U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

91–452PDF 2014

FIGHTING EBOLA: A GROUND–LEVEL VIEW

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH, 

GLOBAL HUMAN RIGHTS, AND 

INTERNATIONAL ORGANIZATIONS

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED THIRTEENTH CONGRESS

SECOND SESSION

NOVEMBER 18, 2014

Serial No. 113–229

Printed for the use of the Committee on Foreign Affairs

(

Available via the World Wide Web: http://www.foreignaffairs.house.gov/ or

http://www.gpo.gov/fdsys/

(II)

COMMITTEE ON FOREIGN AFFAIRS 

EDWARD R. ROYCE, California, Chairman 

CHRISTOPHER H. SMITH, New Jersey 

ILEANA ROS-LEHTINEN, Florida 

DANA ROHRABACHER, California 

STEVE CHABOT, Ohio 

JOE WILSON, South Carolina 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

MATT SALMON, Arizona 

TOM MARINO, Pennsylvania 

JEFF DUNCAN, South Carolina 

ADAM KINZINGER, Illinois 

MO BROOKS, Alabama 

TOM COTTON, Arkansas 

PAUL COOK, California 

GEORGE HOLDING, North Carolina 

RANDY K. WEBER SR., Texas 

SCOTT PERRY, Pennsylvania 

STEVE STOCKMAN, Texas 

RON DESANTIS, Florida 

DOUG COLLINS, Georgia 

MARK MEADOWS, North Carolina 

TED S. YOHO, Florida 

SEAN DUFFY, Wisconsin 

CURT CLAWSON, Florida 

ELIOT L. ENGEL, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

BRAD SHERMAN, California 

GREGORY W. MEEKS, New York 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

THEODORE E. DEUTCH, Florida 

BRIAN HIGGINS, New York 

KAREN BASS, California 

WILLIAM KEATING, Massachusetts 

DAVID CICILLINE, Rhode Island 

ALAN GRAYSON, Florida 

JUAN VARGAS, California 

BRADLEY S. SCHNEIDER, Illinois 

JOSEPH P. KENNEDY III, Massachusetts 

AMI BERA, California 

ALAN S. LOWENTHAL, California 

GRACE MENG, New York 

LOIS FRANKEL, Florida 

TULSI GABBARD, Hawaii 

JOAQUIN CASTRO, Texas

AMY PORTER, Chief of Staff THOMAS SHEEHY, Staff Director

JASON STEINBAUM, Democratic Staff Director 

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

INTERNATIONAL ORGANIZATIONS

CHRISTOPHER H. SMITH, New Jersey, Chairman 

TOM MARINO, Pennsylvania 

RANDY K. WEBER SR., Texas 

STEVE STOCKMAN, Texas 

MARK MEADOWS, North Carolina 

KAREN BASS, California 

DAVID CICILLINE, Rhode Island 

AMI BERA, California 

(III)

C O N T E N T S 

Page

WITNESSES 

Mr. Rabih Torbay, senior vice president for international operations, International Medical Corps ........................................................................................ 4

Mr. Brett Sedgewick, technical advisor for food security and livelihoods, Global Communities .................................................................................................... 18

Darius Mans, Ph.D., president, Africare ............................................................... 24

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Mr. Rabih Torbay: Prepared statement ................................................................. 8

Mr. Brett Sedgewick: Prepared statement ............................................................ 20

Darius Mans, Ph.D.: Prepared statement .............................................................. 26

APPENDIX 

Hearing notice .......................................................................................................... 48

Hearing minutes ...................................................................................................... 49

(1)

FIGHTING EBOLA: A GROUND–LEVEL VIEW 

TUESDAY, NOVEMBER 18, 2014

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,

GLOBAL HUMAN RIGHTS, AND INTERNATIONAL ORGANIZATIONS,

COMMITTEE ON FOREIGN AFFAIRS,

Washington, DC. 

The subcommittee met, pursuant to notice, at 10:07 a.m., in room 

2172, Rayburn House Office Building, Hon. Christopher H. Smith 

(chairman of the subcommittee) presiding. 

Mr. SMITH. Subcommittee will come to order. 

The world community has known of the Ebola virus disease, 

more commonly called just Ebola, since it first appeared in a remote region near the Democratic Republic of the Congo in 1976. In 

previous outbreaks, Ebola has been confined to remote areas in 

which there was little contact outside the villages at which it appeared. 

Unfortunately, this outbreak, now an epidemic, spread from village to an international center for regional trade and spread into 

urban areas in Guinea, Sierra Leone, and Liberia that are crowded, 

with limited medical services and limited resident trust of government. 

The unprecedented west African Ebola epidemic has not only 

killed more than 5,000 people with more than 14,000 others known 

to be affected, this situation has skewed the planning for how to 

deal with the outbreak. 

In our two previous hearings on the Ebola epidemic, an emergency hearing we held on August 7 and then a followup on September 17, we heard about the worsening rates of infection and 

challenges in responding to this from government agencies, such as 

USAID and CDC, and NGOs operating on the ground, such as Samaritan’s Purse and SIM. 

Today’s hearing is intended to take testimony from nongovernmental organizations providing services on the ground currently in 

the affected countries, especially Liberia, so we can better determine how proposed actions are being implemented. 

In its early stages, Ebola manifests the same symptoms as lessimmediately deadly diseases, such as malaria, which means initial 

healthcare workers have been unprepared for the deadly nature of 

the disease that they have been asked to treat. 

This meant that too many healthcare workers, national and 

international, have been at risk in treating patients who themselves may not know they have Ebola. Hundreds of healthcare 

2

workers have been infected, and many have died, including some 

of top medical personnel in the three affected countries. 

What we found quite quickly was that the healthcare systems in 

these countries, despite heavy investment by the United States and 

other donors, remained weak. As it happens, these are three countries either coming out of very divisive civil conflict or experiencing 

serious political divisions. Consequently, citizens have not been 

widely prepared to accept recommendations from their own governments. 

For quite some time, many people in all three countries would 

not accept that the Ebola epidemic was real. Even now it is believed that, despite the prevalence of burial teams throughout Liberia, for example, some families are reluctant to identify their suffering and dead loved ones for safe burials, which places family 

members and their neighbors at heightened risk of contracting this 

often fatal disease when patients are most contagious. 

The porous borders of these three countries have allowed people 

to cross between countries at will. This may facilitate commerce, 

which is a good thing, but it also allows for diseases to be transmitted regionally. As a result, the prevalence of Ebola in these 

three countries has ebbed and flowed with the migration of people 

from one country to the other. 

Liberia remains the hardest hit of the three countries, with more 

than 6,500 Ebola cases officially recorded, probably a significant 

understatement. The number of infected and dead from Ebola could 

be as much as three times that of the official figure due to underreporting. 

Organizations operating on the ground have told us over the past 

5 months that, despite the increasing reach of international and 

national efforts to contact those infected with Ebola, there remain 

many remote areas where it is still difficult to find residents or 

gain sufficient trust to obtain their cooperation. 

Consequently, the ebb and flow in infection continues. Even 

when it looks like the battle is being won in one place, it increases 

in a neighboring country or region and then reignites in the areas 

that look to be successes. 

The United States is focusing on Liberia. The UK is focusing on 

Sierra Leone. France and the European Union are supposed to be 

focusing on Guinea. In both Sierra Leone and Guinea, the antiEbola efforts are behind the pace of those in Liberia. This epidemic 

must be brought under control in all three if our efforts are to be 

successful. 

Last week I, along with Congresswoman Karen Bass and Congressman Mark Meadows of this subcommittee, introduced H.R. 

5710, the Ebola Emergency Response Act. This bill lays out steps 

that are needed for the U.S. Government to effectively help fight 

the west African Ebola epidemic, especially in Liberia, the worst 

hit of the three countries. 

This includes recruiting and training healthcare personnel, establishing fully functional treatment centers, conducting education 

campaigns among populations in affected countries, and developing 

diagnostics, treatments, and vaccines. 

H.R. 5710 confirms U.S. policy in the anti-Ebola fight and provides necessary authorities for the administration to continue or 

3

expand anticipated actions in this regard. The bill encourages U.S. 

collaboration with other donors to mitigate the risk of economic collapse and civil unrest in the three affected countries. Furthermore, 

the legislation authorizes funding of the International Disaster Assistance Account at the higher Fiscal Year 2014 level to effectively 

support these anti-Ebola efforts. 

I would like to now turn to my friend and colleague, Ms. Bass, 

for any opening comments you might have. 

