Testimony of Dr. Rajiv Shah, USAID Administrator, before the House Committee on Foreign Affairs

Thursday, November 13, 2014

Combating Ebola in West Africa: The International Response

Thank you, Chairman Royce, Ranking Member Engel, and members of the Committee for the opportunity to discuss the U.S. and international response to the ongoing Ebola epidemic in West Africa.

Today, as you know, the world faces the largest and most-protracted Ebola epidemic in history. This devastating virus has infected more than 14,000 people and killed more than 5,000 people across West Africa. The epidemic has spread through Guinea, Liberia, and Sierra Leone—countries with fragile health and economic systems and recent histories of civil war or political instability. In addition, the Ebola virus has spilled over into three neighboring countries where the response has been swift.

Most of the families that have been affected already live in desperate circumstances, where securing clean water and food is a daily struggle. In Liberia alone, 58 percent of the population lives in extreme poverty with very few assets to help them cope. It is within this context that Ebola has emerged—threatening our global security and economy. It represents a national security priority for the United States and every other nation in the world.

Thanks to leadership from President Obama and the United States Congress, the U.S. is helping lead an international coalition to tackle this crisis with an evidence-based strategy. I recently traveled to the region to assess the response and met the heroes serving on the frontlines, including health care workers, humanitarians, and local community leaders, who are saving lives and making a difference every day.

We are starting to see early signs of progress as a result of a strategic and flexible approach, but there is no doubt that we must continue to expand the pace, ingenuity, and scale of our response. That is why President Obama has requested $6.18 billion in emergency funding to enhance our efforts to urgently address this crisis and meet longer-term recovery and prevention needs. This response is designed to fortify domestic public health systems, contain the epidemic at its source in West Africa, speed the development of vaccines and therapeutics, and strengthen global health security. It includes $1.98 billion in urgently needed resources for USAID—out of the $2.1 billion joint USAID and State request—to rapidly scale up activities to control the outbreak, support recovery in West Africa, and strengthen global health security.

This unprecedented epidemic requires an extraordinary international relief effort. We are developing an increasing number of public-private partnerships, including with Johns Hopkins and the Paul G. Allen Family Foundation. Many countries are contributing to the effort through both financial and in-kind donations, including a total of nearly $800 million in commitments from other governments. But far more is needed. As President Obama has stressed, governments, international organizations, and the private sector must step up far more aggressively. Sustained support to all three countries and the broader region is essential to lock in our momentum and ultimately defeat this epidemic.


The United States has mounted an aggressive effort governed by four key pillars to stop this crisis: control the epidemic; mitigate second-order impacts, including blunting the economic, social, and political tolls; coordinate the U.S. and broader global response; and fortify global health security infrastructure.

Construction crews work quickly to build a new Ebola Treatment Unit for a growing number of patients
Construction crews work quickly to build a new Ebola Treatment Unit for a growing number of patients
Morgana Wingard for USAID

Across our response, we are working with agility, speed, and responsiveness in a very dynamic environment. During my visit to the region, I saw this focus and flexibility in my meetings with private sector leaders, non-governmental organizations (NGOs), and the donor community. In my conversations with the Presidents of Liberia, Guinea, and Sierra Leone, we discussed the need for robust engagement and coordination as this crisis evolves. We are learning and adapting our strategy to be highly mobile and scalable to quickly respond to flare-ups in rural and hard-to-reach areas.

This is the largest U.S. response to a global health crisis in history. There are currently more than 2,100 U.S. Government personnel on the ground, including the USAID Disaster Assistance Response Team that President Obama has called the “strategic and operational backbone of America’s response.” The response brings together the expertise and resources of the whole of the U.S. Government, including USAID, the Department of State, the Department of Health and Human Services, the Centers for Disease Control and Prevention, the U.S. Forest Service, and the Department of Defense. We are also collaborating closely with partner governments, international organizations, including the World Health Organization, the World Food Program, and UNICEF, and NGOs, such as International Medical Corps and Global Communities. Ultimately, the ramp up of civilian, NGO, host country, and international partner capacity will enable our military to transition home.

Our current efforts are intensely focused on controlling the spread of the disease. The President’s request includes $1.3 billion to contribute to this pillar of our response. Our rapid-response strategy to break transmission of the virus emphasizes five components: effective isolation of cases in Ebola treatment units and Community Care Centers; burial teams to quickly remove dead bodies to prevent further viral transmission; awareness and behavior change at the individual and community level; improved infection control at general health clinics; and an effective command and control system in each country.

In Liberia, we are seeing encouraging progress in highly affected areas, while new cases are emerging in harder-to-reach areas. Overall, the average reported cases per week have decreased by more than a third in the past month. We believe that the rapid scale-up of burial teams across the country—combined with a significant investment in risk-reduction strategies, including changes in traditional burial practices—has contributed to this reduction in transmission.

We continue to adapt our strategy in Liberia to rapidly address these hard-to-reach cases and remain highly vigilant to further outbreaks. We are advancing the Government of Liberia’s fight against Ebola by supporting the medical and non-medical management of Ebola Treatment Units; constructing Community Care Centers; supporting logistics and supply for the international response effort; ensuring nationwide access to safe burials; expanding the mobilization and provisioning of health care workers and supporting widespread community mobilization and information campaigns.

This week, a 25-bed critical care hospital, constructed by the American military and staffed by a 69-person team from the U.S. Public Health Service Commissioned Corps, opened outside of Monrovia. The facility will provide a high level of care to health care workers—both local and international—who contract the virus while treating Ebola patients. Already in Liberia, U.S. support has allowed 8 Ebola Treatment Units to open. In the days and weeks ahead, additional U.S.-built or funded treatment facilities will come on line.

In Sierra Leone, the United Kingdom has surged their response in recent weeks by building on the U.S. model and the lessons we learned in Liberia, including focusing on early gains through burial teams and social mobilizations. With robust engagement from the U.S., the United Kingdom leads international efforts to implement the government’s national strategy to construct Ebola Treatment Units, build Community Care Centers, and scale up burial teams. Through our partners, we are helping strengthen the early identification of suspected cases and contacts to break the chain of viral transmission.

In Guinea, which is roughly three times the population and economic size of Liberia, we have expanded our Disaster Assistance Response Team to meet increasing needs and ensure the effective coordination of aid. Guinea's Forest Region remains the epicenter of the outbreak in that country and continues to pose risks of spread to other parts of Guinea and to neighboring countries. We are supporting the scale-up of critical interventions, including contact tracing, community mobilization, and support for Ebola Treatment Units. This package of interventions will make a substantial difference in Guinea, as we have seen demonstrated in Liberia.

Months into this unprecedented response, critical gaps in resources remain, especially in Sierra Leone and Guinea. We continue to remain focused on addressing key challenges, including supporting health care workers on the frontlines and improving data quality and timeliness. The President’s request in emergency funding is essential to accelerate and expand our efforts as this dynamic crisis continues.


The capacity to respond to a crisis of this scale simply would not exist without the heroic work of health care workers who serve on the frontlines. As President Obama has said, “The medical professionals and public health workers serving in Africa are a shining example of what America means to the world… They make huge sacrifices to protect this country that we love. And when they come home, they deserve to be treated properly.”

At a training session in Sierra Leone, I met the heroes of the response, especially local health workers who have stepped forward to fight Ebola, when so many others have fled. I also met a young doctor from Germany who gave up her holiday to put on a personal protective suit in the stifling heat and train others to work in the hot zone. We need hundreds more just like them. We estimate that at least 1,000 international health care workers will be needed each month in West Africa.

We have taken strong steps to facilitate and enable health care workers. As the response continues to scale up, NGOs are more clearly identifying staffing needs and requirements, enabling them to actively recruit necessary staff. We must ensure that when these brave individuals do volunteer to serve, we do not prevent or unduly discourage them from undertaking this indispensable and selfless work.


Time and again, we have seen the value of innovation in crisis response—from satellite predictive modeling to electronic food vouchers. Through the establishment of USAID’s U.S. Global Development Lab, we are sparking similarly creative and bold thinking today. Thanks to champions like Chairman Michael McCaul and Congressman Joaquín Castro, the Lab is uniting a diverse community of partners—from companies to students—in the quest for ingenious ideas in this effort. That is why President Obama announced Fighting Ebola: A Grand Challenge for Development, a grant competition designed to produce better tools to tackle this disease in a matter of weeks, not years. We are exploring advances in diagnostics that reduce the difficulty of rapidly transporting blood samples over terrible roads; new medical options, such as vaccines and therapeutics; improved designs for personal protective equipment (PPE); and real-time data to better predict spikes and valleys in active cases.

This Grand Challenge has already received over 1,250 submissions, over a third of which are focused on improving PPE. The best ideas will be evaluated tomorrow in a “pitch day” before a committee of experts and may be in the field within months. We are also working with the scientific and research communities to encourage innovative diagnostics that will rapidly identify those who are infected at the point of care. We have also formed a Real-Time Data Team that is working with the UN, private sector, and affected governments to improve the data collection and harmonization critical for accurately informing tactics.

