks ago in a social mobilization subcommittee, another subcommittee, and thank you very much for the support you are giving 

to the entire humanitarian community but also to Mercy Corps. 

Thank you for inviting me to testify today on this critical crisis. 

I speak today in my capacity as senior team leader of the Strategic 

Response and Global Emergencies Team for Mercy Corps, a global 

humanitarian and development organization. I have just returned 

from Liberia, where I served as Country Director for Mercy Corps 

Liberia. 

Mercy Corps has worked in Liberia since 2002, supporting its 

transition from civil war to sustainable economic and social development. While our core programs focus on reviving agricultural 

markets, job creation, and youth entrepreneurship, our Ebola 

response has focused on two pillars: reducing transmission through 

community education and mobilization campaigns, and to mitigate 

the socioeconomic impacts of the crisis on Liberian communities 

and the region. 

For the purpose of this hearing, I would like to focus on the second pillar, as my colleagues have covered already most of the 

health crisis. 

The Ebola outbreak has been largely approached as a health crisis. I am very glad to hear Madam President’s announcement today 

of the launch of the possible comprehensive plan, economic plan. 

From Mercy Corps’ perspective it is better understood as a system 

crisis, the failure of health governance humanitarian systems to 

prevent a disease from disrupting the socioeconomic order of communities and countries. 

Adopting a systems approach to the planning, management, and 

monetary needs are therefore critical, and the recovery efforts must 

right-size emergency efforts and work toward long-term development goals so that future shocks are not as disastrously disruptive. 

In October, Mercy Corps conducted an economic assessment to 

better understand the economic impacts of the crisis in people’s 

daily lives. We found three major findings now guiding our 

response. 

First, household incomes, food security, and food consumption 

have been greatly reduced by the Ebola crisis. Without targeted 

interventions and policy changes now, households could face a critical level of food insecurity by April–May 2015. 

Second, some of the protocols and policies associated with the 

Ebola crisis have put significant strain on the Liberian economy. 

And third, disproportionate economic impacts are being felt by 

youth, self-employed persons, and lower-wage workers. This threatens the stability of Liberia and the region. 

Food insecurity in Liberia was already widespread before the 

Ebola crisis, with 42 percent of the population considered food insecure and 32 percent of children stunted. As a result of the crisis, 

vulnerable households are reducing food consumed at each meal, 

FOREI-43947 with DISTILLER

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purchasing lower quality meals or less expensive food, and eating 

fewer meals. At the same time, some of the protocols deemed necessary for Ebola containment are creating constraints and blockages in the market system. These include border closures, market 

closures, and increased transportation costs and time. 

In August, the Government of Liberia closed borders with 

Guinea, Sierra Leone and Ivory Coast, imposed a 12 a.m. to 6 a.m. 

curfew, and recommended the closure of weekly markets. Goods 

that were previously sourced quickly and cheaply from Guinea and 

the Ivory Coast are no longer available. Traders cannot afford to 

move goods from Monrovia to northern markets due to increased 

costs, and a lot of agricultural goods spoil before reaching their destination due to the curfew. 

Traders currently cannot keep markets alive. Further compounding these economic stressors is the uncertainty of Liberian agriculture. Fortunately, weekly markets have been now reopened. 

This is welcome news. However, policies restricting movement are 

still putting downward pressure on the volume of goods moving 

between markets and households. 

Finally, the impacts of the Ebola crisis have had a disproportionate impact on low-wage workers and the self-employed, who are 

mainly urban youth. Seventy percent of Liberia’s population is 

under 35. Productive engagement of youth was a major priority 

and challenge before the crisis and will now be more difficult. It is 

thus critical that youth are at the center of early recovery planning, implementation and management, ensuring they gain the 

skills, opportunities and experience they need to become active 

drivers of Liberia’s economy. 

There are several short- and medium-term actions that can be 

taken to support markets, prevent a food security crisis, and lay 

the foundations for early recovery. Within the United States, we 

thank you for robustly funding the Ebola supplement and the 

International Disaster Assistance Account in the fiscal year 2015 

appropriations process. As you know, the humanitarian system is 

under extraordinary stress in the face of Ebola, Syria, Iraq, South 

Sudan, and the Central African Republic. 

We further urge that the administration should target short-term 

food security and income recovery interventions toward the worst 

affected communities, with the goal of increasing access to income 

through well-targeted cash programming with careful market 

monitoring. 

All relevant government entities plan and budget for a pro-poor, 

market-based early recovery strategy in Liberia in the region now. 

Strategies should seek to address the root causes of chronic underdevelopment. 

In Monrovia, changes to government-imposed regulations, so long 

deemed appropriate from a public health standpoint, could 

decrease economic stress. This includes opening the borders or 

negotiating an economic corridor to allow essential goods to cross 

from neighboring countries, addressing constraints that policies are 

imposing on trade. Issuing permits allowing commercial vehicles to 

travel during curfew hours and pass more easily through checkpoints is one idea. 

FOREI-43947 with DISTILLER

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Among donors and implementing partners, we recommend monitoring markets, prices, and systems constraints by investing financial resources and human capital in assessments; invest in learning 

and capacity-building; preventing regional economic decline by 

embedding market conflict and political economic analysts in 

regional responsive sectors; and ensuring close coordination between financial institutions, governments, NGOs, and civil society. 

Again, I wish to sincerely thank the subcommittee, and Your 

Excellency as well, for your leadership on this critical crisis, and 

the great honor of extending me the privilege of testifying today. 

I look forward to your questions. 

Thank you. 

[The prepared statement of Mr. Alvarez follows:] 

PREPARED STATEMENT OF JAVIER ALVAREZ

Chairman Coons, Ranking Member Flake and members of the committee, thank 

you for inviting me to testify before this esteemed subcommittee on the critical issue 

of ensuring a sustained and strategic international response to the Ebola crisis. I 

speak today in my capacity as Senior Team Lead of the Strategic Response and 

Global Emergencies unit for Mercy Corps, a global humanitarian and development 

organization saving and improving lives in the world’s toughest places. With a network of experienced professionals in more than 40 crisis-affected countries worldwide, Mercy Corps partners with local communities to help people recover, overcome 

hardship and build resilience to future shocks. 

Mercy Corps has worked in Liberia since 2002, supporting its transition from civil 

war to sustainable economic and social development. Our programs focus on reviving agricultural markets and creating jobs, with a particular focus on youth entrepreneurship and leadership and access to financial services. Our Ebola response has 

focused on two pillars based on close monitoring and assessment of gaps in the 

response: (1) filling a gap in community education on how to reduce transmission 

by mobilizing a robust social mobilization campaign, and (2) mitigating the socioeconomic impacts of the crisis on Liberian communities, and the region. For the purposes of this hearing, I will focus on the second pillar. 

I have just returned from 2 months in Liberia where I served as Acting Country 

Director for Mercy Corps Liberia. My testimony will outline how Mercy Corps sees 

the crisis, highlight findings from our market assessment and gaps we see in the 

current response, and will conclude by suggesting a series of short- and mediumterm solutions to ensure a successful international response. 

MORE THAN A HEALTH CRISIS, A SYSTEMS CRISIS

As my copanelists have detailed, Ebola has wreaked havoc across five West African nations since the outbreak began in February 2014. Liberia is the nation most 

severely affected by the crisis, suffering almost half of all cumulative confirmed, 

probable and suspected cases reported (7,690), with 3,161 deaths as of December 8, 

2014.1 Having originally arrived through the porous border with neighboring Guinea, it has spread from the rural Lofa County to reach every one of Liberia’s 15 counties including the capital city, Monrovia. This has created the most serious Ebola 

epidemic in history, which not only directly threatens the lives of tens of thousands 

of people, but jeopardizes the economic progress and stability Liberia has achieved 

since a protracted civil war ended a decade ago. 

The Ebola outbreak has been approached largely as a health crisis. From Mercy 

Corps’ perspective, it is better understood as a systems crisis—the failure of health, 

governance, and humanitarian systems to mitigate the threat of a disease from disrupting the socioeconomic order of communities and multiple countries. And the 

longer the crisis continues, the greater potential it has to contribute to another systems failure—a failure of market systems. 

Fortunately, Liberians and all West Africans have shown extraordinary resilience 

and ingenuity in the face of this crisis, transmission rates have started to slow and 

some market activities have resumed. However, this is no means for pause. The 

Ebola epidemic continues to cripple the economies of Liberia, Sierra Leone, and 

Guinea; has left thousands of civilians unemployed and hundreds of thousands of 

households more vulnerable to food insecurity; and the social fabric of an already 

fragile nation—just before a tenuous election season—has been further eroded. 

FOREI-43947 with DISTILLER

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Adopting a systems approach to the planning, management, and monitoring of 

this crisis—by broadening the set of analytical tools, planning strategies, and funding streams to address it—is critical to ensuring a successful crisis response and 

building more inclusive, responsive, and resilient communities and institutions 

along the way. 

