U.S. GOVERNMENT PUBLISHING OFFICE

30–396 PDF WASHINGTON : 2018

S. HRG. 114–775 

A PROGRESS REPORT ON THE 

WEST AFRICA EBOLA EPIDEMIC 

HEARING 

BEFORE THE

SUBCOMMITTEE ON AFRICA AND 

GLOBAL HEALTH POLICY 

OF THE

COMMITTEE ON FOREIGN RELATIONS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

APRIL 7, 2016 

Printed for the use of the Committee on Foreign Relations 

( 

Available via the World Wide Web: 

http://www.govinfo.gov 


FOREI-42327 with DISTILLER
COMMITTEE ON FOREIGN RELATIONS

BOB CORKER, Tennessee, Chairman

JAMES E. RISCH, Idaho 

MARCO RUBIO, Florida 

RON JOHNSON, Wisconsin 

JEFF FLAKE, Arizona 

CORY GARDNER, Colorado 

DAVID PERDUE, Georgia 

JOHNNY ISAKSON, Georgia 

RAND PAUL, Kentucky 

JOHN BARRASSO, Wyoming 

BENJAMIN L. CARDIN, Maryland 

BARBARA BOXER, California 

ROBERT MENENDEZ, New Jersey 

JEANNE SHAHEEN, New Hampshire 

CHRISTOPHER A. COONS, Delaware 

TOM UDALL, New Mexico 

CHRISTOPHER MURPHY, Connecticut 

TIM KAINE, Virginia 

EDWARD J. MARKEY, Massachusetts 

TODD WOMACK, Staff Director

JESSICA LEWIS, Democratic Staff Director

JOHN DUTTON, Chief Clerk

(II)


FOREI-42327 with DISTILLER
C O N T E N T S 

Page 

Flake, Hon. Jeff, U.S. Senator from Arizona ......................................................... 1 

Markey, Hon. Edward J., U.S. Senator from Massachusetts ............................... 2 

Knight, Alan, General Manager, Corporate Responsibility, ArcelorMittal and 

Chairman of the Ebola Private Sector Mobilization Group .............................. 5 

Prepared statement .......................................................................................... 7 

Panjabi, Dr. Raj, CEO, Last Mile Health .............................................................. 10 

Prepared statement .......................................................................................... 13 

Glassman, Amanda, Vice President for Programs and Director of Global 

Health Policy, Center for Global Development .................................................. 17 

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

Delaunay, Sophie, Advisor, Doctors Without Borders/Me ́decins Sans 

Frontie`res (MSF) USA ......................................................................................... 21 

Prepared statement .......................................................................................... 23 

(III)


FOREI-42327 with DISTILLER

FOREI-42327 with DISTILLER
(1) 

A PROGRESS REPORT ON THE 

WEST AFRICA EBOLA EPIDEMIC 

THURSDAY, APRIL 7, 2016 

U.S. SENATE, SUBCOMMITTEE ON AFRICA AND GLOBAL HEALTH POLICY

COMMITTEE ON FOREIGN RELATIONS, Washington, DC. 

The subcommittee met, pursuant to notice, at 10:04 a.m., in 

Room SD–419, Dirksen Senate Office Building, Hon. Jeff Flake, 

chairman of the subcommittee, presiding. 

Present: Senators Flake [presiding], Isakson, Markey, and Coons. 

OPENING STATEMENT OF HON. JEFF FLAKE, 

U.S. SENATOR FROM ARIZONA 

Senator FLAKE. This hearing of the Senate Foreign Relations 

Committee, Subcommittee on Africa and Global Health, will come 

to order. 

Just last week, the World Health Organization declared the West 

Africa Ebola epidemic no longer constitutes an international public 

health emergency. However, this does not mean that the affected 

countries of Liberia, Sierra Leone, and Guinea have fully recovered 

from the epidemic. 

Today’s hearing gives us an opportunity to examine West Africa’s 

road to recovery from the deadly outbreak of Ebola that in—in 

2004, that infected more than 28,000 people, took the lives of more 

than 11,000 individuals before the epidemic was brought under 

control. The epidemic decimated already weak healthcare systems 

in the three affected countries. It also has continued to wreak 

havoc on their economies, complicating recovery for governing institutions and hampering a return to normalcy for the citizens of 

those countries. There have been a number of so-called flareups of 

Ebola since the primary outbreak was brought under control, including one ongoing outbreak that has already claimed the lives of 

at least seven people. 

Now, the U.S. Government provided 5.4 billion in emergency appropriations at the end of 2014 to assist affected countries in their 

response. More than $2.5 billion of this funding falls under the 

oversight jurisdiction of this committee. Now, more than a million 

dollars of assistance remains unobligated, with some of it set to expire at the end of the fiscal year, and the remainder to be available 

until expended. This is a substantial amount of money. 

It is incumbent on this committee to examine the successes and 

the failures of U.S. efforts to assist in the Ebola recovery efforts. 

This hearing will especially—is especially timing—or timely, given 


FOREI-42327 with DISTILLER
2 

the news reports that indicate that the White House will ask Congress to reprogram 589 million of existing unobligated balances to 

address the Zika virus. Some of this will come from funds appropriated to fight Ebola. 

At the height of the outbreak, this subcommittee heard testimony 

that called for the establishment of first-rate healthcare systems in 

the affected countries. I think we all share that goal, and it is important to remember that simply providing affected countries with 

the tools they need to stamp out diseases like Ebola is not an economically sustainable model. This kind of health infrastructure 

necessary to address these outbreaks while providing other health 

services can only be sustained by the affected countries, themselves. 

Is the U.S. helping these countries to put their healthcare systems on a path to self-sufficiency? Have we helped mitigate secondorder impacts of the epidemic by focusing assistance in a way that 

helps facilitate economic recovery and development? The physical 

accessibility of health services was a problem before the Ebola outbreak, as was the access to clean water for drinking, handwashing, 

and other activities central to proper hygiene. Are we working to 

continue the kind—these kind of systemic—or to address these 

kind of systemic problems that will likely contribute to recovery 

and certainly contributed to the severity of the outbreak? 

We will examine whether our assistance to affected countries is 

complete enough to consider reprogramming Ebola money for other 

matters. Will that programming come at the expense of long-term 

efforts to help economic recovery in the affected countries and to 

ensure eventual self-sustainability of healthcare systems by the 

countries, themselves? These are questions that we want to answer. 

Lastly, it should be noted that the Ebola recovery funds were appropriated using a supplemental appropriations measure. These 

funds are not subject to spending caps established by Congress, 

and they are not part of any long-term strategic planning effort. As 

Congress prepares to potentially consider appropriation of another 

tranche of emergency supplemental appropriations, this time to 

combat the Zika virus here in the U.S., it is worth examining 

whether this method of appropriating is effective. Does it result in 

smart investments, or is there pressure to simply get the money 

out the door before it expires? 

I look forward to hearing from the witnesses today. I would like 

to thank them for taking the time to meet. I have met with each 

of you before—or three of you in my office before, and I appreciate 

the time and effort you have put into the testimony that you are 

going to give us today, and thank you. 

We will turn now to the Ranking Member, Senator Markey. 

STATEMENT OF HON. EDWARD J. MARKEY, 

U.S. SENATOR FROM MASSACHUSETTS 

Senator MARKEY. Thank you, Mr. Chairman, very much. And 

thank you for your leadership and for scheduling this hearing on 

such an important topic. 

The West Africa Ebola epidemic devastated communities in 

Guinea, Liberia, and Sierra Leone. The virus sickened more than 


FOREI-42327 with DISTILLER
3 

28,000 people and claimed the lives of more than 11,300. While 

new cases of Ebola have been dramatically reduced, Ebola is not 

over, and the conditions that made it an epidemic persist. Last 

week, a 30-year-old woman died of the disease in Liberia’s capital, 

and her 5-year-old son has been diagnosed with the same disease. 

Our thoughts and prayers are with them and all the victims of 

Ebola. But, thoughts and prayers are not enough. We must continue to build up health systems in the most vulnerable places so 

that we can prevent an even worse epidemic from again rising up 

to threaten people in Africa and around the world. 

Through 2014 and much of 2015, people watched with a sense of 

helpless horror as the Ebola virus seemed to spread unchecked. 

Doctors and nurses unable to stem its deadly tide, fell mortally sick 

themselves. That fear took on a new dimension as Ebola began to 

spread. In September of 2014, a man checked into a Dallas hospital, sick with the disease, and many began to fear that the U.S. 

would suffer an outbreak, as well. Of course, the United States did 

not have an outbreak, neither did countries in Europe. The U.S. 

and European citizens are fortunate to have capable health systems that virtually eliminated the risk of an epidemic and saved 

80 percent of those treated, a survival rate far above what anyone 

previously thought was possible. 

As Dr. Paul Farmer has explained, we in the developed world 

have the staff, the stuff, the space, and systems to deal with these 

things. Guinea, Liberia, and Sierra Leone are not so fortunate. 

Ebola infections there became a rampant, devastating epidemic. 

More people got the disease than should have, and more sick people died than should have. 

Beyond the immediate impact of Ebola, the story became even 

more tragic as the disease crippled weak healthcare systems and 

patients had nowhere to seek treatment for routine medical issues. 

Infant and maternal mortality rates soared, and the economy of 

each country was hobbled. Agricultural production was disrupted 

and food and work became increasingly scarce. The scale of Ebola’s 

devastation may never be fully known. 

U.S. leadership under President Obama and the Congress was 

instrumental in stopping the spread of the disease. Thanks to $5.4 

billion in emergency funding to combat Ebola, this type of leadership in the face of our severe threats is not only vital for our national security, but also an essential statement about America’s 

commitment to humanity. Just yesterday, the administration once 

again demonstrated its commitment to protect the American people 

and strengthen global health security by temporarily redirecting 

$589 million from existing Ebola funds to combat the Zika virus, 

a mosquito-borne infection that has broken out in countries of 

Latin America and threatens to spread north. 

In February, the administration asked Congress for an emergency supplemental appropriation of $1.9 billion to fight Zika. We 

cannot look at a false choice between responding to Zika and continuing to build healthcare systems capable of preventing Ebola 

from again becoming an epidemic. I applaud the administration for 

making a good start on Zika. As has often been said, a stitch in 

time saves nine. But, we cannot stop there on Zika, and we cannot 

pull out the threads that we and our African partners are using to 


FOREI-42327 with DISTILLER
4 

stitch together health systems capable of preventing Ebola from 

again becoming an epidemic threat. Congress must act to fight both 

of these threats or be prepared to answer for the consequences of 

inaction. 

On Zika, we must invest all of the resources needed to better understand how this disease is transmitted and the suffering which 

it causes, including babies born with stunted heads and brains. 

Zika is spreading rapidly in South and Central America, in Puerto 

Rico and the Pacific islands. And in a small part of Africa, you can 

see, on this startling map, the World Health Organization estimated the virus will infect up to 4 million people by the end of this 

year. And health officials have warned of the spread of Zika in the 

United States, where its mosquito host is already endemic. This 

next map shows just how much of the U.S. is vulnerable to that 

mosquito and the diseases which it carries. 

While Zika presents a new challenge that America must face, we 

cannot become complacent about the gains we have achieved 

against Ebola. We must build upon the investments made during 

the epidemic and the wake-up call that it provided to the world. 

The health of the United States is intricately connected with the 

health of West Africa, Latin America, and other developed regions. 

As devastating as Ebola was, it is difficult to contract and relatively easy to trace. The next pandemic may not be so forgiving. 

Having strong health systems in place in vulnerable parts of the 

world will be crucial to isolate and stamp out the next inevitable 

threat. 

I want to thank each of our distinguished witnesses for being 

here today. All of your leadership and sacrifice in the face of the 

Ebola epidemic is nothing short of heroic, and we deeply appreciate 

your service. I should also note that several of you have connections to Massachusetts. And I am especially grateful that you are 

representing our great State here today. 

Thank you, Mr. Chairman. 

Senator FLAKE. Thank you, Senator Markey. 

We will now turn to our witnesses. Dr. Alan Knight is General 

Manager of Corporate Responsibility for ArcelorMittal, and—but, 

he also served as chairman of the Ebola Private Sector Mobilization 

effort, which—EPSMG, a group founded in July of 2014 to facilitate 

a mobilized and coordinated private-sector response to the Ebola 

virus. Dr. Raj Panjabi is a Co-Founder and CEO of Last Mile 

Health, a nonprofit organization working to save lives in the 

world’s most remote villages, including in Liberia, where Dr. 

Panjabi was born. Ms. Amanda Glassman is the Vice President for 

Programs, Director of Global Health Policy, and Senior Fellow at 

the Center for Global Development, leading work on priority-setting, resource allocation, and value for money in global health. 

Lastly, we are joined by Ms. Sophie Delaunay, who serves as Advisor to Doctors Without Borders, an organization that was on the 

front lines of the Ebola epidemic. 

We ask you to keep your comments right around 5 minutes. Your 

full remarks will be submitted as part of the record. We just want 

to maximize time for Q&A thereafter. 

So, thank you. And, Dr. Knight. 


FOREI-42327 with DISTILLER
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STATEMENT OF ALAN KNIGHT, CHAIRMAN, EBOLA PRIVATE 

SECTOR MOBILIZATION GROUP, LONDON, ENGLAND 

Dr. KNIGHT. Okay. Good morning. And thank you for the honor 

of speaking here. 

You have my paper, so I will just highlight what I think are the 

most important points in that paper. 

As you said, I come here wearing two hats. One, on behalf of 

ArcelorMittal, who are the largest investor in Liberia, an iron-ore 

mine; our investment, at the moment, of about 1.7 billion, with an 

iron-ore mine railway and port facilities, but also as the, sort of, 

founder, the chairman of the Ebola Private Sector Mobilization 

Group, which was really, for several months, a hub where the private sector with operations within the whole of West Africa could 

get together to exchange notes, share information about how the 

private sector should be responding to this crisis. But, over time, 

that evolved to where we had a bit of a voice and an opinion on 

some of these key issues and, more importantly, with in-country 

groups, a hub where we could exchange resources and assets very 

quickly to NGOs and government partners who needed them—and 

so, trucks, medicines, and that sort of stuff. 

At the time, it was quite unique for such a large number of private sectors to get together and be actively involved in the operational side of fighting such a big issue. And I think that is why 

people sort of still remember it and we still talk about it, and many 

of us are obviously still so active. 

I know a lot of this conversation you want to have today is about 

recovery and ‘‘What next?’’ And so, that is what I really want to 

focus on. 

Firstly, so, what has been the impact on us, as a business? Well, 

it was hard. We were committed, and we succeeded in keeping our 

business running, and not forgetting that some businesses just 

packed up and left the country. We have done that, and we have 

succeeded. The impacts on us, commercially, was, we lost a scaleup project. Just as Ebola happened was when we had planned to 

build a lot of infrastructure to significantly grow the size of our operation. Our contractors went home, and we lost that project. Of 

course, we were distracted with management time, and we had to 

spend a lot of money on the interventions to prevent Ebola from 

happening in our concession area. And let us not forget, make a 

really strong point, we, like most of the private sector, can claim, 

rightly so, that nobody in our operations actually got Ebola. So, the 

interventions we did for their own staff clearly worked. 

What is been harder for us is the perfect storm that has all happened at the same time as the iron-ore prices collapsed, and probably we spend more time in the office now talking about the consequences of that as much as we talk about the consequences of 

Ebola. But, despite that, we are working very hard to keep our 

business functional, and our commitment to staying in Liberia is 

absolutely clear. 

So, I really sort of want to end with just making sort of four 

points about recovery and what we think we can do, and what we 

would like to suggest others help us do on this road to recovery. 

Firstly, this whole issue of travel. For a group of private-sector 

people at the time of the crisis, we spent a lot of time talking about 


FOREI-42327 with DISTILLER
6 

travel restrictions. What happens if somebody from our—America 

or the U.K. goes over and catches Ebola? Can they come home? 

And that sort of—it took a lot of time. And it sort of—the observation was, it was not clear, there is no sort of international convention on the movement of people from these areas where this happens. And so, that became very distracting, and we lost a lot of 

time worrying about that, which we could have been devoted to actually being on the front line. So, I think that there is a space there 

which we can fill. 

There are still—and a lot about the investment—What is the role 

of the private sector? It is about confidence, giving them the confidence to invest in that country. And another conversation we are 

having a lot now is about the withdrawal of our mill, where we 

are—you know, we are nervous about the United Nations security 

support might actually create tensions in the ore and an inability 

to sort of fight some security issues. So, that is now—we talk about 

that as a commercial risk. What will happen when these people 

work out? What can we do together with other people to fill that 

space? 

I think we need to have an honest conversation about infrastructure. You know, you can build fantastic health services, but if you 

do not have roads to get them—get people to those health services, 

it does not actually work. We need roads to keep our business running, and the country needs roads to keep the country working. 

I am using roads as a bit of a metaphor, but infrastructure really 

matters. When our business is running really well, part of our contribution towards these countries is, we actually give money and 

we help build that—some of the infrastructure. But, at the moment, we are really having to focus on our core business. So, just 

at the moment when we need more infrastructure is just at the moment that some of the conventional sources of that infrastructure 

disappear. And I have got some photographs here to show that this 

is not sort of—issue. You know, the—roads—physical roads, if 

somebody could—you know, if somebody wants to have a look at 

them, they are great, but they are just mud tracks. And so, what 

is the road to recovery? Well, the road to recovery could actually 

be roads, you know, sort of—that sort of line. 

And finally, to save space to discuss this. You know, we have— 

there are a lot of very big issues—iron mill, Ebola, commodity 

prices, infrastructure. And I think what EPSMG did when it was 

just about Ebola was a safe space for different people from different 

sectors just to get together and discuss with government officials. 

And I think people are—just underestimate how much can be 

achieved with collaboration and dialogue. 

So, sort of, really, my headline, in my last 30 seconds, is, do not 

underestimate how important the road to recovery is. And a lot of 

that road to recovery will be infrastructure, like roads. And the vehicle being dialogue and collaboration. Where can we carry on with 

our EPSMG-type dialogue on these broader issues, where we can 

get together and talk to government officials in-country, NGOS, 

about what we all really need to move this forward? Where is that 

safe space? 

Thank you. 

[Dr. Knight’s prepared statement follows:] 


FOREI-42327 with DISTILLER
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PREPARED STATEMENT OF ALAN KNIGHT, GENERAL MANAGER, CORPORATE RESPONSIBILITY, ARCELORMITTAL AND CHAIRMAN OF THE EBOLA PRIVATE SECTOR MOBILIZATION GROUP

Mr. Chairman, Ranking Member Markey, members of the subcommittee, thank 

you for giving me the privilege to testify today on the Ebola outbreak recovery efforts in West Africa and the lessons that we can draw from the response. 

It is an honor to represent my company, ArcelorMittal, one of Liberia’s largest investors. I am also here in my capacity as a founding member of the Ebola Private 

Sector Mobilization Group (EPSMG). 

My testimony today will focus on two issues: 

• Examining the role of the private sector in coordinating an effective, rapid response during a crisis, and 

• Looking beyond Ebola and lessons learned and considering the challenges of 

economic recovery. 

As I sit here today, and as you consider my testimony, I would like to suggest 

that the private sector’s largest contribution during the Ebola outbreak was simply 

to keep business running. This was achieved through rigorous risk-planning and 

through the development of health-and-safety systems which minimized the risk of 

employees contracting the virus. 

Going forward, I would like to further suggest that the private sector’s greatest 

contribution, post-Ebola, is to keep business going, not in the face of a health emergency, but in an environment of higher costs, higher risks, and low commodity 

prices. 

It is my hope that this hearing will examine not only lessons learned but what 

steps can be taken to ensure that the region’s recovery is driven by a private-sector 

recovery. 

From risk register to company level mobilization 

First, by way of background, ArcelorMittal operates an iron ore mine, a railway 

of 240 kilometers, and a port in Liberia. Our operations stretch from the border of 

Guinea to the shore of the Atlantic and through three of Liberia’s fifteen provinces, 

Nimba, Bong, and Grand Bassa. We have been operating in the country for ten 

years. At the height of the Ebola outbreak we had nearly 3,000 direct and indirect 

employees. While many of our subcontractors declared force majeure because of the 

health emergency and departed, ArcelorMittal did not. We never left. We never 

stopped working. We stayed operational throughout the peak of the virus. 

As you can imagine, given our footprint and our direct and indirect employees, 

their families, their extended families, and their communities, ArcelorMittal touches 

the lives of tens of thousands of people in the region. During Ebola, that meant that 

our health and safety protocols did as well, and this saved untold lives. 

We monitored the Ebola outbreak carefully. We worked hard to understand the 

virus and make sure that our facilities were prepared to deal with it. We hired experts to advise the company, trained and counselled our staff, and mobilized protective and specialized medical equipment. We also reviewed and refined our emergency response and evacuation procedures, set up a management committee, and 

enacted the appropriate procedures and systems. 

In July 2014, cases of Ebola were reported in Monrovia, Liberia and the risk management triggers were pulled for ArcelorMittal. The company led the way in private 

sector support to the government with the total value of support to the government 

and individual counties estimated at US$1.3 million. 

Although we hoped that the outbreak would not spread any further and endanger 

more lives, we were prepared for it. However, we were not the only company operating in the region and knew that we would have to learn from others in order to 

share what we already knew and to drive a stronger response to the escalating crisis. That is why a call was made to companies we knew, inviting them to join an 

informal conversation in London to share information about the outbreak, compare 

best practices, and collaborate to limit impacts across West Africa. 

EPSMG is born 

The ESPMG started in July 2014 as a one-off gathering of 11 London-based companies who came together to share what they could contribute to help combat the 

growing threat of Ebola. These companies all had an operational footprint in the affected region. 

Awareness of the group spread by word of mouth and more companies asked to 

be involved. The number of companies dialing in for EPSMG calls quickly grew and 

we were soon joined by representatives of aid organizations, international instituVerDate Mar 15 2010 13:37 Jun 19, 2018 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6621 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\04 07 2016 -- 30-396

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tions, and governments. At the peak there were over 100 companies and almost 50 

public bodies and NGOs joining the calls. For one of our December 2014 calls, we 

believe we had over 400 individuals dialing in. 

I call the EPSMG a hub because it was never actually a legal entity with a board, 

budget or articles of association. Our initial focus was to exchange notes on what 

we were doing at our operations. We also decided to write to the Director General 

of the World Health Organization to ask advice on how we could strengthen our response. 

Through this all, we found a common voice. Despite the unprecedented nature of 

the outbreak, group members made a joint commitment to continue operating in 

those Ebola-affected economies and to carry out business as usual, as far as was 

possible. This was no easy feat in the face of emerging restrictions on national and 

international trade as well as travel restrictions. Falling commodity prices bought 

extra complexity to this operating environment. 

Looking after our own people was important but that alone was not going to ‘‘bend 

the curve’’ of the outbreak. What started as an inter-company information exchange 

evolved to advocacy for a global response and a hub where the public and NGO sector had direct access to companies for bilateral collaboration. 

Although aid organizations had the humanitarian and health response expertise, 

we had heavy lifting equipment, transport, accommodation, and other needed resources. Perhaps most critically, we already had all of this in the affected countries 

and were ready to help. The ESPSMG provided a quick and simple hub to learn 

what needs were and helped facilitate bilateral arrangements between donors and 

recipients. 

Country groups, the real success 

From the EPSMG came the EPSMG country groups which were on the ground, 

mobilizing skills and resources in Guinea, Liberia, Sierra Leone, as well as in the 

adjacent countries of Mali and Senegal, to increase preparedness and prevent the 

spread. Most of the EPSMG’s success can be linked to these country groups; the umbrella organization created a sense of community and an environment which enabled an efficient exchange of information. 

We had a clear responsibility to foster stronger relationships with government 

and responders, ensuring that we had the information needed to fight the disease, 

which we could then share within our communities. However, this could only happen at country level and a great success of EPSMG was its ability to help get things 

done on the ground. 

So what did companies do? In some instances assistance meant giving cash, while 

in others it meant donating vehicles for use as ambulances, providing medical supplies, and providing access to logistics, infrastructure, and communications technology. 

People like numbers, but numbers with meaning can be hard to obtain. We believe that, at a minimum, the EPSMG companies gave away least 50,000 liters of 

chlorine, 4 million latex gloves, and 55 vehicles. More importantly, we trained over 

50,000 employees who we estimate reached 350,000 dependents. Another positive 

outcome was the low infection rates within member companies. Thanks to the rigorous planning and precautions taken by our Liberian colleagues, not one of our employees contracted the virus, a fact that most other companies could also report. 

The EPSMG never sought to replace or compete with the governments, donors, 

other coordination groups, or task forces. It was created to provide a simple access 

point into the private sector for joint mobilization. The EPSMG was about practical 

in-field action—not intellectual consensus building. 

By January 2015, the Ebola outbreak curve had been bent. While the numbers 

of new cases reported were still unacceptably high, there were fewer with each passing week. Discussions began on ‘‘the road to zero.’’ With the crisis over, we observed 

that many private sector companies began disengaging from the EPSMG, instead 

channeling their efforts into the daily operations of running a business in post-Ebola 

West Africa. By April 2015, EPSMG was no longer as active as was required at the 

height of the crisis. 

Travel restrictions—our biggest distraction 

With people dying from a highly contagious disease, it was a shock to many of 

us that governments around the world had no formal policies or thoughts on what 

was the right approach to the movement of nationals to and from countries at risk. 

For example, if I, as a British national, flew to Liberia to help fight the Ebola 

outbreak and contracted the disease it was unclear whether I could come back to 

UK for treatment, or whether I would have to stay in Liberia. If so, what would 

happen to me? What if I broke my leg or suffered an illness or injury completely 


FOREI-42327 with DISTILLER
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unrelated to Ebola while in an Ebola-affected area—would I be able to return to the 

UK? It was all unclear. Expatriate employees were concerned about the uncertainties surrounding routine return transport to their home countries and fears grew 

about the availability of medical evacuation for suspected or confirmed cases of 

Ebola. 

We also realized that blanket travel bans were of significant concern to humanitarian responders struggling to get personnel and supplies to the affected areas. We 

lobbied hard on this, as there was too much fear driving decisions. 

As we look at outcomes from this hearing I would ask that this committee considering asking for an international convention on the movement of nationals to and 

from countries suffering a pandemic. It is imperative that a protocol be negotiated 

and agreed before the next pandemic. This is an unnecessary distraction the private 

and public sectors can ill afford to see repeated. 

What did we learn? 

1. The EPSMG’s greatest contribution was preventative action 

The epidemic was rightly seen as a humanitarian disaster, but we observed that 

it is important not to put Ebola in the same box as event-based disasters like floods 

and earthquakes, where the worst outcomes occur suddenly, before businesses can 

intervene, placing the focus on rescue and recovery. While a death toll of 12,000 is 

a disaster, we should remember that the forecast number of cases exceeded 250,000 

in September 2014. Perhaps the forecasts were wrong, or even more likely, the joint 

effort with NGOs, the public sector, and the private sector were successful. Either 

way, this success story is about what was prevented. 

2. Business has been here before—parallels with HIV 

Parallels can be drawn with the long track record many businesses have in managing HIV in their workforces. Whilst the pace of the HIV outbreak was over 

months and years rather than hours and days, many companies in Africa proved 

to be highly effective in mobilizing their staff and resources to prevent HIV from 

spreading. The parallels are noteworthy: the need to change behaviors, the need to 

have the right medicines, the value of peer-to-peer education, and the issues of stigma are all similar. Perhaps most noteworthy was the need for an employer to engage in conversations with employees about topics that they normally would avoid. 

For HIV, this was about sexual behavior; for Ebola, it was about attitudes toward 

funeral rites and traditional care behaviors. Anyone studying the EPSMG contribution should, therefore, also draw lessons from HIV. 

3. Risk management works 

Business risk processes provide a good framework to plan for pandemic risks. 

Since SARS, contagious disease has become a theoretical business risk, but late2013 and early-2014 Ebola cases in West Africa captured the attention of risk managers and their health and safety colleagues. During the worst moments of the outbreak, ArcelorMittal’s top management reviewed the status of the outbreak and our 

actions. This model was replicated across the business network. It works. 

4. Businesses will look after their employees, which means they look after citizens 

The most significant private-sector contribution was undoubtedly the training and 

care these companies offered their own employees and those individuals’ families 

and neighbors. Employees are citizens, so a mass outreach by all the employers will 

reach a significant proportion of the population. I am confident the companies operating in Ebola-affected regions would have done this regardless, but the EPSMG 

provided value as a hub for sharing best practices on how to approach this most 

effectively. 

5. Business interests are also human interests 

To protect a business from such a disease you need to protect your employees. 

Employees are citizens, so business interventions protect the human, as well as the 

economic need. The logic extends from the employee to their family and community. 

What is more, the public sector asked the private sector to stay in-country and remain economically active. The other choice would be to leave the country, which 

would have made matters worse. By staying in the affected countries the private 

sector helped keep economies active. 

6. Rewiring public-private partnerships 

Chairing the EPSMG gave me the rare privilege of getting closer to the workings 

of the public sector. While I deeply respected the individuals with whom I engaged, 

I saw that their desire to deliver results quickly and pragmatically was constrained 


FOREI-42327 with DISTILLER
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by bureaucracy, process, and politics. Governance of the public sector is key but it 

can pay a price in moments of need. 

I was proud to see my business colleagues acting nimbly and quickly, but conscious that many public sector players saw business as merely a source of money. 

The EPSMG was special because it helped to unlock the real contribution from the 

private sector which was not cash, but skills, assets and awareness. The EPSMG 

helped the collaboration and coordination of goodwill, skills, and physical assets. It 

is now clear that the private sector has more to offer than donations and I hope 

the EPSMG (and the business response to HIV) are proof points. The challenge for 

the public and NGO sectors is figuring out how to best utilize this in the future. 

7. The value of simplicity 

It could be argued that the Ebola related events in West Africa were unique. The 

region simply did not have the means to contain the disease. An Ebola crisis would 

not happen in the UK, for example. Even airborne Ebola would be contained by 

measures implemented by the UK government since the SARS epidemic. But while 

this case was unprecedented, valuable lessons can be taken and applied in future 

global challenges. Today, for example, there is general recognition that the private 

sector has a valuable role to play in crisis and humanitarian response. 

But perhaps the most important lesson is the value of simplicity. With the 

EPSMG, a group of businesses saw value in collaborating to protect their people, 

companies, and entire communities from a terrible disease. Learning and resources 

were shared when they were needed. Practical action happened when it was needed. 

When these things were no longer needed the EPSMG was no longer needed and 

naturally, it fizzled out. 

What now? 

We get to zero and stay at zero; we build resilient healthcare systems and delivery mechanisms. Beyond on-going collaborations, our group is making two unique 

contributions in this area. First, some EPSMG members, under Chevron’s leadership, have set up the Center of Excellence for Infectious Disease Control at JFK 

Hospital in Liberia as an on-going platform for training and public-private collaboration. This project is now eligible for a USAID Global Development Alliance grant 

for Ebola recovery. Secondly, the No More Epidemics Campaign has offered to house 

lessons learned from Ebola and keep the EPSMG experience relevant. 

Recovery in West Africa is vital. At ArcelorMittal, we remain deeply committed 

to Liberia. While the combination of market conditions and Ebola posed a challenge 

to our operations, our company is proud that we were able to maintain production 

and contribute to the Liberian economy at a crucial time in the country’s history. 

We continue supporting the country further, even though low iron ore prices required changes to our operating model. But sustaining a private sector recovery cannot be done by a single company, and in this environment, not just by the host-governments. All of Liberia’s stakeholders need to take a look at helping to create conditions for a recovery where jobs are created by a vibrant private sector. 

Going forward, the United Nations and other response groups need to look at the 

private sector as equal partners and not just as donors. The UN Office for the Coordination of Humanitarian Affairs (OCHA) has a role to play here in leveraging 

new relationships and partnerships. 

Again, we need an international convention on the movement of people across borders during a pandemic. We need to address this now, before the next pandemic. 

The battle against Ebola is far from over and many obstacles lie ahead, particularly the fight to sustain the economies of the affected countries. The private sector 

has shown that it can rise to the challenge, working in partnership with other 

stakeholders to deliver the most effective response to the benefit of employees, their 

families, and their communities. It is my hope that the hard lessons from this outbreak can be applied to prevent the next. 

Senator FLAKE. Thank you, Dr. Knight. 

Dr. Panjabi. 

STATEMENT OF RAJ PANJABI, CO–FOUNDER AND CHIEF EXECUTIVE OFFICER, LAST MILE HEALTH, BOSTON, MASSACHUSETTS 

Dr. PANJABI. Chairman Flake, Ranking Member Markey, distinguished members of the committee, thank you for having me here 

to testify today. 


FOREI-42327 with DISTILLER
11 

I just returned from Liberia a couple of weeks ago, and people 

have not forgotten the leadership that all of you have shown, not 

only to mobilize resources, but also to actually come to the front 

lines, as members of this committee did during the height of the 

epidemic. So, I wanted to express and share that gratitude. 

I speak today as CEO of Last Mile Health and as a physician 

and teacher from Harvard, but also as an American citizen. I was 

born in Liberia, and fortunatley escaped the country’s civil war as 

a child. Over a decade ago, I went back to Liberia, and, with my 

colleagues, created Last Mile Health, which, as Chairman Flake 

noted, partners with governments to create national networks of 

what we call community health workers. That is,we recruit people 

from their own villages, give them the equipment, the medicines, 

the training that they need to bring healthcare to the doorsteps of 

their neighbors. 

And today, I am going to make the case that investing in those 

community health workers, especially in rural areas, was one of 

the most effective measures taken by the United States in responding to Ebola. And I also want to make the case that increasing investment in community health workers in rural areas can help stop 

the next epidemic, build back health systems, and even help support and drive economic recovery. 

In West Africa, we lost over 500 of my fellow health workers. 

Many of them were community health workers. This kind of loss 

would be great for any country. It was especially so for mine, Liberia. We had very few health workers, to begin with. When I first 

returned to Liberia in 2005 after the war, we were left with just 

51 doctors to serve a country of nearly 4 million people. Now, to 

put that in perspective, just imagine for a moment all of Washington, D.C., the entire city, being cared for by only eight doctors. 

And you can imagine if you were sick in a city back then, you 

might stand a chance, but if you were sick way out in the remote 

villages, where there were no doctors, you could die anonymously. 

And I bring this up because it has something to do with Ebola. 

The massive shortage of health workers in remote villages has a 

lot to do with outbreaks of zoonotic origin, infectious diseases that 

move from animals to humans. Ebola has revealed that illness is 

universal but access to care is not in these places, and that fact 

places all of us—all of us from, Liberia’s rainforests to American 

cities—at greater risk. Paradoxically, it is exactly in these hard-toreach areas where defeating diseases like Ebola is most difficult. 

The problem is that remote communities, not unlike I imagine 

some very rural stretches of your own States, face what we call a 

triple bias. That is, that the public sector is unable to prioritize remote communities. The private sector often does not see the market potential. And even the nonprofit social sector thinks it is too 

expensive to serve them. Now, that set of conditions brewed a perfect storm to help escalate what was—could have been—a local outbreak into a global epidemic. 

And you only have to think of patient zero, little 2-year-old Emile 

in the borderlands of rural Guinea, Sierra Leone, and Liberia, who 

fell sick with Ebola in December of 2013. A lot has been made of 

what happened from March 2014 and thereafter, what was too slow 

of an initial response. But, between December 2013 and March 


FOREI-42327 with DISTILLER
12 

2014, not only did Emile die, but dozens of people in nearby villages also died. Partly because of a lack of well-supported health 

workers in those remote communities, we lost time. When minutes 

counted, we lost months. It took us months before we recognized 

the outbreak in March 2014. What more could have been stopped, 

in terms of loss of lives, in terms of billions of dollars lost, had we 

had those health workers in place? And so, Ebola and other emerging infectious diseases that start in regions that are in remote communities reminds us that the cost of inaction is greater than the 

cost of action. 

You know, the good news is, is that when the U.S. does invest 

in rural community health workers, their achievements can be dramatic. I have seen it firsthand. Over a year ago, I was sitting in 

a mud-walled hut, working with local rural community health 

workers, helping them respond to an outbreak. A woman, 42 years 

old, had come into the community, died of Ebola, and over a dozen 

people there had also died who had attended her funeral. Now, this 

community, deep in the rain forest, in an area called Rivercess, 

was cut off. It was cut off from electricity, from roads, from phones, 

and days away from the nearest hospital 

We were told back then, as you know, that we could see as many 

as 1.4 million cases of Ebola, that outbreaks like this would spread 

all across the region, and that many of those people could die. But, 

together, we fought back. And that was a major credit to the Liberian government, to the U.S. Government and other partners. With 

other NGOs and a coalition of U.S. agencies, including USAID and 

the CDC, we rallied behind the government to train several hundred front-line health workers. That included people like David, a 

24-year-old who drove a motorbike 6 hours over mud tracks in the 

rain forest to go door-to-door to collect blood samples from people 

who had been exposed. And it included community health nurses, 

like Alice Johnson, who distributed thermometers, masks, gowns, 

and gloves to clinics to help put in place infection control measures. 

And they also included community health workers, like Zarkpa, 

who, while the health system was collapsing all around her, managed to keep all kids who had malaria on treatment and never 

miss a single date. These community health workers risked their 

lives to hunt down the virus, stop it in its tracks, and protect all 

of us. 

And, as you said, the fight is not over. We have seen flare-ups 

in Liberia and rural Guinea last week. There are other outbreaks 

of HIV/AIDS, malaria, tuberculosis. We have seen a spike in child 

and maternal deaths, in malnutrition. You know, Ebola has taught 

us that what works best in an emergency system is not actually an 

emergency system; it is an everyday system that reaches all people, 

that is robust, resilient, and can respond before these threats even 

emerge. If that is our goal, to build such a system, in partnership 

with our Liberian counterparts, to make a sustainable system, we 

must continue to invest in people, we must continue to invest in 

Liberia’s health workforce. 

At this hearing, we heard that call echoed 15 months ago in this 

very chamber by Liberia’s leader, President Ellen Johnson Sirleaf. 

Members of this committee asked her, What is one of your top priorities? She said—I quote—‘‘At the time, we want to build capacity 


FOREI-42327 with DISTILLER
13 

at all levels, especially at the lower levels of community healthcare 

workers.’’ Her government has followed through on that vision. She 

is now launching a revolutionary health workforce program that, 

once fully financed, will train, equip, and pay over 4,000 community health workers, and train hundreds of Liberian nurses and 

doctors across the country. This community health workforce has 

the potential to be a front-line defense that can stop the next local 

outbreak from becoming the next global epidemic. It is also going 

to extend healthcare to all people. And it is going to be great for 

jobs, because it is going to create employment opportunities for 

young, unemployed, rural people. 

In closing, I will say that it is a single program that can save 

lives, create jobs, and stop the next outbreak. Investing in these 

kinds of programs, alongside labs, supply chains, and hospitals, can 

generate great returns, not only for Liberians, but the safety of 

Americans. A lot of U.S. Government agencies, including USAID, 

CDC, HHS, the Peace Corps, as well as international partners, are 

already mobilizing support for Liberia’s health workforce program. 

And I would say, in the face of other global threats, U.S. funding 

towards programs like this must be preserved and sustained over 

the long term if we are going to have a healthcare system led by 

Liberians. 

Mr. Chairman, as Liberians and Americans have shown, those 

who fought Ebola taught us that we are not defined by the crises 

that strike our lives. We are defined by how we respond. Our response is not over. We must demand a health worker for everyone, 

everywhere. That is the only effective response, I believe, to the 

Ebola crisis and to the everyday crisis of premature death. 

Thank you. 

[Dr. Panjabi’s prepared statement follows:] 

PREPARED STATEMENT OF DR. RAJ PANJABI, CEO, LAST MILE HEALTH

Chairman Flake, Ranking Member Markey and other distinguished members of 

the committee, thank you for inviting me to testify. We are grateful to members of 

this Committee not only for the resources you’ve mobilized in the fight against 

Ebola in West Africa, but also for your personal leadership. I just returned from caring for patients alongside community health workers and nurses in rural Liberia 

and my colleagues there have not forgotten that members of this Committee visited 

them on the frontlines of the Ebola epidemic while it was still very active. 

Today, I want to speak about the power of those local health workers. As you 

know, over 11,000 people and over 500 of my fellow health workers—nearly all West 

African—have lost their lives in this fight. I want to dedicate my testimony in honor 

of their sacrifices and the Americans who stood by their side. I will make the case 

that investing in Liberian health workers—especially in remote rural areas—was 

one of the most effective measures taken by the United States in responding to 

Ebola. And I will present the case that long-term investments in rural health workers are more important now than ever to respond to public health threats and build 

resilient, sustainable health systems. 

Liberian health workers have shaped my life. As CEO of Last Mile Health and 

a physician and teacher from Harvard, I’ve had the privilege of working with my 

colleagues on the ground in Liberia for a decade to train and employ hundreds of 

community health workers to serve Liberia’s most remote communities. But their 

mark on my life runs deeper than that. Today, I am a proud American citizen and 

I was fortunate to be born in Liberia where Liberian midwives helped my mother 

bring me into this world. 

I know first-hand how dire conditions can get in the absence of health workers. 

When I was 9 years old, Liberia erupted in civil war. I was one of the lucky few. 

My family was evacuated and eventually resettled in America. Here in America, I 

went from having my hopes crushed in a war to pursuing my dream of attending 


FOREI-42327 with DISTILLER
14 

medical school. But I could not forget where I came from. So in 2005, I returned 

to Liberia as a medical student, to help serve the people I had left behind. What 

I found was utter destruction. After 14 years of civil war, Liberia was left with just 

51 doctors to serve a country of over 4 million people. To put that in perspective, 

imagine the entire city of Washington, DC, having only 8 doctors available to care 

for it. If you fell sick in the city you might stand a chance, but if you fell sick in 

remote villages you could die anonymously. It was in response to this massive shortage of rural health workers that my colleagues and I began our work at Last Mile 

Health. 

What does this lack of health workers in remote areas have to do with the Ebola 

outbreak? While Ebola infections transmit primarily from person to person, Ebola 

and 75% of emerging infectious diseases first enter human populations from animals—that is they have a ‘‘zoonotic origin’. Ebola and other epidemics with a 

zoonotic origin—like HIV/AIDS—often first emerge in the world’s most remote communities. We all know that ‘‘patient zero’, two-year old Emile from rural Guinea 

likely first fell sick in this way with Ebola and died in remote communities in the 

rainforest borderlands connecting Guinea, Sierra Leone and Liberia. In large part 

due to the lack of trained and equipped health workers in rural areas, it took three 

months before an Ebola outbreak was identified. This time lapse allowed the epidemic to spread and as we know, it eventually reached 10 countries, including this 

one. 

Paradoxically, the hardest-to-reach communities are also where zoonotic infections—amongst other diseases—are the hardest to defeat. The problem is that remote communities, not unlike the most rural reaches of your own states, face a triple bias. The public sector, which favors areas that are easier to reach to maximize 

limited resources, is often unable to prioritize remote populations. The private sector, which favors areas with high concentrations of customers, doesn’t see market 

potential. The social sector, which favors reaching more people in fewer areas at less 

cost, deems it too expensive to serve them. 

The good news is U.S. investments in local health workers in remote communities 

can have dramatic results. A little over a year ago, I stood in a mud-walled building 

in one of these isolated, hard-to-reach rainforest communities. I was there to help 

train a group of Liberian health workers in an area called Rivercess. Nearby, an 

outbreak had erupted in a village days from the nearest hospital and cut-off from 

roads, electricity and phones. A young woman there had just died of Ebola, and so 

had over a dozen people who attended her funeral. We partnered with a coalition 

of U.S. agencies, other NGOs, to support the Liberian Government to train and 

equip brave local health workers to respond. 

Investments like these, complemented investments in Ebola Treatment Units, and 

were made across Liberia, with the support of the USAID, NIH, CDC, HHS, the 

DOD and other agencies. With that and other international support, the Government of Liberia and its partners trained and equipped thousands of Liberian health 

workers in remote areas. They included lab technicians like David Sumo, a 24-yearold who drove a motorbike more than six hours over mud tracks in the rainforest 

to collect blood samples from the hundreds of people at risk. Nurses like Alice Johnson distributed digital thermometers, masks, gloves and gowns to clinics to ensure 

infection prevention and control measures were in place. And community health 

workers like Zarkpa Yeoh ensured no child with malaria in her village missed a day 

of treatment even as the rest of the country’s health system was collapsing. It’s 

these rural health workers—alongside American health workers—who have helped 

hunt down Ebola, who are best positioned to help prevent flare-ups, and who can 

help rebuild a health system led by Liberians themselves. 

Last week, the World Health Organization declared the West Africa Ebola epidemic no longer an international public health emergency. But, let U.S. make no 

mistake. The response is not over. The Ebola threat remains real and it has been 

persistent. Counter to conventional wisdom, this epidemic isn’t West Africa’s first 

encounter with Ebola. Medical studies document antibodies to Ebola in the region 

as far back the late 1970s—suggesting the virus has been present and has gone undetected in remote villages in West Africa at least since then. Infectious diseases 

can also act with speed. We have seen already seen flare-ups of Ebola and other 

outbreaks. In the last week alone, new Ebola cases and deaths occurred in both Liberia and rural Guinea. Ebola shut down other health services and we’ve seen an 

increase in other infectious diseases like measles, malaria and pertussis, as well as 

child and maternal deaths. We must sustain a defense that exceeds the persistence 

and speed of these threats. We must help West Africa maintain a high level of capacity to rapidly prevent, detect and respond to flare-ups of Ebola and other public 

health crises. 


FOREI-42327 with DISTILLER
15 

Ebola has taught U.S. what works best in an emergency is not an emergency system—it is an everyday system that is robust, resilient, and functioning before the 

crisis begins. If our collective goal, looking forward, is to work with Liberians and 

other affected countries to build such health systems—then we must continue to 

make smart investments. We must continue to invest in people. We must invest in 

Liberia’s rural health workforce. We’ve heard this call echoed by Liberia’s leaders. 

Mr. Chairman, at another hearing on Ebola hosted by this committee only 15 

months ago in December 2014 in this very room Committee members asked Liberia’s President Ellen Johnson Sirleaf about her priorities. She responded clearly, ‘‘we 

seek to build capacity at all levels, especially at the lower levels of community 

health care workers.’’ 

Her Excellency’s Government has followed through on this vision. The Government is working to launch a revolutionary National Health Workforce Program. 

This program, once fully financed, will train hundreds of Liberian doctors and 

nurses in line with President Sirleaf’s priorities, employ and equip over 4,000 community health workers nationally. This rural community health workforce will bring 

disease surveillance for Ebola and other threats each and every at-risk remote corner of Liberia. They are a frontline defense that can stop the next outbreak from 

becoming an epidemic. It will also build health systems by extending health care 

to the over 1 million rural Liberians who’ve never had health care before. President 

Sirleaf has already called for 2000 rural community health workers to be deployed 

by the end of next year. 

Investing in training, equipping and paying rural community health workers not 

only saves lives in remote areas, but they are also a great economic bet. Recent reports show that by creating jobs, providing ‘‘insurance’’for countries against catastrophes like Ebola, and by extending productive life, rural community health workforce investments in can yield an economic return of up to $10 for every $1 spent. 

Of course, rural community health workers are not a panacea. Investments in 

these workers must be complemented with broader investments in publicly financed 

health systems that include well equipped clinics and hospitals, robust laboratories 

and supply chain systems. We must target these investments not just in cities, but 

also in rural areas. And these investments must align with and reinforce government-led plans. One example includes the recent re-signing of the results-based fiveyear Fixed Amount Reimbursement Agreement (FARA) between USAID and the Liberian Government that invests directly in the Government’s National Health 

Plan.17 Such mechanisms should be expanded because they directly build country 

capacity and help improve the effectiveness and sustainability of U.S. foreign assistance to Liberia. 

As we look forward, we must not forget that illness is universal but access to care 

is not, and as Ebola has taught us, this places all of U.S. at greater risk. The cost 

of inaction on closing this access gap is greater than the cost of action. Mr. Chairman, as Liberians and Americans have shown, we are not defined by the crises that 

strike our lives. We are defined by how we respond. Our response is not over. We 

must demand a health worker for everyone, everywhere. That is the only effective 

response to the Ebola crisis—and the everyday crisis of premature death. 

ANNEX 

NEW REPORT SHOWS THAT INVESTING IN COMMUNITY HEALTH WORKERS IS ESSENTIAL

FOR IMPROVING HEALTH, STRENGTHENING ECONOMY, AND PREVENTING THE NEXT

EBOLA

by Jeffrey Walker and Rajesh Panjabi 

CHWs play the most important and effective role in our fight against disease; it is they who have reached the most vulnerable, they who have been 

able to be the contract tracer, they who have been able without much training to take the risk to go out into the community and bring care. We need 

to urgently invest in the training and building of capacity of healthcare 

workers at the community level.—President Ellen Johnson Sirleaf of Liberia at the Third International Financing for Development Conference in 

Addis Ababa on July 13, 2015 

In May, the World Health Organization declared Liberia ‘‘Ebola free’’after fortytwo days without new cases. While thiswas a remarkable milestone, none of U.S. 

can forget that Ebola killed 4,800 people in Liberia and has already left more than 

11,000 dead across West Africa. While the fight against Ebola continues in Liberia 

and neighboring Sierra Leone and Guinea, one vital measure for epidemic preparedVerDate Mar 15 2010 13:37 Jun 19, 2018 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\04 07 2016 -- 30-396

FOREI-42327 with DISTILLER
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ness has emerged: a robust community health system. As President Ellen Johnson 

Sirleaf stated on Monday at the UN’s Third International Financing for Development Conference: ‘‘We need to urgently invest in healthcare workers at the community level.’’ 

For the past year, we have been asking ourselves how the Ebola outbreak spread 

so quickly and what steps should be taken to prevent such future disasters. A year 

after the epidemic took hold, we know that stronger, integrated community-based 

delivery systems are necessary to help prevent such outbreaks and support progress 

against the top killers of women and children—especially malaria, pneumonia, and 

diarrhea. At the core of such delivery systems are highly-trained, supervised, 

equipped and paid professional Community Health Workers (CHWs), who work in 

teams with other primary health workers (e.g. nurses) to extend care to the most 

vulnerable. 

Unfortunately, financing for community health systems is relatively low compared 

to other health system areas and to priority diseases. Consequently, countries struggle to raise the funding necessary to train, supervise, and pay CHWs. Today, there 

is an estimated shortage of more than 700,000 community health workers across 

sub-Saharan Africa and it will require at least $3 billion each year to address this 

gap. In Ebola’s deadly wake, a number of leaders from African countries and the 

global health community came together to explore how to address this funding problem. We released our initial thinking on Monday at the Financing for Development 

Conference in Addis Ababa through a report titled, ‘‘Strengthening Primary Health 

Care through Community Health Workers: Investment Case and Financing Recommendations.’’The report calls for urgent action by all global stakeholders, including African governments, major funders, and our partners to address funding challenges of CHWs, and provides the following key findings: 

• Supporting Community Health Workers is a game-changing investment: CHWs 

are critical for increasing access to health care and, if scaled up, could save up 

to 3 million more lives each year. They are also a great economic bet, returning 

up to $10 for every $1 spent through productivity gains from a healthier population, from the ‘‘insurance’’ they provide against catastrophes like Ebola, and 

from expanding employment opportunities. 

• Not all Community Health Worker systems are created equal: What we need are 

highly trained and skilled community health workers integrated into the primary health system. While each national context will be different, when building CHW programs policy makers should focus on core factors such as measurement and management of community health program performance, integration 

with the rest of the primary health system, leadership from within Ministries 

of Health, and community engagement in program design. It’s also important 

that CHWs not be construed as ‘‘stand-alone’’ agents of change, but instead are 

effectively linked to broader teams of clinic-based health workers. 

• Countries need to be proactive in developing a financing pathway: When developing a CHW program, countries need to take the initiative to determine program scale, cost the plan, set funding targets and identify specific financing 

mechanisms to reach targets. Countries are used to doing this for other disease 

areas and should apply the same methodology to community health. Support 

from international donors through mechanisms like the World Bank’s recently 

launched Global Financing Facility, will create new avenues for long-term country-led investments for CHW programs, but additional start-up funding remains 

vital. 

In addition to these findings, we went on to make a set of recommendations to 

national goverments, donors, and the broader community. 

• First, we encouraged governments in sub-Saharan Africa to prioritize CHW programs for investment and to create teams to focus on community health financing; 

• Second, we asked international donors and funders to make more grants and 

low-cost financing available to countries wishing to build CHW programs; 

• Next, we urged funders that currently support specific diseases to make more 

of that funding available to support CHW programs, since CHWs are absolutely 

essential for diagnosing and treating diseases like malaria, HIV, and TB and 

preventing epidemics; 

• Finally, we encouraged the broader health community to consider establishing 

teams to work alongside existing initiatives to assess available financing options 

and develop metrics and scorecards to track progress in community health. 


FOREI-42327 with DISTILLER
17 

On the last day of June, when the body of a dead seventeen year old boy tested 

positive for Ebola, Liberia reported its first new case since it was declared ‘‘Ebolafree’’ in May. While the country now has much stronger health capabilities than it 

did at the start of the Ebola epidemic, this sad death is a clear reminder that we 

must remain vigilant and move urgently to make much larger investments in community health systems. Such investments will not only help prevent the resurgence 

of Ebola and achieve our global health goals, but may also help prevent the next 

epidemic. This is crucial as the World Bank estimates that a severe pandemic flu 

is ‘‘virtually inevitable’’ and could cost the global economy up to $3 trillion. The time 

for action is now. 

Senator FLAKE. Thank you. 

Ms. Glassman. 

STATEMENT OF AMANDA GLASSMAN, DIRECTOR OF GLOBAL 

HEALTH POLICY, CENTER FOR GLOBAL DEVELOPMENT, 

WASHINGTON, D.C. 

Ms. GLASSMAN. Chairman Flake, Ranking Member Markey, 

members of the subcommittee, thank you very much for the opportunity to testify today. 

My comments will focus on three U.S. actions that might accelerate progress in the Ebola response: first, a recommitment to recovery; second, an enhancement of efforts to promote global health 

security; and, third, a call to track the money better. 

First, on recommitment to recovery. The Ebola outbreak took a 

serious toll on the affected countries’ economies. Businesses suffered, jobs disappeared. A fifth of Monrovia businesses closed as a 

result of the outbreak. And almost half of jobs were lost. 

Economic recovery is gradual and at risk, due to commodity price 

drops that affect Liberia’s biggest employers, like those of my colleague on this panel. And estimates suggest it could take until 

after 2020 for Liberia to achieve the rate of GDP growth that it experienced prior to the epidemic. 

Ebola was also a shock to the health system. Overwhelmed 

health facilities were unable to provide services. Delayed immunization campaigns led to Liberia’s worst measles outbreak in years. 

And, as we have seen, days after the WHO declared the end of 

Ebola last week, new cases were confirmed. 

After being out for months, from mid 2015, families did send 

their kids back to school and increased use of basic services, but 

two-thirds of households are food insecure in Sierra Leone, and almost 70 percent of the Liberian population lives on less than $1.90 

a day. 

To counteract these effects and ensure continued protection 

against health threats, the U.S. should recommit to recovery in 

ways that will make a measurable difference for firms and economic growth, health system effectiveness, and family well-being. 

In support of firms and economic growth, the U.S. should continue to work to improve the investment climate, address infrastructure deficits, and encourage business support services as well 

as regional investments. These steps are critical to maintaining foreign investments and reviving local firms needed to ensure recovery and sustainability. 

The U.S. must continue its work to strengthen health systems, 

but our efforts have to go beyond capacity-building. More training 

and numbers of people trained are not, themselves, signs of health 

system preparedness. Instead, the U.S. should ensure that counVerDate Mar 15 2010 13:37 Jun 19, 2018 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6602 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\04 07 2016 -- 30-396

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tries structure their healthcare funding to reward improved performance. Increases in children fully vaccinated, reductions in hospital infections, and improvements in child survival are what we 

must seek to achieve with our investments. And to aid families, 

keep kids in school, reduce food insecurity, and get markets working again, USAID should extend its support to cash transfer programs in Ebola-affected, ultra-poor populations. Evidence shows 

that cash is the most efficient way to help families and can counteract the widespread distrust in government that actually contributed to the epidemic’s spread. 

Second, on the issues related to global health security. The next 

outbreak is a matter of when, and not if. Our health and the health 

of our economies depend on modern and flexible response. And to 

get to that kind of response, the U.S. must ensure that the WHO 

is fit for purpose. We should incentivize our partner countries to 

step up their own global health security, and we should invest permanently in disease outbreak preparedness and response. 

The WHO has been rightly criticized for its response to Ebola, 

but its role remains critical. With the change in WHO leadership 

later this year, the U.S. must ensure that the next Director-General has the full confidence of our Congress and the credibility, financing, and support needed to implement much-needed reforms 

and execute its mission. The U.S. should develop stronger incentives for countries to adopt best practices in outbreak preparedness. 

Perhaps financial and reputational incentives to low-income countries that make measurable progress in strengthening their disease 

surveillance should be rewarded. 

Finally, we need to ditch the ad hoc interagency task forces and 

emergency budget requests. To understand the full range of alternatives, Congress should ask the Government Accountability Office 

to explore potential budget instruments that would ensure the 

availability of contingency funding and risk management in the 

event of a major outbreak. 

Finally, we need to track the money better. No existing platforms 

are up to this task. USAID’s regular factsheets offer only snapshots 

of the work underway. Quarterly progress reports from the Offices 

of the Inspectors General only hint at what we might expect as results from our program. And a search on ForeignAssistance.gov 

yields an incomplete record. And, worst of all, there is no way—no 

easy way—to match the reported expenditures across these documents and platforms. 

More than a year ago, the Center for Global Development hosted 

Liberia’s Minister of Public Works, Gyude Moore. We were greatly 

honored to have you, as well, Chairman Flake. At that time, Moore 

asked that the organizations responding to Ebola provide an account of money received and report on how it was spent in the public domain. Our response to his very sensible request has fallen 

short. I believe it is appropriate to hold this off-budget emergency 

supplemental funding to a higher standard. That means not only 

reporting on spending, but linking it to performance. In the absence of such reporting, we lose the opportunity to know what we 

have accomplished and where our next dollar is going to have the 

biggest impact. And we should start now by improving our accounting for any remaining unobligated funds. 


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1World Health Organization. (2016). Ebola Situation Report—30 March 2016. Retrieved from 

http://apps.who.int/ebola/current-situation/ebola-situation-report-30-march-2016 2P.L. 113–235 

3World Bank Group. (2016). World Bank Group Ebola Response Fact Sheet. Retrieved from 

http://www.worldbank.org/en/topic/health/brief/world-bank-group-ebola-fact-sheet 4 International Monetary Fund. (2016). IMF Country Report No. 16/8: Liberia. Retrieved from 

http://www.imf.org/external/pubs/ft/scr/2016/cr1608.pdf 5World Health Organization. (2015). Liberia tackles measles as the Ebola epidemic comes to 

end. Retrieved from http://www.who.int/features/2015/measles-vaccination-liberia/en/ 6 Evans, D. K., Goldstein, M., & Popova, A. (2015). The Next Wave of Deaths from Ebola? The 

Impact of Health Care Worker Mortality. World Bank Group. Retrieved from http://wwwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2015/06/26/090224b082f92f94/ 

2—0/Rendered/PDF/The0next0wave00are0worker0mortality.pdf 

Thank you. And I look forward to your questions. 

[Ms. Glassman’s prepared statement follows:] 

PREPARED STATEMENT AMANDA GLASSMAN, VICE PRESIDENT FOR PROGRAMS AND

DIRECTOR OF GLOBAL HEALTH POLICY, CENTER FOR GLOBAL DEVELOPMENT

Chairman Flake, Ranking Member Markey, and members of the Subcommittee, 

thank you for the opportunity to testify on West Africa’s recovery from a devastating 

Ebola outbreak and the lessons we can learn from the U.S. response to the crisis. 

My name is Amanda Glassman and I am the vice president for programs and director of global health policy at the Center for Global Development, an independent, 

non-partisan think tank headquartered in Washington, DC. CGD conducts policy research aimed at improving the policies and actions of rich countries, including the 

United States, that affect developing countries. 

Along with my colleagues at the Center, I have been watching the Ebola epidemic 

unfold in West Africa and keeping a close eye on the world’s response. As you know, 

this outbreak was unprecedented in scale and impact. Liberia, Sierra Leone, and 

Guinea endured a total of more than 28,600 cases of the virus and 11,300 deaths.1

The disease took a heavy toll not only on families, but also on the health systems 

and economies of the afflicted countries. 

By the time the World Health Organization (WHO) declared Ebola a public health 

emergency in August 2014, it was clear additional resources were urgently needed 

to help West Africa contain the disease. Congress stepped up to the plate, appropriating $5.4 billion in emergency funding, including nearly $2.5 billion to the U.S. 

Agency for International Development (USAID) for international response, recovery, 

and preparedness.2

My testimony will focus on three areas, providing specific recommendations to 

Congress to help West Africa heal and regain lost ground, and to ensure that the 

United States is better protected and prepared to face future global health threats. 

1. Remain committed to recovery with an approach that addresses the needs of 

households, health systems, and firms. 

2. Enhance efforts to promote global health security by improving coordination, developing clearer incentives, and exploring new ways to manage risk. 

3. Track money and progress to ensure accountability and learn what works. 

First, the United States must remain committed to West Africa’s recovery from 

Ebola, addressing the needs of households, health systems, and firms. 

The Ebola virus and the fear it generated took a serious toll on the affected countries’ economies, which lost an estimated $2.2 billion in 2015.3 During the crisis, 

borders and markets were closed and plans to invest in West Africa were put on 

hold. Economic recovery has been gradual. Estimates suggest it could take until 

after 2020 for Liberia to achieve the rate of GDP growth it experienced prior to the 

epidemic.4

Further, Ebola was a shock to already fragile health systems in West Africa. During the epidemic, overwhelmed health facilities were unable to provide services, 

while the fear of contracting Ebola prevented residents from seeking care. Delayed 

immunization campaigns led to Liberia’s worst measles outbreak in years.5 The system also lost healthcare workers, which may have long-term effects on health and 

service delivery. Analysts predict that maternal mortality rates could increase by 74 

percent in Sierra Leone and by a staggering 111 percent in Liberia relative to preEbola rates.6

To counteract these effects and ensure sustained protection against existing and 

new disease threats, the United States should invest in ways that will make a 


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7 Center for Global Development & Overseas Development Institute. (2015). Doing Cash Differently: How Cash Transfers Can Transform Humanitarian Aid. Report of the High Level Panel 

on Humanitarian Cash Transfers. Retrieved from http://www.cgdev.org/sites/default/files/HLPHumanitarian-Cash-Transfers-Report.pdf 8 USAID & HHS Offices of Inspectors General. (2015). Quarterly Progress Report on U.S. Government International Ebola Response and Preparedness Activities: Fiscal Year 2016, First 

Quarter. Retrieved from https://oig.usaid.gov/sites/default/files/other-reports/oig—ebola—quarterly—fy16—021720126.pdf 9MCC. (2015). Liberia Compact. Retrieved from https://www.mcc.gov/where-we-work/program/ 

liberia-compact 10MCC. (2015). Sierra Leone Threshold Program. Retrieved from https://www.mcc.gov/wherewe-work/program/sierra-leone-threshold-program 

measurable difference for household well-being, health system effectiveness, and 

economic growth. 

When it comes to aiding households, USAID should extend cash transfer programs in Ebola-affected communities to help the poorest families pay for food, medical costs, and school fees. Evidence shows that cash is often a better way to help 

people meet their basic needs, can counteract the damage to young children’s nutrition, get kids back to school, and stimulate local markets.7 USAID supports smallscale cash transfer programs in Liberia and Sierra Leone, and these should be 

scaled up.8

On health systems, U.S. efforts must go beyond capacity building. More training 

and number of people trained are not sufficient indicators of health system readiness or performance. Instead, the United States must ensure that countries structure their healthcare financing and payments so that they reward improved performance in health facilities and on health itself. Increases in children who are fully 

vaccinated, reductions in maternal mortality and morbidity, improvements in child 

survival are what the United States must seek to achieve with its investments. 