Ms. BASS. As always, thank you, Chairman Smith, for your leadership and, also, for taking the lead on the legislation that we hope 

to have marked up soon. 

I also want to thank today’s distinguished witnesses and prominent NGO organizations providing critical medical, nutritional, and 

developmental assistance in the most adversely affected nations in 

west Africa. 

I look forward to hearing your updates on how your respective 

organizations continue to combat this deadly outbreak, what trends 

you are seeing, both positive and negative, and what additional 

support is needed as you coordinate with the governments of the 

impacted countries in the international community. 

I appreciate your efforts and outreach to help keep Congress informed of this evolving crisis. The current crisis, as has been stated, has been the largest and most widespread outbreak of the disease in history, creating a particular burden on the countries that 

are involved. 

Since the beginning of the outbreak, U.S.-based NGOs have 

made a significant and sustained effort to support the three countries as they fought the disease. The United States has committed 

nearly $1 billion to build treatment centers, train healthcare workers and burial teams, supply hospitals with protective gear, and ensure the safety and humanitarian support. 

I would, in particular, like to hear from the witnesses what you 

think about the assistance that has been provided. And then I have 

a particular interest in your thoughts around, when we are past 

this crisis, what the U.S. can leave in place and, also, your 

thoughts on how we move forward. 

So we know that the reason why this hit so badly is because of 

the weak health infrastructure in these three countries. 

So out of this terrible crisis, is there a way for us to begin to 

think long term about the future? How do we support the infrastructure of countries? And your thoughts on that would be appreciated. 

The administration has asked Congress for over $6 billion in 

emergency funds in order to sustain the progress that has been 

made and to ensure an end to the crisis. 

This request will expand assistance to contain the epidemic, safeguard the American public from further spread of the disease, and 

support the development of treatments. Sustained U.S. financial 

support and involvement is essential to support the stable governance of these nations, which is jeopardized by the current crisis. 

I also don’t think that we have given much time and attention 

to the fact that we are dealing with countries that could actually 

be moved quite a bit backward, especially countries that have recently gotten past civil war. 

4

So I look forward to your testimonies, and I am interested in 

hearing from you about what we can do to assist your efforts. 

Thank you. 

Mr. SMITH. Thank you, Ms. Bass. 

I’d like to now welcome our three very distinguished witnesses 

who are extraordinarily effective and informed and will provide 

this subcommittee a real insight as to what has been happening 

and what needs to be done. 

Beginning with Mr. Rabih Torbay, who is the senior vice president for international operations and oversees International Medical Corps’ global programs in 31 countries and 4 continents and 

its staff and volunteers numbering well over 8,000 people. He has 

personally supervised the expansion of IMC’s humanitarian and development programs into some of the world’s toughest working environments, including Sierra Leone, Iraq, Darfur, Liberia, Lebanon, 

Pakistan, Afghanistan, Haiti, Libya, and most recently Syria. 

As the organization’s senior representative in Washington, DC, 

he serves as IMC’s liaison with the United States Government. 

We will then hear from Mr. Brett Sedgewick, who is a technical 

advisor for food security and livelihoods for Global Communities. 

He previously served as vice president for the NASSCOM Foundation, for whom he built stakeholder relations with government entities, donors, and NGOs, and oversaw business development. 

Prior to that, he served as Liberia country director for CHF 

International, where he oversaw program design, implementation, 

and monitoring for a range of donors. He also served as Liberia 

technical advisor to Chemonics on a similar basis. 

We will then hear from Dr. Darius Mans, who is the president 

of Africare, where he is responsible for the leadership and growth 

of that organizations. Previously, he fulfilled a number of roles at 

the Millennium Challenge Corporation, including acting chief executive officer and vice president of implementation and managing 

director for Africare. 

In these positions Dr. Mans was responsible for vast and diverse 

program portfolios in MCC compact countries. He also has experience managing 45 country programs around the world as director 

of the World Bank Institute, working as an economist, teaching economics, and serving as a consultant on infrastructure projects in 

Latin America. 

We are joined by Mr. Weber, vice chairman of the subcommittee. 

Any opening comments? 

Mr. WEBER. Thank you for being here. Let’s go. 

Mr. SMITH. Okay. Thank you. 

I turn to Mr. Torbay. 

STATEMENT OF MR. RABIH TORBAY, SENIOR VICE PRESIDENT 

FOR INTERNATIONAL OPERATIONS, INTERNATIONAL MEDICAL CORPS 

Mr. TORBAY. Chairman Smith, Ranking Member Bass, and distinguished members of this subcommittee, on behalf of International Medical Corps, I would like to thank you for inviting me 

to testify today to describe the ongoing fight against the Ebola 

virus outbreak from the ground level. 

5

I have already submitted a lengthy written testimony to the subcommittee. My remarks this morning will highlight key observations and offer 10 recommendations for our Ebola response experience. 

International Medical Corps is a global humanitarian nonprofit 

organization dedicated to saving lives and relieving suffering 

through healthcare training and relief and development programs. 

We work in 31 countries around the world, and we have been working in west Africa since 1999. 

Our response to the Ebola outbreak has been robust in both Liberia and Sierra Leone. More than two-thirds of all Ebola cases 

and over three-fourths of all Ebola-related deaths have come from 

these two countries. 

By the end of this month, we anticipate having a total of about 

800 staff in those two countries, and by year’s end we expect this 

number to exceed 1,000 working in four Ebola treatment units, two 

in Liberia and two in Sierra Leone. 

I would like to take this opportunity to acknowledge the dedicated and courageous international and African national staff 

working in our treatment centers. They are from Liberia and Sierra Leone, as well as many parts of the United States, Europe, 

and other states. 

Our staff is comprised of doctors, nurses, technicians, specialists 

in water sanitation and hygiene, logisticians, mental health professionals, custodial workers, and burial teams. 

In addition to the treatment units, we have established several 

services for groups just now arriving to combat the outbreak. One 

example is a training center on the ground of Cuttington University in Bong County, Liberia. It will teach and train staff from all 

organizations engaged in the fight to contain Ebola and show them 

how to treat patients and stay safe in a potentially dangerous 

workplace. 

We are also responding to the upsurge of Ebola cases in Mali. We 

will be setting up an Ebola treatment unit and developing a health 

worker training program to help the country fight the outbreak. 

Our robust response to the Ebola outbreak has one overriding objective: Contain the current outbreak at its source in west Africa. 

To succeed, we have learned that several key factors must be in 

place. 

One of these is building and safely operating Ebola treatment 

units staffed by well-trained health professionals. Another key factor is using training programs to transfer into local hands the 

skills and knowledge necessary to respond effectively to the Ebola 

outbreaks. 

We must also assure effective coordination among all actors involved in the fight to contain the virus, including the U.N., international and national governments, and NGOs. To turn the tide of 

this epidemic, we must all work together to maximize the strength 

of all involved. 

Finally, we need to conduct expansive data collection and rigorous data analysis to build an accurate picture of Ebola containment and spot any need for new responses. Once we succeed to contain the current outbreak, we must remain vigilant to assure that 

there is no resurgence of this epidemic. 

6

The fight to contain Ebola and prevent future outbreaks will require a substantial investment. I would like to thank the U.S. 

Agency for International Development, particularly its Office of 

Foreign Disaster Assistance, for the funding it has provided to 

International Medical Corps for our Ebola response, as well as the 

support of the U.S. military, particularly in setting up a laboratory 

near in our Ebola treatment unit in Bong County. 

We welcome the President’s emergency request to Congress to 

combat Ebola in west Africa. And based on our on-the-ground experience in fighting this epidemic, we would recommend that the $1.4 

billion allocated for international disaster assistance be increased 

by an additional $200 million, to a total of $1.6 billion, and we recommend that an additional $48 million be added to the Economic 

Support Fund, for a total of $260 million. 

Mr. Chairman, I conclude my testimony by offering 10 recommendations for effective treatment and eradication of Ebola 

virus for the subcommittee’s consideration. 

One, ensure the availability of an adequate number of welltrained, well-protected health workers. One of the most critical lessons learned from this response has been the importance of having 

sufficient human resources prepared to address an outbreak of infectious disease. 

Two, ensure that construction of new Ebola treatment units fits 

the local needs. The work must be well-coordinated and welltrained staff must be ready to work in each facility. We need to remain flexible and nimble and adapt quickly to changing demands 

to response to outbreaks in rural areas. 

Three, ensure that the necessary quantity and quality of personal protective equipment is available. 

Four, improve data collection, surveillance, and referral systems 

that will help individuals receive treatment faster. 

Five, ensure that clear and understandable lines of communications and divisions of responsibilities are established, understood, 

and maintained among coordinating bodies operating in the region. 

A smart and efficient coordination system at the national level is 

critical for an effective response. 

Six, we welcome the advances made over the past few weeks in 

establishing procedure to evacuate and treat expatriate health 

workers who might contract Ebola. We recommend that the systems being put in place now be institutionalized and made part of 

the global preparedness planning in the future for future 

epidemics. 

Seven, we recommend that commercial airspace over Ebola countries remain open so that personnel and resources can move quickly. 

Eight, accelerate and support the production of vaccines. 

Nine, invest in emergency preparedness in west African regions 

to ensure that these countries have the needed resources, proper 

training, and systems in place to respond themselves to possible future outbreak of infectious disease. 

And, ten, finally, Mr. Chairman, basic health services need to be 

re-established in west Africa. People are not just dying from Ebola, 

they are dying from malaria, they are dying from water-borne diseases. Women are dying from the lack of facilities where they could 

7

go for safe delivery. And this needs to be done as soon as possible. 

We cannot wait until the Ebola outbreak is done before we restart 

these activities. 

Thank you, Mr. Chairman and Ranking Member Bass, for the 

opportunity to present this testimony to the committee. I would be 

glad to answer any questions you may have. 

[The prepared statement of Mr. Torbay follows:]

8


91452a-1.eps
9


91452a-2.eps
10


91452a-3.eps
11


91452a-4.eps
12


91452a-5.eps
13


91452a-6.eps
14


91452a-7.eps
15


91452a-8.eps
16


91452a-9.eps
17


91452a-10.eps
18

Mr. SMITH. Thank you very much, Mr. Torbay. 

Mr. Sedgewick, if you could proceed. 

STATEMENT OF MR. BRETT SEDGEWICK, TECHNICAL ADVISOR 

FOR FOOD SECURITY AND LIVELIHOODS, GLOBAL COMMUNITIES 

Mr. SEDGEWICK. Chairman Smith, Ranking Member Bass, members of the subcommittee, thank you for the opportunity to testify 

today on the ways we are working to stop the Ebola epidemic in 

west Africa. 

The following is an abbreviated version of the written testimony 

provided to the subcommittee. 

My name is Brett Sedgewick, and I am technical advisor at Global Communities, formerly known as CHF International, and I am 

currently on the Ebola Task Force. 

From 2010 to 2011, I worked as Global Communities’ Liberia 

country director, and I returned to the U.S. 10 days ago after 

spending 3 weeks in Liberia helping to lead our response on the 

ground. 

Global Communities has worked in Liberia since 2004. In 2010, 

we began a USAID-funded water and sanitation project, working 

closely with the Ministry of Health and Social Welfare. Through 

this program, we began to combat Ebola in April by providing community education, protective equipment, and hygiene materials to 

communities at risk. 

In August, we partnered with USAID’s Office of Foreign Disaster 

Assistance, who have been excellent partners in this fight, to scale 

up our response. Today we are also working in safe burial and body 

management, contact tracing, and ambulance services. 

Safe body management is of the highest priority in stopping the 

spread of Ebola. The bodies of Ebola victims are extremely contagious. In Liberia, it is often customary for the family of the deceased to say goodbye through traditions that involve touching and 

washing the body. The CDC estimates that up to 70 percent of 

Ebola infections are originating from contact with the deceased. 

Global Communities is working in every county of Liberia, supporting 47 burial teams and 32 disinfection teams. We work in 

close partnership with the Ministry of Health. The ministry employ 

the burial team personnel, and we provide training, vehicles, 

logistical support, and equipment. 

The work of burial teams is both backbreaking and heartbreaking. I have accompanied burial teams and seen the incredible 

professionalism with which they operate. These men and women 

work covered in impermeable materials in high temperatures, hiking hours through thick jungle, taking canoes or assembling makeshift bridges over bodies of water. 

They enter communities stricken with grief and fear and carry 

out an incredibly sensitive task with the greatest care for their 

health and for that of others. These men and women are heroes of 

this crisis that deserve our gratitude for assuming great risk and 

social isolation in order to stop this epidemic. While risky, this 

work can be done safely. Not one of our more than 500 team members have contracted the virus. 

19

This work is not without challenges. Many resist identifying 

their dead as infected. They fear they will not be able to mourn 

their loved ones and they themselves will be stigmatized. This is 

why the work of safe burial goes hand in hand with community engagement. Many burial rites are safe, and the teams let communities safely and respectfully say goodbye to their loved ones. 

Another challenge is cremation. In Montserrado County, which 

contains Monrovia, cremation became official policy during the 

height of the outbreak. However, this practice is counter to traditional practices and is met with strong resistance. 

The idea of a deceased loved one being burned, in their 

vernacular, upset many and increased stigma and contributes to 

bodies being unsafely buried or the sick being hidden. 

To combat this, Global Communities, USAID, and the Liberian 

Government are exploring safe burials in Montserrado through 

identifying land that can accommodate a large number of burials 

and has space for families to safely gather and mourn. 

Despite the challenges, safe burial is proving highly effective. We 

began burial team support in August for Bong, Lofa, and Nimba 

Counties. By the first week of October, we had expanded to support 

teams in every county of Liberia. And last month they were able 

to collect 96 percent of bodies within 24 hours. 

We were also able to directly reach over 1,500 communities 

through meeting and dialogue sessions, bringing together senior 

government officials, county health teams, traditional chiefs, religious leaders, community health volunteers, and other local leaders. 

Indeed, it is now being widely reported that we are seeing the 

rate of infection slow throughout Liberia, which is cause for optimism. However, it is not yet time for celebration. We must maintain the level of vigilance that has proven effective and beginning 

to control the spread of the virus. Significant longer term investments must be made in the health systems of the country. 

In closing, Global Communities would like to express profound 

gratitude for Congress, particularly members of this committee, for 

your continued support of this work. The worst Ebola outbreak in 

history can be stopped and will be stopped. 

I look forward to your questions. 

[The prepared statement of Mr. Sedgewick follows:]

20


91452b-1.eps
21


91452b-2.eps
22


91452b-3.eps
23


91452b-4.eps
24

Mr. SMITH. Mr. Sedgewick, thank you very much for your testimony and your recommendations and, really, some of the good 

news, at least somewhat optimistic perspective, that you have provided the subcommittee. 

Dr. Mans, please proceed. 

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

Mr. MANS. Thank you, Mr. Chairman. 

Let me start by thanking you and members of the committee for 

your strong commitment to this issue. I also really want to applaud 

my colleagues here for the tireless work that they are doing on the 

ground. I am honored to be here with them. 

If I may, I would like to start by describing what Africare is 

doing on the ground in the fight against Ebola and then describe 

to you what we at Africare believe are the most important steps 

that need to be taken in order to win this war. 

It will be won by Africans on the ground who time and again 

have demonstrated that they can overcome disease and adversity. 

And, finally, I would like to conclude with what we believe the 

United States can do to stop Ebola in its tracks. 

When the Ebola crisis began earlier this year, Africare imme- diately swung into action. We mobilized more than $2 million in 

private donations to help break the chain of transmission. We have 

shipped personal protection equipment and essential health supplies to all three affected countries through partnerships with Direct Relief and others. In addition, we have been helping frontline 

health workers do contact tracing. 

Throughout the crisis, we have been very focused on community 

mobilization and behavior change. That is at the heart of what 

Africare does across the continent. We believe, while aid from foreign governments and from organizations like ours is vitally important, it will be Africans adopting changes in behavior that ultimately will win the war on the ground against Ebola. 

So far, we have trained more than 300 local community health 

workers. They, in turn, have educated more than 150,000 Liberians 

about Ebola prevention, detection, and care. 

In addition, our team of nearly 100 staff on the ground, all Liberian, are joined at the hip with Liberia’s Ministry of Health to keep 

health facilities open to treat non-Ebola-related diseases, and that 

includes safe deliveries of babies. We are taking into our maternal 

waiting homes women who have been turned away from hospitals 

that are just overwhelmed by the Ebola crisis. 

And since we believe that measurement is absolutely critical, we 

are also working with technology partners to find ways to embed 

data capture within our delivery systems so that we can provide 

good metrics to gauge our performance and real-time information 

about what we are doing to contribute to the war against Ebola. 