MAJOR SOCIOECONOMIC IMPACTS OF THE EBOLA CRISIS

To better understand the socioeconomic impacts of the Ebola crisis on households, 

vendors and markets in Liberia, Mercy Corps conducted an economic assessment in 

Lofa and Nimba counties and in parts of the capital, Monrovia, from Oct. 3–13, 

2014. Findings from the assessment and our ongoing programs in Liberia point us 

to three major areas of focus for the response, and my testimony, moving forward: 

1. Household incomes, food security, and food consumption have been greatly 

reduced by the Ebola crisis. Without targeted interventions and policy changes 

now, households could face a critical level of food insecurity by April/May of 

2015; 

2. Some of the protocols and policies associated with the Ebola crisis have put 

a significant strain on the Liberian economy; and 

3. Disproportionate economic impacts are being felt by youth, self-employed 

persons, and lower wage workers. This threatens Liberia’s, and the region’s, 

stability. 

1. Risk of a food security crisis by April/May 2015 

Food insecurity in Liberia was already widespread before the Ebola crisis, with 

42 percent of the population considered food insecure, and 32 percent of children 

classified as stunted.2 Still fighting to recover from years of civil war, Liberia continues to be one of the world’s poorest countries, ranked 162 out of 169 countries 

in the 2010 United Nations Development Program (UNDP) Human Development 

Index, with up to 84 percent of its population live below the national poverty line, 

on less than $1.25 day.3

As a result of both the Ebola crisis and precrisis economic inequalities, vulnerable 

households started reducing the amount of food consumed at each meal (mentioned 

by over 90 percent of households interviewed in our assessment), purchasing lower 

quality or less expensive food, and eating fewer meals (mentioned by 90 percent and 

85 percent respectively). Seventy-seven percent of those interviewed cited borrowing 

money from friends and relatives as an additional coping mechanism. Households 

in general are spending most of their income on food products. These coping mechanisms could have lasting negative impacts on people’s nutritional status and economic investments and may jeopardize their future ability to recover. 

Constraints on household food security caused by reduced incomes and increased 

prices may also be compounded by uncertain agricultural yields from the next harvest. Upland and lowland rice harvests in October/November and January/February 

may provide temporary relief for agricultural households in Lofa and Nimba counties, but it remains unclear. If the overall situation continues without changes and 

if the economy experiences production decreases, food insecurity would increase significantly by April/May 2015. 

2. Constraints in the market system imposed by the Ebola response 

Some of the protocols deemed necessary for Ebola containment are creating additional constraints and blockages in the market system, namely: 

• Border closures, 

• Closure of markets, and 

• Spiked transport costs and increased transportation time due to the 12 a.m.- 

6 a.m. curfew, checkpoints, and other regulations. 

Regarding border closures, the Government of Liberia closed borders with Guinea, 

Sierra Leone, and Ivory Coast and at the same time recommended the closure of 

weekly markets as Ebola prevention measures in August 2014. As a result, goods 

that were previously sourced quickly and cheaply from Guinea and Ivory Coast are 

no longer available due to border closures, causing vendors to source replacement 

goods at higher prices with longer transportation times. 

One vendor we spoke with previously spent 2,000LD on a trip to Guinea to purchase goods for her shop. Now with borders closed, she must travel further to Monrovia to purchase goods and the trip costs her 5,000LD. She passes this cost increase along to her customers through increased prices at her shop in the market. 

Weekly market days have been reopened to allow for increased trade between 

counties. This is great news. However, policies restricting internal movement are 

FOREI-43947 with DISTILLER

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still puting downward pressure on the volume of goods moving between markets 

and households. 

The impact of Ebola policies on transport prices has also been significant. Border 

closures and reduced consumer demand have contributed to an increase in transport 

costs and a reduction in the number of vehicles transporting goods. Checkpoints and 

regulations limiting the number of passengers in vehicles, the inability of vehicles 

to travel during curfew hours, and delays due to road blocks have also contributed 

to the increase in transportation prices. A rapid assessment of the transportation 

market is needed to help inform a short- and medium-term program to increase 

access to transportation for economic purposes. A more robust transportation system 

can reduce market costs for consumers, including for food items, increasing households’ food security. 

3. Disproportionate economic impacts on workers and self-employed, including youth 

The economic impacts of the Ebola crisis have had a particular impact on workers 

and those who are self-employed—particularly youth in urban areas. A cell phone 

survey commissioned by the World Bank throughout October and November indicates generally lower incomes and jobs being shed in both the wage-earning and the 

self-employed sectors—sectors largely composed of youth.4

Liberian youth, defined as 15–35-year-olds, represent a third of the country’s population, with 70 percent of its total population under 35. Productive engagement of 

youth a priority and major challenge for economic development efforts even before 

the crisis, as social ties between youth and their communities were severely damaged by the country’s long civil war, the resulting displacement, and rural-to-urban 

migration making. 

Many of these youth have been frustrated by the international community’s postconflict response to Liberia for over a decade, feeling that their opinions have 

marginalized from planning processes and their capacities for productive engagement in society disregarded. In this capacity, youth are key to reducing risks of 

future instability in Liberia. 

It is thus critical that youth are at the center of early recovery planning, implementation and management, ensuring they gain the skills, opportunities and experience they need to become active drivers of Liberia’s economy. 

RECOMMENDATIONS FOR IMMEDIATE AND FUTURE ACTION

There are several short- and medium-term actions that can be taken in the U.S., 

in Monrovia, and within the humanitarian response to mitigate the cascading socioeconomic impacts of the crisis on households and the region, prevent a food security 

crisis in April/May 2015 and lay the foundations for early recovery. 

Within the U.S., we recommend that: 

1. Congress robustly fund the International Disaster Assistance Account in the FY15 appropriations process at $3.5 billion given the extraordinary demands on the 

global humanitarian system in the face of Ebola, Syria, Iraq, South Sudan, and the 

Central African Republic. As you surely know, the United Nations appealed Monday 

for a record $16.4 billion global appeal in order to address unprecedented global 

humanitarian needs in 2015. 

2. The administration should target short-term food security and income recovery 

interventions toward the worst affected communities, with the goal of increasing 

access to income through well-targeted cash programming with careful market monitoring to ensure food supplies are available. 

3. All relevant government entities should simultaneously and jointly plan and 

budget for a pro-poor market-based early recovery strategy in Liberia that addresses 

the root causes of underdevelopment. U.S. strategies should be aligned with those 

of Liberian youth and civil society, the Government of Liberia, U.N., World Bank, 

and other major actors, and must seek to lay the foundations for an economic recovery agenda that addresses the root causes of economic inequality, stagnation and 

chronic underdevelopment. 

In Monrovia, changes to government-imposed regulations, so long as deemed 

appropriate from a public health standpoint, could lessen the spikes in transportation costs that are reducing economic activity and increasing household vulnerability. These include: 

1. Open the borders or negotiate an economic corridor to allow essential goods to 

cross from neighboring countries by traders screened at the border. 

2. Address constraints that the curfew is imposing on trade. Issuing permit to 

commercial vehicles to travel during curfew hours and facilitate their passage at 

checkpoints could immediately address some of the time burdens that traders currently face. 

Within the donor and implementing partner community: 

FOREI-43947 with DISTILLER

36 

1. Monitor markets, prices and systems constraints iteratively by investing financial resources and human capital in sustained multisector assessments. Pay close 

attention to any shortages or adverse economic effects and take corrective actions, 

as necessary. 

2. Invest in learning and capacity-building throughout the response. We have a 

responsibility to learn from this crisis, capture and utilize transferable knowledge, 

and support local leadership of Liberians at every level of the response. 

For example, Mercy Corps’ current USAID-funded social mobilization Ebola prevention program, the Ebola Community Action Platform, has a major learning component focused on real-time information gathering to understand how communities 

respond to information in this crisis, to inform feedback on immediate improvements 

to programming and lessons for strategic planning to disaster risk reduction and crisis prevention in the future. While I did not focus on this program during my testimony, I am happy to discuss it in Q&A. 

3. Stay ahead of the potential for regional economic decline by embedding market, 

conflict and political economy analysts in the UNMEER structure, and ensuring 

close coordination between financial institutions such as the World Bank and African Development Bank, government actors and NGOs. 

Again, I wish to sincerely thank the subcommittee for its leadership on this critical crisis, and the great honor of extending me the privilege of testifying today. I 

look forward to answering any questions. 

———————— 

End Notes 

1http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html. 

2DHS , Republic of Liberia—2013. 

3World Bank, Liberia—poverty headcount ratio. http://data.worldbank.org/Country/Liberia. 

4World Bank, Update on the Economic Impact of the 2014 Ebola Epidemic on Liberia, Sierra 

Leone, and Guinea, December 2, 2014. http://www.worldbank.org/en/topic/growth/publication/economic-update-ebola-december. 

Senator COONS. Thank you very much, Mr. Alvarez. 

I would like to thank the entire panel. 

We have a relatively brief period, so I will have us go to 5-minute 

rounds, and I am just going to ask one question of each of the four 

of you. If I could ask for a relatively concise answer, that will allow 

my colleagues a chance to question as well. 

You have said, Dr. Farmer, this is a caretaker disease in the context of very weak health systems. I will carry the phrase ‘‘zoonoses’’ 

with me from this hearing, something I will drop casually in social 

settings in Delaware and impress people with my great knowledge 

of zoonoses, something I was previously unfamiliar with. 

The challenge of having a clear term for what it means to do 

public health systems strengthening I think can best be summarized this way. As Senator Durbin said to me, when we roll up a 

major intervention that includes DOD and the Public Health Service and then leave, sometimes we look at what are we leaving 

behind. And I hope we would instead look at what are we doing 

to build health forward. 

What are we doing, as you put it, Dr. Peterson, to invest in 

building sustainably? Are we, as we respond to this emergency, 

building sustainable public health systems for Liberia, Sierra 

Leone, Guinea, and the region? 

So, Dr. Farmer, my question for you: What is the one thing in 

your view that we would do that would most contribute to building 

forward a meaningful public health system? 

To Dr. Peterson, one of your points was that we need to more 

effectively listen to the faith community on the ground. What is the 

number one thing you would urge us to do to incorporate that into 

our responses? 

FOREI-43947 with DISTILLER

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To Mr. Gaye, how do we engage the African diaspora better and 

mobilize the resources that the President referred to of the many 

doctors and health care workers who have fled the region during 

conflict and could possibly be returned back? And how does health 

worker safety play into that? 

And if we have any time left, Mr. Alvarez, what role does stigma 

play in the economic impact? My concern is that the regional economies, as you pointed out in great detail, are heading south rapidly, 

and if we do not open borders and reduce stigma, we will not 

return to economic growth and thus real recovery from this Ebola 

outbreak. 

Thank you to all four witnesses. I would urge you to endeavor 

to give brief replies. 

Dr. FARMER. Concision is not my strong suit, Senator, but I will 

skip ahead from the obvious point that we need these four S’s: 

staff, stuff, space, and systems. It is a point that has been made 

by the President, by everyone here. 

I think, to take a critical look at the legacy of our investments, 

we should just use some examples. When we say we need to build 

local capacity, that term can be distorted and perverted in many 

ways. It could end up meaning, as it often does, 2-day workshops 

on infection control, say, or clinical management of Ebola. That is 

not really what our colleagues and partners need. 

They need the same things that we have, formal credentialed 

training programs in medicine, in nursing, in public health, and in 

health care management. Those take years to build. That is why 

I think the President mentioned the Human Resources for Health 

program that the Clinton Foundation had been working on with 

the Ministry of Health for many months before the crisis. That is 

a program that deserves to be supported, and it is what our partners are asking for. 

So the differences between a workshop, fine, but not what we 

need, which is long-term training programs. It took me 8 years to 

train as an infectious disease doctor. It takes a surgeon even more. 

And there is so much human capital in this part of the world, there 

is so much talent. Give them a chance to have formal training. 

The second point I will just pass on is look at the infrastructure 

that we are building. I actually had a picture—I am sorry I do not 

know how to resurrect it on the screen—comparing an Ebola treatment unit that I saw in rural Liberia with the hospital that we 

built in rural Haiti, also an unelectrified region. It is the largest 

solar-powered hospital in the developing world today. It is the largest training center for Haitian doctors and nurses. It is the kind 

of investment that we need to link to our emergency response in 

West Africa. 

Thank you. 

Senator COONS. Thank you, Dr. Farmer, and thank you for being 

with us. 

Dr. Peterson. 

Dr. PETERSON. Thank you for your question. I think that the best 

way to explain how we can listen better to communities and link 

to faith-based organizations is to talk about some of the things that 

are actually happening and happening well in Sierra Leone, and I 

saw it more in Sierra Leone than in Liberia. 

FOREI-43947 with DISTILLER

38 

World Vision is leading a number of coalitions. The coalitions 

include Christians, Catholics, and Muslims together. One coalition 

is pulling together burials, safe and dignified burials in 12 of the 

14 districts, allowing families to have someone to pray for their 

loved ones, to meet the cultural traditions. They are also trusted 

by the donor, in this case DFID, because the Ministry of Health 

money did not actually pay the burial teams, but World Vision as 

an organization that knows how to do fiscal management can manage logistics, can do fiscal management, and is beginning to do that 

very critical service to the community in a way that both meets 

donor needs and meets the people’s cultural needs. 

Similarly, there is another coalition, again Muslim and Christian 

and Catholic, that is looking at what are the important messages 

that the community needs to hear, what are their fears, how do we 

frame the science that we have from CDC and NIH in a way that 

it is understandable in a faith language. They are putting together 

training for faith leaders—Muslim, Christian, pastors, priests—and 

beginning to reach through that whole network of faith leaders into 

the communities, which will begin to transform behavior. I think 

that is how we can do it. 

Thank you. 

Senator COONS. Thank you. 

Mr. Gaye, briefly. 

Mr. GAYE. Yes. Thank you for the question on how to better 

engage African diaspora. There is a lot of talent sitting in this 

country, and in these phases of crisis there are a lot of people who 

want to help. 

I think there are only two very simple things we need to do, and 

they are both about information. A lot of people want to help. They 

do not know where to go. If we manage to create good information 

flows and collect a repository of groups that are doing this, I think 

that we will go a long way. 

The second thing we need to do is to build on the platforms that 

already exist. There are some very good examples of practices that 

I would certainly encourage. The Global Health Corps is one of 

these. I think the young Barbara Bush is leading that. It is very 

clever in pairing up young American and young foreigners to 

engage in an internship. In fact, IntraHealth is hosting two of 

them. They might even be in the room. So programs like that need 

to be replicated because I think they expand the idea that you 

could serve Africa by being here. 

Then we can look into examples in the private sector. Pfizer, for 

example, has a great global health program where they encourage 

their employees to go overseas. For the majority of companies that 

have these programs, it would be fantastic for the diaspora that 

works with these companies to know these programs exist. So I 

think we need to publicize more of this. 

It is all about information and providing the right information. 

Senator COONS. Thank you, Mr. Gaye. 

Mr. Alvarez, in one sentence, how do we deal with economic stigma? 

Mr. ALVAREZ. So, yes, I think it is part of an equation. The stigma of the survivors returning back to their communities is becoming a huge issue, as the representative already mentioned. There 

FOREI-43947 with DISTILLER

39 

are more and more survivors. So the ones that want to come back 

are sometimes ostracized and sidelined. So those people, if we see 

them as engines of change in the economic recovery, we are losing 

a huge opportunity. 

Again, it all comes down to information, misinformation, community involvement. And, of course, you know, the movement of goods 

has been reduced, and we see that as affecting the livelihoods of 

households. There will be more food insecurity. 

So stigma is going to become the next big issue. Messaging so far 

has been focusing on ‘‘Ebola Kills,’’ ‘‘Ebola is Real.’’ It has been 

more promoting the negative. Now we are at a juncture that that 

messaging needs to change, and we have to offer people the hope 

and the forward looking that we are seeing from the fears. 

Thank you, Mr. Chairman. 

Senator COONS. Thank you, and I would like to thank our whole 

panel. 

Senator Flake. 

Senator FLAKE. Thank you. 

I appreciate the testimony, and I know it must be intimidating 

speaking with the President of Liberia literally looking over your 

shoulder here. [Laughter.] 

It speaks well for her that she wants to hear what is going on 

here. 

I just have one, in my limited time here, one question that I hope 

all of you can address very briefly, and I hope that we can follow 

up with you. 

We have a phenomenon here often when we fund operations 

overseas—just take Afghanistan, for example. We are finding many 

examples now of appropriating a lot of money that builds a facility 

that was right and proper for an occupying force but does not serve 

those who are left behind. We have talked with some of you saying 

we need to address the concerns of health workers that will be 

there afterward, after the expats leave. 

What would you caution us in terms of how we appropriate, and 

procurement rules, and whatever we have to deal with here to 

make sure that we can respond nimbly to the changes that are 

being made? I would think that we may not have thought a couple 

of months ago that Liberia would be in the situation that they are 

right now with just 10 new cases per day. We want to make sure 

that the funding we provide, the resources we provide are addressing the needs now and in the future rather than addressing needs 

in the past. The last thing we want are facilities that we built that 

were fine for a lot of expats there or the response that we have had 

in the past rather than public health centers that we need in the 

future. 

What cautions would you give us or what advice in terms of our 

role here in terms of oversight now that can help for the long term? 

Dr. Farmer, any thoughts? 

Dr. FARMER. Thank you very much, Senator. That is a terrific 

question, and I think if I were to signal the biggest trap I think 

for us—for you and for us—is the trap of double standards, which 

is very common, I fear, in development work in public health, international health. 

FOREI-43947 with DISTILLER

40 

Example: If we build a facility, one of the things that we should 

be pushing for as a metric is very low case fatality rates. So, in 

other words, people who are diagnosed with Ebola, what is the 

harm of saying, as people who are supporting this, we want to see 

less than 10 percent die? We want 90 percent survival rate. What 

is the harm of that? There is no harm. 

