Testimony of Ariel Pablos-Méndez, MD, MPH, Assistant Administrator for Global Health, before the House Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations

Thursday, August 7, 2014

Combating the Ebola Threat

Chairman Smith, Ranking Member Bass, and Members of the Subcommittee, thank you for inviting me to testify on the response of the U.S. Agency for International Development (USAID) to the Ebola outbreak in Africa. Thank you also for your support for USAID’s humanitarian and development programs, in particular our global health work.


The ongoing Ebola outbreak in West Africa is the largest and most-protracted ever recorded and it shows no signs of waning as the affected countries have been unable to control the outbreak on their own.  Since December 2013, Guinea, Liberia, Nigeria, and Sierra Leone have reported more than 1,600 confirmed cases.  New cases continue to be recorded indicating that the outbreak – which has an overall fatality rate of 55%– has not been contained. I am truly saddened to see the devastation and loss of life caused by the outbreak, and I would like to express my condolences to those who have been affected or lost loved ones.  This outbreak is severe, but it can be controlled, and the U.S. Government is working to confront this tragedy with a serious response to address the threat and assist affected countries in their response.

The spread of the deadly Ebola virus in Liberia, Guinea and Sierra Leone is also a reminder of the vast development needs that persist in some of the region's poorest countries despite rapid economic growth and investment. As a development agency, USAID is very concerned about the current Ebola outbreak in West Africa – and its potential for expansion – because of the health, economic, and social impacts this disease is having in the affected countries.  We are guided by our Agency’s mission statement - we partner to end extreme poverty and promote resilient democratic societies while advancing our security and prosperity – in our efforts to support countries’ efforts to build their resilience to this threat. Countries that already have limited ability to provide health care for their citizens can ill-afford to lose health care workers to sickness and death, have health facilities close, or have other health and development priorities affected by the outbreak. 

USAID’s targeted response to the current Ebola outbreak in West Africa is appropriately an immediate response to the crisis at-hand.  However, there also needs to be longer-term response that reflects the importance of monitoring and diagnosing viral threats that originate in animals. Such a response is critical to ensure future reoccurrences of the virus are contained prior to transfer to humans, where possible. In addition, it’s critical that we build on ongoing health systems strengthening efforts, which help ensure a viral outbreak is contained at the earliest stages through improved access to care, health workforce training, and enhanced communication once diagnosis is made.

The lack of previous experience with Ebola virus in the affected countries has severely hampered efforts to contain the outbreak. Because Ebola had previously appeared in East and Central Africa, prevention and systems strengthening efforts that might have held the virus at bay and reduced its spread and terrible impact were not in place in West Africa. The initial delayed detection of the virus allowed it to spread and communities and health care workers have not had the information and necessary supplies to reduce their risk of being infected. 

Targeted Response to the Current Ebola Outbreak

The current total USAID funding dedicated to the Ebola response in West Africa is $14.55 million since March 2014 when the outbreak was first reported. In partnership with the World Health Organization and UNICEF, we provided an initial $2.1 million to support the deployment of more than 30 technical experts, provide operational support for response efforts, including 35,000 sets of personal protective equipment and supplies (including hygiene kits, soap, bleach, gloves, and masks), and distribute information on Ebola virus to the general public and health workers.  This equipment provides critical protection for those working on the frontlines of pandemic outbreaks – preventing human exposure to highly pathogenic viruses and other emerging infectious diseases by limiting the risk of animal-to-human and human-to-human infections during outbreak investigations and response, human case detection and treatment, as well as other activities. The funding to the World Health Organization builds on a $1 million annual investment that USAID has made since 2009 to enable responses to priority pandemic prevention and response.

On August 4, the U.S. Ambassador to Liberia declared a disaster due to the effects of the Ebola outbreak.  In response, USAID has activated a Disaster Assistance Response Team (DART).  The DART, comprising team members in Monrovia, Liberia, and Conakry, Guinea, will coordinate planning, operations, logistics, administrative issues, and other critical areas of the interagency response.  The U.S. Centers for Disease Control and Prevention (CDC) will staff public health and medical response positions on the DART.  An initial DART member is already on the ground in Monrovia, and the DART Team Leader arrived in Monrovia on August 6.  Additional DART staff will arrive in-country in coming days.  To further facilitate coordination, USAID and CDC will exchange liaison officers in the Emergency Operations Centers in the United States. 

This week, USAID announced an additional $12.45 million of Global Health and International Disaster Assistance funding to support efforts by CDC, the World Health Organization, and NGOs to ramp up the Ebola response.  Specifically, this funding will go toward the expansion of Ebola outbreak programs in the affected countries.  These programs will provide technical experts to assist in outbreak response, help trace people who may be infected with the disease, as well as provide health clinics and households with hygiene kits, soap, bleach, gloves, masks, and other supplies to help prevent the spread of disease. USAID also has an additional 70,000 sets of personal protective equipment already in central and southern Africa that can be deployed to West Africa for use in the Ebola outbreak. 

USAID is closely coordinating its response to the Ebola outbreak in West Africa with the U.S. Departments of State, Health and Human Services, and Defense along with the World Health Organization and other donors.  Mechanisms have been established for U.S. Government coordination in the field and in Washington. As part of the larger package of support from the U.S. Government, USAID is currently assessing what additional assistance may be needed.

Foundational Investments in Combatting Pandemic and Emerging Threats

In this modern, interconnected world, threats old and new need to be continually monitored because they cannot necessarily be contained in their country of origin. More than a decade ago Severe Acute Respiratory Syndrome (SARS), which began in southern China and lasted about seven months, killed more than 900 people in 29 countries. Some estimates of the cost to the global economy were above $40 billion. Ebola and Marburg viruses in Africa, the H7N9 avian influenza in Asia, and the novel Middle East Respiratory Syndrome (MERS) coronavirus in the Middle East remind us that pathogens of animal origins can and do emerge and can quickly spread across the globe. While they typically recur, they can be controlled if the general public, health workers, veterinarians, and wildlife specialists are appropriately educated on the threat and containment and if health systems are appropriately strengthened.