APPROACH TO SECONDARY IMPACTS OF THE CRISIS The consequences of this crisis will persist long after the epidemic is stopped. Trade has slowed, agriculture has been disrupted, and economic systems have been shaken. In a matter of months, Ebola has placed at risk development gains that took years to achieve. Containing Ebola over the long-term and protecting our own national security fundamentally requires us to invest in resilient health and agricultural systems in West Africa.

As a component of our response, we are heavily focused on mitigating the secondary and longer-term impact of the crisis. The President’s request includes $388 million to address urgent food insecurity and help avoid the destructive consequences of the epidemic for regional prosperity and stability, which ultimately affects our own national security.

The interventions we are scaling today—from improved hygiene behavior to health infrastructure—have the potential to significantly improve child and maternal survival throughout the region. They will also strengthen the ability of local health systems to report threats in real-time and stop health emergencies before they become epidemics.

We will work with countries to restart services in parallel with containment of Ebola. With the countries’ health systems paralyzed by the sheer volume of Ebola cases, communities face many other health threats. Many die from lack of access to safe delivery, treatment of childhood infections, and other diseases. Our assistance during this restarting phase includes giving families access to health information and essential health commodities. To the extent available, we will help develop innovative approaches to providing life-saving services that do not detract from Ebola containment.

Food Security: To help support families affected by Ebola, USAID is providing targeted in-kind food rations to affected households and communities cut off from markets, as well as specialized food commodities to meet the acute need for supplementary and institutional feeding necessary for Ebola treatment units, community care centers, orphanages, and other specialized feeding programs. If the number of people infected continues to rise, so will the acute food assistance needs. Interruptions in the harvest, restrictions on movement, and a slowdown in trade could severely disrupt markets, reduce household incomes, and lead to food shortages.

The Famine Early Warning Systems Network, a USAID-funded predictive system, has issued an alert that a major food crisis may occur early next year—depending on how the epidemic evolves. To prevent this crisis from happening and accelerate economic recovery, USAID is structuring its emergency food assistance to address immediate food needs while also supporting local markets and food production. These emergency activities will complement the longer-term efforts of Feed the Future to accelerate the recovery of health and agricultural systems in the Ebola affected countries. Through a new regional Feed the Future effort, we will help build the medium and long-term agricultural resilience of farmers to future shocks. In recent years, we have had new flexibilities that allow us to use the right tool to provide food assistance in different contexts. In West Africa, the World Food Program plans to purchase 3,600 metric tons of rice on local markets in Liberia to sustain market functionality in the region. This purchase will include approximately 600 metric tons of rice from farmers supported by Feed the Future in Liberia.

Global Health Security: Our investments in global health security focus on two high-priority objectives: preparing unaffected countries to rapidly detect and control any introduction of Ebola during the current epidemic; and preventing and reducing the threat of future outbreaks. Using a combination of regional planning meetings and direct country level technical assistance, we are helping countries develop and test national Ebola Preparedness and Response Plans. By mid-2015, all 14 neighboring West African countries will have detailed Ebola preparedness plans, at least one laboratory capable of detecting the Ebola virus, and trained personnel at border sites to identify and manage suspect cases. This approach can also be used to prepare countries for other public health threats. Nigeria’s successful effort to contain the Ebola outbreak demonstrates the effectiveness of a highly engaged government and a rapid and coordinated local response.

Efforts are already underway to plan for rebuilding these health systems in coordination with the Department of Defense’s Cooperative Biological Engagement Program. We will support rapid assessments in collaboration with other donors, and we will review lessons from the past decade of health system rebuilding before the outbreak. With country officials and other donors, we will help plan for building back resilient systems that can withstand unexpected disease outbreaks and serve the health needs of the countries’ populations.

The President’s emergency request will further this effort and build resilience to dangerous pathogens that can “spill over” into humans. Since 2005, USAID has supported the routine monitoring of dangerous new animal pathogens and put in place capacities for their rapid detection and control. This work, which has proven highly effective in reducing threats, has been targeted in a limited numbers of geographic hot spots. This request will be used to build on this success and expand into other hot spots to protect against future spillover events and reducing infectious disease threats.


It is not a coincidence that Ebola has taken hold in nations only recently emerging from decades of conflict and poverty. Again and again, we have seen the intersection of extreme poverty and vulnerability push communities to the edge of survival and challenge our own sense of security and prosperity. This crisis only underscores the vital importance of our Agency’s mission: to end extreme poverty and promote resilient, democratic societies while advancing our security and prosperity.

Even as we see positive signs in the response, we know that more must be done to keep up our momentum. Every Ebola outbreak in history has been stopped, and the current epidemic will be too. But it will continue to require great speed, cooperation, creativity, country leadership, and—most importantly—courageous men and women serving on the frontlines.

Thank you.

Combating Ebola in West Africa: The International Response
Foreign Affairs