No American has died from Ebola because when they get into the 

embrace of our—granted—dysfunctional health care system, they 

get good critical care, and you cannot take care of people with 

Ebola who are losing up to 10 liters of fluid a day from vomiting 

and diarrhea without good medical care, with an intravenous line 

and a nurse or a physician administering it. 

So I think we should reject the double standards. What is appropriate for the physiology of a Liberian or a Sierra Leonean or a 

Guinean with Ebola is the same as what is appropriate for us. It 

is just that they do not have the systems, and we should help them 

build them. 

I think the other big trap is related; the trap of the contractual, 

the trap of thinking there is a beginning and an end to this accompaniment process. This is going to be a long term. We are making 

significant investments in West Africa. We should be thinking long 

term, just as the President said. We have to link our emergency 

response to rebuilding systems, and that is going to take a long 

time. 

Senator FLAKE. Thank you. 

Dr. FARMER. Thank you, sir. 

Senator FLAKE. Dr. Peterson, briefly. 

Dr. PETERSON. Yes, thank you. I spent a lot of time in Afghanistan, so I actually really appreciate that question. The rebuilding 

of the health system within Afghanistan, I think, is very appropriate for this issue because, in fact, they did it fairly systematically. 

I will also repeat my earlier comment that listening is very helpful. The Minister of Health of Afghanistan said no-thank-you to a 

great big clinic hospital in the center of Kabul. What she wanted 

for her country were rural centers, training of midwives and community health workers. And that, in fact, built the long-term 

sustainability. 

The other thing that Afghanistan did that I think would make 

a difference in this Ebola response is they focused on management 

training for the health system, for the provincial and medical and 

district directors. How do they actually do fiscal accountability? 

How do they do supply logistics? Some of our NGOs provided that 

kind of expertise for health systems management, and I think that 

was really key. 

The other piece in the management rebuilding that helped there 

and could make a big difference in Africa is the whole health management information system, another not very sexy acronym, but 

set up data that provided transparency so that it was harder for 

money to go astray and easier to know whether you were truly 

making the difference in improving the health system. 

If we took some of those experiences that worked well in Afghanistan, not everything worked well, but those things that did work 

well and applied it to rebuilding the health system in the West 

African context, I think we would do better. 

FOREI-43947 with DISTILLER

41 

Thank you. 

Senator FLAKE. Well, thank you. 

My time is up. But if you can briefly, very briefly, respond? 

Mr. GAYE. So, just a couple of points. One: is it is a different type 

of mind-set to get into building these systems because it does take 

a little longer. I know that the issue of the health workforce is not 

new. Senator Durbin, I know for a fact that in 2008 you supported 

legislation to support the health workforce. So that is the first 

mind-shift we need to make. 

Second, we do need to have a good strategy to guide this investment, a strategy that is going to do one thing, make sure that at 

the country level we have checks and balances. The way you are 

going to do this is by investing more with civil society. There are 

a lot more actors in the countries that are ready to jump in, and 

we just need to create a safe space and a good space for them to 

engage and support the government work. 

Mr. ALVAREZ. Thank you. Just one very quick point. I think one 

of the more intelligent approaches to funding of partners in Liberia, agencies like Mercy Corps, we would like to see very flexible 

approaches to funding. I mean, the situation is evolving. There are 

a lot of moving pieces. So moving from an emergency standpoint 

that we are close to coming to an early economic development 

phase that will allow us to be able to be responding to the reality 

on the ground. 

I think another very important piece of advice, very humble 

advice to give the committee, would be that partners have continuity on the ground. When we saw that the outbreak was there, 

a lot of partners left the country. I mean, agencies like Mercy 

Corps and other agencies stayed put, and we have to stay put. 

There was a fear of the unknown, but we stayed put, and we continue doing our business. 

So I think that will be another piece of advice. Thank you. 

Senator COONS. Thank you, Senator Flake. 

Senator Durbin. 

Senator DURBIN. Let me address—and I invite President Sirleaf. 

Perhaps she can join in responding. Let me address the economics 

that I found in some parts of Africa. I do not know West Africa as 

well. Here is what I found when it came to the health care staff 

and people engaged in this field. 

I found that there was a limited capacity for training and education. There was a long-term commitment necessary so that they 

would develop the skills and training necessary to become doctors, 

nurses, even health care workers. There was a limited capacity in 

terms of what training was available, teaching was available, colleges were available. 

I found that those that did graduate many times became employees not in the private sector but in the public sector, working for 

the government of their countries. 

I found that they were paid, by Western standards, a very small 

amount of money each month, and that many times went unpaid 

for months when the countries would get into budgetary problems. 

I found that these skilled health workers, whether they are doctors or nurses in particular, were often poached by England, 

Europe, and the United States, which could offer them multiples of 

FOREI-43947 with DISTILLER

42 

their promised salaries in Africa, and they took the invitation and 

left. 

How do we stop that from happening? We are talking about an 

investment here in a bill we are about to vote on of $5.4 billion, 

according to the Chair, into these countries. I would imagine 

whether it is Liberia, Sierra Leone, or Guinea, that this is a dramatic increase over the usual public health budget in each country. 

This is going to fall like manna from the heavens, and the question 

is how do we translate that into long-term growth of the workers, 

the health workers that create public health systems, when there 

is always the lure of leaving and making a lot more money? 

Dr. FARMER. Well, I am sure the President has something to say 

on this. She comes to mind in the exchange we had, Senator. As 

you all know, the nursing and medical schools are closed in the 

course of the epidemic. So the training is not happening. 

Going back to this experience in Rwanda with the Human 

Resources for Health program that we have been proposing 

through the Clinton Foundation and working with our Liberian colleagues, but also in Haiti, to say when have we succeeded in stopping the brain drain? Is it by limiting the free movement of the 

professionals? No. It is by drawing them back into better health 

care systems, including public systems. If I were to name a third 

trap, in response to Senator Flake, it is that if we avoid the public 

sector, that will be a mistake, the Liberian institutions for example, or Sierra Leonean institutions. 

The hospital I mentioned in rural Haiti may have been built by 

Partners in Health, but it was built by Partners in Health with 

people from your city, in fact, as you know, very rapidly, 18 months 

after the earthquake, as a public facility, a teaching facility, and 

that is why the head of surgery came back after 20 years at Harlem Hospital. That is why the head of medicine came back, Haitian, 15 years in France. That is why the chief of nursing, raised 

in the United States but a Haitian-American, is there. They have 

good facilities, and that is a metric we can use if we are putting 

in billions of dollars. 

Senator DURBIN. Can I invite President Sirleaf? Could you 

address how much is a doctor or nurse or health care worker paid 

in Liberia, and can you put it in the context of the average wage 

and whether they are above that? 

President SIRLEAF. Let me say that I was a little bit disappointed 

in ourselves that we were not paying our doctors as much as they 

should get. Yes, they get much of what the average wage is, but 

they do get less than, say, some of our high-level officials, and that 

is something that we are going to correct. Doctors were getting 

anywhere between $1,500 and $3,000 U.S. dollars, and we do have 

certain high-level officials that get well over that, somewhere 

between $5,000 and $6,000. So we are going to have a policy decision that says that they are going to earn as much as our highest 

officials earn because they make a great investment to get to where 

they are, and they certainly give great service to our country. So 

that is going to be corrected. 

Senator DURBIN. Thank you. 

FOREI-43947 with DISTILLER

43 

President SIRLEAF. I do agree generally with all the testimony 

that has been made, and I would just like to make three quick 

points. 

First, our plan is an evolving one. It is an evolving one that 

makes the transition from containing Ebola to improving our 

health care systems to going on to economic recovery. And that 

evolving plan will ensure that we will have permanence in trying 

to ensure that we are able to respond to any such breakdown, 

whether it is through Ebola or a recurrence, or whether it is 

through other types of diseases. 

It will also enable us to have personal capacity through increased 

per capita incomes that will enable people to live better and to 

respond to their own health needs in a much more effective way 

on a personal basis. 

The second thing is capacity. I could not agree more with Dr. 

Farmer that capacity is the key. In our 10-year plan for improving 

the health care workforce is to build that capacity at all levels, particularly at the bottom—it is like a pyramid—training over 30,000 

health care workers at the community level to provide basic health 

services, and then moving on up to ensure that we then have the 

physician assistants, the midwives, the nurses, and then finally at 

the apex, the doctors who are very specialized. So we want to see 

that plan implemented. It is a long-term plan, but we want to get 

it started, and we want to make enough progress within the next 

2 to 3 years. 

Finally, the involvement of the communities. Our success in 

Ebola has been the active participation and ownership of our communities. As long as we got them involved where they took responsibility to go there and find the sick, to call and have them taken 

to treatment centers, to be able to respond to those quarantined in 

the communities, to work with us, we began to get success. So we 

are going to, in this final push, make sure that the community 

workers take the lead role and we provide them with the support 

they need for us to get this job done. 

Thank you again for this great hearing. 

Senator COONS. Thank you, Madam President. Thank you for 

your remarks today. 

Senator Shaheen. 

Senator SHAHEEN. Thank you. I do not have anyone in particular 

to direct my question to, but as we look at the outbreak in Mali 

and the potential for other countries, neighboring countries in 

Africa to be affected, how concerned should we be about that? What 

kind of lessons have we learned that will help us address those outbreaks, and why was Nigeria able to respond so quickly and 

address the outbreak there? 

And finally, are there any lessons from our involvement with the 

AIDS virus and the PEPFAR program that should have translated 

here or that we should be looking at as we think about the current 

outbreak of Ebola? 

Whoever wants to take it. 

Dr. FARMER. We are dying to take it. 

Dr. PETERSON. All of us. [Laughter.] 

I do not think I can speak for Nigeria except it certainly had a 

more intact health system, which helped enormously. For Mali and 

FOREI-43947 with DISTILLER

44 

the other countries where the health system is weak, it is a danger. 

One of the things that I think we could do much more quickly and 

much better is take what we have learned in Liberia and Sierra 

Leone and bring it there. 

I went from Liberia for 10 days and then to Sierra Leone, and 

both countries were frantically working on their burial protocols 

and their case management protocols and their logistics protocols, 

and they were both doing it at the same time. Well, we now have 

them, both countries have them. We could take that learning and 

bring it to those countries. 

Senator SHAHEEN. Could I just interrupt for a minute? I apologize, but when you say ‘‘we,’’ who are we talking about as ‘‘we’’? 

Is this something that we are hopeful that all of the organizations 

that have been working in the currently affected countries will do? 

Is this something that the U.N. mission should do? Is this something that the United States, that all of us—who is the ‘‘we’’? 

Dr. PETERSON. A brilliant question, because in each of these 

places it is the combination of the aid agencies and the local governments that are heading every single one of these committees, 

pillars, et cetera. I found that there was not any communication 

going on between Sierra Leone and Liberia. In fact, because I had 

sat in both of those meetings and I was on their email list, I 

started getting all of the case management protocols from Liberia 

and said could I send these to Sierra Leone, and I was a complete 

outsider. 

So this is that cross-cutting collaboration. If there was somebody 

who would take that broad view and say here are all the things 

that we have learned—maybe it is UNMEER—and bring it to the 

next country so that they do not have to go through, actually which 

was what was several months of very good and very hard work, in 

order to do that collaboration. 

As far as learning from the AIDS, I will give an example again 

from the faith community. World Vision had put together a platform they called Channels of Hope for HIV/AIDS. It was designed 

to train pastors, imams, other clerics in that sensitive HIV issue, 

how do we talk to these faith leaders about AIDS and sex, and how 

do they talk to their congregations. World Vision is using that very 

same platform for training on Ebola to imams, priests, and others. 

So those are the kinds of uses of AIDS platforms that I see going 

on that we should continue. 

Thank you. 

Dr. FARMER. Can I just say, Senator, that this is the pertinent 

question in global health, because prior to PEPFAR, there were no 

major huge programs in global health. They were post-colonial 

projects. They were public sector engagement inside one’s own 

country. So this was the big game changer. 

There is kind of an ugly secret that preceded it that is worth 

remembering, in the spirit of your question, and that is socialized 

for scarcity. What our colleagues, what we did in public health was 

to pit prevention against care. 

Of course, that is why the epidemic continued unfettered, 

because these arguments about managing scarce resources, they 

really lacked any kind of intellectual depth. They were really all 

just about funding and scarcity. 

FOREI-43947 with DISTILLER

45 

What turned that around and made this a success story, especially in the most heavily affected areas? Easing the scarcity with 

substantial investment, of the level you are talking about for Ebola, 

and then integrating prevention and care. Then guess what happened? People who were told—and this point was made already by 

the President and by several of us. If you are told that you are 

going to die if you get Ebola, then why not stay home? But if you 

are told we can help you, we can take care of you, we can help you 

survive, we can make sure you get treatment, people come in for 

screening, and then we can find out who does not have Ebola and 

get them treated for malaria or whatever else, or get them back on 

therapy, including treatment for AIDS. But we need to avoid, this 

time around, that debate, pitting prevention against care. 

Senator SHAHEEN. Thank you. 

Mr. Gaye. 

Mr. GAYE. Yes, a couple of quick points on lessons from HIV/ 

AIDS. Of course, we see great results when there is rapid mobilization and engagement of everybody that needs to be engaged. We 

saw the tremendous impact of engaging religious leaders in the 

HIV/AIDS fight. So with Ebola we have a lot of similarities with 

stigma and rumors and so forth. So, I think that we can apply 

these lessons immediately. 

On the question of should we worry: yes, we should worry, 

because the health systems of these countries are extremely weak. 

This is the time when you say I wish we had invested more in 

frontline health workers and health workers that were closer to 

their communities, because in the end they are the ones who are 

delivering the services. They are the ones. I mean, we have seen 

it. Study after study has shown that we can reduce these people 

leaving if we recruit at the community level, at the local level, 

because when people are recruited and trained where they are 

from, they tend to go back, and they tend to stay there. 

So those are some of the things that I think we could do. 

Senator SHAHEEN. Thank you. 

Mr. Alvarez. 

Mr. ALVAREZ. Thank you very much. So, what I saw there when 

I was in Liberia was that the numbers started to go down and 

there was a trend identified that was stable between 10 and 20 

cases that the person had mentioned, and in my view it has been 

a lot about information. The system, the health system has been 

able to produce detailed information, where these contacts were, 

which countries, what contact tracing they had, and that information has been able to feed back into the response and be able to 

track down the disease. 

So it has been a reverse trend. Whereas before the disease was 

hunting us, now the Liberian Government and other health 

authorities are hunting the disease because they know where they 

are. 

So, how worried should we be about all of this? Very worried. 

But we think that closing down the borders, if we have that information, should not be one of the measures, or at least the borders 

are porous anyway, so we should be able to let people cross. I 

mean, in the north, food insecurity is becoming a big, big issue. 

Markets are closed. There were traditional border crossings, and 

FOREI-43947 with DISTILLER

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we should still put in the systems to monitor people crossing those 

borders, to be able to first sell their goods, and second get their 

goods. 

So it is very important data and how these data are being produced to respond locally to this disease. Thank you. 

Senator SHAHEEN. Thank you all very much for being here today 

and for your great work. 

Senator COONS. Thank you, Senator Shaheen. And thank you, 

Senator, for focusing us on what are some of the basic questions 

here. Having invested billions of dollars through PEPFAR in what 

is understood as the fight against HIV/AIDS, we have also 

strengthened health systems in dozens of countries. And the progress in fighting polio, for example, has largely been made possible 

by the health system investments made through PEPFAR. It is our 

hope that we will focus our response to Ebola in also strengthening 

systems regionally. 

Senator Markey. 

Senator MARKEY. Thank you, Mr. Chairman. Thank you for having this very important hearing. 

Dr. Farmer, could you talk a little bit about the different cultures 

in Liberia as opposed to Sierra Leone and Guinea? 

And we congratulate you, Madam President, for your tremendous 

leadership and work in helping to really focus in and isolate this 

problem in your country. 

But just generally speaking, could you just explain why it is so 

successful in Liberia and not so much in the other two countries? 

Dr. FARMER. Thank you, Senator. 

He is setting me up, Madam President, because he knows I 

also have a Ph.D. in anthropology, which makes me cautious in 

answering. 

I have heard, and read as well, about differences in those two 

countries that are fundamentally cultural, linguistic, historical differences that would determine the pace at which there has been 

uptake, for example, of safe burials or improved infection control 

practices. You have heard those claims made as well. 

I am not sure that it is a good idea to put too much faith in those 

claims yet because we have failed so far in Sierra Leone to have 

a real collision between modern medicine, including prevention, 

and Ebola, and that is true as far as safe burials goes as well. 

So, the focus for us, as Anne said, should be on listening to people, on talking to religious leaders, and that has been done perhaps 

more successfully in Liberia than elsewhere, and I wish I knew 

more about Guinea. But in each of these places, the response needs 

to do that better, to listen more carefully, to engage with religious 

leaders and families in their homes, and to have frontline workers 

be our other bridge, as well as religious communities, to the household. 

It is not that that is an a-cultural process, right? But that is 

something that is—working with community health workers, in my 

experience, has worked in Haiti, in Boston, in Rwanda. It is a 

structural intervention that needs to be shaped to local cultural 

practice but can give a very big return, I think, regardless of which 

part of West Africa we are. 

FOREI-43947 with DISTILLER

47 

Senator MARKEY. Do you think it would be helpful if there was 

a larger U.S. presence in the other two countries given what has 

now happened in Liberia, that if we ramped up a larger U.S. presence in the other two countries, that it could make a big difference 

in telescoping the timeframe that it would take in order to successfully replicate what has happened in Liberia? 

Dr. FARMER. You know, I would just say having a larger 

expatriot presence is a good thing if those expatriots, regardless of 

their origin, have the skills that are needed, and some of those 

skills are clinical skills, as was noted. That is, delivery is a big 

problem, Senator. We have the right ideas, we have the information, but we are not delivering, especially that last mile, in rural 

areas. 

So logisticians we still lack. President Sirleaf said before that 

there is more electricity generated to power the Dallas Cowboys 

stadium than the entire country of Liberia. 

So there are things that we need, and I would say bring it on. 

I think the United States, as Pape Gaye said, we have had this 

mantle of leadership in global health for the last dozen years, if not 

15, and I think we would be welcome. So are the Cubans welcome 

because they are bringing delivery capacity, and so are those who 

can bring laboratory capacity and logistic capacity. 

We have a long way to go, it seems to me, especially out in the 

rural areas. 

Senator MARKEY. Dr. Peterson. 

Dr. PETERSON. Thank you. I went from Liberia to Sierra Leone, 

so I got to see a little bit of the comparison, and when I look at 

the epidemiology of what happened, the Ebola epidemic made a 

round, a very fast, fierce round through Liberia, and we saw a lot 

more cases there early on than we saw in Sierra Leone. Sierra 

Leone is doing the same round, started in one part of the country 

and moving from hot spot to hot spot, but it has done it more 

slowly. 

I think what we are seeing now is completely predictable because 

the place it had not yet reached was Freetown. It had not reached 

Freetown with its slums that have no running water, that have no 

sanitation, where people are very close together. It was just arriving there as I left a month ago. So Sierra Leone has a larger population. 

In the end, are the epidemics going to be really different? I do 

not know. We can and should roll up a much stronger response in 

the urban and peri-urban areas, especially of Sierra Leone. It is 

possible in each of the countries they could do another round 

because it has been hot spot to hot spot. I think we are now ready 

to jump on and stop each one of those new satellites from expanding, and that should be our focus. So, back to the communities and 

identifying every patient. 

Senator MARKEY. Thank you. 

Senator COONS. Thank you, Senator Markey. 

Senator Murphy. 

Senator MURPHY. Thank you very much, Mr. Chairman, and 

thank you, Senator Flake, for convening this hearing. 

Very impressive, Madam President, your testimony and your 

willingness to continue to be part of this hearing. 

FOREI-43947 with DISTILLER

48 

Senator Markey really asked the questions that I wanted to ask, 

and so I saw, Mr. Gaye, you nodding your head. So I am just going 

to extend the question to you, and I will really focus on the second 

half of Senator Markey’s question, which is this query of where the 

United States should be and whether there is a role for us in 

Sierra Leone commensurate to the role that we have been playing 

in Liberia. 

The British are there, but there have been criticisms of their 

ability to put together the kind of coordinated effort that we have 

helped, along with the President and her team, in Liberia. So, I 

would just love your thoughts on this question as well. 

Mr. GAYE. Sure. Yes, I think there is a great role, a critical role, 

a strategic role for the United States to play. I am not sure that 

the answer would be to send more people from here. I think we 

should strive to foster local solutions. I think we should recruit 

President Sirleaf, who has taken great leadership here and who 

has really demonstrated what we need to hear more and see more 

from the African leadership: a high level commitment to the issue 

of the health workforce. 

This is the human part of the health system. This is the entry 

point. Without the person, without the people, without the health 

workforce, we just cannot do anything. So we need to embrace this 

idea of a people-centered health system. When people think about 

health systems they usually think about infrastructure, the supply 

chain, or the costing. Economists come and give you a lot of the 

studies. 

Paradoxically, we do not think about the most important element: the people we are trying to serve and the people who do the 

serving. This is why I think we need to, again, reelevate the importance of the health workforce, get the local commitment and look 

for local, national, and regional solutions in the long term. The 

United States is better placed than anybody to orchestrate that 

because of this leadership that we have been talking about. 

Senator MURPHY. The quickest way that the United States can 

deploy more personnel is through the military. Have we reached 

the limit of what military personnel can do inside—we are talking 

about Liberia, but the British have people, other places—or is there 

a utility to increase the numbers throughout the region from the 

one sole source that we have that is quickly deployed, being our 

military? 

Mr. GAYE. We need to win this fight quickly, so I think we need 

to bring all the forces we can to do that; as long as we also take 

the opportunity to reengage and recommit to really building the 

systems that are going to make sure this does not happen again. 

Senator MURPHY. Dr. Peterson, I am going to ask a version of the 

same question that has been asked a number of times, which is 

how do we sustain this effort, and I want to just maybe ask you 

the question in this frame. We talked about the fact that there is 

a lot of money all at one time, and anyone else can answer this as 

well. 

How do we think about time-releasing this money? Should we be 

thinking about mechanisms by which this money is spent over a 

longer period of time rather than all at once? If we think about how 

we actually make this be impactful 5 years from now, is this not 

FOREI-43947 with DISTILLER

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just about what we choose to fund at the here-and-now moment? 

Should we consider reserving portions of it, or should we just spend 

it all now on the crisis and then come back to Congress and fight 

for more later on? As this might be our only bite at the apple, and 

if you have this kind of money and this kind of leverage, how do 

you spend it? 

Dr. PETERSON. Thank you very much. I think perhaps both. We 

clearly have an urgent task that needs to be done now. But if we 

only address it from the urgent standpoint, if we do not reach out 

and deal with the economic issues, the drivers that are leading food 

insecurity and breaking quarantine, all these other issues are both 

important for the society itself and they are also part of the driver 

in the people’s and the communities’ response for infectious 

disease. 

Our emergency response teams are not used to doing development. They are not used to working in community and talking in 

community. So I actually think we need a mix. We need OFDA in 

there saying, okay, what is the most important thing to do in the 

next 3 months, and we need the other side of the foreign aid that 

is looking at what are the systems, how do we build it, how do we 

build the capacity locally, and that will mean not one-year funding 

a bunch of times, which will always be urgent responses, but some 

longer term funding that says this rebuilding, as the President has 

said, is a long-term endeavor. 

If I could also just speak to the DOD? 

Senator MURPHY. Sure. 

Dr. PETERSON. I think there is a role. I had a number of the faith 

organizations say please would we get DOD to help bring our stuff 

to us, home protection kits, PPEs, that they cannot get from one 

side of the country to the other side of the country. Our military 

is brilliant at that. 

So there are roles, again, for our military, our aid organizations 

to work with communities and locals to get the most needed 

resources out to the places where it will make the most difference. 

Senator MURPHY. This is a hearing happening in an amazing 

week in which this committee is grappling with a question of how 

we authorize force in the Middle East and whether there are ways 

in which we exert military influence and power that do us more 

harm than good. My hope is, especially with this new allocation of 

significant resources in the omnibus, that this is going to be maybe 

the pinnacle of success stories in terms of how the United States 

exerts influence around the world. This is a combination of humanitarian aid, public health dollars, and military support that can, at 

the end, be able to paint a way out of a crisis that a few months 

ago seemed to many in the short term to be unsolvable. 

So as we all on this committee try to figure out what America’s 

footprint moving forward in the world is, this is going to be a 

source of, I think, some very positive lessons learned. 

Thank you, Mr. Chairman, for focusing us on this today. 

Senator COONS. Thank you, Senator Murphy. And I would like 

to thank all the members of the subcommittee who have joined us 

today. Thank you, Senator Flake, for a strong and good working 

partnership through the course of this Congress. 

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I would like to thank all of the four folks who have provided testimony today, to Mr. Alvarez, to Mr. Gaye, to Dr. Peterson, to Dr. 

Farmer. Thank you for your service, for your example, and for your 

tireless dedication to improving public health. It is indeed our hope 

and our prayer that in our emergency response we are focused on 

building sustainably very strong public health systems in the three 

most directly affected countries and across the region, and that we 

will continue to work together in very real and meaningful partnership. 

And to Madam President, thank you for being our very special 

guest today, thank you for providing remarks, and thank you for 

showing an unusual interest in what actually is done by Members 

of the U.S. Senate. It is not a common experience for us—— 

[Laughter.] 

Senator COONS [continuing]. To have a President as interested in 

the deliberations of the Senate as you have been today. We are 

grateful for your tireless leadership of your nation, of the region, 

and of our world as we continue to try and find ways to stand up 

to the challenges of inequity and inequality, and as we try to 

believe a better future into being for the Republic of Liberia and 

the United States. Ours is a long and positive friendship between 

our nations, and I am grateful for your time with us today. 

President SIRLEAF. Thank you. 

Senator COONS. Thank you all very much. 

We will hold the record open until the 11th for any members of 

the committee who might have questions for the four witnesses 

who testified today. Thank you. 

With that, this meeting is adjourned. 

[Whereupon, at 12:32 p.m., the hearing was adjourned.] 