For decades, USAID has been a leader in the control and prevention of infectious diseases. Today, USAID-funded programs are pivotal in the fight against HIV/AIDS, malaria, tuberculosis, neglected tropical diseases, pandemic influenza and other emerging threats – and the Agency is prepared to work with other partners in the U.S. government and elsewhere to transform the current threat in West Africa into another story of resilience in the face infectious disease, with Congress’ support.

Recognizing that diseases such as Ebola, H5N1 and H7N9 avian influenzas, and MERS and SARS Coronaviruses periodically spill over from animals to cause outbreaks (and sometimes pandemics) in humans, USAID invested a total of $1 billion since 2005, including $72.5 million in FY14, in its Emerging and Pandemic Threats program that is strengthening the capacity of 18 countries in Africa and Asia to more-quickly and effectively detect and respond to viral threats, including Ebola. The program is testing samples from more than 21,000 animals and USAID has identified over 500 new viruses related to ones known to cause disease in animals and people. This program grew out of USAID’s initial response to H5N1 avian influenza in 2005 and is working to identify interventions to reduce the risk of the animal viruses spilling over and spreading in human populations.  The strategy of preventing human infectious with animal viruses by reducing viral spread in animals has been very successful for H5N1 avian influenza.

The Global Health Security agenda is an effort between the U.S. government, other nations, international organizations and public and private stakeholders, to accelerate progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority. As part of this agenda, USAID is focusing on hotspots of previous disease emergence in countries and epidemiological zones where the risks of spillover, amplification and spread are greatest. As a result of USAID’s efforts, capacities of local animal and human health staff and laboratories to detect, prevent and respond to diseases have been strengthened in 18 countries where new pandemic threats are most likely to emerge. We have developed regional networks in Africa and Asia involving more than 65 veterinary, medical, public health, and environment schools to train future practitioners in the fields of public health, medicine, veterinary sciences, and ecology in Africa and Asia to address future threats. The Agency is developing and testing a Public Health Emergency tool with the World Health Organization and CDC  and is actively supporting countries in Africa to develop national preparedness plans to respond to threats such as Ebola. Critically, USAID is also working to address behaviors which contribute to disease threat for specific high-risk populations.

At present the program is focused on East and Central Africa as well as South and Southeast Asia, a strategic decision to invest in a targeted set of the highest risk countries to get maximum impact for our investments. If there are resources, the viral surveillance methodology and the Public Health Emergency tool could be applied to West Africa to expand detection and response capacities. 

Foundational Investments in Health Systems Strengthening

With many villagers across Africa  living great distances from health facilities or lacking transport to reach them, frontline health workers are often the first and only link to providing essential health services. In many cases during this outbreak, health workers were not equipped or trained to manage Ebola in West Africa underscoring the critical need for investment in health workers and health systems.

Guinea, Liberia and Sierra Leone are among 83 countries worldwide that the World Health Organization in 2013 reported to have below the minimum ratio of doctors, nurses and midwives (22.8 per 10,000 population) needed to provide basic health services to a population, and severe inequities in workforce distribution also exist within these countries. The World Health Organization and the Global Health Workforce Alliance estimate at least 7.2 million doctors, nurses and midwives are currently needed globally – a gap that could creep to nearly 13 million by 2035

In addition to the need for an adequate number of health care providers, all health workers need to be well trained in infection control protocols equipped with knowledge about transmission, and then provided with the needed equipment and supplies to fully implement their knowledge and skills. USAID has supported the development of occupational health and safety guidelines in numerous countries, and partners with international health organizations also dedicated to protecting the health of health workers, such as the International Council of Nurses and their Positive Practice Environments Campaign. The state of the health workforce and health systems of the affected countries hampers the ability of these countries to respond to the Ebola outbreak – but these countries are hardly alone in having inadequate training, support and numbers of health workers, especially in the rural areas where this outbreak took hold.

We are beginning to see a greater focus on health workforce and systems from many countries that are critical for both responding to disease epidemics and to providing the essential care that can save millions of lives every year. For example, 55 countries last year made concrete commitments to how they will improve their health workforce, including Guinea and Liberia.

U.S. investments are strengthening the global health workforce, increasing the capacity of African states to prepare, monitor and respond to disease outbreaks, but the Ebola outbreak highlighted serious gaps that remain.


Healthy, productive citizens are essential for global economic growth and regional security. Sound health systems are able to address pandemic threats. Our investments in health systems are made as part of efforts to address health needs in areas as diverse as HIV/AIDS, infectious diseases like malaria, tuberculosis, pandemic influenza and other emerging threats, child and maternal health and nutrition, and family planning and related reproductive health – but they pay dividends across sectors, including with respect to infectious diseases such as Ebola. 

This outbreak in West Africa is a sobering reminder of the lethal consequences of limited infectious disease surveillance and response capacities in any country. The outbreak also reminds us that infectious diseases require prevention efforts and global vigilance, as they know no borders. It is a humanitarian imperative and national security necessity to contain the current Ebola outbreak as quickly as possible.  The best investment the global community can make to prevent or mitigate future outbreaks is to assist developing countries to strengthen their own health systems, including infectious disease detection and response capacities.   This is a core competency of USAID and, in coordination with other U.S. Government partners, we will continue to make this a priority within our Agency’s development efforts.

Thank you very much for giving me the opportunity to testify. I look forward to your questions.

Combating the Ebola Threat
House Committee on Foreign Affairs, Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations