CDC & Health Officials Coronavirus Budget Testimony Transcript

Rosa DeLauro: (00:00) Aware of this issue, which is really very, very troubling. And that is that the Administration has ordered the immigration court to immediately remove Coronavirus posters, and it just says that the immigration court staff nationwide had been ordered by the Administration to take down Coronavirus posters from courtrooms in waiting areas. The Executive Office for Immigration Review, which falls under the Department of Justice, told all judges and staff members in an email Monday that all of the Coronavirus posters, which explain in English and Spanish how to prevent catching and spreading the virus, had to be removed immediately. Rosa DeLauro: (00:46) I just wanted to say that whatever one's view is on any issue that we face in this nation, whatever your personal views are, whatever your ideology is, that we cannot, we cannot in this public health crisis play fast and loose with people's health, no matter what we believe. It is a moral responsibility for us to make sure that everyone is protected. So it just came to my attention, and [inaudible 00:01:24] public health. Rosa DeLauro: (01:28) So Dr. Redfield, we welcome you to see, have you here and your colleagues who are with you. Dr Liliana Arias, associate deputy director for public health science and surveillance. Dr Deborah Hori, director of the National Center for Injury Prevention and Control. Sherri Berger, a chief strategy officer and chief operating officer. I might say, I also want to acknowledge Dr. [Messinier 00:02:01] who I know is not here, but she was in here and helped to provide us with a bipartisan briefing that we had for the subcommittee in February, and sorry not to see her here as well. Rosa DeLauro: (02:14) In fact, before we proceed to CDC's FY21 budget request, let me start with where we are all probably starting today, and that's with Covid-19. I first want to commend the thousands of public health experts on the state and the federal level who are working so hard to keep us safe during this outbreak. That includes you, Dr. Redfield, as well as all of the CDC staff. Rosa DeLauro: (02:42) We are in a crisis, and there are questions about our preparedness and ongoing response efforts. I'm very concerned, and I think we all are, about our nation's testing capabilities for Coronavirus. Other countries have been testing thousands of people for weeks, but the US is woefully behind the curve. The low number of positive tests in the US is likely a byproduct of under testing, as opposed to an accurate count of the prevalence of Coronavirus in the United States. My understanding is that the testing kits are now being distributed across the country, and commercial firms are involved as well, but the delay has been unacceptable. While CDC rapidly developed a new test for Covid-19, the majority of the initial test kits sent to the laboratories were faulty, and there were weeks of delays before replacement kits were sent out. During this time, CDC maintained a narrow testing criteria. It makes us ask if the health of our country was put further at risk because of these actions. I expect there will be a lot of questions today about testing, and those delays. Rosa DeLauro: (03:56) Another concern is emergency funding. The Congress came together last week and we passed an eight point three billion dollar emergency supplemental, on a bipartisan and bicameral basis. It includes $2.2 billion for the Center for Disease Control and Prevention. This funding will support CDC as well as state and local health departments who are critical to responding to this outbreak and to saving lives. Rosa DeLauro: (04:23) But when this crisis arose, the CDC had only $105 million available in the infectious diseases rapid response reserve fund. The supplemental added 300 million. I've been a leader for years on a public health emergency fund, and have repeatedly introduced legislation. The public health emergency act to provide five billion dollars in emergency funding for the public health emergency fund, so that you can act with alacrity and with flexibility. We can only imagine where we would be if we had had five billion at the outset, instead of 105 million in the rapid response reserved fund. Rosa DeLauro: (05:12) The former shadow health minister of South Africa, [Willmot 00:05:16] James, who is a global public health expert, has said of public health infrastructure, and I quote, "Why do we lurch from crisis to crisis and lapse into complacency in between?" This outbreak is a reminder of the importance of a well-prepared, well-trained, well-trusted, well-funded public health system. Because beyond Covid-19, professionals at CDC day in and day out, are working to combat foodborne illnesses, influenza, to promote healthy lifestyles, to reduce and prevent the use of tobacco products, and on and on. It's important work, and it's why we are proud of what we were able to do. And this committee in increasing CDCs funding in 2020 by $636 million, nine percent above the 2019 level, and was done on a bipartisan basis. Rosa DeLauro: (06:13) Some of those highlights include, for the first time in more than 20 years, funding specifically to support firearm injury and mortality prevention research. The first year of a multiyear effort to support modernization of public health data surveillance and analytics at CDC state and local health departments. And the first year of a multiyear initiative to reduce transmission of HIV by 90% over the next 10 years. The establishment of a suicide prevention program, tobacco prevention, specifically given the e-cigarette and vaping epidemic among our young people. Increases for global disease detection, that's global health security. As you've outlined in your remarks, Dr. Redfield, the global health security is critical to our national security, and the infectious disease rapid response reserve fund. Rosa DeLauro: (07:04) Unfortunately, the president's 2021 budget proposal reverses this progress. The budget proposes to cut CDC by $693 million, nine percent below the 2020 appropriation. And despite the presentation of the president's budget, which claims that infectious disease, global health, and preparedness were prioritized in CDCs requests, key programs would be cut. Rosa DeLauro: (07:29) The public health data initiative, the public health workforce program, the infectious disease rapid response reserve fund, and that allowed CDC to quickly respond to Covid-19. This subcommittee will not be pursuing the administration's proposed cuts. To cut from our public health infrastructure during an outbreak is beyond consideration. Instead, we together intend to invest in the CDC and our nation's public health system. We will not lurch from crisis to crisis, and lapse into complacency in between. We cannot. This Coronavirus outbreak makes that clear. Rosa DeLauro: (08:05) I will stop there. We look forward to your discussion of the budget and other policy areas under your jurisdiction, and appreciate your all being here today. Before we turn to you, let me turn to my colleague, the ranking member of the subcommittee, my colleague from Oklahoma, Congressman Tom Cole for any remarks. Tom Cole: (08:23) Thank you very much Madam Chair, and I make a few remarks off the cuff before I actually get to my prepared statement. And this is an area that I think my chair and I certainly strongly agree on. I'm never critical of somebody here that comes and presents the president's budget. That's appropriate. It's your job. I always call it the OMB's budget though, to be fair, and I'll just state for the record. I'm quite sure that we won't be cutting the CDC anytime soon. I suspect quite the opposite, and we will be building on the things this committee has done really over five years. Tom Cole: (08:56) A number of years ago I actually had a discussion with then OMB director Mulvaney, and made the point, whatever budget you send up here, we're going to increase spending on NIH, CDC, and strategic stockpile. And then later on we added that rapid response infectious disease fund, an idea that our chair had been championing for many, many years. Tom Cole: (09:16) I think those were all really good decisions and I think we're seeing the benefit of them now, and I suspect we'll stay on that course. What you do, and I thank all of you for doing it, and the splendid professional you lead are absolutely indefensible, or excuse me, indispensable, we've got to correct that one right away. Indispensable in defending the people of the United States. I mean, I really do. And Dr. Redfield and I have had this discussion before. I think of you as the biomedical equivalent of the Pentagon. And what we do there protects the American people in one way. But what we do here protects them in another way, and probably frankly on a day to day basis a much more immediate and much more impactful way, and much more likely to have a problem like we're dealing with now, than we are to have the kind of threat to the lives of Americans. Tom Cole: (10:09) So again, thank you for what you do and I suspect this committee on a bipartisan basis will continue to make these investments going forward. Good morning Dr. Redfield and thank you for coming to be with us this morning. I almost again was going to do what I did with Francis Collins. How's your week been? I wonder, I think about you guys a lot. We know this has been an extraordinarily stressful time for you, and one in which you're doing great work for the American people. And I know Coronavirus is at the forefront of everyone's mind this morning. You and the public health experts at CDC are front and center in defending our people. Tom Cole: (10:46) In addition to hearing about Coronavirus this morning, I'm hoping we can also discuss other priorities I know we all share, such as reducing opioid abuse and overdose deaths, addressing the threat of antibiotic resistance, and preventing the growing problems associated with chronic diseases, all critical public health issues for our country. As the United States continues to monitor and respond to Coronavirus, I'm encouraged that Congress and the Administration work together across party lines to deliver critical resources for the days and weeks ahead. In such a highly polarized and partisan environment, I'm very encouraged that we could set aside our differences and quickly deliver on such a high priority item for the health and safety of the American people. It took just nine days for the Administration to submit information regarding a supplemental appropriation need and bipartisan bicameral congressional action. The vote in the house was overwhelming, as it was in the Senate, and I hope you can continue, and I suspect you can continue, to count on a bipartisan robust support to aid in your efforts to keep our communities prepared and able to respond. Fortunately, long before the Coronavirus ever infected as first patient, Congress was already preparing for this sort of public health emergency in a bipartisan way. Tom Cole: (12:06) Five years ago, Congress began shaping policies and prioritizing investment in our readiness, including boosting funding year after year for the National Institute of Health, Center for Disease Control and Prevention, and the strategic national stockpile. But perhaps our greatest lifeline in these past few weeks was the prior establishment of and investment in the infectious disease rapid response reserve fund, which was immediately available to you, the CDC, our number one public health defender. Indeed, because Congress had the tools in place ready to deploy at a moment's notice, the Administration's been able to direct a swift and decisive response from day one, not losing any time and protecting our citizens. Tom Cole: (12:48) I want to associate myself with the chairman, I mean, I would like this fund to be larger. And we originally proposed 300 million. I know we both, living within the budget realities, would have liked to have done more. I'm pleased that Congress did the 300 million in the supplemental, and going forward, I hope we can build on that given what we've got to work with. I know we have many priorities here, but again, the outcome that we got was the aim in our creation of the reserve fund, and while it's unfortunate we had to use the fund, I'm glad the resources were available. I hope more are available in the future. Tom Cole: (13:21) While there's still a long road ahead with many unknowns, I'm encouraged that one of those unknowns is not whether the funding will be there for our public health defenders to continue in their response. Along with providing generous funding for the resources we need to prepare for, prevent, and respond to Coronavirus, I'm proud that the supplemental responsibly replenishes the infectious disease rapid reserve fund, with $300 million to help us respond quickly to any future threat. As we have unfortunately seen, and are continuing to witness, a deadly new disease is just a plane ride away. That's why the global health security is also a such a critical component of preparedness. Having our public health experts deployed all around the world, an idea, actually that you first raised with me, Dr. Reginald, a number of years ago, to respond to new public health threats where they exist in the country of origin and before they reach our shores is a really good idea. Tom Cole: (14:22) We're likely to never know where the next threat may appear, so ensuring a strategy covering all regions is necessary. I look forward to hearing more about your plans for global health security. There are many other topics I'd like to address today, among them work addressing influenza, combating the opioid epidemic, progress toward treating chronic diseases that threaten our most vulnerable populations, and reducing antibiotic resistance. But as our time is limited, I'll end my statement here and look forward to continuing our conversation. Yield back my time, Madam Chair. Rosa DeLauro: (14:59) Thank you. Yield to the chair of the full appropriations committee, Congresswoman Nita Lowey of New York. Nita Lowey: (15:04) I thank Chair DeLauro and ranking member Cole for holding this hearing. Dr. Redfield and the distinguished panelists, we welcome you. Thank you very much for joining us. Nita Lowey: (15:14) First, Dr. Redfield, I want to thank you for meeting with me last week. We spent more than an hour together, and I appreciate your commitment and your expertise. Two short weeks ago, I planned to raise the Trump budget's continued neglect of CDC, its backward and misguided recommendations to cut chronic health resources and the harsh impact on health outcomes of Americans. After working for more than two decades to restart federal investments in gun violence prevention research, I was eager then to discuss the types of research that may be funded. We would like to hear about progress on other important investments in the fiscal year 2020 spending bill, including a new data modernization initiative, child sexual abuse prevention research, and combating the epidemic of youth vaping. And by the way, that's an issue that is pervasive. I first learned about it from my 15 year old grandchild, that 60% of the class was vaping. And it's not getting better, it's getting worse, but unfortunately today we have a new epidemic on our hands. Nita Lowey: (16:28) One week ago, my home county of Westchester, New York, had its first confirmed Coronavirus case. Today we have 98, with a total of 142 throughout New York State, more than 700 nationwide, including tragically, 26 deaths. This stunning increase requires every level of government to work together, and aggressively to contain and stop the spread of Covid-19. With the recently enacted eight point three billion dollar emergency supplemental, the federal government can aid state and local health departments in assisting patients, and mitigate the extent of the virus. However, due to the Administration's failure to treat this threat seriously, initial faulty test kits, the Administration's slow approvals for laboratories, slow distribution of working kits, more people are likely to be infected, and sadly, we're hearing those statistics. Nita Lowey: (17:41) It is imperative that the federal government have a multi-agency approach to ensure tests are available for all who may need one, without delay. Can't go backwards. Unfortunately, there was a real delay, and that's why it was spreading. Earlier this week I sent a letter to Secretary [Asar 00:18:06], Commissioner Han, and yourself, urging you to use all powers at your disposal to quickly approve qualified labs in New York. Nita Lowey: (18:18) I had a conversation with the governor of New York. They're ready to move. They need you to approve these labs, including hospitals, private labs, other state facilities, and to permit both automated and manual processing. I want to stress that again. If it's taking more time for the federal government to catch up on the state level, this is real solid movement and we need you to approve. Obviously all these labs and facilities have to go through a process, but as quickly as possible. There are labs in New York awaiting approval that could greatly expand testing capacity by thousands per day. I don't know why they're waiting approval. Maybe you can address that in your comments, but that could expand capacity by thousands per day, as may be the case throughout the country, if only the federal government would get off the sidelines and approve these facilities. Nita Lowey: (19:19) So in your remarks, I'd be most appreciative if you could tell me why it's taking so long. You don't have enough people to check the facilities? I don't get it. Or the facility's not adequate, not up to your standard? We need to know. If the word I'm getting from the governor and his staff and the people involved in this issue, that they're ready to move, why aren't they being approved? As Covid-19 comes closer to pandemic status, we must do all we can to protect the public. I look forward to our discussion, and again, I thank you for the personal interaction we had. I appreciated the opportunity, and I look forward to hearing from you, all of you, today. We look forward to the facts, so that we can move as quickly as possible. This is an emergency. Thank you. Rosa DeLauro: (20:11) Thank you. And with the comment I made earlier, Dr. Redfield and from my colleagues, because I want to be accurate. Just a while ago, the Miami Herald, after they published a story right now, the Department of Justice spokesman contacted the Herald to say, and I quote, "The signs shouldn't have been removed. It's now been rectified." So the outcry against that really moved things around. But I wanted to make sure that the record is accurate. Dr. Redfield, your full written testimony will be entered into the hearing record and you're recognized for five minutes. Robert Redfield: (20:49) Thank you very much, Chairwoman DeLauro and ranking member Cole, and obviously Chairwoman Lowey. Thank you very much for letting us here, and all the distinguished members of the committee. Let me first really thank you for your support of CDC. Your investment enables CDC to protect the health and safety of the American people. As we're seeing right now with Covid-19, infectious diseases can emerge anywhere and spread everywhere. We have slowed the spread of Covid-19 to the United States, as a consequence of the positive impact of the investment in public health that has been there at the federal, state, local, and tribal level. CDC has identified securing global health in ensuring domestic preparedness, eliminating disease, and ending epidemics as our top strategic priorities. We've also identified the core capabilities that support the entire agency's programmatic efforts, including the monitorization of surveillance and data analytic systems, the state of the art of laboratories, and the building [inaudible 00:21:58] maintain a premier public health workforce. The rapid response fund that you mentioned, as well as building a solid foundation around the globe to address our global health security threats. Robert Redfield: (22:12) CDC has leveraged every one of these capabilities so far in our response to the Covid-19 outbreak. The president's fiscal year 2021 budget provides seven billion dollars to CDC to support these and other important public health priorities. When it comes to global health threats, though, I believe that CDC is the tip of the spear. As with the defense department having four deployments in strategic regions across the globe, CDC will build a longstanding sustainable regional footprint. This approach will increase CDC's ability to meet the public health challenges wherever they occur. The world depends on CDC's expertise and the state of the art laboratories. The budget does include $10 million to help maintain these laboratory capacity, equipment and specialized training. Robert Redfield: (23:01) The budget also supports the infectious disease rapid response fund, which has enabled CDC to respond immediately to the Covid-19 outbreak, and it also helped us provide a sustainable response to Ebola in the DRC. Like Covid-19, new influenza virus strains can emerge from animals, and spread very quickly among humans. Today, influenza surveillance is being leveraged to ramp up our Covid-19 surveillance. Severe influenza pandemics threaten the lives and can disrupt our health system, military operations, and our economy. The budget includes an additional $40 million to protect Americans from influenza. The budget also includes an increase of 13.6 million to address the growing threat of tickborne disease. CDC's ability to prevent disease, depends on accurate, timely data and the public health workforce that can use that data to predict the next outbreak. Robert Redfield: (23:59) During my time at CDC, we focused on bringing the reporting time to real time. This request supports the public health data monitorization strategic multi-year initiative that brings public health data into the 21st century. CDC relies on data for every important public health issue we attempt to address. The loss of a young mother due to pregnancy complications is another devastating occurrence in a family. The budget includes $12 million to increase and improve our maternal health in America, where every maternal death will trigger a public health response to understand what caused that death, to try to identify important interventions. Robert Redfield: (24:42) Finally, CDC is committed to ending epidemics. The budget includes an increase of $371 million to support the president's initiative to end the HIV epidemic. CDC is deploying proven approaches to alter the direction of HIV infection rates in the United States, as we are doing with the opioid and drug overdose epidemic. Overdose deaths have declined by 4.1% between 2017 and 2018. The budget includes $476 million for overdose prevention, and an additional $48 million to address infectious disease related to drug use disorder. Robert Redfield: (25:21) CDC and our public health partners are the nation's first line of defense against these disease threats. We are committed to working with you to protect the health and wellbeing of all Americans, and I look forward to answering all your questions, including, Chairwoman, the question you asked, I will answer that also. Thank you. Rosa DeLauro: (25:44) Thank you, Dr. Redfield. CDC has been working to respond to Covid-19, including utilizing quarantine authority that hasn't been used in decades. And over the last couple of weeks, though, we've moved from a strategy of quarantine to a strategy of mitigation. People are following CDC's guidance of calling their healthcare provider to get evaluated. Healthcare providers are facing the reality that they can't get their patients tested. Other countries are testing thousands, South Korea testing 10,000 people a day. We are behind the curve. My understanding is that testing kits continue to be distributed. Commercial firms are involved as well. I want to try to keep within five minutes for all of us. Why is the US behind other countries when it comes to testing availability? Why was there such a delay in CDC's ability to replace the test kits sent to the public health labs? And then I have a question that, Dr. Redfield, [crosstalk 00:26:45]. Robert Redfield: (26:45) Thank you very much, Chairwoman. We obviously got first notification of this new disease on, actually New Year's Eve, December 31st, in Korea and China. And the Chinese fairly rapidly published the genetic sequence at the end of the first week of January. We actually worked at CDC based on that, and it created a diagnostic test that really I think tested the first person in January 17th. So fairly quickly, we had a diagnostic test up and running at the CDC, which is our job, to get that technology available for the public health laboratories of the country. And we let them know, and they began sending in samples. I think we had our first diagnose in January, I think it was 21st, from the state of Washington. Obviously at that time, it took time to fly the samples to CDC and run them. Sometimes it was a three day turnaround, four day turnaround, occasionally even a five day turnaround. Rosa DeLauro: (27:47) Excuse me, Dr. Redfield, tell me. Why are we behind other countries, and why was there such a delay in the ability to replace the test kit sent to public health labs? Robert Redfield: (27:59) Yeah. I think we'd very rapidly developed a test. Then we had to expand that test to go to the public health labs. When that was scaled up by the contractor, the public health labs then need to validate it to make sure the test works. When they did try to verify it in their hands that it works, some of the labs found that one of the reagents wasn't working correctly. It's part of our quality control procedure. We then had to tell them to hold off on using those tests for public health. They can still send the samples to CDC. We work to correct it with the FDA. That was corrected in a very short time, and then that was replaced. Robert Redfield: (28:33) I think the most important point about the availability of testing that I want to say, is CDCs focus was to provide testing for the public health system. There's a whole nother system we need testing for, clinical medicine, and I'm happy to say now with LabCorp and Quest, both operational as of yesterday, there's really a laboratory testing availability to any doctor's office that can go through LabCorp and Quest. The CDC's primary job was to get it out to the public health system of this nation. Rosa DeLauro: (29:03) But nevertheless, you've got people who are asking for a test who cannot get a test. The overarching question is, did CDC's delay in producing functioning test kits and its insistence on maintaining a narrow clinical definition for testing lead to an increased transmission in our communities? Did the delay undermine CDC's traditional public health efforts of track and trace? Robert Redfield: (29:29) I'm not willing to concede the second. I am willing to say that we had to go through a regulatory process here to get our test out, and our test was approved for very specific settings. So when the test DOA was approved by the FDA, it was approved for use in high risk individuals that were coming at that time from China. And then later it was expanded to individuals with pneumonia. And then later, as you know, we've expanded now to any physician that feels there's a need or public health person can order that test. But it was a series of going through that regulatory process- Robert Redfield: (30:03) In order that test, but it was a series of going through that regulatory process to get that test available. Rosa DeLauro: (30:06) But I think the conclusion is that we are behind the curve and testing when South Korea can test 10,000 people in a day. If I can very, very quickly if you can. Otherwise I'll come back. You got 2.2 billion for CDC, we want your assurance that the funds will be allocated quickly and we also going to need you to outline CDC's plan for its share of the emergency supplemental and deal with what your top priorities are. What should the American public see in the next coming weeks? Robert Redfield: (30:36) I can assure you we're going to get that money out very quickly and much of it to the state and local health departments to operationalize this. But I'd like Ms. Berger to comment more. Rosa DeLauro: (30:49) Okay, well I don't want, everybody, we got a lot of folks here. Ms. Berger: (30:52) Well, thank you very much for the opportunity and thank you for moving so quickly to provide us with the funding and our top priority is to get funding out to the state and local jurisdictions. Using the congressional language that we received, our top priority is to get 90% of the preparedness grant amount out to the 62 current grantees as quickly as we can and we plan to be able to do that in the next two weeks. Rosa DeLauro: (31:15) Do you have enough resources? Do you have enough resources? Robert Redfield: (31:24) I think the most important thing that you all realize is to make sure that CDC is over prepared for a response not under prepared. Rosa DeLauro: (31:32) Okay. That means resources. Thank you very much. Ranking member Cole. Tom Cole: (31:36) Thank you very much Madam Chair. Tom Cole: (31:41) I appreciate those questions on the testing, they were very much mine as well. So since we've covered part of that, let me ask you something very different that probably be a more pleasant question in some ways. Look, we're not going to cut CDC by $700 million. What this committee will wrestle with is what's the appropriate increase, honestly going forward and what are the things we need to prepare you as best we possibly can to deal with the things like you're dealing with right now. And again, this committee has seen this coming for a very long time. It's been a bipartisan consensus, actually Congress has been ahead I think in this area of of both the last two administrations. So given that you, what are the thing, because we're going to have to ask you this question at some point, what are the things you really need if you had as much money as you would like, as opposed to the budget that you're assigned? Robert Redfield: (32:34) Thank you very much, Congressman Cole. I'm hoping that the legacy for the time I get to lead CDC is really one thing, I help rebuild the core capabilities of the public health system in this country. That is data, not data when I get presented something that I know what happened two years ago, but I want predictive analysis to be the name of the game, not just for CDC, but for the entire public health structure of this country. I need laboratory, we were just talking about to be so prepared that the complexities that we've gone through these last six weeks are not going to be an issue because we've invested heavily in laboratory capacity in the public health labs of this thing. I want to build a public health workforce that right now those of you who know, for example Seattle, where I was just out visiting, King County in Seattle is probably the best public health, one of the best public health, if not the best public health, in the nation. They're struggling right now. Robert Redfield: (33:33) That's not what we need. We need to be prepared. I need the rapid response fund to be robust so that it can really roll out, and finally I need a global health security foundation across the globe that can protect this nation following the regional strategy. That's what I need. Core capabilities and it will help every program. It will help diabetes, it will help cancer, it will help smoking, it will help infectious disease. That's what I need. Tom Cole: (33:58) I would suggest in the interim, because again, building a budget takes time as everybody up here knows, that you work with us to put dollar figures to those kinds of, so we can, chair's going to have difficult decision, our counterparts in the Senate will, but I'll make a bet the budget for this agency is going up, not down. And so the critical thing for us is to work with people that really know what they're doing honestly, so we can get you those dollars in the appropriate amounts so we can go forward. Second to area, and again, not to beat on you in a for a budget that I know you don't agree with, but I was disappointed to see the Good Health and Wellness in Indian Country Program, one of the only programs that funds public health in native areas, once again proposed for elimination. Tom Cole: (34:44) Let me just assure you that isn't going to happen. And I know your own commitment in this area. So I suspect I know where that proposal came from, but I would like you to expand on what you think we ought to do because every set of statistics we have puts Native Americans last and just about every health category and risk and this is everything from trying to make the Indian health service more robust, but also this is a unique population in some ways. It has some special challenges. What do you think we ought to do to try and end that disparity again [inaudible 00:35:20]. We have lots of minority population. My good friend, Ms. Lee always points this out, appropriately so, with African Americans too. But these, we need to try and erase these disparities. Robert Redfield: (35:34) Thank you, Congressman Cole. I think you know my personal views on this. We're continuing to make progress, we think that the Good Health and Wellness Indian Country Program is obviously extremely important. It supports 27 tribes, urban Indian organizations, and throughout our country. Obviously there's key areas of critical importance in chronic disease, opiate, injury, environmental health issues. There's been a movement as you know, to the American Health Block Grant and the Public Health Data Monitorization Initiative. Both of these, I think can really help to support. I think we're trying to move away from disease specific interventions as opposed to allowing the community to travel, community health to look and see what are the really important health issues that they need to address and then appropriate the resources in that regard. But it obviously it's an important area that we also would like to see continued to be effectively. Hopefully there'll be more flexibility and maybe some gain in efficiency, allowing the local groups to decide exactly how to invest the money in chronic disease rather than saying they have to do with this for this, and this for this, for this to this. That was our attempt, sir. Tom Cole: (36:52) Thank you very much. Thank you Madam Chair. Rosa DeLauro: (36:55) Congresswoman Lowey. Nita Lowey: (36:56) Dr. Redfield, as I mentioned, as you know in my home county of Westchester, New York, 98 cases have been confirmed in just one week. New York is trying to take aggressive steps to combat the virus by increasing testing capacity, has asked the federal government for approval to use qualified hospitals, private labs, additional state facilities to process tests. How many test kits does the CDC had the capacity to deliver on a daily basis? And how is CDC and FDA working to increase testing capacity in state? How long will it take for these facilities to be approved? And how long does CDC believe it will take until a rapid response test is available for health providers? I got the impression that CDC was a stumbling block and New York was raring to go and producing these kits and they didn't get approval. I won't tell you the other things I heard. Robert Redfield: (37:58) Thank you for that. I've probably heard them all times 10, okay. First let me tell you that I've worked very closely with Howard Zucker, your health commissioner in Albany. February 29th he requested that he could co use our EOA to bring up the Wadsworth Lab, FDA approved it the same day, February 29th. Actually we were on the phone last night because he's one of the first state labs now to try to go to a much more automated, what we call high throughput system, because we can't just do it, they have to verify. I'm hopeful that the verification run that should have been completed last night and they'll be the first public health lab to be able to use the very high throughput system. Secondly, I want to say the same day, February 29th, the administration gave regulatory relief to any CLIA approved lab that wants to develop the test, to develop the test and use it. So there's no delay from the United States federal government perspective. Robert Redfield: (39:03) Some major medical centers, for example, in the State of Washington and others are up and running and doing their tests. All they have to do is be CLIA approved to do clinical testing, and then they have to verify themselves that the test works. They have 15 days afterwards to file the EUA, so that they can actually go forward on February 29th if they chose to go forward and develop that test. Third is, we've worked, there are three New York labs that have requested testing from CDC and we have provided it and we will continue to provide what they request. They make a request to IRR how many kits they want shipped out, they're shipped out to them. Fourth and most importantly, was the decision of the diagnostic industry. In a meeting we had with the Vice President and all the leaders, they didn't come together as independent companies. They came together all together and said, "How do we help get diagnostics throughout this country?" And I know the two big ones, major LabCorp and Quest are operational as of yesterday in doctor's offices throughout this country. Nita Lowey: (40:11) Oh, I have a minute and a half. I'll talk quickly. Robert Redfield: (40:16) They tell me they speak shorter. I know, it's hard for me that I'm trying for you chairwoman. Nita Lowey: (40:18) I know it's hard. One of the reasons COVID-19 appears through spread so substantially in New York has had a patient was being treated for several days in a hospital before he received the correct diagnosis. We now know that healthcare professionals working in that hospital as well as two other area physicians, have tested positive. We're already facing a nursing shortage. I'm very concerned about our health workforce and whether the health care system will collapse under its own weight of nurses, doctors, and other health professionals and not protected. What guidance is CDC providing to healthcare providers in particular emergency departments to minimize the number of personnel exposed to COVID-19. I guess we have 55. Robert Redfield: (41:06) We have a guidance and I think, correct me, I think our updated guidance is going out today on infection control procedures. I will say one of the greatest vulnerabilities of this nation right now is nursing homes. CMS recently uped the resources. They actually have all their inspectors now told not to worry about all the other stuff they inspect for, all they want to do is infection control, infection control, infection control. This is a critical issue. In the state of Washington there's 600 healthcare professionals that have been exposed in the state of California, 600 exposed. We don't have that much redundancy to have that many. So it is critical. I will say, one thing I want to say that I think is important, this epidemic started in China. That was helpful for us because we knew that was the risk. 99% of the cases that occurred last night occurred outside of China. Robert Redfield: (41:58) This isn't China. Right now the epicenter, the new China, is Europe and there's a lot of people coming back and forth from Europe that are not starting to see these communities and we are moving quickly to understand how to address Europe. But that's why you're seeing more in New York. That's why we're seeing more. Again, we're going to try to really reinforce that early consideration of coronavirus and treating individuals as if they have coronavirus is what the hospital system has to do. I think the diagnostics now have penetrated to the degree that clinicians will get a very timely diagnosis. Nita Lowey: (42:36) Let me just say quickly in conclusion, I would hope based upon these particular incidents that all those in the emergency room, this seems so basic, are tested before they see a patient because it was shock, some of the stories we've heard a really shocking. Thank you. Thank you Madam Chair. Rosa DeLauro: (42:55) Congresswoman Herrera Beutler. Congresswoman Herrara Beutler: (43:06) Thank you so much for coming out to Washington state. I joined with you and Vice President Pence and almost our entire delegation to come out, and I appreciate your willingness and readiness to be available to our public health workers all the time. All the time. I'm sure you're enjoying the time delay that we experience. We're very grateful for that, and a shout out to our public health workers. I do think that Washington state's public health system is, I think it's the best in the country. And as you said, we are struggling. I wanted to bring up a couple of questions to clarify. So I know CDC is partnered with a private manufacturer to make test kits available and the amount of kits is increasing exponentially, it's happening now. That being said, I find it interesting that when my colleagues who are in contact with someone who later tested positive were able to get tested almost immediately and quickly receive their results, while folks in my district and across Washington state are unable to get their testing results back. So I do find that people are now getting tested, and I was on the phone with one of my local public health agencies yesterday. Congresswoman Herrara Beutler: (44:15) But what I'm being told is, so if they go, so we're trying to get people into the University of Washington. But people who go locally, they get them and it goes to the state lab, there's still a delay. I mean we've been waiting for about five tests for a number of days. Every day, the headline is, "Still waiting for the test results." Could you quickly speak to that? Robert Redfield: (44:33) [inaudible 00:44:33] question, and it's why I hope in the time I get, I accomplish what I want in building core capability. These public health labs need redundancy. They don't have it. This is when I go back about the core capability of data lab people, rapid response fund, and the global health. The truth is we've not invested, we've underinvested in the public health labs- Congresswoman Herrara Beutler: (44:56) So there aren't enough people to run the test? Robert Redfield: (44:57) There's not enough equipment, there's not enough people, there's not enough internal capacity, there's no surge capacity. Congresswoman Herrara Beutler: (45:03) So we're being told that they also, so even the UDaB, so UDaB can process about a thousand a day and there's capacity there if the clinicians will send it there versus public health, but does UDaB then also still have to be validated by the state? Because we're being told that. Robert Redfield: (45:17) All UDaB, which they've done, had to do is live on the 29th when the regulatory relief has done and they are CLIA approved lab, they just had to develop their own test, they didn't have to use CDC's, we've published exactly how to do it so anybody can replicate it. All they have to do is run to make sure their