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF SENATOR ROBERT MENENDEZ

I’d like to thank Senator Coons for convening the subcommittee to examine efforts 

to halt the spread of Ebola in West Africa. I’d also like to thank our esteemed guest, 

President Ellen Johnson Sirleaf, for consenting to join us, as well as witnesses from 

the NGO community. I would also like to take a moment to not only thank, but to 

commend, the many brave volunteers who are and have been on the front lines on 

the battle to stop Ebola. 

Madam President, our sympathies are with you and all the people of Liberia who 

have been affected by the outbreak. We stand resolute in our commitment to help 

end this very clear threat to international health. 

We all know the figures associated with Ebola: over 17,000 people infected. More 

than 6,000 lives lost. What we must also keep in mind is the enormous toll this is 

taking on survivors and those in the broader community. Over 3,000 children have 

been orphaned. Livelihoods have been disrupted with a potentially devastating economic impact. Children have been out of school for months. Thousands of people are 

unable to obtain lifesaving interventions such as immunizations, prenatal care and 

malaria treatment because poor, already overtaxed medical systems cannot cope 

with the dual demands of crisis response and routine care. 

The United States Government has led the way among donors, working with the 

Government of Liberia to halt the spread of Ebola before it becomes a pandemic, 

building treatment centers, sending thousands of units of personal protective equipment and laboratory materials to the subregion, and helping health officials with 

contact tracing, airport screening, training in safe burials, and medical testing and 

treatment. The U.N. has stepped up in an unprecedented way, with the establishment of the U.N. Mission for the Ebola Emergency Response. However reports from 

Sierra Leone about a rise in infections, and concerns about lack of accurate information about the widespread nature of the threat is troubling. We must work to ensure 

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that we are sharing lessons learned from efforts in Liberia with our U.K. and 

French partners who have taken the lead in working with the governments of Sierra 

Leone and Guinea to bring infection rates under control. We can do more to share 

best practices on the health care response and social messaging efforts, and to coordinate our efforts on the ground. 

While we may have seen progress in Liberia, the danger posed by Ebola is far 

from over. Congress is working now to act on President Obama’s request for $2 billion in emergency funding for continued U.S. assistance to the beleaguered countries 

in West Africa. The money will be used to fund critical efforts by the U.S. Agency 

for International Development, the Centers for Disease Control and Prevention, and 

the U.S. military to contain and end the outbreak and to mitigate its secondary 

effects. Once the outbreak ends, we must look at ways to support improved global 

health systems in order to prevent another health crisis like Ebola from emerging. 

Today I hope our guest and witnesses will address—among other things—whether 

and how we need to change the approach we are taking in the three most heavily 

impacted countries so that mitigation efforts are carried out in disease hot spots, 

and what we are doing to ensure non-Ebola patients can obtain care. I’d also like 

your views on what we need to do in the long-term to strengthen health care systems so that countries in the subregion—and beyond—to better respond to this type 

of crisis in the future. 

Again, I offer many thanks to all of our panelists today. Welcome to the committee. We look forward to hearing from you. 

PREPARED STATEMENT OF SAVE THE CHILDREN

West Africa is now battling the deadliest Ebola outbreak the world has ever seen. 

The scale of the crisis is unprecedented in terms of geographic distribution, infection 

rate and the number of people killed by the disease. Save the Children is working 

urgently in Liberia, Sierra Leone, and Guinea to halt the epidemic before it spirals 

further out of control. Serious steps must be taken now to relieve the suffering of 

children and families affected by the outbreak. To this end, we urge policymakers 

to take the following actions: 

1. Fund the Administration’s proposed Ebola emergency funding package. In particular, we urge Congress to fund the International Disaster Assistance (IDA) 

account at a total of $3.5 billion for FY 2015 to make sure that as we address Ebola, 

we are not neglecting to fund critical responses to other crises such as those in 

Syria, Iraq, and South Sudan. This $3.5 billion includes: 

• $1.4 billion requested by the administration for the International Disaster 

Account in the emergency Ebola funding package, 

• $2.1 billion requested by the NGO community for the International Disaster 

Account for FY2015. 

2. Immediately strengthen public health systems in affected countries to address 

not only treatment of Ebola, but also the delivery of other essential health services. 

One of the main causes of the Ebola outbreak getting out of control was weak, 

underfunded, and understaffed health services. It is therefore crucial to build strong 

local health systems to enable communities to prevent and respond to future outbreaks of Ebola and other infectious diseases. 

3. Invest in Education. Children are losing out on critical months of learning as 

school year start-dates are delayed and schools in affected areas are closed. The 

postponement of primary exams and closed schools significantly increase the risk of 

permanent dropout and the loss of learning gains achieved in recent years by investments made by USAID in education. To ensure children receive a quality education, 

funding must be provided for quality home-learning programs, teacher training programs, home-based instructional materials, radio-programs, and text messaging that 

cover the national curricula. 

4. Meet the needs of vulnerable children. Many children living in affected countries 

are traumatized by the loss of a parent or death of a family member and may be 

left without appropriate care. Stigma and fear may further contribute to isolation 

or rejection of children affected by Ebola. Efforts must be made to locate, identify, 

and register unaccompanied children to ensure that adequate alternative familybased care is provided. This care must be in line with the International Guidelines 

for the Alternative Care of Children. Moreover, children accompanying their family 

members to health facilities but who are not accepted into the health facility for 

treatment of Ebola should be cared for, monitored, provided with access to basic 

services and receive appropriate psychosocial support. 

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5. Address the Impact of Ebola on household food security and livelihood activity. 

In Liberia and Sierra Leone the price of food has increased in some markets since 

the start of the crisis, threatening to deepen the vulnerabilities of already poor and 

food insecure households. Some reports indicate that lower productivity also threatens the flows of production from the affected areas to main markets, with implications for wider food security in the West and Central Africa regions. The U.S. Government should invest in a thorough food security and livelihoods assessment in 

countries affected by Ebola to assess the impact that Ebola has had on income and 

food sources. In addition, targeted food assistance should be provided to isolation 

units, Ebola-affected families, and communities under quarantine and at risk of 

Ebola. Care should be taken that food assistance modality and distribution procedures align and support larger public efforts to prevent the spread of Ebola. Finally, 

trade must continue to and from affected countries to maintain economic activity 

and ensure adequate food and nonfood supplies. 

We welcome the committee’s attention to the Ebola crisis and appreciate U.S. 

Government efforts to address the threat of this crisis for the over 2.5 million children under the age of 5 living in areas affected by Ebola. As the needs in the region 

continue to escalate, so too must our humanitarian commitment. We sincerely 

appreciate your attention to these important issues, and look to both the administration and Congress to marshal the necessary support, including in appropriations 

legislation, to reduce the suffering and improve the outlook for the children and 

families of West Africa. 

PREPARED STATEMENT OF CATHOLIC RELIEF SERVICES

Catholic Relief Services (CRS) is the official international humanitarian agency of 

the U.S. Conference of Catholic Bishops (USCCB), assisting poor and vulnerable 

people in 100 countries on five continents. Without regard to race, creed, or nationality, CRS programs address food security, agriculture, health, education, emergency 

relief, and peace-building. 

As part of our integrated, multisectoral approach, CRS supports more than 180 

health programs in nearly 50 countries across Africa, Asia, and Latin America. In 

partnership with the local Catholic Church and other faith-based and nongovernmental organizations, CRS health programs directly support more than 26 million 

people. These partnerships often connect us to communities inaccessible to government and provide the kind of local knowledge that builds sustainable solutions. 

The West Africa Ebola outbreak is the largest since the virus was discovered in 

1976. The first case was documented in Guinea in December 2013; since then, there 

have been more than 17,000 reported cases of Ebola virus disease (EVD), with just 

over 5,689 reported deaths in eight countries in Africa, the United States and 

Europe. The World Health Organization (WHO) has indicated that the outbreak 

may be stabilizing in some areas. Case incidence is stable in Guinea, stable or 

declining in Liberia, but may still be increasing in Sierra Leone. 

Stopping Ebola transmission requires behavior change (people must understand 

what puts them at risk and take action to protect themselves), strong case management (prompt identification, isolation, and treatment of those who are infected), contact tracing (identification, isolation, and surveillance of those who have had contact 

with infected people) and safe and dignified handling of deceased bodies. Despite 

aggressive containment efforts, the World Health Organization (WHO) predicts that 

transmission will continue for at least 9 more months. 

CRS has been active in the response since the outbreak began to spiral out of control, capitalizing on our existing programming capacity in the region and our extensive experience with natural and man-made disasters throughout the world. CRS 

has been working in West Africa for more than five decades (51 years in Sierra 

Leone, 24 years in Liberia, and 12 years in Guinea). In addition to committing more 

than $1.5 million in private resources, CRS has leveraged our health, food security, 

education, and other programs to rapidly and effectively respond to the Ebola outbreak. In addition, CRS has to date been awarded $5 million from the U.S. Government, through the generous support of USAID and CDC. 