More money should be tied to improved results instead of specific inputs or staffing 

models. 

In support of economic growth, the U.S. government, in coordination with other 

donors, should work to improve investment climates, address infrastructure deficits, 

encourage business support services, and look for opportunities to strengthen regional ties. These steps are critical to attracting foreign investment and reviving 

local firms. A new Millennium Challenge Corporation compact to address roads and 

electricity in Liberia and a threshold program in Sierra Leone to improve water and 

electricity service delivery are complementary steps in the right direction.9 10

Next, we must enhance our efforts to promote global health security by improving 

coordination, developing clearer incentives, and managing risk. 

The next outbreak is a matter of when, not if. Our health and our economies increasingly depend on modern, flexible responses to these imminent threats. The U.S. 

government must take steps to (1) ensure the WHO is fit for purpose; (2) incentivize 

countries around the world to step up their health security; and (3) invest permanently in disease outbreak preparedness and response. 

The WHO has been rightly criticized for its slow response to the Ebola outbreak. 

But the role of the WHO remains critical. It is in a unique position to set standards, 

initiate and coordinate incidence and pathogen tracking, and strengthen health-system responses. With a change in WHO leadership later this year, it is incumbent 

upon the United States and the global community to ensure the next leader of the 

institution has the credibility, support, and respect needed to govern effectively and 

implement much-needed reforms. 

The U.S. government, through USAID or the Centers for Disease Control and Prevention, should develop incentives for countries to adopt best practices in disease 

response and preparedness. By rewarding countries on the basis of progress toward 

strengthening disease surveillance and preparedness, the United States could more 

effectively leverage limited resources and ensure results. 

Lastly, we need to ditch the ad hoc interagency task forces and emergency budget 

requests. To understand the full range of alternatives, Congress should ask the Government Accountability Office to explore potential budget instruments for ensuring 

permanent preparedness and protection in a way that manages risk. One option is 

to contribute to the World Bank’s Pandemic Emergency Financing Facility. Another, 

complementary option would be to develop our own global health emergency fund 

that would allow for faster release of financing to assist countries in need and provide coordinated funding at each stage of pandemic preparedness, response, and recovery. 

Finally, Congress should require U.S. agencies to report data on Ebola spending 

and progress to a consistent, integrated and publicly available platform. 


FOREI-42327 with DISTILLER
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No existing platforms are currently up to the task. USAID’s regular fact sheets 

offer snapshots of the work underway, but lack the detail to determine how most 

money is being used. Quarterly progress reports from the Offices of the Inspectors 

General provide a more comprehensive outline of the U.S. response, but program 

descriptions only hint at expected outputs and outcomes. A search of the term Ebola 

on ForeignAssistance.gov yields some results, but it is unclear how much of this incomplete record is related to the supplemental funding. Worst of all, there is no easy 

way to match the reported expenditures across these documents and platforms. 

More than a year ago, the Center for Global Development hosted Liberia’s Minister of Public Works Gyude Moore. At the time, Moore stressed the need for accountability when it came to the money being provided to fight Ebola in Liberia. 

He asked that the organizations responding to Ebola provide an account of the 

money they received and how it was spent. Our response to this sensible request 

has fallen short. 

While all U.S. assistance should strive for greater transparency, I believe it is appropriate to hold this off-budget, emergency, supplemental funding to a higher 

standard. Crises of this scale and novelty complicate procurement and data collection, especially when there are multiple agencies involved in the response. This 

makes it all the more critical that we are vigilant when it comes to recording how 

much has been spent and where, and what we are getting for our dollars. That 

means not only reporting on spending but linking it to performance indicators and 

targets. In the absence of such reporting we lose the opportunity to determine what 

we have accomplished and where our next dollar would have the greatest impact. 

We should start now by improving our accounting for the remaining unobligated 

funds. 

The WHO’s recent declaration of the end to the public health emergency in West 

Africa was good news, but there is more to be done to address flare-ups and realize 

full recovery in Liberia, Sierra Leone, and Guinea. 

The devastating epidemic should serve as a wake-up call. Congress can ensure a 

stronger U.S. response to health threats and guard against future ones by supporting recovery focused on households, health systems, and firms; promoting global 

health security through coordination, incentives, and risk management; and encouraging improved aid transparency in crisis response. 

Senator FLAKE. Ms. Delaunay. 

STATEMENT OF SOPHIE DELAUNAY, ADVISOR, MEDECINS 

SANS FRONTIERES, NEW YORK, NEW YORK 

Ms. DELAUNAY. Thank you, Chairman Flake, Ranking Member 

Markey, and members of the subcommittee, for providing me the 

opportunity to address you today. 

This outbreak prompted one of MSF’s biggest emergency ever, 

and valuable lessons were learned from this strategy, and it is vital 

that they be acted upon. Needless to say, we also learned our own 

lessons in this process. 

But, today I am going to share with you MSF’s perspective regarding one specific issue, the state of biomedical research and development, R&D, because Ebola not only revealed existing challenges in the current R&D system, but teaches us lessons that are 

also applicable to other public health emergencies priorities, from 

tuberculosis to antibiotic resistance to Zika. 

So, today, where do we stand when it comes to preventing, diagnosing, or treating Ebola? As we speak, we are still lacking an accurate and rapid point-of-care Ebola test that caregivers could use 

in the triage area to find out immediately whether a patient has 

Ebola or not. The few therapeutic options identified as effective, 

such as ZMapp, also present severe limitations in terms of availability and cost. On the vaccine side, there is one promising candidate, but, again, its use will be made more complex by cold-chain 

requirements or its perceived side effects. So, this is to say that 


FOREI-42327 with DISTILLER
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current solutions are not ideal. And a number of key questions remain about the disease, and more research is needed on it. 

But, based on our lessons learned, MSF would like to see 

changes in the way biomedical R&D is conducted, and would like 

emphasize four priorities. One is to invest in needs-driven R&D before the next epidemic. The second is to start clinical trials as early 

as possible once an outbreak is identified. The third priority is really to maximize existing knowledge about the disease by sharing 

data and biomaterial among scientists. And the fourth priority 

should be to ensure that, once research is done, the products are 

indeed available and affordable to the population it needs. 

So, let me go back to my first point about investing in research 

before the next outbreak. We know that R&D takes time and that 

we cannot wait for another outbreak before initiating research on 

lethal disease. So, we need to continue investing in research on 

Ebola, for Zika, and other neglected disease. And incentives for innovations are essential, but they need to work as intended and for 

the patients they claim to support. 

And, to this point, in 2007, Congress created an incentive program for research on neglected diseased called the FDA Priority 

Review Voucher Program, the PRV. This program rewards a research institution which successfully registers a product for neglected disease with a voucher allowing this institution to actually 

fast-track any other project in its portfolio through the FDA regulatory process. 

So, this is a very valuable programs, but two changes must be 

made to it. First, it should include a novelty requirement to ensure 

it actually induces new investments in R&D and is not awarded to 

already-existing drugs or vaccines. Second, the PRV should also require an access strategy to ensure that patients which the PRV intends to benefit will have affordable and appropriate access to the 

products. 

These recommendations are not just rhetorical. They result from 

our own experience in dealing with leishmaniasis, tuberculosis, and 

malaria, where PRVs were granted for drugs that had been available in other countries for years, and also from our persistent 

struggle to access affordable medicine and medical innovations. 

So, my second point is about implementing trials early in the 

emergency response. The lesson is that we started the trials much 

too late, and, as a result, the trials could not be deemed conclusive. 

So, we recommend that product calls and ethical guidelines for 

clinical trials during emergency be predefined in the interepidemic 

period. 

My third priority is maximizing access to available knowledge, 

because collaborative research involving a timely sharing of data 

and specimen is being increasingly recognized by the scientific community as an essential means to incentivize research. MSF, which 

has cared for more patients with Ebola than any other organization, in terms of treatment, has collected valuable data that we 

would like to share, and we would like to see it used ethically for 

research priorities by the scientific community. The CDC, itself, 

certainly holds the largest collection of EVD-specimen library from 

this experience. Nevertheless, our attempt to support the WHO in 

establishing networks of biobanks and data-sharing platform is 


FOREI-42327 with DISTILLER
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very poorly supported by actors, including the U.S. counterparts. 

And there is still a very significant gap between the rhetoric and 

action. 

I would like to go to my fourth and final point, ensuring that the 

final products when research is done are available and affordable 

to population in need, because innovation without access is actually 

meaningless. And we hope that, you know, improvements to the 

Priority Review Voucher Program to ensure medical products are 

available would be an important step, but there is still an urgent 

need also to address the global crisis on raising drugs and vaccine 

prices. 

So, in conclusion, I would like to say that significant scientific 

advances are still required against Ebola and other deadly neglected disease. Ebola shocked and shook the world, giving us another opportunity to reflect on how we approach R&D. And as Zika 

has most recently demonstrated, it is in the interest in—of all 

countries, including the United States, to guarantee that appropriate mechanisms are in place to maximize the benefit of research 

and improve our response to future outbreaks. 

Thank you. 

[Ms. Delaunay’s prepared statement follows:] 

PREPARED STATEMENT OF SOPHIE DELAUNAY, ADVISOR, DOCTORS

WITHOUT BORDERS/ME ́ DECINS SANS FRONTIE` RES (MSF) USA 

Thank you Chairman Jeff Flake, Ranking Member Edward Markey, and members 

of the subcommittee for providing Doctors Without Borders/Me ́decins Sans 

Frontie`res—also known as MSF—the opportunity to share our perspective regarding 

the Ebola outbreak in West Africa, and some of the lessons MSF has garnered in 

its wake. 

The Ebola Virus Disease (EVD) outbreak in West Africa was the most significant 

global medical challenge MSF faced between 2014 and 2015. As we speak, recent 

cases declared in Guinea and Liberia attest to the continued challenges posed by 

the virus.MSF’s response to this outbreak has been unprecedented, and prompted 

one of our biggest emergency interventions in the 40 years MSF has been operational internationally. MSF responded across the region in Guinea, Sierra Leone 

and Liberia, but also in Mali, Senegal, and in Nigeria, and cared for one third of 

all infected patients throughout this outbreak. From March 2014 to December 

2015—MSF set up and managed 15 Ebola management centers, with 40 to 250 beds 

in each facility, and also provided Ebola management training to national governments, international responding agencies—including the CDC, U.S. Public Health 

Service and the 101st Airborne Division—and other non-governmental organizations. 

Across many sectors, valuable lessons were learned in the past two years, and it 

is vital that these lessons be acted upon. Needless to say, we also learned many of 

our own lessons in this process. Today, I am going to share with you MSF’s perspective regarding one specific issue: the state of biomedical research and development 

(R&D). Notably, Ebola not only revealed existing challenges in the current R&D system; but allowed us to learn lessons that we think are also applicable to a large 

number of other public health priorities, from tuberculosis, to antibiotic resistance 

to Zika. 

Ebola starkly illustrated how critically important it is to develop tools for infectious diseases before an outbreak occurs, as well as how challenging it can be to 

respond when adequate tools aren’t available. This was not just an Ebola problem, 

though; it’s an R&D problem, a systemic problem. And the consequences should 

really come as no surprise. Ebola was discovered nearly 40 years ago, but only after 

the outbreak devastated thousands of lives across West Africa and reached the U.S. 

and Europe, were significant R&D efforts launched to deliver tools to prevent and 

treat the disease. 

Historically, Ebola has primarily affected rural populations in sub-Saharan Africa, 

and therefore the development of tools to prevent, diagnose, or treat the disease has 

not been a priority. Almost no R&D efforts were focused on Ebola until the midVerDate Mar 15 2010 13:37 Jun 19, 2018 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6621 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\04 07 2016 -- 30-396

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1 Van den Bergh R, Chaillet P, Sow MS, Amand M, van Vyve C, Jonckheere S, et al. Feasibility of Xpert Ebola Assay in Me ́decins Sans Frontie`res Ebola Program, Guinea. Emerg Infect 

Dis. 2016;22(2):210-2106 

2000s, when the virus was identified as a potential bioterrorism threat in several 

countries. Thereafter, the U.S., Canada, and a few other governments began supporting some basic research projects for Ebola. 

However, the primary objective was to protect citizens of the countries sponsoring 

the research, not necessarily to address the needs of people affected by the disease 

where it occurs, in Africa. Therefore, crucial characteristics, such as product affordability or user-friendliness in resource-poor settings, were not really taken into consideration. Moreover, some of the public funding for this research dried up due to 

national level budget cuts, and several potentially promising treatments and vaccines stalled in the early stages of development without a sponsor to take them forward. 

When the current outbreak started, research was incomplete and products had 

not been developed, despite the earlier public investments. Following the introduction of Ebola cases on U.S. and European soil, a number of trials for new vaccines 

and treatments were initiated. The beginning of these trials, however, also coincided 

with decreasing numbers of new cases. 

Today, where do we stand when it comes to preventing, diagnosing or treating 

Ebola? Should there be another Ebola outbreak tomorrow, or an outbreak of another 

deadly and neglected pathogen, will we be better equipped to provide relief and 

treatment to the people affected by the disease? How can the R&D efforts be improved upon? 

I would like to address a few of these questions now: 

Firstly, in the area of diagnostics: the traditional Lab-based polymerase chain reaction (PCR) test used to diagnose EVD is very accurate, but the time taken between obtaining a blood sample and getting a result can be considerable,1 and can 

take several days in some cases when samples need to be shipped from remote 

areas, as we have seen in West Africa. By using other types of accurate tests that 

can be positioned in more peripheral settings (such as the GeneXpert assay), our 

teams were able to reduce the time needed between sampling and result notification 

by 50%. Considering that the earlier a patient is treated, the more likely they are 

to survive, this is significant progress. The diagnostic process, however, is still time 

consuming and labor intensive. What is still lacking today is an accurate and rapid 

point of care Ebola diagnostic test that caregivers could use in the triage area to 

find out immediately whether a patient has Ebola or not. 

Secondly, regarding therapeutics, three main types of products were tested or 

used in the treatment of patients: antibody-based products (i.e. ZMapp, convalescent 

serum), antiviral products (i.e. favipiravir, brincidofovir), and to a lesser extent, 

commercially available drugs repurposed for Ebola due to demonstrated in vitro activity (i.e. amodiaquine). None of the trials have been fully conclusive. In many 

cases, due to the decreasing numbers of infected individuals available to participate 

in trials, the sample size was just too small to lead to definitive conclusions. 

The most promising results were found with ZMapp (licensed to Mapp Biopharmaceutical). There are on-going discussions in the United States to offer ZMapp 

under an ‘‘expanded access protocol’’ until it reaches licensure. However, other limitations for its use remain—including the potential high price of ZMapp and the limited production capacity. MIL77, a biosimilar of ZMapp which is produced in China 

is more likely to be available in large quantities and potentially at a lower cost. We 

are also now seeing many second generation drugs in the pipeline, but these products are unlikely to pass through the necessary trials before the next outbreak. One 

question, in this case, is whether it could be possible to rely exclusively on data in 

animals and in healthy volunteers to approve new treatments for Ebola. 

Regarding vaccines, the good news is that there are now many more vaccine candidates in the pipeline. One of them—rVSV-ZEBOV acquired by Merck—is currently 

the most advanced candidate. Yet, even if scientists are able to confirm its efficacy 

and safety, it still will not be the perfect vaccine for Ebola due to several significant 

limitations. The vaccine currently needs to be stored at -80 °C (-112 Fahrenheit); it 

protects only against Zaire Ebola virus and not for other Ebola species or other 

filoviruses such as Marburg; the duration of its immunity is unknown; and the management of recorded side-effects—such as post-vaccination fever—will constitute a 

challenge during an epidemic. 

As you can see, and despite a remarkable mobilization in accelerating Ebola research and development, current solutions are not a panacea. From my preceding 

assessments, we can conclude that, if there were another outbreak of EVD tomorVerDate Mar 15 2010 13:37 Jun 19, 2018 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6621 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\04 07 2016 -- 30-396

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row, the tools will surely help but we cannot ascertain that we will contain the virus 

or save the lives of most patients. 

Lastly, there are still a number of crucial questions related to the course of the 

disease itself. For example, how long does the virus linger in body fluids? This question leads to complications in a significant number of survivors and to the potential 

risk of sexual transmission several months after a patient could be otherwise confirmed as Ebola-free. More research is needed. There are other sequelae for Ebola 

survivors that require further research, including post-traumatic stress disorder. 

MSF would like to see changes in the way biomedical R&D is conducted, including 

by pursuing the following: 

1. Invest in patient and needs-driven R&D before the next epidemic; 

2. Test these candidates and start clinical trials as early as possible once the outbreak is identified; 

3. Maximize existing data and knowledge about the disease—by sharing it among 

scientists; 

4. Ensure final products are available and affordable to populations in need. 

1. Investing in research before the next outbreak 

Research and development can be a lengthy and laborious process and years can 

pass before it delivers the right drug or vaccine. We should not wait for another outbreak before initiating research on lethal diseases. Due to biosafety considerations, 

Ebola benefited from public research in the past decade, but this early stage research was never translated into biomedical breakthroughs for at-risk populations. 

Despite representing more than 10% of the global disease burden, only 4% of new 

drugs and vaccines approved across the world were indicated for neglected diseases 

between 2000 and 2011. It takes vision and needs-driven priority setting to invest 

in R&D for neglected diseases, and such vision could save lives when outbreaks like 

Ebola occur. We need to continue investing in research for Ebola, Zika, and other 

neglected diseases or epidemic-prone emerging pathogens. 

When incentives for innovation exist, especially if paid with public funding, they 

should benefit those most in need. For example, in 2007, Congress created an incentive program for research on neglected diseases called the FDA PRV program. The 

program works as follows: if a company, research institution or organization successfully registers a product with the FDA from a list of eligible neglected diseases, 

it is rewarded with a voucher, known as an FDA priority review voucher (PRV), allowing it to fast-track any other product in its portfolio through the FDA regulatory 

process. The voucher can also be sold to another company. The PRV program was 

recently improved, by lifting limits on transfers of the PRV for neglected diseases, 

increasing the potential appeal and value to prospective PRV recipients. The latest 

PRV has been sold for US$350 Million—a considerable amount of funding for R&D 

in the field of neglected diseases. 

However, two changes must be made to ensure the FDA PRV program works as 

intended and for the patients it claims to support. First, the PRV program should 

have a novelty requirement to ensure it induces new investments in R&D and is 

not awarded to already existing drugs or vaccines. Secondly, the PRV should require 

an access strategy to ensure that patients and treatment providers which the PRV 

intends to benefit will have affordable and appropriate access to products. These 

recommendations are a direct result from our experience in dealing with leishmaniasis, tuberculosis and malaria, where PRVs were granted for drugs that had been 

available in other countries for years, or from our persistent struggle to access affordable medical innovations. 

2. Implementing clinical trials early in the emergency response 

Prior to the EVD outbreak, MSF had never been involved in clinical trials in the 

midst of an emergency intervention. Yet, even though the trials were fast-tracked, 

relative to traditional timeframes, they started too late. When the number of Ebolainfected cases started to dwindle, as a result, trials could not be deemed conclusive. 

Clinical trials pose formidable logistical, technical and ethical challenges in an 

emergency situation. Yet, they are feasible and accepted by local communities when 

all information is shared openly. With adapted and transparent trial designs in 

place, medical organizations could promptly experiment candidates and augment the 

chances of expeditiously finding new medical solutions. MSF recommends that protocols and ethical guidelines for clinical trials during emergencies be pre-defined 

and agreed upon during the inter-epidemic period so when the next emergency occurs, trials can commence much sooner. The United States has, and continues to 

invest millions in the response and containment of epidemics. It is well placed to 


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2MSF Ebola Treatment Centers admitted over 5,200 confirmed Ebola cases, of which almost 

2,500 have survived 

ensure that such mechanisms are in place to improve the response to future outbreaks 

3. Maximizing access to available knowledge 

Outbreaks, be they of Zika, Ebola or influenza, are always contained through a 

combination of community, national and international efforts. Science is no exception to this rule; there, unity is also strength. 

Collaborative research, involving timely sharing of data and specimens is being 

increasingly recognized as an essential means to incentivize research and leverage 

our understanding of diseases. Despite having learned a great deal about Ebola, 

many unanswered questions remain which will continue to hamper our ability to 

fight against the disease. 

More than two years after the first case was confirmed in Guinea, responding 

country agencies, international organizations and NGOs involved in the response 

are still unable to draw a complete picture of the data, nor of the biological samples 

collected during the outbreak. Each of us holds a piece of the puzzle. 

MSF, which has cared for more patients with Ebola than any other organization,2

has collected valuable data that we would like to share and see used ethically for 

research priorities by the scientific community. The CDC certainly holds the largest 

EVD specimen library ever collected. Nevertheless, our attempt to support the WHO 

in establishing networks of biobanks and data sharing platforms for EVD and 

emerging pathogens is poorly supported by the many actors involved—starting with 

the U.S. counterparts. A significant gap remains between rhetoric and action. 

Knowledge sharing and collaborative research are often acknowledged in principle 

but they face tremendous resistance when it comes to implementing them. And too 

often, they come too late, once the outbreak has begun. 

Collaborative science should be an integral part of the culture and the response 

to outbreaks, with clear standards and frameworks in place beforehand to optimize 

the limited knowledge available. I regret to say that should another outbreak hit 

tomorrow, there is no ethical or organizational framework in place to ensure the collection and sharing of biospecimens or the standardization of accurately collecting 

routine data. 

As Zika has most recently demonstrated, it is in the interest of all countries, including the United States, to guarantee a culture of knowledge and data sharing 

in biomedical research. 

4. Ensure final products are available and affordable to populations in need 

Innovation without access is meaningless. Improvements to the FDA PRV program to ensure medical products are made available to patients and treatment providers will be one important step toward broader changes that are urgently needed 

to ensure the R&D system delivers appropriate and affordable health technologies. 

There is an urgent need to address the global crisis of pharmaceutical companies 

raising drug and vaccine prices. MSF is advocating for changes in the way biomedical R&D is financed by separating cost of research and development from the 

price of final products. 

Likewise, global quantities of available products may not be sufficient to meet all 

needs. There may be a need to ration them at the global level. Member States of 

the World Health Organization should agree on a code of conduct on stockpiling of 

strategic drugs and vaccines. In order to make the best and most equitable use of 

those products, a collective stockpiling mechanism needs to be discussed under the 

auspices of the WHO. 

CONCLUSION: 

Significant scientific advances are still required against Ebola and other deadly 

neglected diseases. Once a disease is known and starts being documented, the lack 

of adapted and affordable medicine is rarely unavoidable. This is often caused by 

our inability or unwillingness to implement lessons learned and a needs-driven approach. Ebola shocked and shook the world. It gave us another opportunity to reflect 

on how we approach R&D. 

The multiple health crises that patients are facing, including those treated by 

MSF, must be addressed. Every day, patients go without access to critical medical 

tools because such products are either not affordable, not suited to the conditions 

in which patients live, or simply do not exist because patients suffer from a disease 

not seen as a commercially attractive market. 


FOREI-42327 with DISTILLER
27 

These are challenges we have faced for decades but in 2016 several governmentdriven processes will take place that seek to address different aspects of the failures 

of the R&D system and to create global norms and efforts to deliver appropriate and 

affordable medical tools, including negotiations at the World Health Organization, 

the United Nations General Assembly and the G7/G20. This a critical and historic 

opportunity to make a political choice to sustain improved medical outcomes. 

Being a major contributor to both the responses to global health emergencies and 

to research and development, the United States government can and should lead by 

example by boosting collaborative and open research, including but not limited to 

neglected diseases and emerging pathogens, ensure global investments in R&D are 

coordinated, target priority health needs and deliver medical tools that are available 

and affordable to patients and medical treatment providers by de-linking the price 

of drugs from their R&D cost. 

Senator FLAKE. Thank you, Ms. Delaunay. 

Start with a round of questions now. 

Dr. Knight, can you give some assessment of U.S. programs in 

our aid, our 5.4 billions, most of which was used initially, some left 

over. But, how could we have better utilized the private sector in 

Liberia? In what ways did we fully leverage the resources that 

were there, and what could we have done better to utilize those resources? 

Dr. KNIGHT. I think it boils down to a very simple sort of attitude, which is historically—and we saw it in the beginning of the 

Ebola outbreak—that the private sector was often sort of seen as 

just remote, ‘‘Just give us a check and let us get on with it.’’ And 

they underestimated just how much physical resource we had in 

the way of assets, expertise, way around the country. And sometimes the really basic stuff, which sometimes gets in the way, like 

just somewhere to sleep that night, access to a Land Rover, access 

to a bulldozer, and somebody to drive it. And so it sort of goes to 

that sort of almost closing remark I made in my more formal entry 

about just dialogue and collaboration. 

And so, treat the private sector as an operational tactical partner, and start the dialogue with them as quickly as possible. 

I mean, we were lucky with the EPSMG, because we had the 

idea, and people came to it. What if we had not had the idea? Yes. 

Who else could have that idea. And just make it a prerequisite, 

when you go into these types of operational places, fields, Who are 

the big private sector? Who is having a conversation with their big 

boss in their big corporate office? And who is going to have a conversation with them in the country? And I think you will be 

shocked. If you take the conversation away from the check to, ‘‘How 

can you physically help us with assets, skills, and expertise?’’—people want to help. So, very simple answer. Treat them as an operational partner. 

Senator FLAKE. Right. I have seen the pictures that you have—— 

Dr. KNIGHT. Yes. 

Senator FLAKE.—of the roads around Liberia. Give—can you give 

some outline of how much of the country is inaccessible during 

much of the year? Just—you have operations in various parts of 

the country. How difficult is it, in terms of infrastructure that 

would relate to healthcare centers as well as businesses? 

Dr. KNIGHT. Well, I will give you an example which I am familiar 

with. You know, to go from Monrovia to our mine, when everything 

is right—you know, the sun is shining, the road is dry—it can take 

3 hours. When we get to these conditions, it can take 10–12 hours. 


FOREI-42327 with DISTILLER
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So, imagine trying to run a business, just getting assets, let alone 

people, to and from that site. We used to have a helicopter, but we 

have now grounded that as part of our cost-cutting messages. So, 

imagine if somebody gets hurt. Imagine if we break a leg and we 

need to get somebody to Monrovia. We have got to move them on 

those types of roads. You know, who would want to work in that 

environment? You know, I mean, sort of saying things such as, ‘‘We 

want to create confidence and incentives for people to invest in 

these countries.’’ You know, these really basic things get in the 

way. So, a muddy, destroyed road really makes businesses suffer. 

You asked me what percentage. I do not actually know the number, but it is a lot, and it is making a noticeable difference. 

Senator FLAKE. All right. Thank you. In Arizona, we dream of 

muddy roads like that. But—[Laughter.] 

Senator FLAKE. Dr. Panjabi, it was touch-and-go for a while during the height of the outbreak, when—there was a case here in the 

U.S., someone who had traveled from West Africa. And there was 

a real push for a travel ban that would have affected those countries and cut off airline service. Fortunately, we avoided that. What 

would that have done, in your view? How would that affected— 

have affected your operations and others? 

Dr. PANJABI. Thank you, Mr. Chairman. 

You know, I was in Liberia at the moment that traveler was 

here, and, you know, to be very honest with you, it would have felt 

like an infected wound was being cut off. But, besides the moral 

dilemma there, and leaving people behind, it would not have been 

very strategic. The most important thing that the U.S. did was to 

keep those doors open to allow health workers to go there and help 

stop the infection at its source. So, from a strategic perspective, it 

was wise to keep the doors of this country open. 

Senator FLAKE. Thank you. As far as lessons learned, I think 

that is one that we have to learn again and again, not to overreact 

on some of these epidemics that make the matters worse. And, 

frankly, that would have been a big blunder on our part, I think, 

had we pushed through and allowed that to happen. 

Give us an idea what these local health centers—President 

Sirleaf has talked about, in the next—before she leaves office, to 

have, I think, 2,000 or so in rural areas. Is that achievable? And 

how can we help? And are we helping in that effort? 

Dr. PANJABI. Well, the good—what President Sirleaf—amongst 

her priorities in the health system, in addition to labs and clinics 

and hospitals that need to be refurbished and equipped, she has focused in on the health workers. The number you mention is around 

the community health workers. In one effort, she has seen that you 

can extend healthcare to the most remote communities, there are 

about 1.2 million people out of 4 and a half [million] in the country—that do not have any physical access to healthcare. So, this 

will bring healthcare to those regions. Those are exactly the places 

where Ebola is likely to reemerge. And it also is going to create 

jobs. We know that rural unemployed people, men and women, is 

not—is a big issue for the country. It always has been, from all perspectives, economically and securitywise. This is a chance to give 

employment to 4,000 people out there. 


FOREI-42327 with DISTILLER
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She [President Sirleaf] has asked for 2,000 of these workers to 

be deployed for the sake of healthcare and jobs by the time she 

transitions office at the end of the next calendar year. The U.S. is 

already stepping up to mobilize this kind of support, and a number 

of agencies I mentioned in my testimony have been designing this 

program, along with the Liberian government. It will be government-led. Private groups will also be involved in helping roll it out. 

Speed is of the essence, I think, to help stop the next Ebola, but 

also to make sure we take advantage of the fact that there is phenomenal leadership from the country itself that is being asked to 

push forward. 

So, I think what can be done, from the Congress’s perspective in 

the U.S., is to make sure that that momentum is preserved, the 

funding is preserved for that kind of initiative that is so important 

as a priority to her, and that it is amplified and there are commitments made to the long term. This is something that is not going 

to be built back in a year or even in the next 18 months. It will 

give us a big headstart, but it took years to start to rebuild the 

health system after our war, and it is going to take years to put 

this in place. But, it will have a high return on investment. 

Senator FLAKE. All right. 

Before I turn it to Senator Markey, let me just say—dealing with 

Liberia with an epidemic like this, I cannot imagine having done 

that with the prior administration or others that did not work directly with us. And also, on the back end, to have the President of 

Liberia come back and thank us, and thank the American people 

for the resources and the taxpayer monies that were spent is something that perhaps is not heard often enough by the taxpayers out 

there who fund these kind of efforts. But, there was genuine gratitude and a willingness to work with us to make sure that we can 

prevent this kind of outbreak in the future. 

So, with that, turn it over to Senator Markey. 

Senator MARKEY. Thank you, Mr. Chairman, very much. 

Without the United States and international community moving 

in to help and build the structures and help the healthcare system, 

how capable would these countries have been to deal with this 

issue? How indispensable is the United States, in other words, in 

dealing with this issue? 

Ms. GLASSMAN. The U.S. has obviously had an indispensable 

role. And, most importantly, is helping with the logistical response, 

funding the many nongovernmental organizations who deployed 

healthcare workers to meet the need. But, even more importantly, 

as a signal of commitment to the rest of the nations of the world 

that this was an important problem that needed to be solved, because we cannot go it alone. This is obviously something that affects the world community. 

Senator MARKEY. So, if there are, which there will be, additional 

Ebola flareups, Lassa fever flareups, what is the capacity for these 

countries to deal with it in the absence of the United States being 

there to provide assistance? 

Ms. GLASSMAN. Well, I mean, you have seen how poor the West 

African countries are. Other countries have more resources to be 

able to mobilize on their own. But, unless we, as the United States 

Government, are creating better incentives for governments to put 


FOREI-42327 with DISTILLER
30 

their own money towards basic public health programs, disease 

surveillance, healthcare workers, infection control, results in 

health, I do not think we will get to sustainability anytime soon. 

So, I think that is something that we need to think about, going 

forward. 

Senator MARKEY. So, we will have to be there in order to ensure 

that, when these flareups occur, that the problem is contained 

quickly. Is that what you are saying? 

Ms. GLASSMAN. So far, the United States seems to have been the 

first responder in many cases—— 

Senator MARKEY. And that will have to continue, in your opinion? 

Ms. GLASSMAN. In low-income countries, I think that will have 

to continue. 

Senator MARKEY. Yes, thank you. 

And what about the survivors? They are particularly vulnerable. 

What kind of additional assistance will they need in order to be 

able to deal with the aftermath of their families being afflicted with 

this disease? 

Dr. PANJABI. I can take that. 

You know, Senator Markey, I—what is needed is good 

healthcare. I mean, you brought up, in your opening remarks, that 

the survival rate for people with Ebola in West Africa was dramatically lower than it was for people that were brought here. They had 

the same disease, but they had different healthcare systems. So, 

what we need for Ebola survivors is ongoing care. A number of 

them have ophthalmological/eye problems. Of course, there is the 

potential for the disease to be retransmitted through sexual transmission. So, focusing there [on strengthening healthcare] will also 

help care for those people and help, from a public health perspective—— 

Senator MARKEY. How high is the threat for reinfection? 

Dr. PANJABI. Well, you know, I am not an expert in reinfection, 

itself, but we do know, for instance, that our initial estimates of 

how long the Ebola virus exists in semen was an underestimate; 

it is actually much longer. And we are still learning exactly how 

long it can last. But, certainly beyond the 90 days we initially 

thought, and several more months after that. So, you know, continued monitoring is also going to need to happen. And that is not 

going to come from anything but actually providing healthcare to 

these Ebola survivors. 

Senator MARKEY. Okay. What are the lessons that you think we 

can take from Ebola and now apply to Zika, in terms of protecting 

those countries that are already infected and the United States as 

we head into the warm-weather months? And—— 

Dr. PANJABI. Yes. 

Senator MARKEY.—at least 200 million people are potentially in 

areas that could have Zika outbreaks before the end of this year. 

What are the lessons that you would have us take from that? And 

what kind of actions should the United States take in order to deal 

with that potential threat? 

Dr. PANJABI. Yes. Well, I think that the effort to bring in capacity to detect early, respond quickly, and then prevent these things 

from coming back is critical. So, health workforces are important. 


FOREI-42327 with DISTILLER
31 

The training is important. You know, the lab systems are important. Vaccine delivery and creation is important. 

We need to also remember that 75 percent of emerging human 

infections are of zoonotic origin. That means that they are coming 

from animals to humans. They may spread human-to-human in 

some cases, as Ebola does primarily, but they are happening in remote parts of the world. Zika itself was discovered initially in a forest in Uganda in the ’50s. So, you know, can we detect these earlier 

in those remote parts of the world to identify the next threat that 

we do not even know about yet? I mean, that—— 

Senator MARKEY. Just going back to what you said earlier about 

how we had to move in minutes and we were moving in months 

and years. 

Dr. PANJABI. Yes. 

Senator MARKEY. Do you feel that there is a sense of urgency 

here? 

Dr. Knight, could you talk about that, in terms of the lessons of 

Ebola, given the fact that Zika is on our border. 

Dr. KNIGHT. I think, you know, the lesson is, How would you 

work with the private sector? I mean, this sort of reducing the response time from months to minutes. The private sector is already 

established in those places. You know, it is an email. It is a phone 

call. And it is a request. And we can mobilize, because we have got 

systems and logistics there. 

You know, what can the private sector do? It can talk to everybody who works for them. It can talk to everybody who supplies 

them. It can talk to their neighbors. And if every single big-, medium-sized company in those infected countries was doing that, it 

makes a big difference. You know, you have a very special relationship in an employer-employee relationship. 

Senator MARKEY. Well, how do you feel about this transfer of 

funding out of Ebola and over to Zika at this time, Dr. Knight? 

Dr. KNIGHT. It is hard, because, as you sort of said, it is sort— 

it is a big of a moral maze. But, if the question is, Have we done 

enough to stop Ebola happening in Liberia? Have we done enough 

to create the right momentum towards economic recovery in Liberia?—the answer is no. 

Senator MARKEY. Have we done enough to put in place the protections that we need against Zika, from that perspective? 

Dr. KNIGHT. Well, I—I am not close to Zika, so it is not fair 

to—— 

Senator MARKEY. Dr. Delaunay, how do you feel about that? 

Ms. DELAUNAY. MSF is not working in the countries where—affected by Zika either, so I am not really able to answer your question. But, I can just say that, indeed, there is still a lot to be done 

for Ebola, both in terms of system strengthening and research to 

understand this disease. And if it is about shifting from one priority to another, then it is worrying, because this is one of the lessons that we learned from Ebola, that we need to be prepared. It 

is going to come back, and science needs to goes on. 

Senator MARKEY. Yes. So, your basic message is to fund Zika at 

the levels that it should be funded, but do not underfund Ebola as 

a result of making that choice—almost a ‘‘Sophie’s choice’’ between 

the two diseases and the impact it can have on families? 


FOREI-42327 with DISTILLER
32 

Ms. DELAUNAY. Absolutely. Absolutely, yes. There is still a lot to 

be done on Ebola. And our big concern is that, when the cameras 

have left these countries and the—there are still lots of lessons 

can—that can be implemented, especially in terms of—because it 

is not just about funding, it is also, as Amanda was saying, you 

know, trying to be more effective with the funding that we do. And 

in the field of science, it is clear that one big lesson is being prepared and being organized to gather that data, to share knowledge, 

is going to improve the scientific advances. 

Senator MARKEY. Okay. 

Thank you so much. 

Senator FLAKE. Thank you. 

Senator Isakson. 

Senator ISAKSON. Thank you, Chairman Flake. 

Being a Senator from the State of Georgia, I am very proud of 

what the CDC and Emory University did in the contribution toward the terrible Ebola outbreak. And I have a few questions regarding the CDC on that line. 

And, Dr. Panjabi, I would really like to ask you, if I could for just 

a minute. We have—in our supplemental appropriation, we talked 

about a goal of establishing many CDCs around the world, maybe 

as many as 20 of them. And Bill and Melinda Gates and International Association of Public Institutes and others are working on 

that goal. Would it be helpful to disperse that type of delivery system around the world? And would there be enough countries who 

would be willing to make the financial contribution to help make 

that happen? 

Dr. PANJABI. Thank you, Senator Isakson. 

A short answer is yes, that it would make a big difference. In the 

middle of this crisis, at the beginning of it, the Liberian government and Ministry of Health, we were sitting in these rooms. There 

was—it is not that there were not any actions taken at that level. 

There were 30–40 people meeting every day, including the Minister 

of Health, trying to respond to the initial outbreak. One of the most 

effective things the CDC helped with was putting in an emergency 

operations center and helping—organized even the decisionmaking 

around that, called an incident management system. So, whether 

it is the field epidemiology training programs that the CDC wants 

to put in place or an initiative like that, I think the—efforts like 

that will be critical. As long as we are trying to transfer and support the skills of local health workers, we need to build that capacity in those countries. 

A question of whether other groups will be behind this, I know 

that the African Union and others are looking to try to focus on 

that. The idea of an African CDC or a CDC based in Africa, is 

something that I know a lot of groups, both specific governments, 

but also as a community of African states, for instance, and I imagine other parts of the world will be interested in. 

Senator ISAKSON. I was interested in Dr. Knight’s comments 

about engaging the private sector early on in the effort, and what 

you did, yourself, to recognize what needed to be done to protect 

your people and your assets. Is there a catalyst anywhere in Africa 

to take best practices and lessons learned from this Ebola outbreak 


FOREI-42327 with DISTILLER
33 

and try and train countries so they are better able to respond on 

their own? Is anybody synthesizing that? 

Dr. KNIGHT. The World Economic Forum took a lot of interest in 

Ebola, and they took a lot of interest in, obviously, what we did as 

the private sector, being the World Economic Forum. So, they have 

codified and written down everything we did. And in Turkey, U.N. 

are hosting the humanitarian sort of big convention. And again, it 

is clear that they have now sort of—they are beginning to look at 

the private sector in a different way. 

The tough thing about what we did was that it was in—it worked 

because it was quite informal, and it was not wrapped up in process and governance. So, it is actually quite hard to sort of codify 

something which works when it is quite informal. So—but, my 

message to people at World Economic Forum, the United Nations— 

it goes back to the earlier comment. It is—the moment you need 

to mobilize on any humanitarian crisis, one of the questions in 

that, sort of, first page should be, ‘‘Who are the private-sector players out there? Let us get them together and talk to them.’’ 

Senator ISAKSON. Right. 

Dr. KNIGHT. And if you start to overinstitutionalize something, 

people sort of—the private sector sort of go, ‘‘Oh, this is going to 

be membership fees. This is going to be governance. I am going to 

have to commit something politically. I am not quite sure.’’ But, the 

moment there is a crisis, they are eager and keenly enthusiastic 

help. So, it is just how quickly you engage, the moment you need 

players on the ground with equipment and assets. 

Senator ISAKSON. Yes, do not overbureaucratize the response, or 

it will take entirely too long. I think that is what I hear you saying. 

Dr. KNIGHT. Yes. Yes. 

Senator ISAKSON. Because time—— 

Dr. KNIGHT. Do not overbureaucratize, but jump on the opportunity as soon as you need it. And—you know, and all of us are 

saying what the big lessons from Ebola was: We all could done 

more, quicker. And that is the other thing, you know. And I think 

what worked for the private sector, as well, was the fact that we 

had a risk-management system. You know, it is very textbook, it 

is very business school. But, when it works, it really works. You 

know, we were testing what would happen if Ebola became serious 

back in about February. 

Senator ISAKSON. Right. 

Dr. KNIGHT. We had everything in place. All our staff were trying to—when we had the big outbreak in Monrovia, the first deaths 

in Monrovia, we literally just turned on a switch and we were 

there. We were testing people. We were communicating with people. Because we had planned it. We had rehearsed it. And we were 

ready. 

Senator ISAKSON. Yes, I was really proud of Dr. Frieden, at the 

CDC, and also our military. A lot of people have forgotten, we deployed military assets in West Africa to build some of the temporary facilities so we could isolate those that had the infection, 

keep them from spreading it to others. So, it takes a multiple set 

of efforts. 

Dr. KNIGHT. Yes. 


FOREI-42327 with DISTILLER
34 

Senator ISAKSON. And a private-sector partnership with governments that are prepared to respond and have a best-practices plan, 

if we have another one, God forbid, will be an improvement on the 

lessons we learned from this one. 

Dr. KNIGHT. And to go back to the private-sector contribution, 

many of the foundations and the ground-clearing for that was actually done by our equipment and our bulldozer drivers. You know, 

you cannot build a medical center without foundations. And we just 

turned up and did it. So, all that extra bit of complication for real 

mobilization, we just did. You know, and it is just very—it is 

very—we underestimate the power of these very simple, straightforward support. Very easy for us to drive bulldozers—— 

Senator ISAKSON. And we are also—we have some—— 

Dr. KNIGHT. But, we just got to it quicker. 

Senator ISAKSON. We had a lot of private sector, like Samaritan’s 

Purse and religious-based organizations did a tremendous—deliver 

healthcare services. In fact, one of the people who was transferred 

from West Africa to the United States at Emory University was a 

Samaritan’s Purse physician who was infected in Africa. And that 

was the first big controversial issue about bringing somebody into 

the country. But, because we did that, I think it was a—it was a 

good thing, obviously, for the patient, but it was a good thing for 

the entire epidemic and the—— 

Dr. KNIGHT. Yes. 

Senator ISAKSON. Thank you very much for your efforts. 

Senator FLAKE. Thank you. 

Senator Coons. 

Senator COONS. Thank you, Chairman Flake, Ranking Member 

Markey, to Senator Isakson, my good friend, to all of you for your 

remarkable work in this field and for your testimony today. 

The principal point you are making is that Ebola is not over and 

that the significant amount of resources that the United States has 

appropriated to try and address Ebola should not be redirected 

elsewhere, that, frankly, we should also be investing, simultaneously, in a response to Zika, and that all the conditions that led 

Ebola to go from largely unknown to a significant challenge to a 

global concern are still there. 

When you say, Dr. Panjabi, it is a zoonotic illness, there is an 

animal reservoir of Ebola that has probably been active in West Africa 40 years, that we have now discovered. There have probably 

been a whole series of small outbreaks in remote villages that the 

rest of the world never knew about. And there is, of course, the 

possibility, that this virus will mutate and become more lethal. 

What we see on the ground in Liberia, in Guinea, in Sierra 

Leone, economies that have not yet fully recovered, may not recover for a number of years. Grassroots healthcare systems that 

need to be fully built out. And, of course, we commend President 

Sirleaf for her terrific work in leading the effort the deploy community health workers across the country. But, there is so much more 

to be done. Porous borders and a lack of any sort of a modern 

healthcare infrastructure in the remote places in these three affected countries led to the outbreak. 

One lesson, I think, that was most poignant at the time was 

that, at the moment when Ebola broke out into Nigeria, in the Port 


FOREI-42327 with DISTILLER
35 

Harcourt area, I think there was a global collective gasp at the real 

prospect that Ebola would get loose into major metropolitan areas 

into the international travel community and metastasize globally. 

And it did not. It was contained, quickly and well, and in no small 

part because of, of course, the brave public health workers in Nigeria, volunteers, and the infrastructure. Investments made by the 

United States through our PEPFAR program, and through our efforts against polio built some of the labs and the communications 

and the infrastructure and the public health systems used to prevent an outbreak. 

So, if I hear you right, your central message to us across many 

concerns is this: To the U.S.—do not stop investing in making sure 

that we have addressed all the things that, because they were not 

addressed, led Ebola to be so lethal so quickly, so broadly. Have a 

clear path forward on vaccine testing and development. Have a 

clearly developed ethical structure and incentive structures. 

Medecins San Frontieres, you have shared with us that concern, 

and, I think, a very powerful and important one. We need to have 

a framework for data-sharing and for vaccine development that is 

proactive, not reactive. It is very hard to do effective field trials in 

the middle of disaster response. As Dr. Panjabi has said, continue 

to build out grassroots community health worker networks across 

the region in the country. And, as Dr. Knight has said, we have 

private-sector partners all over the continent and the world who 

can and should be proactively engaged in planning for the next 

pandemic. 

Zika, which is a challenge, is not what I think we are most concerned about as a group, which is a truly lethal global pandemic. 

Ron Klain, who I think served admirably as the President’s Ebola 

coordinator, has recently published a piece in which he raises the 

specter of a truly global pandemic that would be faster-moving, 

more lethal, and more readily shared than Ebola was. And he 

makes a number of suggestions. So, let me move to asking what 

you see about both lessons learned, the need for our continued investment, and the suggestions that you and he have made. 

And let me not close my opening without saying that it was the 

people of Liberia, in my experience there in December of 2014, volunteers from around the world, who were really on the front lines 

in making the lifesaving difference, and, in 500 cases, giving their 

lives as health workers. But it was, as Senator Markey said, the 

United States that was the indispensable nation that brought to 

bear, at a critical moment, in the rainy season, when there was a 

near collapse of the nation of Liberia, absolutely essential logistical 

supplies, resources, funding, trained personnel that helped Liberians turn the corner. This was, I think, a moment of great partnership and of great leadership by the United States, the international community, and by thousands of volunteers from around 

the world. 

But, there are critical lessons learned about how to reform the 

WHO, about how to reform the accountability and transparency of 

data, about how to improve the grassroots healthcare networks of 

fragile nations, and about how to plan for the next outbreak. 

So, let me turn, if I might, to the issues raised by Ron Klain. He 

has suggested that, within the United States, we should have a— 


FOREI-42327 with DISTILLER
36 

an identified National Security Council coordinator to manage 

interagency responses. He suggested investment in just the sort of 

CDC that Senator Isakson was asking about, regional CDCs—Africa first, but in other geographies—that have the capacity to mobilize cutting-edge analytical capabilities, field tests, and to coordinate field trials. He suggests that the global health security agenda, Global Health Security Act and the agenda that it would authorize, needs to move forward, that we need to continue, as a 

country, to invest at the grassroots. And he suggests a parallel to 

FEMA that would be essentially a public health emergency management agency. 

As was mentioned in passing, one of the things that most impressed me about the response I was able to see in December of 

2014 was its coordination. There were dozens and dozens of nonprofits, of government ministries, of U.N. agencies, of U.S. entities, 

and there was a regular, clear, weekly meeting, with a public agenda, with everybody in the same room at the same place at the same 

time, using the National Incident Management System that has 

been built out in the United States by FEMA to coordinate response, to identify and prioritize investment. That was truly encouraging. And a number of the folks from the DART team at 

USAID, who I met with, said, across a half-dozen other disasters, 

they had never seen that work so well. That was partly due to private-sector engagement and leadership, in terms of skills and capability. It was partly the U.S. But, it also was a reflection of the 

very strong Liberian-American community. There were dozens and 

dozens of Liberian-Americans who had returned to help lead the 

government and ministry responses. 

So, please, if you would, respond to a number of those proposals. 

I know that was a long survey of the different issues. Each of you 

have spoken to them in your testimony, but if you would focus and 

sharpen. What are we missing? What do we most need to do next? 

And I assume you agree that Ebola is not over, the conditions that 

create it have not gone away, and, if anything, we need to double 

down on the investments we are making, and make them count. 

If you would, in order. Dr. Knight, please. 

Dr. KNIGHT. I agree with everything you said. You know, Ebola 

is not over. But, I might put a slightly different context in it, that, 

in such a globalized world, the risks of pandemics is more severe. 

You know, and that might help some of this conversation about, 

How much do we appropriate funds? It is actually—this is an 

emerging and growing problem. Very mobile world, et cetera. 

The other question, What do I think of the recommendations? 

They all seem—I support them all, obviously, but the missing one, 

I think—and I mentioned it in my opening comment—is, in a world 

where there was a serious pandemic and an infectious pandemic, 

what are the conventions, protocols of people traveling from one 

country another? You know, if I was to send 10 people to a country 

to help fight a pandemic, what do I do with them if one of them 

gets the disease? Can I fly them home to treat them in my hospital 

in my country? Or they then have—they have to stay in that country? Because it changes who I ask and what I ask of them. It—if 

it is clear somewhere, it was not clear at the time. And it almost 

feels like—I do not understand how international systems work, 


FOREI-42327 with DISTILLER
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but it almost feels like there should be an international convention 

on the movement of people across borders during the time of a pandemic. And maybe with different trigger levels. When it is beginning to happen, it is more accessible. When it is really severe, borders might have to shut. I do not know. But, do not let us work 

it out during the next one. Let us have it written whilst we enjoy 

not having one. 

Senator COONS. I do think, Dr. Knight, the establishment by the 

U.S. Public Health Service, which has been sort of an unsung hero 

of this, of the treatment facility out at Robertson Airport, was especially critical, because it allowed international volunteers, public 

health professionals to have some confidence that, when they contracted Ebola, they would get world-class care without having to be 

repatriated. I met with a number of the Liberians and foreign nationals who had survived Ebola because of their treatment there. 

We have no plan or convention around that—— 

Dr. KNIGHT. Let us, Yes, codify, write it, and say that is how we 

will deal with that scenario. 

Senator COONS. Excellent. 

Dr. KNIGHT. Otherwise, it interferes with decisions sometimes. 

Senator COONS. Dr. Panjabi? 

Dr. PANJABI. Thank you, Senator Coons. 

You are right, Ebola is not over. The conditions, as you said so 

eloquently, that created it are still there. And it is true that the 

medical literature reports that we were warned about this. We just 

did not see it. As late as—as far back as the 1970s, there was literature from West Africa that reported antibodies—meaning that 

people were exposed to Ebola. It just was not caught. And so, there 

are these blindspots—and that is what I would say is missing—in 

global health. We ask, in making investments in global health, 

what disease to focus on. Is it HIV and AIDS? Is it Ebola? We have 

started to ask more of the question of how to do it. Amanda 

brought up great suggestions about focusing on performance, focusing on the health workforce. We have not asked enough about who 

and where the distribution of those resources have gone. 

Take the State of Alaska, for instance—a homegrown example— 

600,000 square miles, 600,000 people. Instead of deciding to allocate resources just on a dollar-per-capita basis, which would have 

left every small remote community out of that calculus, they asked 

the question, How far are people from healthcare? If there are 50 

people in a village or a community, if there are 100 people, how far 

are they from a C-section? If they are 60 minutes or more from a 

C-section, regardless of population size, you are going to be designated a ‘‘frontier community,’’ which means you are going to get 

a higher earmark in the budget. This is the Office of Rural Health 

Policy here at HHS. 

Those kinds of policies and financing innovations need to come 

to global health if we are going to focus on the blindspots that lead 

to the hotspots of disease. And to get there, that first has to start 

with tracking conditions in those areas. So, we need to be asking 

about distribution. Who and where? If it is medicines, is it getting 

to the last mile, is it getting to all people? And can we prove that? 

Can you hold people accountable to cover each and every person? 

Great agendas are already been put forward. The Global Health 


FOREI-42327 with DISTILLER
38 

Security Agenda, you mentioned one of them. There is no way you 

can stop emerging infectious diseases if they are zoonotic if you do 

not go to places where they first emerge. But, there is also broader 

agendas and synergies with the investments you all have already 

made in HIV and AIDS, in tuberculosis and malaria, in strengthening health systems. There is a grand agenda to get universal 

health coverage out to all parts of the world that do not have it. 

These are synergistic. 

And I think that is just the second point I would make that is 

more subtle, perhaps, is, we cannot pit different diseases against 

each other, but we also cannot pit different strategies against each 

other. Last week, a bunch of community health workers who were 

delivering care for mothers and children discovered a pertussis, a 

whooping cough, outbreak in that region. You know, you could have 

said, ‘‘Well, those community health workers are not disease responders, they are not focusing on disease surveillance, so let us 

not fund primary healthcare.’’ When, in fact, now they are the front 

lines of a disease response. 

So, these are synergies. It is not either/or. And I think there is 

a lot of leverage yet to be had in linking these agendas together. 

But, the goal, I think, again, the big blindspot, is, we are not reaching the last mile. There are 400 million to one billion people on the 

planet who live out of complete reach of healthcare, even in the 

21st century. And if we do not reckon with that, we are not going 

to, I think, be able to stop these outbreaks from happening. 

Senator COONS. Well, thank you, Doctor. And thank you for your 

particularly brave and persistent and powerful work, along with 

Paul Farmer and the Partners in Health. The model that you have 

been advancing is a huge ‘‘aha’’ moment, I think, for all of us. 

If you could, briefly, Amanda and Sophie. 

Ms. GLASSMAN. Yes. Thank you, Senator. 

I agree totally, there should be a global health czar that has 

power over the interagency and the budgetary tools needed to assure that all the agencies are moving in the same direction. But, 

that said, I think we also need to structure our financing of response to infectious disease, whether they are outbreaks or whether they are protracted issues, in a way that avoids repeat disease 

earmarks and repeat emergency funding. As we have said, it is not 

if, it is when. 

So, you know, can we change? We have been doing this since the 

time of PEPFAR. And we seem to like disease-specific earmarks. It 

is great to know you can talk more specifically about what is happening, but we can still have that accountability and, you know, 

the impact on people’s lives without having to name money by disease-specific intervention. 

And finally, the Global Health Security Agenda, very important. 

We have been doing a lot of training, meeting, and capacity-building. I worry that we are not creating enough incentives for outcomes on disease preparedness. So, we know what a good disease 

surveillance system looks like, but did we know whether Brazil’s 

disease surveillance system was working well? Did it have complete 

coverage? Were they able to respond? Brazil is a big federal country like our own. They face a lot of the same issues. How do we 

get subnational entities to be prepared for public-health outbreaks? 


FOREI-42327 with DISTILLER
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Are they really recording all the deaths? Do they have the capacity 

to do that? 

And I will end there. Thank you very much. 

Senator COONS. Sophie? 

Ms. DELAUNAY. Thank you, Senator, for your eloquent summary 

of our recommendations. 

I would like to make a comment about the Global Health Security Agenda and the CDC. 

On the Global Health Security Agenda, of course we see a lot of 

value in the U.S. taking a leading role in trying to address the response to outbreak. And one of the value is actually that you have 

been able to get onboard a number of countries. And the response 

to an outbreak never takes only one actor; it takes a whole range 

of actors. So, that is a very valuable issue. 

Our only concern with the Global Health Security Agenda is 

that—is hoping that the agenda is not just driven by security concerns, because what we have learned, and what we learn repeatedly in humanitarian and medical situations, is that the best way 

to actually address health issue is to be patient-driven, is to try to 

respond to the needs of the patients first, and not necessarily when 

we feel a threat. There were some research about Ebola in the beginning of the 2000, when there was a fear of bioterrorism, and 

then it was abandoned. And so, the—you see the risk of actually 

attaching an agenda to security issue, as opposed to health consideration and needs of the population. 

Regarding the CDC, I would just like to share a very recent experience. We are—first, we have been working very, very well with 

the U.S. CDC in Liberia, as you may know, hand-in-hand during 

several—during 2 years. We also recognize that there is a major 

need for better surveillance. And we have engaged in talked with 

WAHO, the West African Health Organization, on data-sharing. 

And it was interesting to see that actually they wanted every discussion were going back to the African CDC. So, they want the African CDC. They want this to happen. And provided that the 

United States is able to actually help them set this up and help 

them develop the ownership and the capacity to run such a initiative, it will definitely be a game-changer in the region. 

Senator COONS. Well, thank you. 

Thank you all. Thank you for your service. 

And thank you, Chairman Flake and Ranking Member Markey, 

for convening this important hearing and for staying engaged and 

being such leaders on this important issue. 

Thank you. 

Senator FLAKE. You bet. And thank you, Senator Coons, for actually traveling to Liberia in the height of the epidemic. That was a 

gesture that was much appreciated by all, and certainly courageous 

on your part. 

Let me just say, in the form of kind of a question, but a statement—Ms. Glassman, you talked about the perils of supplemental 

funding. I think a lot of the discussion today is around—you know, 

we have disease-specific funding that we appropriate. It is, frankly, 

far easier to appropriate, from a standpoint of an elected official, 

when there is an issue like Ebola or like—or HIV/AIDS in Africa. 

With an epidemic level, it is just—it is easier to move money. That 


FOREI-42327 with DISTILLER
40 

is why we do it. But, it does not serve us very well in the long 

term. 

And if I look at our global health budget, the request for 2017 is $8.5 billion; enacted, 8.1 billion for last year. When are we going 

to actually bite the bullet and say, ‘‘All right. We need to increase 

that, and decrease the likelihood of a supplemental needed later?’’ 

Or do we go another direction? 

Ms. Glassman, do you have any thoughts on that? You have 

shared some in your testimony, certainly, but I would like to have 

you detail that a little more. 

Ms. GLASSMAN. Thank you, Senator Flake. 

Well, it is a very difficult political task to do, but I think the idea 

of trying to increase funding and still hold ourselves accountable 

for results in specific disease areas is a good combination. That 

way, we can use our funding rationally, but we are still accountable for the outcomes in the diseases that we care about, the infectious diseases, and the preparedness that we care about. So, I 

think maybe that is a compromise that would be politically feasible. 

Thanks. 

Senator FLAKE. Well, certainly from our point of providing oversight, and a lot of the funding is through this committee, if we have 

a regular appropriation cycle that includes this money, it gives us 

opportunities through the hearing process, budget committee hearing processes, to actually scrutinize and scrub and see, you know, 

what worked and what did not. So, I hope that we can move more 

in that direction. 

Senator Markey, did you have any followup—— 

Senator MARKEY. Yes, if I may, please. Thank you, Mr. Chairman, very much. 

I would like to, again, come back to this Zika question. I think 

it is very important, because there is clearly a dynamic tension now 

that is opening up, in terms of the willingness of Congress to appropriate the monies that are going to be needed to deal with both 

of these diseases. And maybe you—Dr. Panjabi, maybe you could 

talk about this issue again, in terms of the need to ensure that 

there is funding for the Zika epidemic as it moves throughout that 

region and towards the United States at an ever-accelerating pace. 

What would you recommend that we put in place, given the lessons 

that we have learned from Ebola? And would you recommend to 

Congress that they replenish the money that they are taking, that 

we could reprogram out of Ebola, and ensure that there is, at the 

same time, full funding for Zika so that we do not, unfortunately, 

lose the lessons of the Ebola crisis, lose all of the—you know, the 

basic hard-won human tragedy that had to be suffered through because we did not act quickly enough, because the world did not respond quickly enough, because the WHO did not respond quickly 

enough? What would you recommend to us, as an institution, in 

terms of the funding and how we should proceed? 

Dr. PANJABI. Well, you know, the way I think about this is, these 

are not separate battles in a single war. You cannot win one or the 

other and win the war. These are two different wars to fight. And 

we have to be able to maintain our defenses in—on both fronts, 

whether it is in West Africa or in Latin and South America now, 


FOREI-42327 with DISTILLER
41 

in the Americas. So, I do think whatever can be done, from the 

Congress perspective, to both provide the support that is needed to 

respond to Zika and, where needed, replenish, if that is what is 

needed, the funds that are being moved away from Ebola, but also 

actually—and again, tie that to performance. I mean, there are 

clear targets here of what is needed to be done. These are—you 

know, the—we need to get kids vaccinated in West Africa. We need 

to make sure that community health workers are paid and supported. Lab systems need to be strengthened. Health-worker readiness needs to be there. They need to have protective gear, gloves, 

and gowns. If we continue to do that in West Africa, we will help 

stop the next threat there. 

Some of those same lessons and interventions are what is needed 

in Zika, whether it is training health workers, equipping them appropriately. And, you know, I think that the Global Health Security 

Agenda, what the CDC has put forward, is very straightforward: 

prevent, detect, respond. That kind of agenda, of investing in that, 

will be very helpful. 

You know, we also know that Zika has been present—as I mentioned earlier, the first cases were in West Africa and Nigeria, of 

human infections. Right? So, by investing now, post-Ebola—or 

while we are trying to fight Ebola, still, and also recover, but also 

set it up to be resilient against Ebola in West Africa, we are also 

setting it up to be resilient against other kinds of diseases, if we 

do it the right way, whether that be Zika, if it reemerges there, or 

whether it is other infections. So—— 

Senator MARKEY. So, as you look at WHO and what just happened with Ebola, have they learned the lessons, in your opinion, 

Doctor, of what just occurred in West Africa? 

Dr. PANJABI. I do think the WHO—a well-supported, fit-for-purpose WHO—is going to be important to helping stop and respond 

to these outbreaks. I think they play an essential role. Have the 

lessons been learned? I think they are still being learned. I think 

that—— 

Senator MARKEY. What do you think the big problem was, Doctor? Why did they not see it? Why was it not—why was the alarm 

bell not ringing so loudly that they did not respond? And why, in 

your opinion, should we have any confidence that any reforms are 

going to change that attitude? 

Dr. PANJABI. I think the central primary reason is that this went 

undetected? Right? As I mentioned in the testimony, you have an 

Ebola infection that moves from an animal reservoir into a human 

reservoir—a human population, initially, in really remote areas. 

Health workers are not supported there. They are unpaid or they 

are underpaid, they are unequipped or underequipped. And if you 

do not have a health system in these remote areas, you are going 

to miss—it took 3 months; when minutes counted—every minute 

counted, we lost months. So, by the time March rolled around, of 

2014, to catch up with that response was—we were already behind 

several steps from the epidemic. So, I think that still is the central 

issue, is making sure surveillance in primary healthcare services in 

the most remote areas are there. That includes good data and monitoring. Had those pieces been in place earlier on, any institution, 

whether it was the governments in those three countries, the 


FOREI-42327 with DISTILLER
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WHO, the U.S. Government, they all would have been better prepared to respond. And again, I think that is the focus now that 

needs to be there for all of us, is to make sure, where we know 

there are disease hotspots likely to happen, and there are blindspots in healthcare reaching those areas, we need to double down 

on investments in those places. 

Senator MARKEY. Thank you, Doctor. 

Thank you, Mr. Chairman. 

Senator FLAKE. Well, thank you. 

Thank you all for sharing your time and your experience and 

your expertise. This has been very enlightening to all of us. Appreciate the preparation that went into this. 

The hearing record will remain open through Friday. And so, as 

you receive questions, if you could respond promptly, then your responses will be part of the record. 

So, with the thanks of the committee, this hearing is adjourned. 

[Whereupon, at 11:31 a.m., the hearing was adjourned.] 

Æ 


FOREI-42327 with DISTILLER