Testimony of Assistant Administrator Nancy Lindborg before the Senate Committee on Homeland Security and Governmental Affairs

Wednesday, November 19, 2014

“Preparedness and Response to Public Health Threats: How Ready Are We?”

Thank you, Chairman Carper, Ranking Member Coburn, and Members of the Committee for the opportunity to discuss the U.S. response to the ongoing Ebola epidemic in West Africa and other emerging health security threats.

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. Previously Ebola has been contained in small, rural outbreaks, but today's epidemic is a sobering reminder of what happens when the disease encounters weak health, economic, and governance systems, as evidenced by its rapid spread in Liberia, Sierra Leone and Guinea —fragile, conflict affected states.

We have also seen isolated cases in Nigeria, Senegal, Spain and the United States, and a new outbreak now in Mali, reminding us that we live in an increasingly interconnected world. This underscores why we must stop Ebola at its source in West Africa, and build resilient health security systems so that we can prevent, detect, and rapidly respond to future outbreaks before they become epidemics. These efforts are a national security priority for the United States and many other nations in the world.

Before the Ebola outbreak, USAID had implemented programs monitoring, detecting, and controlling animal-borne diseases like Ebola that can spill over into humans. USAID efforts have helped decrease the number of countries affected by outbreaks of H5N1 Avian Influenza from 53 to 10 between 2006 and 2014. Just this year, we helped the Democratic Republic of Congo and Uganda identify and contain outbreaks of Ebola and Marburg hemorrhagic fever. We have seen the importance of investing in preparedness in the front lines of these diseases, yet nations around the world still lack basic capacity to address outbreaks before they become international security threats. This is why the Obama administration launched the Global Health Security Agenda (GHSA) this year.

If we are to beat the diseases of tomorrow, we must double-down on our commitment to tackle Ebola today, learn the lessons of our response, and help the most vulnerable nations on Earth prepare for Ebola and the next threat they will face. Thanks to leadership from President Obama and the United States Congress, the U.S. is leading the international coalition to tackle Ebola.

President Obama has requested $6.18 billion in emergency funding urgently needed to address this crisis and meet longer-term recovery and prevention needs. 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 capacity to address threats immediately, in support of the Global Health Security Agenda.

This unprecedented epidemic requires an extraordinary global effort, and we have seen the importance of U.S. leadership to galvanize a worldwide response. Sustained support to all three countries, the broader region, and other vulnerable nations is essential to lock in our momentum, defeat this epidemic, and guard against future outbreaks that threaten human life, our national security, and the global economy.


When Ebola began jumping borders and migrating to urban centers, the U.S. mounted an aggressive whole-of-government 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 the global health security infrastructure.

This is the largest U.S. response to a global health crisis in history. On August 6th, USAID deployed a Disaster Assistance Response Team—or DART—to the region to coordinate the U.S. response. The DART is working with departments and agencies across the U.S. government, including the Department of State, the Centers for Disease Control and Prevention (CDC) and other staff of the Department of Health and Human Services, the U.S. Forest Service, and the Department of Defense. There are currently more than 2,100 U.S. Government and military personnel on the ground in West Africa.

As I witnessed firsthand during my recent trip to Liberia, in a country with few roads and a crippling rainy season, the flow of people, supplies and sanitation is complicated yet crucial for an effective response. The DART, which President Obama aptly described as the “strategic and operational backbone of America's response,” is coordinating this complex pipeline of resources. USAID is also collaborating closely with partner governments, international organizations, including the UN Mission for Ebola Emergency Response (UNMEER), the World Health Organization (WHO), the World Food Program, and UNICEF, and NGOs, such as International Medical Corps and Global Communities.

Our current efforts are intensely focused on controlling the spread of the disease, and we are making progress, but quite frankly we need resources to get this to the finish line. The President’s request includes $1.3 billion for this pillar, which has five key components: 1) effective isolation of cases in Ebola treatment units (ETUs) and through community care; 2) burial teams to remove dead bodies safely and quickly to prevent further viral transmission; 3) awareness and behavior change at the individual and community level; 4) improved infection control at general health clinics; and 5) an effective command and control system in each country.

The U.S. government has taken the lead in Liberia, where we are now seeing encouraging progress in highly affected areas. U.S. support in Liberia allowed 8 ETUs to open and more than 65 burial teams to be scaled up across the country. More than 200 tons of personal protective equipment, infrared thermometers, chlorine, and plastic sheeting have been airlifted for the response in Liberia and the region.

Overall, the average reported cases per week in Liberia have decreased by more than a third in the past month. We believe that the rapid scale-up of burial teams, combined with intensive community outreach across the country, has contributed to this reduction in transmission. However, we are also seeing new cases emerge in rural and harder-to-reach areas, so we are adapting our strategy to be highly mobile and scalable to track the evolution of the virus.