Though primarily a health emergency, the Ebola outbreak has wide ranging 

effects. It is setting back a full decade of development progress in fragile states 

emerging from civil conflict. The ripple effects of this crisis include the following: 

• Routine health care: Prior to the crisis, the affected health systems suffered 

from inadequate personnel, low quality services, poor public confidence and poor 

health outcomes. Ebola is increasingly straining these already weak systems. 

Nearly 600 health care workers have been infected with Ebola, of whom 380 

have died. Essential health services such as routine childhood immunization 

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have ceased in many areas, and most health experts predict a surge in deaths 

from preventable illnesses such as measles, malaria, and diarrhea. Prenatal and 

obstetric care have also been compromised, and thousands of women are being 

forced to deliver at home without a skilled birth attendant, placing them and 

their babies at risk. In addition, Ebola survivors face stigma that can negatively 

affect their physical or psychosocial well-being. Many more people will die from 

lack of routine health care than will die from Ebola. • Livelihoods and food security: Agricultural activities, including this year’s harvest, will be heavily impacted. Many families have lost productive members and 

in some instances have been unable to access their farms due to travel restrictions and quarantines. There are indications that market disruptions and fears 

related to Ebola may result in price increases, limited produce in the market, 

and decreased income from cross-border trade with neighboring Mali and Senegal. Agricultural production is expected to be lower than usual, leading to an 

earlier and more pronounced lean season and negative coping strategies such 

as eating seed; FEWS NET predicts a ‘‘stressed’’ situation in heavily affected 

areas of Sierra Leone and Liberia. • Education: Schools In Guinea, Liberia, and Sierra Leone have been closed since 

last summer, with potential far-reaching negative implications for children, who 

are losing valuable education time and may be at increased risk for child labor 

and early marriage. Universities and technical training institutions are also 

closed, which will make it difficult for countries to replace their skilled labor 

force (particularly health care workers). • Vulnerable children: In Guinea, Liberia, and Sierra Leone, we are seeing a rise 

in street-children, in violence against girls and early marriage, pregnancies; 

hazardous under-age labor, and rising stress. We must be careful about hasty 

interventions that are not evidence-based and about ‘‘creeping orphanages’’ that 

devolve from interim care centers. 

In response, CRS teams are setting up and supporting five community care centers to quickly triage and isolate possible Ebola patients. We are training 3,000 

health workers and providing personal protection equipment in Guinea and Liberia 

to help provide access to routine health care for an estimated 3 million people. In 

addition, CRS was instrumental in the reopening of St. Joseph’s Catholic hospital 

in Liberia’s capital, Monrovia. The oldest hospital in Liberia, it serves as a referral 

facility for all other health facilities in the country, public and private. Now open, 

St. Joseph’s is not only treating Ebola patients, but also offers routine health care, 

which has largely become unavailable due to stress on the local health system. 

In addition, CRS is working to curb transmission of Ebola through programs that 

aim to educate and change behavior, with particular emphasis on using mass media, 

including radio and text messages, to promote awareness and increase knowledge. 

We have also capitalized on our strong connection to local communities, training 

religious leaders and volunteers to raise awareness and promote behavior change. 

CRS and our partners have already reached more than 2 million people with these 

messages. 

The WHO estimates that 70 percent of Ebola transmission occurs through exposure to dead bodies. In Sierra Leone, CRS manages 19 burial teams (9 in Port Loko, 

6 in Bombali, and 4 in Koinadugu) that conduct hundreds of safe and dignified burials in order to prevent further infections and respect families’ religious practices. 

CRS is also collaborating with religious and traditional leaders to ensure access to 

and acceptance of safe and dignified burials. 

Historically, outbreaks of EVD have been limited in scale and duration. The current outbreak is the largest and most complex in history, with more cases and 

deaths than all other outbreaks combined. Why has this particular outbreak evolved 

into a regional crisis? One reason is the location. In the past, Ebola has appeared 

in isolated, remote villages that had limited contact with outsiders; the virus was 

geographically contained until the outbreak quickly ran its course. In contrast, the 

current outbreak emerged for the first time at the intersection of three countries, 

spreading along porous borders and well-traveled roads until it arrived in the densely populated capital cities of Monrovia, Freetown, and Conakry where it claimed the 

majority of its victims. 

Misconceptions, fear and distrust have also facilitated the spread of Ebola. Many 

sick people are not seeking care due to unfamiliar and sometimes frightening isolation procedures, low trust in health services, and perceived poor quality of care at 

treatment centers, helping to propagate the virus at an alarming rate. Traditional 

burial practices are another factor. Throughout the region, it is customary for relatives to wash and prepare bodies at home. While these practices are an important 

part of West African cultures, they expose family members to infectious bodily 

fluids. 

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And the slow international response allowed the outbreak to gain momentum 

while local authorities and NGOs struggled to respond. 

But by far the largest contributor to the spread of Ebola has been weak health 

systems. Guinea, Liberia, and Sierra Leone all face a critical shortage of health 

workers, inadequate health financing, poor access to data for decision making, and 

weak supply chains. The virus appeared and spread for 3 months before health 

structures were able to identify its presence. None of the three countries had enough 

health professionals to trace the virus to its origins and isolate all those who had 

been infected. When tracing procedures identified infected people, many treatment 

centers quickly reached full capacity and many observation units were not fully 

staffed. Country health institutions also lacked the trained staff and volunteers 

needed to run education and awareness programs that would help people avoid infection and bury loved ones in a safe yet culturally acceptable manner. Those health 

centers that were up and running often lacked the necessary and life-saving equipment to treat Ebola patients and prevent the spread of infection. Personal protective 

equipment (PPE) is only effective if used properly but overworked health workers 

and improper training have resulted in nearly 600 health workers contracting the 

disease. 

Furthermore, Guinea, Liberia and Sierra Leone are among 83 countries that do 

not meet the WHO’s minimum recommended number of health care providers 

needed to provide basic health services (22.8 per 10,000 people). In most of these 

countries few, if any, local partners have the existing capacity in all areas (including 

clinical skills, strategic information, laboratory services, finance, health supply 

chain) that are required to sustain routine and emergency health services. 

For this reason on September 23, 2014, the USCCB and CRS sent a letter to 

National Security Advisor Susan Rice to urge the U.S. Government to implement 

a multipronged approach: continue emergency response (case detection, treatment, 

contact tracing, safe burial) until the outbreak is contained, restore essential services (such as preventative and routine care) and focus on health systems strengthening to prevent future disease outbreaks from overwhelming local and regional 

health networks. 

Strengthening health systems is critical to ensuring sustainability, equity, effectiveness and efficiency, all of which contribute to positive health outcomes. Building 

strong health systems will require expert technical assistance to all key stakeholders—including Ministries of Health, local technical organizations, civil society 

organizations and faith-based health networks—until regular monitoring demonstrates successful outcomes. An abrupt end to expert technical assistance will jeopardize programs and patients. 

A successful effort will require a number of partners with varied expertise. The 

HIV epidemic has taught us that sustainable health care is multidimensional and 

all interested stakeholders must be engaged to bring their knowledge to the table. 

In particular, the role of civil society organizations (CSOs), especially faith-based 

organizations (FBOs), cannot be understated. Faith-based institutions are often the 

most trusted organizations. They play a vital role in the health systems located in 

resource limited settings. FBOs support national efforts; they offer complementary 

services, in many places assisting those the government does not reach; they help 

ensure accountability; and they advocate for strategies that match needs on the 

ground. As we assist countries in building resilient, high quality care delivery systems, we must ensure continued synergy between faith-based and civil society actors 

and local governments. The effectiveness of faith-based health system strengthening 

was demonstrated, in part, by CRS’ AIDSRelief project. With support from PEPFAR, 

the 9-year program provided lifesaving HIV care and treatment services to more 

than 700,000 people through 276 health facilities in 10 countries. Working largely 

through rural and faith-based facilities, AIDSRelief established basic packages of 

care and treatment that exceeded what many thought possible in a resource-constrained environment. Instead of merely offering HIV tests and dispensing medicine, 

AIDSRelief helped our partners to build strong supply chains, operate high-quality 

pharmacies, manage state-of-the-art laboratories, and use timely-accurate data for 

decision making. More than 30,000 participants—doctors, nurses, pharmacists, and 

other health care workers—attended training sessions that built and strengthened 

their skills to provide high-quality medical, laboratory, pharmaceutical, and other 

services. 

We urge the U.S. Government to lead other donor nations in developing and funding a coordinated, long-term humanitarian and development strategy for the 

affected region that rivals that of PEPFAR in its scale and scope. This new program 

for Africa should include immediate humanitarian assistance and health systems 

strengthening through ongoing technical support to build laboratory capacity, train 

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and retain health workers, strengthen supply chains for medicines and commodities, 

and ensure sustainable financing for the future. 

USCCB and CRS deeply appreciate U.S. leadership in West Africa, without which 

this crisis on top of so many other crises might have spun totally out of control. Our 

Nation’s Ebola response will require a long-term strategy, sustained funding, and 

continued sacrifice from brave men and women willing to act out of love and concern 

for those less fortunate. 

Æ 

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