And I should tell you we are doing all of this without any funding 

from the U.S. Government so far. 

But let me describe what we believe in addition needs to be done 

in the face of this challenge. Progress is being made, but much, 

much more needs to be done. 

We certainly strongly support the President’s emergency request 

and hope the rest of the G20 countries will step up to the plate and 

25

do more. But it is not just more money that is needed. It is important how that money is used. 

There is a need for better coordination and planning of these 

emergency treatment centers. We believe we clearly don’t need as 

many ETCs as were originally planned in Liberia, for example. 

Very important to take the efforts to control Ebola to the community level. That is where the bulk of care is provided by family 

members, by neighbors, by local health workers who really are the 

first responders in this crisis. 

We also hope that USAID will be given the flexibility to allocate 

its resources as needed to ensure there will be an agile response 

to what we have seen as a rapidly evolving epidemic. 

And, in addition, very important, we believe that it is essential 

that civil society in the effected countries be given the support and 

space needed to help ensure the best use of an accountability for 

Ebola funding. 

Finally, Mr. Chairman, let me say a few words about what more 

we believe the United States can do. 

One of the big lessons of this crisis is that donors need to move 

beyond the old approach of vertical programming, of targeting resources to specific diseases like malaria and HIV/AIDS, as important that those are. 

We need to invest in strengthening public health systems, especially community-based management of diseases. We also need to 

take advantage of this crisis to build the health infrastructure that 

the affected countries will need for the future. The investments 

being made now during the crisis need to help them build more robust and resilient health systems. 

As the Liberian President has said, we must ensure that everything we do now is not just with the aim of ending the outbreak, 

but to ensure that we come out with a stronger, efficient healthcare 

system. 

And, finally, Mr. Chairman, it is my hope that the U.S. Government will commit to support long-term economic growth in the region. I hope you will join me in urging the Millennium Challenge 

Corporation to quickly finalize its programs in Liberia and in Sierra Leone. Its significant investments in the key drivers for 

growth will be what is needed to help these countries get back on 

the higher growth path that they were on before the Ebola crisis. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Mans follows:]

26


91452c-1.eps
27


91452c-2.eps
28


91452c-3.eps
29


91452c-4.eps
30

Mr. SMITH. Thank you. Dr. Mans, thank you very much for the 

extremely valuable work you are doing, but, also, the insight you 

provide our committee. 

Let me ask you a couple of questions, to all three of you. 

You mentioned, Dr. Mans, that you have 300 local volunteer community health workers that you have trained who, in turn, have 

educated some 150,000 Liberians about Ebola prevention, detection, and care. 

In your statement, Mr. Torbay, you talked about the need to ensure the availability of adequate, well-trained, well-protected 

healthcare workers. 

How close are Liberia, Guinea, and Sierra Leone to having an optimum number of healthcare workers who are adequately trained? 

What is the deficit? 

I mean, this is excellent information and very encouraging information. Are you finding people have been scared away because of 

the fear of contracting it themselves? 

So if you could provide that information to us. 

Secondly, Mr. Sedgewick—which I would point out parenthetically we are both from New Jersey. Welcome. 

You talked about how the safe body management is of the highest priority to stopping the spread of Ebola, and you mentioned the 

CDC number of up to 70 percent of cases originating from contact 

from the deceased. 

I think a lot of people are not unaware, but they have not known 

how stark the transmission is at that period of time when somebody has passed away. And you have very good information about 

your teams reaching 96 percent of bodies within 24 hours over the 

last month. 

How many of the folks that should be reached are not being 

reached, just to try to get a sense of the unmet need? And what 

is the role that clergy and church are playing? 

Obviously, when somebody passes away, we all turn to our faith. 

The church plays a key role, obviously, in funerals. 

What role are they playing from the pulpit and in any other way 

of getting that message out about the contagious nature of someone 

who is deceased from Ebola? 

With regard to personal protective equipment, Mr. Torbay, that 

is the third point that you made—how available is it, especially to 

those volunteers and those indigenous individuals who might not 

have access to it, as some of the NGOs do, going in? If you could 

just speak to that. Are we where we should be? Anywhere close to 

it? Because, obviously, that is one way of protecting. 

And then, Dr. Mans, you had mentioned, and rightfully so, the 

deep concern of President Sirleaf. When I spoke to her, she raised 

the concern, and you have echoed her concern here today, about 

other diseases that continue to have a devastating impact on people in the three affected countries, including Liberia. 

Congratulations and good work on the safe delivery aspect, to 

help both mother and baby have a venue where they can give birth 

as safely as possible. You might want to expand upon that. 

How many women are we talking about who have gotten help 

through your work? 

31

I have other questions, but I will ask those first and then yield 

to my friend and colleague and then come back for a few others. 

Mr. TORBAY. Thank you, Mr. Chairman, for your questions. 

I will start with the health workers gap. What we are doing at 

the International Medical Corps is focusing on training health 

workers that will be working in Ebola treatment units. That training is a 14-day intensive training that includes hands-on training 

actually treating patients in an Ebola treatment unit. 

As you probably know, when you work in an Ebola treatment 

unit, you cannot work for more than an hour or, maximum, 2 before you get out because of the heat, because of the pressure, because of the stress, and we want to make sure that those workers 

go out before they get tired and dehydrated because this is when 

mistakes happen. So we are extremely careful about that. 

In terms of the healthcare gap, we are coordinating with agencies 

that are doing community work, such as, you know, Global Communities, Africare, Samaritan’s Purse, and other groups as well, 

and the idea is to combine and coordinate the community-based approach with the treatment-based approach because one cannot 

work properly or be effective without the other. 

As you know, Liberia and Sierra Leone, even before Ebola, had 

very low doctor-per-patient ratios. We are talking 1 doctor for 

100,000 in Liberia, and that is before 324 health workers have died 

from Ebola. So you can just imagine the gap. 

One thing that is critical to the health gap, we cannot be only 

reactive. Anytime there is an outbreak, this is when we decide to 

train. We need to build a stronger healthcare system. We need to 

build a stronger preparedness system in all of these countries. And 

we need to focus on health workforce development. 

Again, it is not just the infectious diseases. It is the malaria. It 

is the safe delivery. It is diarrhea. It is vaccine-preventable diseases that children are dying from. 

I think we are on track in terms of training health workers for 

the Ebola response, but what we are doing in our Ebola training 

facilities is that we will be turning it in the next couple of months 

to an infectious disease academy that covers much more beyond 

Ebola. 

And this is the sustainability aspect that we are encouraging all 

of our colleagues to look at, what comes beyond Ebola. 

Mr. SMITH. Mr. Sedgewick. 

Mr. SEDGEWICK. Thank you for your question. 

To address your second question on unmet need, I would like to 

point out that the 96 percent of bodies that are collected within 24 

hours, that is within 24 hours of the death of the individual, not 

of the phone call. So much of that 4 percent is because of a delay 

between the death and the phone call and the assignment of the 

team. 

That is a big effort that we are working on in terms of our social 

mobilization and the social mobilization that all of the other partners are doing to ensure that that phone call happens very early 

on. Ideally, we are hearing about the status of the individual well 

before they pass. 

As much as possible, our success is made significantly easier by 

our colleagues, like IMC, running ETUs and having the volume 

32

and the beds available to treat those individuals. It is much better 

for the individual to first get community care and then get to the 

ETU, that allows our teams to do a lot less work, which is a great 

situation to be in. 

In terms of the larger question of unmet need, it is very difficult 

to understand. We do a lot of work with the communities, trying 

to understand if there are people dying that are getting hidden, 

and it is all anecdotal. 

I know that the African Union and the CDC have been working 

on doing some studies on this and they found limited volumes of 

people hiding, but any are devastating. 

So we are really working on making sure that the stigma goes 

down, which would encourage everyone to call and to reduce that 

unmet need. 

In terms of volume, we are completely mobilized and we are able 

to respond very quickly. We have mobilized new teams within a 

day. So we are able to make sure that, as hot spots come up, the 

teams are positioned and available and responding immediately. 

On the second part of that question regarding clergy and faithbased leaders, they are a core part of how we interact with the 

communities. Our historical interactions in Liberia have been focused on Bong, Lofa, and Nimba Counties. And so we have really 

strong relationships not just with the religious leaders, but with 

the traditional leaders and with the health leaders. 

That made our initial entry with burial teams fairly straightforward. You can’t drive one of our vehicles through those counties 

without getting stopped and having them ask how is so-and-so and 

how is so-and-so’s baby. They are so engaged there that it made it 

very, very straightforward. 

When we moved to other counties, especially in the southeast 

where we have less of a historical presence, we very quickly realized that we had to do really extensive interactions with religious, 

health, and traditional leaders, and they have been incredibly helpful in making sure that the communities know why we are there, 

that we are there for a good reason, that we are helping, and that 

we are able to do our work respectfully, closely, and rapidly. And 

so that has been a core part. 

The religious leaders have been really helpful, and the traditional leaders, who also serve very important roles at the community level, have been very important for making sure that our 

teams are able to operate rapidly and safely. 

Mr. SMITH. Thank you. 

Mr. MANS. On personal protection equipment, no, we are nowhere near where we need to be. There are shortages of all kinds 

of equipment, including gloves for medical personnel to use. 

So what Africare is doing is working with the private sector here 

in the United States, the big suppliers of equipment, like J&J and 

so many others, to be sure that we can get a steady supply of 

consumables into all health facilities in Liberia, working with all 

of the NGO partners, because we are a big believer in collaboration, that no one of us can do this alone. 

And, second, on safe motherhood, you may know even before the 

Ebola crisis Liberia had one of the highest rates of maternal mortality in the world and headed in the wrong direction, increasing. 

33

So a big focus for us has been in building more and more of these 

maternal waiting homes and working with the private sector in Liberia to raise the money to do so. So far, I think we are up to about 

20. 

And in these facilities, the point is to bring access to communities because women who were expecting were not able to get to 

these health facilities, which are so few and far between. And that 

is something we intend to continue to do post-crisis. 

Mr. SMITH. Thank you. 

Ms. Bass. 

Ms. BASS. I again want to thank all of you for your testimony. 

I think it has been extremely helpful. And I have questions for 

each of you. 

Mr. Torbay, in your recommendations, the second one says you 

wanted to make sure that the construction of the ETUs are appropriate for the needs of each country. 

And so I was wondering if you find what is going on now is not 

appropriate. You know, are you saying this in response to something that needs to be improved? 

Mr. TORBAY. Thank you for your question. That is actually a very 

important question, and we have been discussing it over the past 

week. 

There had been plans to build a certain number of ETUs in every 

country based on findings that are about 2 months old. 

The situation is evolving rapidly, and we need to make sure that, 

as it evolves, we do not stick to the old plans, that actually we 

adapt and we are flexible enough so that if there is no need for an 

ETU, let’s not even build that ETU. 

If there is a need for mobile teams that would go out and get patients to an Ebola treatment unit that has empty beds, let’s do 

that, because we are seeing some Ebola treatment units that have 

an overflow of patients and some Ebola treatments units——

Ms. BASS. They are empty. 

Mr. TORBAY [continuing]. That actually have empty beds. 

Ms. BASS. Right. 

Mr. TORBAY. And we need to make sure that we balance that. 

Ms. BASS. I heard about that, too, and I had thought that one 

of the reasons was because the population was, you know, afraid 

to come forward and the best case is that they are not needed, but 

that that wasn’t the issue. 

So why do you have that discrepancy? And then I guess what you 

are saying is why Dr. Mans was saying that maybe ETUs is not 

the way to go right now. 

But I will come back to you, Dr. Mans. 

Mr. TORBAY. Well, first of all, the virus is moving. It is not staying in one county. So you build an Ebola treatment unit in one 

county. You get it under control with the work between the community-based approach and the treatment approach. 

It is getting under control, but then it is appearing in another 

country——

Ms. BASS. Right. 

Mr. TORBAY [continuing]. In another county. So that is why there 

are large numbers in certain areas and lower numbers. And those 

need to be coordinated. 

34

And we support the community approach because, at the end of 

the day, Ebola started at the community level and this where it 

should die, at the community level. 

Ms. Bass. Right. 

Mr. TORBAY. And we need to make sure that the community centers are well equipped and the staff are well trained to detect and 

isolate so they could refer to the treatment units for further treatments and those that are negative could be discharged back into 

the community. And this is what needs strengthening, and this is 

the work that is being done now on the ground. 

Ms. BASS. So you know how I said in my opening that I was interested to know if any of the things that we were building: Should 

they stay? I have not been inside an ETU. I have just seen them 

on TV. 

Is there any value to the ETUs that were being built being left 

there for either other infectious diseases or other health needs? 

Mr. TORBAY. You know, some of those ETUs are not built to 

last——

Ms. BASS. Okay. 

Mr. TORBAY [continuing]. Which is fair enough. They are built 

with temporary material that would last for a few months, and 

that is good enough. 

But one of the approaches we are following is we are trying to 

build a more permanent structure that could be later on turned 

into something else. It could be turned into a training center or a 

clinic. And that is the sustainable aspect of it, and that is what we 

are encouraging. 

There will be a need for isolation wards or isolation units in west 

Africa that need to remain there even after we contain Ebola because chances are there might be other diseases, or Ebola might resurface, and there is a need for the facility as well as equipment 

and trained staff there. 

Ms. BASS. So it was the first time I have heard someone talk 

about that the only time a healthcare worker can be with a patient 

is 1 to 2 hours. 

Now, I have seen the equipment and I have seen the stories that 

talk about the heat, but that implies a large number of healthcare 

workers. 

So if you are only with the patient, you know, for an hour or 2 

and you leave, then do you have relief? Do you understand what 

I am saying? 

Mr. TORBAY. Absolutely. 

Ms. BASS. So how does it work? 

Mr. TORBAY. In our Ebola treatment unit in Bong County in Liberia, it is a 70-bed treatment facility. We have 230 staff members 

working there. 

Ms. BASS. Wow. Okay. 

Mr. TORBAY. We work around the clock. So it is by shifts. 

Ms. BASS. I got it. 

Mr. TORBAY. When a doctor goes out, another one will be in to 

replace him. 

Ms. BASS. And so, when the person leaves after being there an 

hour or 2, they take a break of how long? And then I imagine they 

go back for——

35

Mr. TORBAY. Yes. It really depends on the level of exhaustion 

and dehydration. Usually, it is not less than 3 to 4 hours. They 

need to recover before we bring them back in. 

Ms. BASS. Wow. Okay. 

And, Dr. Mans, maybe you could respond to this one if you wanted to add anything about the ETUs. But, also, I know that there 

was an issue around the healthcare workers at one point and them 

being paid and them wanting hazard pay, and I was wondering 

what the situation was with that, if that has improved. 

Mr. MANS. Sure. Thank you, ma’am. 

You know, I agree completely with what Rabih has just said 

about the ETCs as part of the strategy. 

Ms. BASS. ETCs. 

Mr. MANS. Emergency treatment centers. Sorry. 

And there are some certainly challenges around planning and coordination. For example, we have seen, you know, the United 

States Government construct a 100-bed emergency treatment center, you know, 3 miles from where MSF is operating one. The Chinese Government has built one in between. And, yet, communities 

where there are hot spots not very far away, but not accessible easily by road, can’t get into any of those. So, again——

Ms. BASS. So how does that happen? 

Mr. MANS [continuing]. The challenge of planning, coordination——

Ms. BASS. How does that happen? 

Mr. MANS [continuing]. Is what is very important. 

Fundamentally, it is a responsibility of government. 

And so I think finding ways, again, as Rabih, I think, summed 

up so well, making sure that there is a more mobile response to 

be able to get people into the facilities where they need support. 

Because what worries me in this is the gap that I see in talking 

to Liberians about these big numbers that they hear that has been 

committed to Ebola and the actual response that is taking place on 

the ground. 

And so I think it is extremely important to be sure that the planning is done effectively, that that communication is out there, so 

that citizens’, in these countries, expectations can be better managed. 

The other thing I just wanted to add is about training, which 

was discussed earlier, which I think is extremely important. We 

think a lot about it; we work with community health workers and, 

of course, there is a big challenge. 

There are so few doctors in Liberia. Just take one example: 4 

million people, 425 doctors. But it is a big challenge, I think, to 

provide not just more training for medical personnel, but some of 

this pre-service training at the technical level is desperately needed 

and could be done pretty quickly. 

And I think that there are institutions here in the United States 

that can provide the kind of support that is needed to ramp up preservice training as well as supporting in-service training by institutions in the affected countries. 

Ms. BASS. Now, both of you or maybe all of you made reference 

to we need to take it to the community and have the community 

36

be involved. And I wanted to know if maybe you could be specific 

about that. 

I certainly understand the community piece in terms of the contact tracing, identifying, people that are infected. 

And then what? If there are not ETCs, ETUs, whatever, then 

what? So you are taking it to the community, you have identified 

a person. Then what? You follow me? 

Mr. TORBAY. I can try to answer that. 

The role of the community is critical. As you mentioned, contact 

tracing is critical. Informing the authorities is also very important, 

informing burial teams so they could remove the body. 

But also very important is to educate the community about what 

to do if they see someone presenting with symptoms, how to isolate 

that person and make sure that also they have at least gloves or 

things to protect themselves, but to make sure that they isolate 

and inform the different authorities, be it the health workers or the 

community health workers. 

This is critical because what is happening is that there are people that have Ebola that are staying in the same room with five 

other people, and that cannot happen. The isolation is critical and 

this is where the education at the community level becomes very 

important because that is the only way we can contain it. 

Ms. BASS. So should there be smaller ETCs? Because I understand isolating the person. But if you isolate the person without 

treatment, the person is just going to sit there and die. 

Then you said that the ETCs are maybe in inappropriate places 

or maybe they are not needed. But in the places where they are 

not needed, then what happens to the person? 

Mr. TORBAY. That is a very valid question. 

There are community care centers that are being established, 

which are like mini Ebola treatment centers. 

Ms. BASS. Okay. 

Mr. TORBAY. And the idea is those patients will be taken there. 

They will be isolated. They will be cared for until the test is done. 

Then they are referred. So the important thing is for them to be 

taken out of their home. 

And I would just like to add one thing as well that you mentioned initially about the U.S. Government and the ETCs. 

In our discussion with the U.S. military, as well as with USAID, 

about the need for Ebola treatment units and where they should 

be, we have seen that they have been extremely flexible and receptive. 

So if we tell them, ‘‘Hey, there is no need for us to staff this one. 

Let’s move it there,’’ they have been extremely responsive to recommendations. And I would like to commend them for that. 

Ms. BASS. Okay. And, Mr. Sedgewick, you might want to respond, but I wanted to ask you a series of questions around cultural practices. But go ahead and respond. 

Mr. SEDGEWICK. Yeah. I would like to catch up a little bit and 

I would like to reiterate that flexibility on both the designation of 

where the ETUs are and, in general, that flexibility that, in particular, the USAID DART, and the general response has been really fantastic and it has allowed us to make sure that we are able 

to position resources as quickly as possible. 

37

On the issue of the community, we spend a lot of time and have 

spent a lot of time since April going over what the best way is to 

interact with the community, and that is a lot of these dialogue 

sessions that I have been talking about. 

It is really focused on making sure that we are not top-down, we 

are not distributing leaflets and just doing radio shows, though we 

are doing that, but really making sure that it is a conversation 

with the community about what Ebola is and what it is not and 

having them come up with their own solutions that we work 

through. 

And that has been able to allow us to make sure that the communities, when they have a suspected case, that they put the community member in a separate location, that the communities are 

doing a lot of their own monitoring, and making sure that they are 

making that phone call. 

Really, that phone call is the most important thing, making sure 

that that victim or suspected victim is isolated. Them making that 

phone call is really huge. 

In the long term, before we started, before this fire hit, we were 

doing these water and sanitation activities with the government 

and we were successful in working with over 350 communities in 

Bong, Lofa, and Nimba on proper sanitation and proper hygiene. 

And that effort was incredibly successful. 

In all 350 communities, in Bong, Lofa, and Nimba, which are 

some of the hardest hit communities, none of them have been affected by Ebola. 

And it really goes to show that, if you make that long-term investment, if you prepare the communities before it hits, it has a 

huge impact and it really prevents that from happening. And I only 

wish that we were able to hit all the communities in Liberia before 

the virus hit. 

Ms. BASS. So I wanted to ask if you would expand a little bit 

more. 

You were talking about the cultural practices. And I do understand—first of all, it was really something when you said that 70 

percent of the transmissions were due to contact with people who 

had passed away. 

How long is a body contagious? 

And then my colleague was asking about the role of the faith 

community. And I was just wondering if faith leaders—since, obviously, the traditions are a part of people’s faith, if they were taking 

the lead in getting people to deviate, to divert, from traditional 

practices. And I would imagine that would be really hard. 

You said that they have come up with ways to safely say goodbye, and I thought you said that they did that with all of the protective gear on. And I was wondering if that is what you meant. 

And then, finally, I want to know what happened to you. You 

were there. You came back. Did they hold you in a tent at the airport? I mean, I am glad they didn’t, if they didn’t. But how did you 

sneak back in? 

Mr. SEDGEWICK. Great. Well, thank you. And that is a series of 

great questions. 

I will answer the last one first. I was met at the airport. There 

was an ‘‘X’’ on my piece of paper as I was trying to get out——

38

Ms. BASS. Seriously? 

Mr. SEDGEWICK [continuing]. You know, that pulled me over to 

the side. And so I conducted an interview with the CDC. 

Ms. BASS. What airport? 

Mr. SEDGEWICK. Dulles. 

And they were really great. They streamlined the process as 

quickly as possible, asked me about my potential level of exposure, 

which was very limited, and took my temperature. 

And, since then, I have been in daily contact with the DC Department of Health. I live in DC, so that I am in contact them 

every day. I self-monitor, take my temperature twice a day, and 

monitor any symptoms, of which I have none. 

But I would like to reiterate that they, the CDC and the DC Department of Health, are really focused on the partnership aspect of 

it and the fact that we are working together on this and that they 

understand why I am there and why I went and that it is not an 

antagonistic relationship, that we work together. 

And that allows not just me, but everyone coming back, to feel 

free and happy to discuss our health with the Department of 

Health and with the CDC, and that really opens up that dialogue. 

It makes it, I think, much more impactful in terms of a monitoring 

tool. 

On your question about safely saying goodbye, we don’t allow the 

community members to don PPEs as a prevention tool because it 

requires a lot of training. We do actually, though, allow them to 

don some PPEs to make them feel better because, honestly, the 

burial teams are wearing full PPEs. It is fairly intimidating. 

And so, if it makes them feel better to wear some PPEs, we allow 

them to do that, but we don’t allow them anywhere near the body. 

And they have to——

Ms. BASS. So it was the burial teams you were describing? 

Mr. SEDGEWICK. Yeah. The burial teams are wearing the full 

PPEs. The community members are allowed to attend the burial 

and, if they want to, they can wear some limited PPEs, but, really, 

they are not allowed close. 

But that allows them to understand what is happening, where 

the burial is, to watch the process, which is incredibly important, 

to make sure that they are engaged and to make sure that the next 

time there is a victim, that they make that phone call. 

So that interaction really takes the bulk of the time. The way 

that the burial teams interact with the communities and make sure 

the burial is done in a respectful and dignified way is a huge part 

of their time. 

The other small item that I wanted to respond to was on the hazard pay, which is a really important aspect of the response, actually. Because these are really brave people doing really important 

work, but they do want to make sure that they are being compensated. 

And so that is a part of our efforts, is to make sure that that pay 

is happening on time and really working to ensure that. It is a 

small amount of money by our standards, but it is incredibly important to make sure that they understand that they are valued 

and that the work that they are doing is important. 

39

Ms. BASS. Just quickly to the two last questions, which were how 

long is a body contagious——

Mr. SEDGEWICK. Oh. I’m sorry. Yes. 

Ms. BASS [continuing]. And then if somebody could address the 

abandoned children. Where are they? What is happening to them? 

Mr. SEDGEWICK. Sure. 

On the length of time that a body is contagious, we don’t exactly 

know. And the CDC and the WHO are looking at this. And so that 

is why we are just focused on—it is a long time. 

It is on the order of weeks. And so that is why we make sure 

that the body is, you know, covered in chlorine, placed in a body 

bag, covered in chlorine again when it is buried. 

It is alternating soil and chlorine so that there is no risk. The 

virus doesn’t last very long in water even. So it is very low risk to 

the water tables. But we also make sure that burials happen above 

the water table just to make sure. 

Ms. BASS. Thank you. 

Mr. SMITH. Thank you. 

Just a few follow-up questions. 

At our September 17 hearing, Dr. Kent Brantly from Samaritan’s 

Purse spoke at length about a number of things, having lived 

through it and having survived. One point that he made was that 

the 120-bed isolation unit at his hospital, ELWA, was turning away 

as many as 30 infectious individuals each day. 

And I am wondering, with the ETUs, has that changed or is the 

capacity growing? The military certainly is in the process, and you 

might give an update on how well you think the United States 

military is doing in creating that capacity. 

