tv Key Capitol Hill Hearings CSPAN November 14, 2014 7:00am-9:01am EST
[ gavel bangs ] >> good afternoon, everybody. the full committee of the appropriations committee will come to order. the purpose of today's hearing is on the united states' government response to fighting ebola and protecting the united states of america. today, we will hear what we are doing and we will hear what resources are needed to do that fight. first of all, the -- congratulations are in order to some of our checks who have won
we want to acknowledge senator reid and senator con's victory and on this side, we want to acknowledge the victory of senator cochran and senator collins and we want to congratulate them and note the -- note their victory. today is a day where we really have to pay attention to an international and national challenge that we are examining. a look at an infectious horrific disease that is wasting a key continent in west africa and also threatening the united states of america. but for me, this will be the last full committee hearing that i will chair. before we go into the substance and i make my statement, i want to thank senator shelby and his
staff for the wonderful way that we have been able to work together and though we will exchange gavels, we will also continue to exchange the views in the way we have. i have found in senator shelby and on the other side of the aisle, always a tone of civility and candor and an ability to, in this committee, to try to try to work together and find common ground to deal with america's problems in a way that achieves sound results and to do it in a way that's affordable. i think that's characteristic of our committee and i hope that as we move ahead, that we will continue to do so. i would also particularly note senator cochran, who chaired this committee before and who also, during the time of senator inouye's passing, was a very important bridge to help me as
senator shelby and i both moved into new rules and senator, i'm going to acknowledge your graciousness and wisdom. so, we are about to, on january 3rd, change who controls the united states senate. but until now, this committee's chaired my me and i look forward to working with my colleagues to deal with really moving what i hope will be an omnibus and that we, on december 11th, will not be voting on a cr, but be voting on an omnibus that meets our fiscal 2015 responsibilities and also deals with the urgent need that we are going to hear today. i'm deeply concerned about ebola and, of course, so is all of america, both at home and abroad. i think there's a national consensus that agrees that we need to contain the disease and we need to eradicate it. and also, face very clearly the fear that it generates.
now, the epidemiology tells us that there have been 13,500 cases of ebola in west africa. here in the united states of america, there are currently no cases of ebola and we look forward for that to be ratified or correct by our esteemed panelists. however, the united states of america has treated nine, n-i-n-e patients with ebola, two have contracted it in texas, the west africa. eight have recovered, one, regrettably, has passed away. so, there have been nine in america, 13,500 in west africa. the situation is serious. and it means that all of government has to respond in a way to do so. my strong suggestive principles
are this, first, we must fight the disease at its epicenter in west africa, in liberia, guinea and sierra leone. we also want to look at the countries contiguous to these three areas that has not spread beyond these three countries. we want to use the expertise of the department of state, usaid, cdc, dod, nih, fda, any government agency that can play a role in making the world, west africa safe and us safe is where -- what we want to do. the second principle is we must protect america and we must do it at your points of entry. and finally, in looking at our country, we need to utilize the best science and employ our public health and public health safety agencies in a way that's effective that's the center for disease control, state and local health departments and scientists developing vaccines and treatments at nih and
approving their safety and efficacy at fda. as we look at what government's going to do, i want to thank the people, both in our own country and all over the world, that have really been working on this. doctors and nurses, lab technicians, disease detectives, aid workers, soldiers from our own defense department, working shoulder to shoulder in africa and also working at our border, and our ports of entry here and in our own country. in these important agencies, usaid, state, cdc, hih, fda, ever and of course, our ever had-ready military. there have also been very wonderful volunteers that were willing to go to the danger zone and we want to thank them for their role that they played in west africa. we also want to thank those in
our own country who though not called upon places like university of maryland and johns hopkins in my own community were ready to be able to deal with this. i'm glad today to have witnesses from our major government agencies to present testimony. ordinarily, protocol calls for the most senior cabinet member to testify first. in my usual kind of out-of-the-box way of thinking, i'm going to deal with the problem rather than focus on protocol. you know, sometime in the senate, there's a lot of pomp and circumstance. i'm gonna dispel with the pomp and get to the right circumstances. so the way we have organized the testimony is to really start internationally to hear from the department of state and then mr. lumpkin from the department of defense, then going to our ports of entry, then with silvia burrell, who will be here to talk about hhs. we will hear from deputy secretary of state heather
higgin bottom, accompanied by nancy anymore berg of usid who will tell us how are we going to do this in west of a nick ka and how are we going to do it not only in those three countries but in the contiguous countries. we are then going to turn to assistant secretary of defense, mr. michael lump kin. we know that's the official ebola coordinator designated by secretary hagel and he's accompanied by major james laravair. then we will hear from secretary jeh johnson to discuss america's ports of entry. then from secretary health and human services, silvia burrell, accompanied by dr. freiden of cdc and dr. anthony fauci of nih. and then we say to drs. fauci and friedman, mr. lindberg, vet good general who's here, we will ask you to join us after they testify to be able to answer questions from really this
robust participation that we have. opening statements will be from the four witnesses. now, we have before us an administration request to contain and fight ebola. an emergency spending request of $6.2 billion. because the ebola, in my mind, meets the criteria for emergency spending. it's sudden, unanticipated, unforeseen, urgent and temporary. the request includes funds from the state department and u.s. id for $2.9 billion. the department of defense to develop technologies to fight ebola and shorten vaccine development, $112 million. the department of health and human services to contain ebola, both with cdc in west africa and remember, cdc is both here in our country and also in west africa. to also fortify, strengthen domestic capacity to treat ebola
with treatment centers available in every state and the appropriate personal protective equipment for caregivers, like our very valued and treasured nurses. we also have money in here to develop new tests for treatment and vaccines, which would be a total of 3.12 billion for hhs. so, state is talking about 2.9 billion. hhs 3.12 billion. 112 for department of defense and right now, homeland security says it's okay but it needs a lot of flexibility. now the reason i talk about my colleagues to focus on not only the money, but on funding in an emergency, i say to my colleagues, we face infectious disease emergencies before. one under president bush in 2006 and the other in 2009 under president obama. we worked on a bipartisan basis to do this.
in 2009, we were faced with the h 191 -- h1n1 flu epidemic. we provided 6.4 billion and designated that as emergency spending. the bipartisan emergency response in 2009 mired what he we did to help president bush, again, bipartisan basis, when we faced avian flu when at that time, congress responded with 6.1 billion in emergency funding. so, we have done this before when we have been faced with an emergency related to infectious disease. i would hope that we would follow the models that we have used in the past. today, we live in a world that's free from smallpox, that cut polio cases by 99%. now we have to tackle the new
diseases and we have to have a strong worldwide public health effort, vaccines to prevent diseases, therapeutics to treat diseases, the people and the infrastructure to do that. we have also invited, in addition to government, we have asked for the american hospital association, crucial ntos, and also schools of public health, like the bloomberg school and may own state of johns hopkins to submit testimony. i want to acknowledge that we have got 56 submissions already and we will definitely pay attention to them. the common themes are sustained investment is needed in public health, both at home and abroad and emergency money is needed in the short term. so, that kind of lays out the framework for the hearing. i look forward to the testimony and now i turn to my colleague, senator shelby. >> thank you -- thank you, madam
chair. today as the chairperson has laid out, we will discuss the administration's $6 billion request to address the ebola outbreak, both domestically and in west africa. given the size of the request, the slow progress in detaining plans for how the money will be spent and some of the missteps made so far, careful oversight and scrutiny. as we have seen in recent week, the vast majority of american health care professionals have little to no experience with this virus. the appearance of the disease on our shores can have devastating consequences for our health care system and our society at large. consequently, it is the fundamental responsibility, i believe, of the federal government, to respond effectively to this crisis. every prudent step must be taken to protect the american people. instead of an effective response, what we have
witnessed, i believe these past few months from various agency has been confusing and at times contradictory plans. for example, the cdc's guidance to hospitals has been a moving target. this uncertainty may have exposed health care professionals to unnecessary risks. the administration also has sent mixed messages on the issue of quarantine. while the president has discouraged straight quarantine rules, defense secretary hagel has prudently put in place a 21-day mandatory quarantine for troops returning from west africa. in addition, the administration did not call for enhanced airport screenings for travelers entering the u.s. from west africa until months after the epidemic became severe. it still remains to be seen whether these cursory screenings will be effective. not surprisingly, americans have been frustrated by the lack of
clarity and coordination within their government. even though the president has named a so-called ebola czar to coordinate a response, all reports indicate that he has no actual authority to direct government agencies here. from the beginning of this outbreak, the administration has appeared to be preparing for only the best case scenario. competent crisis planning must include contingencies for the worst case scenario as well. therefore, i think we should not rule out any reasonable options to prevent the reintroduction of ebola in the u.s., including travel and visa restrictions. if the history of disease outbreaks has taught us anything, it is that things can change quickly and without warning. therefore, federal agencies must be ready to aggressively implement a clear and organized strategy. it is my hope that today's witnesses can assure this
committee and the american people that the president has a plan, that the funds he has requested are necessary to execute it, but we will wait our testimony. thank you, madam chair. >> mr. shelby, thank you. ms. higgin bottom, i'm going to ask you to start and then we will go down the line. >> chairwoman mikulski, ranking member shelby and distinguished members of the senate appropriations committee, thank you for the opportunity to testify today on the u.s. department of state and u.s. aid emergency request for assistance to combat the ongoing ebola epidemic. i'm pleased to be accompanied by nancy limb bourg, usaid assistant administrator for the bureau of democrat circumstance conflict and humanitarian assistance who is helping to lead usaid a response on the ground. madam chairwoman, i have submitted to the committee a detailed statement for the record and in the interest of time, i will briefly summarize
my statement here. the ebola epidemic in west africa has already resulted in over 14,000 ebola infected persons and over 5,000 deaths. while liberia, sierra leone and guinea have borne the brunt of the epidemic, we have also seen cases in mali, nigeria, senegal and spain. and of course, isolated cases in the united states highlight the u.s. national security implications of this national epidemic. the department of state and usaid are working in concert with agencies represented at this hearing today and alongside our global partners to stop the spread of the ebola virus at its source. the state and u.s. aid strategy to eradicate ebola in west africa rests upon four pillars, controlling the epidemic, managing the secondary consequences of the outbreak, building coherent leadership in operations and ensuring global health security. state and u.s. aid have taken
immediate action within existing resources to begin implementing this strategy. u.s. aid deployed a disaster assistance response team or a darth team to lead the u.s. response on the ground in all three affected countries. secretary kerry create and ebola coordination unit to drive our diplomatic efforts to raise international contributions. over $1 billion in bilateral commitments and near lids 800 million commitments to the u.n. have already been made as a result of these efforts, alongside our colleagues across those of government, we are beginning to see results but it is important to recognize that the epidemic is not yet controlled and that the number of cases will continue to grow. it's clear that we must intensify and scale our efforts to eradicate the epidemic and to do so will require additional resources. the department of state and usaid are jointly requesting $2.9 billion to end the epidemic at its source in west africa,
including $2.1 billion in base funding to meet immediate needs and $792 million in contingency funding to address emerging requirements as the epidemic evolves. $1.3 billion in base funding will be directed to the first pillar of our response strategy, controlling the outbreak. these resources will support the construction, staffing and operation of up to 20 ebola treatment units and establish and staff up to 150 community care locations in ruralal and hard-to-reach areas in the region. this funding will also be used to scale up contact tracing, train and mobilize health care workers and safe burial teams and remen nish vital logistics and supplies, including personal protective equipment. our base request also includes $388 million to support the second pillar of our response strategy, mitigating second order impacts.
ebola has decimated the health system's infrastructure within these three countries and has wreaked half vong on local economies. we are particularly concerned about food security. the usaid funded famine early warning systems network has issued an alert that a major food crisis is expected to occur in 2015 if the epidemic proceeds through march. our funding request seeks to counter these destructive consequences, which if left unchecked, will undermine our efforts to combat ebola at the source and could create instability in the region. our base request includes $77 million to support the third pillar of our response strategy, coherent leadership and operations. these funds are critical to expanding the department's medical support and evacuation capacity in the region and for supporting key diplomatic operations, such as ebola coordination unit and the usaid staff engaged in the ebola response. finally, our base request for the fourth pillar of the strategy, ensuring global health
security in west africa includes $62 million to support pandemic preparedness and strengthen public health systems in liberia, sierra leone and guinea and 278 million to prevent the spread of ebola to other vulnerable nations through the global health security agenda. in sum, our emergency request will allow state and usaid to scale up our existing efforts across all pillars of the response strategy. we are seeing some promising signs on the ground, but it is clear that the epidemic is not yet controlled. these resources are imperative to eradicating the ebola outbreak at its source, which is the most effective way of protecting americans here at home. thank you for your time and i look forward to your questions. >> mr. lump kin? >> chairwoman mikulski, ranking member shelby and distinguished members of the committee, thank you for the opportunity to testify today regarding the department of defense's role in the united states comprehensive ebola response efforts, which is a national security priority in
response to a global threat. due to the united states military's unique capabilities, the department has been called upon to provide interim solutions that will allow other departments and agencies the time necessary to expand and deploy their own capabilities. the united states military efforts are also galvanizing a more robust and coordinate international effort, which is seeming to contain this threat and reduce human suffering. before address the specific elements of the dod's response efforts i would like to share my -- and increasing response. after recently visiting liberia, i was left with a number of overarching impressions that are shaping the department's role as we support usaid. first, our government has deployed a top-notch team experienced in dealing with disasters and humanitarian assistance. second, the liberian government is doing what it can with its very limited resources.
third, the international response is increasing rapidly due to our government's response efforts. fourth, i traveled to the region thinking we faced a health care crisis with a logistics challenge. in reality, we face a logistics crisis focused on a health care challenge. fifth, speed and scaled response matter. incremental response -- responses will be outpaced by this dynamic epidemic. finally, the ebola epidemic we face is truly a national security issue. absent our government's coordinated response in west africa, the virus spread brings the risk of more cases here to the united states. i'd like to now turn my attention to dod's role in our nation's ebola response efforts in west africa and here at home. in mid-september, president obama order the department to undertake military operations in west africa in direct support of usaid. secretary hagel directed the
u.s. military forces undertake a two-fold mission. first, support usaid in an overall u.s. government effort and the second is respond to department of state requests for security or evacuation assistance if required. great patient care of ebola exposed patients in west africa is not part of dod's mission. secretary hagel approved unique military activities falling under four lines of effort, command and control, logistic support, engineering support, and training assistance. in the last eight weeks, dod has undertaken a number of synchronized activities in support of these lines of effort to include designating a named operation, operation united assistance, establishing an intermediate staging base into senegal. providing strategic and tactical airlift. constructing a 25-bed hospital in monrovia. constructing 12 ebola treatment units in liberia.
training local and third country health care support personnel, enabling them to serve as first responders and etus, ebola treatment unit, throughout liberia. in all circumstances, the protection of our personnel and the preservation of any additional transmission of this disease remain paramount planning factors there is no higher operational priority than protecting our department of defense personnel. dod has also increased support to the departments of health and human service and homeland security, the league agencies for ebola response in the united states, by activating a medical support team that can rap midly augment the centers of disease control convention and capabilities anywhere in the country. we have longer term assignments to combat ebola, requesting $112 million for the defense advance research project agency, darpa, in this emergency funding
request. the $112 million for darpa will support intermediate efforts aimed at technologies relevant to the ebola crisis. this includes new research focused on utilizing the antibodies of ebola survivors to provide temporary immunity for infected patients and the accelerated development and testing of new ebola vaccines and diagnostics. these efforts complement existing development at the national institutes of health and the defense threat reduction agency. with more than 50 years of experience successfully developing technology to develop seemingly impossible goals, darpa is uniquely positioned to fulfill a critical role within the whole of government response to contain and eliminate the ebola outbreak. because darpa's approaches to these research and developments die verge from conventional avenues, they have a real potential to produce game-changing advances in the prevention, diagnosis and treatment of ebola. in conclusion, we have a comprehensive u.s. government
response and increasingly, a coordinated international response. the department of defense's interim measures are an essential element of the u.s. response to late necessary groundwork for the international community to mobilize its response capabilities. with that, i would like to introduce my colleague behind me, major general jim laravair, the joint staffs director for political military affairs with regard to africa. the general and myself look forward to answering your questions. thank you. >> secretary johnson? >> thank you, chairman mikulski, senator she will business you have my prepared statement. let me just mention a couple of things in my five minutes. first, we all agree that the thing necessary to -- that the key priority is ensuring the safety of the american puchbl i agree with chairman mckulski that first and foremost that means fighting the disease at
its epicenter. let me mention a couple of things about screening we are doing with regard to passengers who may come to the united states from the three affected countries. first of all, we have the authority to issue do not board orders to air passengers who may seek to travel here from the three affected countries. we have, in fact, used that authority on occasion to prevent people from leaving the three affected countries to come to the united states. we have, in fact, used that authority already if we have reason to believe the person might be infected with the virus. the second thing i would like to mention is that in the affected countries with our assistance and advice, they have put in place screening to screen outbound passengers from the three affected countries. that includes taking temperatures and other mechanisms. fourth, we have worked with the
airlines that fly from those countries to our country. i have personally engaged airline ceos about the ebola virus. i know that cdc issued guidance to the air lines about flight crews and cleaning cargo and cargo personnel. there are no longer any direct flights from the three affected countries into the united states. there was at one point, there is no longer. to fly from the three affected countries to the united states, you have to get on one of a handful of flights that go through transit airports, mostly brussels, paris and morocco. at one point in may, the number of flights leaving any of these three countries to any place in the world is over 400. some data to suggest that month to month, it is about 600. it is now down to about somewhere between 100 and 150 flights in an entire month from those three countries to any
place in the world. the number of passengers daily that fly from those he affected countries into the united states used to be an average of about 150 per day. that is it fluctuates significantly day to day, some days, i look at the numbers daily, some days, it's as many as 100 or 75 or a little over 100. some days, like today, for example, it's just five or six much the averagesing? now about less than 100 on handful of commercial flights. we have set up enhanced screening at the five airports that were receiving approximately 95% of the itinerary passengers coming from those three countries. they are newark, jfk, dull less, atlanta and chicago. that enhanced screening, as you
probably know, involves a passenger declaration, enhanced questioning and taking their temperature and asking for and looking for symptoms of the ebola virus. that screening, to date, has received approximately 2,000 passengers. we have also identified through our questioning by our customs inspectors, a number of people who have flown indirectly from the three countries. they, too, have been submitted for enhanced screening. and on october 22nd, we used our authority to effectively funnel everyone coming from the three affected countries into those five airports that are conducting the enhanced screening. the other thing i will say is that at every port of entry at this point, land, sea or air, we are prepared to engage in secondary screening. if we identify somebody from the three affected countries who may
have the ebola virus, guidance has gone out to our customers personnel. we have put in place protocols for people who may be arriving by vessel. we have authority to identify people from the last five ports of call if any of those are from the three affected countries. we put in place protocols there. we continually evaluate whether more is necessary. so i look forward to your questionings. thank you very much. >> thank you. secretary burwell. >> chairwoman mikulski, ranking member she will business thank you all and committee members for inviting me here today to discuss the department of health and human services response to the ebola epidemic and our request for funding. as you know, we are deeply focused on domestic preparedness and since the first cases of ebola were reported in west africa in march of 2014, the united states has mounted a
whole of government approach to protect the american people and to contain and eliminate the epidemic at its source. at hhs, this response involves close coordination and collaboration of the national institutes of health, the centers for disease control, of the food and drug administration, of the office of global affairs, the office of the assistant secretary for preparedness and the office that has the u.s. public health service commission corps, which i think everyone knows has deployed to the region and i'm blessed today to be joined by both dr. freiden and dr. fauci today, who will join me as part of the questioning. we believe we have the right strategy in place, both at home and abroad. and the strategy is designed around four core principles. the first is to strengthen our domestic preparedness and while we may see additional cases, we
are confident that we can limit the number of cases in the united states. second, to stop the epidemic at its sources in west africa, as my colleagues have discussed, that, in turn, will protect our homeland. third, we need to alaska sell rate the research and development of vaccines, rapid diagnostics and theraputics so that we work on the crisis right now as well as think about preventing future crises in the future. and fourth, we need to invest in our public health capacity around the world through the global health security agenda. this is something that was started before the ebola epidemic but it is something that i think we see the incredible importance of right now. this preparation, in turn will help prepare the u.s. as part of the strategy, the administration is taking a number of actions and some of these actions are delivering results. for example, we are hearing
encouraging news from the hospitals that have treated ebola patients, as was reflected in the chairman's testimony, eight of nine individuals treated so far have survived. second, we have seen signs that our screening and monitoring system is working. recently in oklahoma, north carolina, oregon and maryland, individuals were identified with potential symptoms. those were reported to local authorities through the correct protocols. they, therefore, were transported through appropriate protocols that did not expose anyone. we are very fortunate. those cases have all been negative in the past weeks. but this is the kind of thing that is part of this emergency funding. we need to continue and support the local and state efforts as well as cdc and efforts to do. last week, there was also an important milestone. those sides will have been monitored in ohio and dallas came off of their 21-day incubation period. and they are no longer being monitored. we need to make sure that we
support state and local public health officials to be able to continue to do this kind of work. to date, more than a quarter of a million health care personnel have been trained by the cdc and the assistant secretary for preparedness and response, doctors, nurses, emts, fire departments, but we need to continue this training and make sure that the training is getting through. in west africa, the strategy is showing some positive results but as we saw in mali and learned last night there are additional cases there. while the u.s. government's response to ebola outbreak to date has resulted in progress, additional funding is needed and that's what we are here to talk about today. our department request is $2.43 billion in emergency funding. first, the funding will allow the department to enhance our ongoing preparedness here in the united states and our efforts to ensure that states and localities are prepared. for example, it will be about the purchase of ppe, that
personal protective equipment, training of thousands of health care workers. second, the emergency request will further strengthen the department's i don't going work to contain the ebola in west africa. we will continue to work with communities, governments and other partners on the ground in west africa to ensure that people are promptly diagnosed, effectively treated and if they die, safely buried. third, this request will expedite the research, development, manufacturing, production and regulatory review of the vaccines, diagnostics and therapeutics to combat the virus. finally, with an eye toward detecting and preventing outbreaks of this magnitude in the future, the emergency request will strengthen our global health security around the world. and this means providing that there are safe and secure laboratory capabilities to fight the diseases and emergency response capability in countries if these diseases occur.
i understand americans are concerned. ebola is scary and it's a deadly disease that is new to the united states. we have taken active steps here and abroad to protect the public health and safety of the american people and this emergency funding request is vital to continuing that work. i want to just conclude by recognizing the health care workers who are on the front lines of this response, both here at home as well as abroad, including the more than 650 department -- from our department at hhs who have deployed to either west africa or served here in the united states. we are proud of these brave and dedicated men and women across our department. i also want to recognize the men and women who are health care workers in this nation who have treated the parents that are here. and also recognize those who are suffering right now in the three west african countries where this is the worst. members of the committee, thank
you for inviting me. i look forward to your questions. thank you. >> thank you very much, secretary burwell. now, in order to get to questions, we limited the number of people testifying we don't limit the number to people who can answer questions. each one of have you been accompanied by really experts and esteemed witnesses, so if they could come up and join the table, doctors freiden and fall chill, the good general, the coordinator usaid, ms. lind berks you-all want to come up and get there so that, you know, we can have wide open discussion and wide-open questions. i'm going to go to the first question, wait till the general gets settled.
and everybody a he is got their names. before i get to actually to my question, first of all, i'd like to thank, again, all of you at this table and at the tables you have in why you are respective agencies here and around the world. i really want to say that as we have watched this unfold in both west africa and here, i want to thank you, because i know many of you worked a 36-hour day. and i know many of you worked a ten-hour workweek. so think we need to say that as we evaluate what does it take to be able to respond in an effective bay? it was a crisis, which calls for the need for maintaining a critical infrastructure and our critical public health infrastructure. i also want to particularly acknowledge those institutions in states that really stepped forward to treat the patient, emory university, the university of nebraska and of course, the
nih special clinical studies center, all three that were there to meet the needs of the american people as they returned home that needed our help, our prayers and quite frankly, our medical advances. so, we want to thank them for that. you know what it shows was, you know, these weren't red states or blue states, these were american states so as we look forward on solving this, it has to be looked that the way. now, let me get right to my question, which is this. my job as united states senator and i know at this table is to protect the american people and also, protect the people that are protecting us. and this, therefore, goes to the people who render hands on service or those that were concerned about doing this work. so, let me go to secretary burwell, to you. in your testimony, you talk about domestic preparedness and thank everyone for the gallant
and generous and dedicated work of health care workers here. but i was also really wore rained wasn't only really worried but so were the national nurses united, i receive adler from them that really articulated my concerns. what they said to me, and now i quote them, is that the president needs to invoke his executive authority to maintain uniform national standards and protocols, that all hospitals must follow safety-protected patients or health care workers and the public. they then go on to talk about the personal protective equipment needed, particularly hazmat equipment, and they identified the actual osha standard number. my question to you, secretary burwell, is do you feel confident that now in the way we are responding, that the doctors and the you were ins who are actually touching patients have the protective equipment that they need, that these are national standards for not only the equipment but the training
so that we have a national response regardless of whether where someone might appear that needs help? could you share with us and did you respond or did the president respond to the national nurses united request? >> so, with regard to the issue of make something you are that our health care workers were prepared, i think we need to think about it in a number of different levels. the first is in that screening and monitoring and that's what state and local health care workers are doing, with then checking on the people who have come from these countries. second is that that initial front line worker, in a health care institution that needs to be able to detect and isolate, ask the right question. if off fever what is your travel history? the next is the level where treatment will occur and as we describe in our submission, this will be in a more state by state basis and where the cases are in terms of treatment. the question i think the nurses were posing was on the category that had to do with that front line. as i mentioned in both my oral and written testimony, at this
point, we have trained over 250,000 people. what we need to do now, and that's part of what this request is about, is to make sure that that training continues and extends and we need to measure it, what we are hearing when we hear from the nurses, we want to make sure we respond. do they know? is the training working? do they feel confident? right now, we are working with the association of state and tribal health care organizations to make sure that we are going to put in place a measurement so we can understand they have what they need with regard to training much the second part the nurses mention is ppe, protective equipment. >> yes. >> provided guidelines to the cdc in terms of what's needed, training and what to do, the second issue is access to that and through the assistant secretary assistance and sport, bart ta, working with the manufacturers, producing 24/7 now, working with them and working with the states to make sure that those who have the greatest need and will most likely treat get that equipment. >> well, madam secretary, let
follow up on this. so do you feel confident that we have -- that if ebola appears, you used -- on page four of your testimony, the maryland case example, a young lady came in, she took her temperature, she thought she might have it, she wasn't gonna go to nih, she was gonna go to either mary land or hopkins. that those who would be once identified with the high temperature, et cetera, that they would have the equipment and that they would know how to use the equipment, but regardless of whether they are at a high-tech urban hospital, like a hopkins or a maryland, an academic center, but could be a community-based hospital in a rural area, that you would be ready to respond to see that they had the equipment and the training? >> that is why we are doing the, aggressive training that we are doing. >> do we have the -- do you feel confident that we have this now or we are in process?
>> right now, what we have seen in all the cases that you articulated and all those that have come through, also providing at the border a kit so any individual that is coming through, which is where the case would originate gets a phone number they are supposed to call. they get a to take their own temperature. >> what i need to get is for that nurse to feel that if she has to walk into a room and provide the care that she has taken an oath to do, along with the doctors and others that are the support staff that they're going to have what they need to do the job and that they also have what they need to protect themselves. >> that is what we are working to do with all the training. at this point we've trained 250,000 and the funds that were -- >> isn't this what your money is for? >> yes. >> really? >> to continue this effort. >> isn't that part of the public health infrastructure? >> it is. it is the basic not just for
ee eebl. >> i have to put their minds at ease, but that we have their back and we cover their back and their arms and legs, et cetera. a question for our constituents that go towards the military. we're now sending our military in harm's way to protect against terrorism but now we're sending them to get ebola. my constituents were deeply concerned that in deploying our military to do the task that you just identified that they were going to be exposed to ebola and we were putting them in harm's way to get ebola. do you believe in your employment and if the good general needs to respond, are our military actually going to come in contact with people with ebola and our are military at risk of getting ebola?
and are we sending them in harm's way with a disease? >> in my opening remarks, dod personnel are not doing direct patient care of those that are infected with the ebola virus. we've taken great steps to ensure that our military personnel receive comprehensive training before we go, that we monitor them while they're there and we have a controlled monitoring situation. i'll defer to my joint staff counterpart who can go into the specifics about it. >> general, welcome. >> thank you very much. >> we've instituted four levels
of predeployment training for all personnel who are going for our transient peoples, think about air crews flying in, not getting off the airplane, and flying out. graduating up to personnel who will be in country, who will have to interact with liberian nationals as they go about their day-to-day business. those personnel will receive training in how not to come in close contact with those personnel and will be issued ppe that they will carry with them in the cases necessary. health care professionals who will be in country at the two rural hospitals, one in morovia. senegal, who will be there to treat our military personnel for regular injuries and be able to treat them if they somehow do come in -- do contract ebola. and, finally, to the highest level of training for our lab workers who are there now,
testing blood samples as part of the support there. yes, we've got a complete protection package for those personne personnel. >> i look forward to you perhaps submitting an answer to that. we protect those who are trying to protect us. senator shelby? >> thank you, madame chair. on october 17th, president obama named ron clain to a white house post responsible for coordinating our response to the ebola crisis. how many times have you met with mr. clain since his mo appointment and what has he brought to the table that was missing? madame secretary, start with you. >> i've been in touch with mr.
clain every day since he has begun, face to face, by phone or by e-mail. in terms of what he has brought to bear it's been my experience and my experience last time when i served in government, the importance of policy coordination, i was there at the beginning of the national economic council where we did much consultation. it's a very important role in terms of when a whole of government is occurring. and mr. clain is doing a -- >> what has mr. clain brought to the table? >> i can't say i've been in touch with him every single day. i've been in touch with him countless number of times. >> okay. >> i believe that the critical value that ron has brought to this is coordinating the federal response between and among all
the agencies, components you see represented here and having somebody who is dedicated full time to the white house to doing exactly that. >> secretary? >> nearly every day in contact with him and he has done an outstanding job of doing just that, coordinating and singular focus for the administration of coordinating across interagency. >> i've just been back from maternity leave for two weeks, senator. ron was appointed to his position prior to my returning. >> you'll be excused. >> since then we've had frequent interactions. it's the policy coordination that's so key to our response. >> to your knowledge, does mr. clain have the authority or power to direct your agencies to perform any specific actions or is it main ly trying to bring yu
together? >> with regard to the execution of the agency's responsibilities, those sit with me and the head of the operating division like dr. freeden. >> secretary birdwell, states that issued more stringent rules for returning health care workers, stating we don't just react based on our fears. we react base d on facts. as we've all known, secretary hagel has approved mandatory quarantine for troops who have been deployed to the ebola-affected areas. furthermo furthermore, we have limited, we hope, patient contact while civilian medical workers will have direct patient contact. what facts, that was the word the president used, should we
base quarantine guidelines on had, ma'am secretary? >> certainly, i will also -- i will start but then turn to dr.s freeden and fauchy. we've determined level of risks. quarantine base system based on their level of risk. and that's based on the epidemiology, i think dr. fauchy has been working on this well over 30 years, in terms of the experience that we see. that's how we determine what's done with each and every group of people and different groups of people. that's how we base the decision. that's an individual basis often which is why we monitor directly and actively every day those health care workers that return. >> is the assessment -- i'll direct this to you, too, doctor, since you'll be in on this. in the assessment of risk difficult when people are coming
from various countries and perhaps don't divulge where they've been? i know you can keep up with it to some extent. is the assessment tough to come by? >> several levels of assessment, first to assess the fever to see if someone is ill and then to determine the cause. second to see what exposures they may have had working in an ebola unit or are being a health care worker otherwise or having potential exposure to someone who may have had ebola. but for every one of the individuals who returns, we ask the states to undertake an active monitoring process and we facilitate that process, as secretary burwell said so they're taking their own temperature and if develop fever, they rapidly contact the health department of their state where they can be safely transported to a facility that is ready for them.
ebola, as far as everything we've seen only spreads from someone who is ill. it doesn't spread from someone who is not ill. if you can find that illness quickly and isolate them, then you can stop them from transmitting to anyone else. that, essentially, is the way of protecting not only their health but the community's health. >> doctor, you want to add -- >> sure. so in some circumstances when we stratisfy risk, there is sometimes the functional equivalent of a quarantine if someone is at high risk. it isn't as if it's all or none, but not saying there's a blanket quarantine we're being somewhat reckless of making everyone have the same sort of movement. i took care of nina pham. i'm in the low if not moderate risk. if i had to be quarantined i wouldn't be able to be here
testifying. because of the fact that i'm low and not zero risk -- >> maybe you would have liked that. >> if you are, we're going out the door. >> right. >> doctor, to dr. freeden, head of the centers for disease control, what can you say to the american people today about their and it's widespread of a possibly ebola outbreak in this country? >> we certainly understand people's concerns. ebola is scary, deadly. and the images from africa are frightening. but ebola spreads by direct contact with we know unsafe care giving in the home or health care facility and unsafe burial practices. the burial practices that are spreading ebola in west africa
are not things that we do here, not to be concerned about. but care giving is. that means for every individual who comes back from a place that may have ebola, very important to be monitored actively for 21 days. at the first sign of any symptom, even if it's not severe illness, what we're seeing now is, as appropriate. people are coming in, being tested. coming in and being isolated. as soon as that happens, we reduce the risk of spread. so from everything we've seen the last nearly 40 years working on ebola in africa and from everything we've seen here, no household contacts became infected, ebola doesn't spread like flu or measles or other infectious diseases but it is deadly. that's why the hospital infection control is so important. but from everything we've seen, we do not think a large outbreak is at all likely in this country. it's just not how ebola has spread either here or in africa
to date. >> why it reached epidemic proportions in the first place. a major public health emergency but it should not be a cause for panic or journalistically provoked fear among our populous. it should serve as a reminder and a wake-up call. let me read you something that senator mark hatfield, former chair of this committee said when he retired in 1996. he gave us his farewell speech on the senate floor. here is what he said, and i quote. it was at the end of the cold war. this is exactly what mark hatfield said. quote, the russians are not coming. the greatest enemy we face today
externally are the viruses are coming. the viruses are coming. end quote. 1996. former chair of this committee. a decade later, a similar warning at the emergence at the avian influenza. another virus will emerge with the potential to create a global disease outbreak. history teaches us that everything we do today to prepare for that eventuality will have many lasting benefits for the future. mike levitt, end quote. both were right. syndrome, mers. yet during this time, when new viruses are emerging and new viruses are becoming drug resistant, we reduced
investments in nih and cdc and acting short-sighted cut that is have left us less prepared. we have to accept the fact that we don't live on an island with airline flights every day around the world, every virus is de facto and airborne virus. we must stop chasing diseases after the fact. we cannot be everywhere at once and we will never run faster than a microbe. our only chance lies in building public health systems capable of detecting and stopping diseases before they become epidemics. we have the knowledge, right here. we have the expertise and the systems to combat ebola and other infectious diseases. our challenge here is to act calmly, based on science and facts and with resolve, double our resources and build that
capacity. i say that because there's some talk in this emergency funding that we should only address ebola and not look to future viral outbreaks and viruses. so i looked up the word emergency. this is emergency funding, right? >> we hope so. >> emergency funding. it comes from the word emerge. how about that? emerge. merriam-webster dictionary says it's a need for e mechlt rgent relief. this is to stop a disaster. that's what this is. viruses are mute ating. some of them, we know, are becoming more drug resistant and diseases that we are looking at now, ebola is just one of those. they're now global in their impact.
dr. freeden, you and i have spoken many times on our trip to africa, a year and a half or so ago, to stop these diseases where they start. those conversations as well as the work of a group started by your predecessor, jeff copeland, inspired me to create a federal health program in last year's appropriations bill. we must invest in countries with weak public health systems so they can stop these disease before they cross the borders. we only need look at h5n1, southeast asia, to be reminded of the virus threats that are still out there. they're still out there. i've said before if h5n1 starts jumping from birds to humans and humans to humans, we better look out. it will make ebola look like a picnic. so the need to address the
emergency now to keep it from coming on our doorstep at home. approximately $600 million at your request would go to doing just that. but considering the need, that seems very low to this senator. very low. $600 million to build the cdcs, to put in the laboratories, get the equipment, train the technicians, train the epidem yolgss? it seems low to me. can you explain that number? what do you hope to accomplish with that investment? and could we use more to address emerging, emergency outbreaks? dr. freeden? >> thank you very much. you don't need to look any further than the difference between what happened in nigeria with ebola and what happened in liberia with ebola to see what a difference prepared public
health systems make. in nigeria, through extensive effort, because there was an emergency operation center, because there was a laboratory network, because there were trained disease detectives, because there was a public health system that could respond to the outbreak, they stopped it. it took enormous effort but they stopped it. and today, from that importation, nigeria is ebola free. the world would be a very different place today if liberia, gui nechlt a and sierra leone had those systems in place a year ago. they could have contained this outbreak. global health portion of this request aims to protect not only these countries but ourselves against that type of threat whether it's the next ebola, the next sars or even the next hiv. there are three fundamental areas we work in. they're all very specific, measure measurable and will leave behind as temporary assistance something that will
protect us for many years to come. the first are prevention methods, how to ensure we keep our laboratories safe, that we stop the spread from animals to human whenever possible. and that we're able to immunize with whatever we can to reduce the risk of things spreading. second, and the largest component is detection. putting in place the laboratories, the disease detectives and also the surveillance systems to find problems when they first emerge so we can stop them at the source before they spread. thi third, of course, is the response. emergency operations systems, the ability to work with medical counter measures and to stop outbreaks before they spread. those are the three key interventions that we would be able to implement with these emergency funds to protect ourselves against these emergencies going forward. >> thank you, doctor. i see my time is out. i'm sure i just think that's a low figure confronting what we have to confront worldwide. and i'll ask a point of personal
privilege. this is probably my last -- >> yes, i woos going to note that. >> -- committee meeting after serving on it 30 years. let me thank you all to your commitment to public service and for your great leadership. if you don't mind i especially want to thank tony fauchy with whom i've had a 30-year relationship. we both came here at the same time. you came there. i came here. you have had the better of it, believe me. also, thank you for your great leadership at nih and also dr. frieden with who i have had about a decade-long association, first in new york city and later at cdc. thank you for your great leadership. and to staying calm and targeted and focused when others around you might be losing their heads. thank you very much. thank you, madame chair. >> i think we could say the same about you. i don't know about the calm part. >> i don't know about that.
>> by the way, we're going in the order of arrival, so -- >> yeah. let me start with you, secretary burwell. in your written testimony, you mention the contribution that emery made, the university of bre. i would think the cdc would recognize the guidelines you're using, significant input was provided by those institutions. as i have looked through the request for funding here, $6 billion request, we have money to reimburse the world health organization. we have money to reimburse civil aviation organization. i could go on and on. i don't see funding that would be available to reimburse any institution in the united states that provides care and treatment
and training relative to ebola. i've talked to staff for the relevant subcommittees and talked to some of the members. and it appears to me to be an oversight. and it would seem to me to be logical, because you asked emery to take patients. you asked the university of nebraska medical center to take patients. we were glad to do it. but it seems at this point some assistance in terms of reimbursement would be appropriate because treating an ebola patient is a world different than treating mike johans who walks in with a severe case of the flu. do you know what i'm saying? go ahead, secretary. >> so, with regard to, i think there's the issue of the treatment facilities and there
is funding within this request to make sure that we have treatment facilities around the country and that there will be funding. but with regard to the special institutions like the university of nebraska and dr. gold and the team there, who have had the opportunity to spend time and talk to, and the emory folks, what we have done is there is funding about the creation of an education training facility and it is our hope that both of those institutions will team with cdc. we will do financing for those institutions to be part of our training of the other institutions and hospitals around the country. with regard to the specific issue of treatment and the treatment of patients, to date, much of the conversation has been between private insurers and the hospitals themselves. if this is something that the congress -- to date it has not been an issue that has come to us. if this is something that folks want to discuss as part of this funding, we're happy to entertain that. >> great.
it's an appropriate discussion because the private insurer, when they look at the cost of care for an ebola patient, i mean, it's through the roof. they will cover a minuscule amount if there is private insurance coverage. it will come nowhere near to cover the cost. and i will tell you what you know already. and that is in the early days of this problem, couple of months ago, you folks were scrambling to figure out what to do with these patients. we were glad to be there. this was -- this was started when i was governor. we're just glad we have world-class treatment there. we want to be helpful but again i think it's a conversation we need to have. second point i wanted to make here -- and i think this is a very important point. i understand the expediency of putting money in each state.
each state will get a certain amount of money. it seems that the formula is based upon population. i think we're going to look back in three or four years. i'm not going to be here to question you about it. but i think we're going to look back and say i wonder what that got us. here is the reason. treating an ebola patient is very, very challenging. and there is risk involved if it's not done properly. i don't know that every hospital out there would want to get into this business, to be honest with you. i think some hospitals around nebraska would say they seem to be doing a pretty good job over there in omaha. let's fund them and support them. i think you need a more regional concept than what is called for by this legislation, because there are facilities out there
that were way ahead in terms of what was provided here. i would like your reaction, secretary. and then i would like the reaction of the director of centers for disease control to what i've just said. >> so with regard to the question of where we do treatment in the nation and how we do that, what we have started with is certainly we were fortunate that the congress had funded and we had supported the university of nebraska, nih and emory to be bio facilities. those are our anchors. >> i'm not convinced that there were federal funding. maybe a very small amount. but i think it was a state initiative. >> as those then go out from that ring of three, what we've done is we have focused our effort on the five airports that secretary johnson said that's where the cases we believed would come in. so we put in place the training and cdc did that training in conversations with the other hospitals for new york, dulles,
o'hare, atlanta and newark. and so that was the next ring in terms of treatment, to your point of the question of a strategic approach. and then beyond that, we have been doing tracking of where the income of the people are coming. that is how we are starting in terms of your question about a focused approach. as we have started this process, though, many states have approached us because of their desire to make sure that they have a facility within their state. as we were thinking about it, where is the concentration and where is their geographic proximity so that a patient could be within eight hours anywhere in the united states as well as what we're receiving in terms of incoming. that's how we have started to design and are working on where
the phils should be. states reaching out to us as well as the strategy we're seeing analytically and the risk. >> it's really a question of stratifying risk and which hospitals can do what. with the active monitoring program, we'll have a head start on being able to plan for if someone has just come back, where would they go. the issue of ebola is one deadly infectious disease that's complicated to take care of in hospitals. but the more -- the broader issue is hospital infection control for ebola and other deadly infections. and what can we do to strengthen what each state has in their hospitals? something that's valuable not just for ebola but other hospital acquired infections.
>> with a small amount of money that's going to each state, what you're going to end up with is double wide units that won't be adequate for the next crisis. i just think that money is going to go out there and it's just not going to be enough to do the kind of work that you're trying to describe to this committee. thank you, madame chair. >> to the gentleman from nebraska, first of all, you sent me a letter on this matter just a few days ago. when i went to acknowledge the receipt of the letter, asking for consideration and of funds for hospital workers and also for those hospitals that agree to treat and are able to treat these patients, i think the gentleman raises an important point. >> thank you. >> i'm not sure it can be addressed urgently in this supplemental but it could be
ebola or another infectious disease and i think we need to look at this. i want to acknowledge the validity of the issues you've raised because for those of us who faced -- and i don't mean it in a way to say oh, my god, we faced it. but we're willing to provide care as the university of nebraska, we should be committed to support those hospitals. it's costly. >> yeah. >> it is costly. and in this era of stringent reimbursements from the private and public sector, hospitals are already stretched to meeting their bottom line and if the generosity of spirit and the technical capability to absorb, your point is we shouldn't add to the fiscal burden while they have to deal with the care burden and also the stringent reimbursement systems that they're already under. is that kind of your issue in a nutshell? >> madame chair, it is exactly.
we want to be helpful. we never had any reservations about this. and i could not be more proud of what was happening there. but the cost in this is just huge. >> so let's talk about this, okay? >> let's keep working on it. >> okay. senator reed? >> thank you very much, madame chairwoman and thank you, ladies and gentlemen, for your testimony. one of the major objectives we have is to suppress the disease in west africa. one critical factor is health care workers. can you elaborate how internationally we're doing in terms of local health care workers, supporting them and also attracting international volunteers? the bottom line is do we have enough health care workers to deal with this crisis? >> stopping ebola at the source in west africa requires improving care and burial, two key ways it's spreading. usaid has stepped up safe burial
services. department of defense and others are helping to establish treatment units. one of the things that is encouraging is 90% or more of the health care staff caring for ebola patients in west africa are from those countries but there's still a need for international assistance. one of the things that has been very encouraging is the african union has been willing to send hundreds of health care workers in. that's in process now. we've also seen an increase in health care workers from other parts of the world. and one of the things that we try to ensure that every step is taken to make care as safe as possible there. there's still a gap, as nancy can discuss, to help address the epidemic at the source. not only to save lives there, but to protect us here as well. >> what are we doing to fill that gap is the obvious question. either you or your colleague can
respond. >> yes, thank you. as you know, there's a significant need for health care workers and, in part, because it's a very high burnout job. we have to continue to replenish the pipeline. there's a significant effort to recruit internationally. i would just add that ensuring that they have the training and equipment that they need is an important part of the equation. and having them feel comfortable, that if they go and serve, they will be taken care of. to that end, our colleagues from dod have built a hospital, 25-bed hospital that is being staffed by u.s. public health care workers, medical personnel. and we are working with dod, with w.h.o. and others to have a continual supply of protective gear and dod has stood up a training facility in monrovia to
ensure the specialized training that's required. >> on that very note, if i may, to train u.s. health care workers going over, cdc began a training course in alabama in conjunction with the fema site there. all the u.s. public health service workers went through that training. it's based on years of experience that doctors without borders have. and that's the type of very intensive training that we're implementing. >> and the resources asked for in this legislation will be. >> absolutely. >> and without these resources the gap will persist and the disease will be further beyond our means of suppression? >> these resources are essential to stop the outbreak in africa and protect us. >> secretary lumkin, dod is set up there.
the question is, that i've gotten, is how do you get to the last mile, dakhar, supplies, trained personnel out? and the other issue comiing basd on our discussions is the end of the rainy season, what impact does that have? does that give us special urgency in getting this bill done? >> thank you for the question. i would like to address the issue with the end of the rainy season first. i think that's a temporal issue before us. liberia gets 200 inches of rain a year. what's been moving during the rainy season is people by foot. many roads are closed and, therefore, carrying the disease. what's hard to do is get supplies to where they need it to be. that's why it was crucial to build up these logistic networks. in the drying season, you have more freedom of movement for people, is one. which means an increase in spread of disease potentially, but also the temperatures go up.
the time that health care workers can spend in their ppe, personal protective equipment, is reduced significantly. so that adds another burden. i will defer. >> senator, thank you very much for the question. intermediate staging base is fully operational at this time with 101st brigade running that operation there. they've established a rotator flights, c-130s down to monrovia. from there we have helicopters on the deck that can take personnel and equipment out to the various locations or to do what they need to do. we've got the -- starting to get the equipment and the personnel in place, able to transfer that equipment to the last tactical mile. >> my time has expired. quickly, ma'am. >> senator, quickly, part of what this request does is enable funding so that dod can depart and there's a civilian capacity in place for logistics,
including the last mile transport. >> thank you, madame chair. >> senator blount? >> thank you, madame chair. there was a report november 7th that said that public health experts warned that the actual number of ebola-related cases and deaths in africa was likely much higher than the numbers being reported. do you have an opinion on that report one way or another? >> we have previously estimated that there is probably underdiagnosis and underreporting of cases. so, yes, we believe the number of true cases is larger than the number of reported cases. >> do you have any idea how much difference there might be? >> in . as many as 2 1/2 times more than were diagnosed up to
that point. since that point we believe that the monitoring systems have improved and we don't have a more recent estimate of the difference between what's reported and what we actually think may be happening. >> i think in guinea and -- the numbers have gone up pretty dramatically lately and seem to be heading the other way in liberia and sierra leone, is there a reason for that? >> we see different trends within each of the three countries and different trends in different areas in each of the three countries. in guinea, waves of disease, increasing then decreasing, from a forested area deep in the country, which is where the outbreak is believed to have begun. and where it has never been completely controlled. that has been the epicenter for sources receding other parts of the forest area. not only in guinea but the other two countries. in the parts of each of the
countries which have implemented the strategy, we have proof of principle. we've seen big decreases in cases in individual areas when we get the safer care contract care, infectious control and health care systems those standard disease control methods that have worked for every ebola outbreak and i'm told now have worked for the firestone company and near monrovia, which implemented them and individual community. we ha >> how long should this money last that you're asking for? and what's the significance of the contingency fund and how long in the future do you think that money will be there? >> in the context of what we know, as director frieden just talked about, the evolution of the epidemic is something that
ebbs and flows. in terms of what works we believe that the base amount of funding is the amount of money that we need across the departments. that will stave off the epidemic. the contingency fund was asked for because to the point that was made in opening remarks about preparedness an preparedness and making sure when we have elements than aren't predictable, we want to make sure that that funding is in place. and that funding would be for different types of things and to give you some examples, if another country, another ring country, has a number of cases and starts to be elevated like a guinea, a sierra leone, or a liberia, that may change the needs. another thing that could change the needs that we would use the contingency funding would be is if we actually get a vaccine and we're still at a stage where we believe you need to do deeper and would do more distribution of vaccines to a broader group
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