In Sierra Leone, the United Kingdom has surged their response in recent weeks by building on the U.S. model and the lessons learned in Liberia, including focusing on early gains through burial teams and social mobilizations.

In Guinea, which has roughly three times the population of Liberia, we have expanded our Disaster Assistance Response Team to meet increasing needs, especially in Guinea's Forest Region, the epicenter of the outbreak. We are scaling up efforts where we have seen the most returns, including contact tracing, community mobilization, and support for ETUs. These efforts will make a difference in Guinea, as we have seen demonstrated in Liberia.

The President’s request is essential to accelerate and expand our efforts as this dynamic crisis continues. The base request for USAID and the Department of State totals $2.1 billion and includes: $1.8 billion to control the outbreak, address food insecurity and other secondary impacts, and to support coherent leadership and operations. It also includes $278 million to provide urgent capacity needed to advance the Global Health Security Agenda, which will help prevent Ebola from spreading and stop emerging threats before they become epidemics that threaten Americans.


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 frontline. In addition to the 5,000 local healthcare workers needed once the regional response is operating at scale in January, we estimate that at least 1,000 international health care workers will be needed each month in West Africa. Recruiting these humanitarian heroes—and removing disincentives for them to volunteer—is critical to winning the battle against Ebola.

In partnership with WHO, Médecins Sans Frontières (MSF), and the Department of Defense, we have established a training site in Liberia, at which DOD is training up to 500 healthcare providers per week, enabling the healthcare workers to provide safe and direct supportive medical care to Ebola patients. This cadre of trained health workers will have the skills and knowledge of infection control standards to contain Ebola today, and ensure preparedness for future outbreaks.

Earlier this month, a 25-bed critical care hospital, constructed by the U.S. military and staffed by a 69-person team from the U.S. Public Health Service Commissioned Corps, opened outside of Monrovia. The facility is providing high level of care to health care workers—both local and international—who contract the virus while treating Ebola patients.


Advancements in innovation will make us more responsive to today’s battle against Ebola and tomorrow’s future challenges. 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, improved designs for personal protective equipment (PPE), and real-time data to better predict spikes and valleys in active cases. The Grand Challenge has already received over 1,250 submissions, over a third of which are focused on improving PPE.


Beyond its devastating human toll, Ebola has shut down health systems, threatened livelihoods, and rolled back development gains that took years to achieve. Since the outbreak began, the number of births in Liberia attended by a medical professional has fallen by 30%, and maternal mortality is rising fast. The World Bank reports that the losses to Guinea, Liberia, and Sierra Leone could reach $359 million by the end of this year. To contain Ebola and other public health threats over the long-term, we must invest in resilient health and agricultural systems in West Africa.

USAID is actively working on mitigating the longer-term impact of the crisis. The President’s request to Congress includes $190 million to address urgent food insecurity and avoid the destructive consequences of the epidemic for regional prosperity and stability, which ultimately affects our own national security.

To counter food insecurity, USAID is providing food aid to households and communities cut off from markets, and supporting food assistance for ETUs, community care centers and orphanages. To support health systems in Liberia, USAID is scaling up infection control support to non-Ebola specific health facilities country-wide. We will train health care workers on infection control protocols, and provide supplies, such as PPE, to non-Ebola health facilities in Liberia.

We will also work with countries to restart routine services. 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 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.

The efforts we are scaling up today—from improved hygiene behavior to stronger health care systems—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.


The Ebola epidemic brings into stark relief the importance of investing in stronger global health and preparedness systems to prevent, detect, and rapidly respond to emerging health threats. Over the past decade, infectious disease outbreaks have sown fear, cost lives, and been a drain on the global economy. To contain threats like Ebola before they threaten global security, we must invest in shoring up capacity in states with weak health and preparedness systems. USAID is helping to prepare unaffected countries to rapidly detect and control any introduction of Ebola both during and after this epidemic. Using a combination of regional planning meetings and direct country level technical assistance, USAID is partnering with the CDC to help 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 Centers for Disease Control and Prevention and the Department of Defense’s Cooperative Biological Engagement Program. We will support rapid assessments in collaboration with other donors, and we will review lessons and also leverage previous capacity provided by the U.S. and other donors before the Ebola epidemic. 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 Public Health Emergency Framework developed by USAID, in cooperation with WHO and CDC, will also continue to assist countries in Africa to more rapidly identify the cause of public health events so that an effective response could be triggered, and to conduct after-action reviews to identify areas for improvement. Piloted in the Democratic Republic of Congo and Uganda where we were able to quickly identify and contain outbreaks of Ebola and Marburg this year, this Framework will be expanded to other countries between 2015 and 2019.


Investing in urgent needs now – before they become global epidemics that threaten Americans – is an emergency. Ebola has shown us that. The Global Health Security Agenda (GHSA), launched by the United States with international partners in February 2014, seeks to advance a world safe and secure from infectious disease threats like Ebola and to bring together nations from all over the world to prevent, detect and rapidly respond to outbreaks before they become epidemics that threaten Americans. The funding we are requesting is urgently needed, and includes activities that are necessary to stop the spread of Ebola to travel hubs in priority countries and also to reduce the potential for future outbreaks of infectious diseases that could follow a similarly devastating, costly, and destabilizing trajectory.

USAID is uniquely positioned to establish elements of needed capacity, in coordination with the CDC. This includes a focus on strategies that unite animal health specialists, medical professionals, and environmentalists to effectively monitor and rapidly respond to emerging infectious diseases, especially animal viruses that spill over into human populations, including Ebola, Avian influenza, and the Middle East Respiratory Syndrome (MERS) Coronavirus.

Since 2005, USAID has monitored these viruses in animals, and supported their rapid detection and control. USAID’s Pandemic Threats program has identified 900 viruses and helped mitigate risks where these diseases are most likely to spread to humans, such as live animal markets and places where bush meat is hunted and sold. Moreover, surveillance and lab capacity was strengthened in countries around the world where new public health threats are likely to emerge, and USAID responded to more than 20 infectious disease outbreaks in animals and humans.

We have proven that we can do this before and we can do it again with Ebola and other disease threats. A primary focus to date of USAID’s pandemic prevention efforts has been the threat posed by H5N1 Avian Influenza. With USAID support, efforts to enhance viral monitoring and contain outbreaks in poultry have resulted in a decrease in the number of countries affected by H5N1 from 53 in 2006 to 10 in 2014. These efforts have proven results, underscoring the need to build upon successful models and expand their application to Ebola and other viruses in West Africa and elsewhere.

Now that Ebola has emerged in West Africa, it is likely to reoccur periodically as the virus is now endemic in certain wild life animals in the region. This is why now, more than ever, we must do more to expand our ability to monitor infectious disease threats like Ebola and build up the ability of vulnerable countries to detect, trace, and control outbreaks before they reach epidemic proportions. Over a decade ago, the Severe Acute Respiratory Syndrome (SARS) cost the global economy an estimated $40 billion. Some have estimated that SARS cost the U.S. alone approximately $7 billion. This is in addition to the devastation in lives lost and global economic costs from the anthrax attacks, H1N1, and other disease threats that we are fighting every day on the ground – like MERS – even while we work to stamp out Ebola in West Africa.

The President’s request would allow us to expand the Emerging Pandemic Threats program to get ahead of these threats. With this funding, we will urgently enhance viral monitoring, strengthen laboratory capacity; and link human and animal disease reporting systems so that cases can be reported in real-time. This program, which has proven effective in reducing emerging health threats such as H5N1 Avian Influenza, has until now targeted a limited number of hot spots. The President’s base request of $278 million for Global Health Security will expand these efforts into hot spots in Africa and Asia where the risk of a virus emerging is significant and there is a history of emerging threats such as MERS. These efforts will allow us to detect Ebola and other emerging threats in wild life reservoirs before it reaches human populations. We will track the movement of the virus within its wildlife hosts, increase lab capacity to process samples quickly, and monitor human behaviors that increase opportunities for Ebola spillover to mitigate the risks of outbreak.

These efforts will build the capacity of CDC and USAID to prevent, detect and rapidly respond to outbreaks before they become epidemics that threaten the United States. We will prioritize urgently needed investments in vulnerable nations, transport hubs, and states without the capacity to prevent global spread of Ebola or stem the tide of future threats. It is important to maintain the flexibility to make adjustments given the dynamic national and global health security environment.


This unprecedented crisis underscores the importance of tackling fragility and extreme poverty. Ebola preys on weak systems, wreaking havoc in communities least prepared to fend off the disease. That is why we must work not only to control the epidemic at its source in West Africa, but to bolster our global health systems. These investments are critical if we are to avoid having future outbreaks that follow a similarly devastating and costly path. This effort is core to USAID’s mission to both end extreme poverty and promote resilient, democratic societies that advance our global security and prosperity.

This is a fight we cannot afford to lose, and we must keep our momentum. To beat Ebola and prepare for the future, we must double down our efforts in concert with our global partners. We can beat this disease, but we will need all-in ideas and a commitment to see it through to prevent lives lost and future threats to our national security and the global economy.

Most importantly, we must commend and honor the health care, military, and humanitarian workers who are helping to turn the tide in West Africa. Their sacrifice and commitment to fight against Ebola is helping to save lives in West Africa and keep us safe and healthy at home.

Thank you for your time today and for the vital Congressional support that makes these efforts possible.

Preparedness and Response to Public Health Threats: How Ready Are We?
Committee on Homeland Security and Governmental Affairs