He also made a very strong point about those who will stay in 

their home and will be cared for by loved ones, husbands, wives, 

children. He said, ‘‘If we do not provide education and protective 

equipment to caregivers, we will be condemning countless numbers 

of mothers, fathers, daughters, and sons to death simply because 

they chose not to let their loved ones die alone.’’

And I’m wondering, since, obviously, isolation is one of the keys 

to breaking the transmission chain and many of these infected people will stay at home, is the outreach to the individual caregivers 

as robust as it should be? 

Let me also ask, at the second hearing, Dr. Fauci from NIH used 

the word ‘‘exponential’’ time and time again during his testimony. 

We had a group of top people, including the head of USAID, at a 

hearing last week of the full committee, and that word wasn’t uttered once. And I asked them, ‘‘Are we seeing a turn?’’

You know, CDC had said that, if the rate of increase continues 

at the pace in September, there could be as many as 1.4 million 

cases by late January. Where are we, in your view, in terms of the 

estimations of how large this epidemic may grow? 

Let me also ask you about one of the 10 points that you have 

suggested to us, Mr. Torbay, the importance of a capable ambulance network. 

And I am wondering, since so many people can’t get to an ETU 

or any other kind of health facility, where is Liberia, and perhaps 

the other two countries as well, but I think you know more about 

Liberia, in terms of ambulance capacity? 

40

And, also, if I could, all of you might want to touch on this. You 

know, Dr. Brantly may have been helped by ZMapp. We still don’t 

know. There are other drugs still in the pipeline, vaccines and curative potential drugs. 

I was amazed and positively shocked when you said, Mr. Torbay, 

that the rate of fatality at your Bong County Ebola unit in Liberia 

is approximately 26 percent. That is far lower than the average fatality rate in the three affected countries. 

And I am wondering, what is being done there to achieve those 

remarkable results in terms of mitigating fatality? So if you could 

speak to those issues. 

Mr. TORBAY. Thank you, Mr. Chairman. 

I would like to start with the last question about the low fatality 

rate at our Ebola treatment unit in Bong. 

We are not using any miraculous drug or any testing drug there. 

What we are doing is working with the community to make sure 

that patients are referred to the Ebola treatment unit as soon as 

possible. That has been one of the major factors in lowering mortality rates. 

And as you have seen even here in the U.S., those that were 

caught early on and sent to the hospital, they survived, and those 

that were late did not make it, unfortunately. And, for us, that is 

extremely important. 

Our treatment is very basic. It is palliative care. It is hydration. 

It is balance of electrolytes. It is making sure that people actually 

are healthy enough for them to fight the virus on their own. 

One very critical component of, actually, our success has been the 

U.S. Navy lab that was set up right next to our Ebola treatment 

unit. It used to take us 5 to 7 days before we would get the test 

results for a suspect case. Now it takes us 5 to 7 hours. 

So, basically, people are coming in. We are testing them. If they 

are positive, they are put in the treatment ward. If they are negative, they are sent home. And that cuts down on the potential exposure as well. This has been critical for us as well. 

Mr. SMITH. Excuse me. 

That would be of people manifesting some symptom? 

Mr. TORBAY. Correct. 

Mr. SMITH. Okay. 

Mr. TORBAY. Correct. They manifest symptoms. They are put as 

a suspect case until they are tested. Then we decide whether it is 

positive or negative. 

Mr. SMITH. And if they are not manifesting a symptom, no testing is done? 

Mr. TORBAY. No. 

Mr. SMITH. Okay. 

Mr. TORBAY. This actually ties into your question about the 

Ebola treatment unit capacity. Actually, the lab facilities are playing a critical role because the Ebola treatment units accept suspect 

cases. And that is why they were turning a lot of cases away, because they did not have the capacity to test a lot of those patients. 

They have to keep them there until they are tested. 

So with the additional number of labs that are being established 

in Liberia and Sierra Leone, that is helping out and it is no longer 

the case. Hardly any unit is actually pushing patients away. The 

41

situation in Liberia, and this is something that Dr. Shah, I think, 

mentioned here in his testimony, is looking better than it looked 

a couple of months ago. The numbers are lower. The new cases are 

lower than it was before. It is much better than what we estimated 

2 months ago. And if we continue on the right track—and we have 

to continue with the same momentum, we cannot slow down—we 

will get it under control. 

And the same applies for the other countries. Liberia—now we 

see the numbers in Sierra Leone, actually, are increasing at a 

much faster rate than Liberia. So we need to work together—community, the treatment, the host government, as well as donors and 

other governments and the military—to contain it. And Liberia 

could be a really good success story. 

Now, we shouldn’t start celebrating yet. We have to be very careful. It is still not under control. It is looking positive. If we continue, we will get it under control, but it is too early to actually 

start celebrating. 

On the individual family protection, this is something that is 

definitely important. This goes back to educating the family, but 

also giving them basic protection equipment, gloves, mask. 

But at the same time, we do not want to give them a false sense 

of protection. We do not want them to think that, just because they 

have gloves and a mask, they are okay to be near a patient. We 

need to make sure that the education takes place properly and that 

they are very well aware of the risks even with the protection. And 

that is very critical. 

Ambulance network. That is very important in all three countries. And, you know, we turned pickup trucks into ambulances. 

We turned anything that we could get our hands on into ambulances. We are looking at different types of ambulances, including 

air ambulances that could take patients from faraway counties into 

our Ebola treatment units. It is much better and much cheaper 

than setting up another Ebola treatment unit in some of those 

counties. 

There is a need to increase that capacity, and there is also a 

need to train staff working in ambulances because that is a very 

risky job when you are in an ambulance. It seems that there is a 

move now to actually get ambulances in there. There are a lot of 

ambulances being donated. We are buying a lot of ambulances. 

Also, we look at alternative ways of transportation. 

Mr. MANS. Yes. If I may, I just wanted to add to Rabih’s point 

about getting to that inflection point on the Ebola crisis. 

I think this combination of getting both the hardware right and 

the software right, hugely important. One, these ETCs and getting 

many ETCs out into communities, getting community care centers 

to improve access. 

On the other side is what I see happening on the technology 

front and very quickly so that we are in a position to do a better 

job of testing, tracking, and treating the virus. 

On the testing side, a number of rapid diagnostic tests are becoming available, being tested out on the ground in the next couple 

of months. 

A lot of work is being done with U.S.-based technology companies 

working with people on the ground to develop tools to automate 

42

contact tracing, to bring the power of technology into this to be able 

to do a much better job of tracking and doing surveillance. 

I think that, too, is coming in addition to what is happening on 

the treatment side. So like my colleagues, I am very hopeful, but 

we cannot be complacent or declare victory. There is still a lot of 

work to be done on all these fronts. 

Mr. SEDGEWICK. I would like to go through a few of your questions because I think they are really interesting and show the 

changes, especially in reference to Dr. Brantly’s testimony. 

I believe there was sort of a vicious cycle that was going on at 

the early stages where there was not enough testing. So there were 

not enough beds. And so Ebola patients were being turned away 

from the ETUs both because of the lack of testing and just the simple lack of beds and healthcare workers. 

And so then the victims are turned away. They go back into their 

community and they infect others and they pass away. And the 

burial teams at that point were overstretched. 

And so both of those issues being addressed—the ETUs having 

the available beds and then the burial teams being able to collect 

all the bodies—really had a significant impact on lowering the rate 

of transmission. 

And then that cycle continued to bring down the number of Ebola 

victims going into the ETUs. So that has been one of the big flips 

that has happened since Dr. Brantly testified, which is, you know, 

wonderful to hear, obviously. 

And I would like to reiterate that, while the communities do need 

protective equipment and do need education about how to handle 

the sick, that risk of the false sense of prevention that Mr. Torbay 

brought up is something that we are very careful about, that just 

because they have got a mask and gloves doesn’t mean that they 

are going to be able to safely handle victims. 

And, you know, the ETUs are not at all wasteful in terms of how 

they are put together. They are very straightforwardly put together. As he mentioned, most are temporary structures. And they 

are the fastest, lightest, high-quality treatment that you can get. 

And so, as you move down from that, you do incur some risk, in 

terms of the community care centers, that have to be looked at very 

carefully to make sure that the quality of care at those ETCs are 

very, very high. 

In terms of the projections that you mentioned, I think a lot of 

those projections were if nothing happened, if we don’t do anything. 

So now that we are doing something—and I think we are doing a 

lot—that is bringing down a lot of those projections. And I think 

we will look forward to future projections as they come forward. 

On the ambulance network, it is something that we are involved 

in in responding to. And we got into a lot of the other activities 

that we are doing, such as contact tracing and ambulance work and 

the community engagement work in the southeast, because we are 

locating our teams at the county health team. So we have a significant relationship with every county health team. 

And we make sure that the burial teams are run out of that 

county health team. And so, when they say, ‘‘Hey, our ambulance 

broke down. Can you help us out?,’’ we are able to immediately respond and very, very quickly to make sure that they have another 

43

ambulance or that their ambulance gets repaired. That has allowed 

us to engage about 10 ambulances that are being run out of different county health teams as they have requested it from us. 

And I think that aspect of it—to make sure that we are hearing 

directly from the county health teams in some of these incredibly 

remote counties—some of them take 2 days to get to on a good, dry 

day—and we are able to hear from them immediately when they 

have these needs—allows us to respond very quickly. 

I know Ranking Member Bass stepped out. But I think, on the 

orphan issue, it is a pretty significant issue that is being looked at 

by a lot of different NGOs. The entire question of how you respond 

to the families that are affected—orphans, widows, widowers—is 

really significant, and it is one of the lasting effects of this virus. 

Mr. SMITH. Just let me conclude with these following questions. 

Who is really in charge, like in Liberia? Is it the Ministry of 

Health? We know that WHO came under some withering criticism 

in mid-October from a report about how they had missed it and 

had inadequate staffing. I am just wondering, who is truly in 

charge? UNMEER, what role do they play? We know CDC is playing a very significant advisory and leadership role. 

And, secondly, on the issue of training community healthcare 

workers, could you just give a sense what their ages are. Are they 

older, more experienced people who have come back into the system? Are they young people who are stepping up to the plate? I 

mean, what does that look like? And does USAID provide any kind 

of salary support? 

We know that, in catastrophic situations, very often that kind of 

subsidy can be provided. I remember being in Sri Lanka after the 

tsunami, and we were paying salaries to individuals to do work, to 

do cleanup. And it not only was motivating, but they were actively 

doing the cleanup of their own homes and communities, and there 

was that significant subsidy to help them get money in their pocket 

to get their businesses going locally. And I am wondering if USAID 

or any other entity in government is providing any salary support. 

Mr. TORBAY. The Liberian Government is in charge, and they 

should be in charge. At the end of the day, that is their country 

and we are just guests there. And we only work through them and 

with them. And I don’t think any of those countries were prepared 

for such an outbreak and especially countries like Liberia and Sierra Leone that have suffered from a long civil war and they were 

trying to recover from that and they still haven’t fully recovered, 

in addition to the other systemic issues within the health systems 

there. 

The World Health Organization, CDC, and NGOs work to support the Liberian Minister of Health and Social Welfare, and they 

have people seconded to them. They have a body that coordinates 

the Ebola response, and they have people from different agencies 

supporting them. 

One thing that we definitely—going back to your initial question 

about what needs to be done to make sure that we do not go back 

there, we cannot afford to go back to where we were before the 

Ebola outbreak in terms of systems in those governments. We need 

to build the systems much better than they were before because, 

as we saw, they weren’t that effective. 

44

One way to do it is actually to support the Liberian, Sierra 

Leonean, or the Guinean Government, the Ministries of Health, 

build their systems, train their staff, give them all the support that 

they need to move things forward. You know, they are doing what 

they can, given the limited capacity and capabilities that they 

have. 

UNMEER is now playing a more robust role than they did a 

while ago. As I mentioned in my testimony, there still needs to be 

clarification in terms of who is responsible for what and who is coordinating what. That is very important. And I think, as discussions take place on the ground, that should be clarified. 

I will answer briefly about the health workers. And I am sure my 

colleagues here would give you a more detailed answer. 

Most of our health workers that are working with us, the majority of them are younger. They are college kids or people who went 

to school or are working in the market, but they are younger. And 

those are the ones that have been working with us mostly. 

In terms of USAID support, USAID has been very generous with 

us and other NGOs working on the ground. Whatever we ask them 

for, including salaries for staff working at the community or at the 

Ebola treatment units, there hasn’t been any hesitation. 

I do not know what is going on in terms of support for the Liberian Government, who should be paying—or who is paying the incentives. But as far as we are concerned, they have been extremely 

generous and effective and very pragmatic in their approach. 

Mr. SEDGEWICK. I would like to reiterate that the Government of 

Liberia, in general, is leading the effort and the Ministry of Health 

and Social Welfare in particular. 

Tolbert Nyenswah, who is the Assistant Minister of Health and 

has been leading the incident management system, has been a 

really great coordinator of the effort in those meetings, which happen, I think, about three times a week, makes sure that everyone 

is on the same page. 

That has been our approach, is to make sure that we are 

leveraging the resources that they have and supplementing what 

they have to make sure that we are successful and that they are 

successful. And doing so has allowed us to move very, very quickly 

and be very responsive, as I mentioned before. 

That said, the other actors, especially the USAID DART, have 

been incredibly responsive and excellent at coordinating their efforts and their various arms. The DART has been a really incredible partner for us to make sure that, as the situation changes on 

the ground, we are able to move very, very quickly. 

On the community health workers, the system in Liberia that existed before was for all the community health workers to actually 

be community health volunteers. So they were unpaid volunteers 

that received supplemental support in some way or other occasionally. And I believe that, depending on what the activity is, they are 

getting some limited level of support. 

Certainly from our side, when we do activities, they do get some 

incentive payments. If they are able to bring—if they are able to 

achieve certain deliverables, then we do give them some payments 

occasionally. I don’t know if they are receiving large-scale salary 

from the Ministry of Health at this point during the emergency. 

45

Mr. MANS. The only thing I would add, again, as I said earlier, 

is the great frustration that exists within Liberia, this crisis and 

the gap between what people perceive is actually happening on the 

ground and these very big numbers that the public hears about. 

The Government, the President in particular, has been very 

forceful in demanding that the Government be very focused on this 

agenda. As you may know, she just had a shakeup in the cabinet. 

She replaced the Minister of Health to be sure that she has the 

leadership in that ministry to see this thing through. 

So there is no sense of complacency. Quite the opposite. They are 

leading and working very hard to ensure that there is a joined-up 

government approach on their side, just as the United States Government has taken a joined-up whole-of-government approach. 

Mr. SMITH. Thank you. 

Just to conclude, I mentioned in the outset that we had just introduced H.R. 5710, the Ebola Emergency Response Act, and many 

of you have provided insights as to what ought to be in there. 

I would ask you to take a look at it to see if it covers all the 

bases, if you will, and if you could see your way clear, after you 

look at it, you know, to perhaps support it, because I do think we 

are talking about a sustainable problem that needs a sustainable 

response. 

And, you know, the good work that our House Appropriations 

and Senate Appropriations Committees have done, particularly 

when the DOD asked for a reprogramming request that was huge, 

it was done without the slightest bit of hesitation. 

But we need to have the authorizers, I think, as well making 

sure that we leave no stone unturned as well in mitigating and, 

hopefully, ending this crisis. So please take a look at the legislation, if you would. 

Anything you would like to say before we conclude? 

Mr. TORBAY. I would just like to thank you for your leadership 

and the leadership of the U.S. Government. We are very proud of 

what has been achieved so far and the continuous focus on resolving this issue. And, again, thank you for having us here today. 

Mr. SMITH. Thank you. 

Mr. SEDGEWICK. I would like to reiterate that thanks. 

And the efforts that you see on the ground in Liberia in particular are really incredible, and a large volume of that is due to 

the leadership of the U.S. Government and the leadership of the 

subcommittee to make sure that it happens. 

So it is truly inspiring when you are in Liberia seeing the response happen and seeing the effort, the impact that we are all 

having. So thank you. 

Mr. MANS. And I want to thank you for your continued leadership long after these headlines fade, and they will, to be sure that 

everybody is focused on how to rebuild in Liberia the health sector 

and get these countries back on track. So thank you for your leadership, sir. 

Mr. SMITH. Thank you so very much. 

And, again, I want to thank you for your expertise, your tremendous leadership, the three of you. It is just remarkable. 

And, that said, the hearing is adjourned. 

[Whereupon, at 11:32 a.m., the subcommittee was adjourned.] 

(47)

A P P E N D I X 

MATERIAL SUBMITTED FOR THE RECORD

48

f


91452n.eps
49

Æ


91452m.eps