controls work, they don't have to send it to us, they don't send it to the FDA. Congresswoman Herrara Beutler: (45:39) Completely decoupled then. Robert Redfield: (45:40) They go. In 15 days they have to file to the FDA. I want to say one thing about that, why it's important, why are they different? The public health labs, we built the technology in those labs to monitor flu. That uses a certain equipment, which we call a thermocycler. That equipment, maybe a good lab could do 300 tests a day. University of Washington can use these high throughput machines like New York is about to do. Those machines can do thousands, and thousands, and thousands. They are converting to those high throughputs, but the public health system has never had the equipment to do the high throughput. Congresswoman Herrara Beutler: (46:20) Okay. I apologize, I have to reclaim because we don't have a lot of time left. So there is a lab in my district, so I'm grateful that Quest and LabCorp are coming online, that's important. I have a lab in my district who has worked with CDC on HIV Well and they have found it impossible to get in contact with CDC on COVID-19 testing. Due to the fact they weren't able to get samples back from CDC, they had to resort to getting their RNA samples from Israel. Now I know there are smaller, and UDaB actually in the beginning days had some of this challenge, they had to develop basically their own tests, they went through it all themselves, I know that the administration has been working with the big guys to get them going for capacity purposes. I would be grateful if they could also be responsive to some of the smaller guys, because in the rural areas we just need more people and if these labs are willing to do it, go ahead. Robert Redfield: (47:11) Congresswoman, if you gave me the specifics, I'm happy to look into it. Congresswoman Herrara Beutler: (47:14) I will do that. I will do that. The one last question I had, and I'm sorry I'm breezing through this, has to do with nursing home guidance. I know that Seema Verma has, and the administration has a new focus on enforced protocols. Had people been following protocols we'd be in a better place today. However, what I'm hearing at the ground level is yes, things go up on a website, but my local public health said, "I don't have the capacity to go into every single home and make sure everybody's doing," I'm paraphrasing. How can we help make sure that the nursing homes in our communities right now today are getting the information, and are at least communicating about what they're going to need or what they will need and and how can you help with that? Robert Redfield: (48:01) We've put together specific guidance and we will continue to try to make sure I know Seema and CMS is going to be aggressively making sure each of the nursing homes are up, because this is our vulnerability. When you see tragically the 27 people that we've lost and I think 23 of them have been in your state, and many of them had been in that nursing home. So this is a really a priority to get that up and running, infection control up and running, provide the technical assistance. This is our number one vulnerability right now. Congresswoman Herrara Beutler: (48:36) Thank you. Rosa DeLauro: (48:38) Thank you, Congresswoman Roybal-Allard. Congresswoman Roybal-Allard: (48:42) Welcome and thank you for being here. During the time that I've been on this subcommittee, we have justifiably double the NIH budget once and are on a trajectory to do so again. However during this same time period, the CDC budget has remained relatively flat, despite the fact that credible research has shown that every dollar invested in public health results in 67 to $88 in benefits to our society. CDC funding is critical for maintaining infrastructure at state and local health departments. Over the last decade, our failure to robustly fund the CDC has resulted in our local and state health departments losing 25% of their staff since 2008. If there has been a failure in our coronavirus response, I do not believe that it reflects on the competency and effectiveness of CDC, but rather on our chronic underinvestment in the public health system. Congresswoman Roybal-Allard: (49:48) That is why I strongly support the 22 times 22 initiative to increase the CDC budget 22% by the year 2022. I'd like to take this opportunity to give you another chance to share your professional judgment about public health funding. What do you consider to be the greatest funding needs for the CDC right now and is our current level of investment enough to ensure the best federal, state, and local response? Not only to the coronavirus but also while responding to a public health emergency such as COVID-19, do you have the capacity to maintain responses to the ongoing substance abuse epidemic, maternal mortality, health crises, hepatitis outbreaks, and of course addressing chronic disease such as asthma and diabetes? Robert Redfield: (50:52) Thank you very much. Thank you very much, Congresswoman. It gives me a chance to reinforce once again what my goal is as CDC director and that is to rebuild the public health infrastructure, not of just CDC but of the whole nation. As you know, about 70% of the funding that is appropriated to CDC is used to go out to the state local tribal health departments. We provide the funding really for the backbone of public health across this nation. Like CDC, the state, and local, and territory health departments are underfunded and I want to rebuild the core capabilities so that we have data and data monitorization. Wouldn't it be nice if we had a data system that every health department in this country right now could see in real time, so that we could predict what's going on, and where to go, and where to put assets. We don't have that. Robert Redfield: (51:45) Wouldn't it be great if we had the redundancy in our labs, so we're not arguing about whether they can use a high throughput system because they don't have the technology to do a high throughput system. These labs need to be equipped, not at CDC and New York and California, but the whole country. We need to basically get more people into public health and get programs there. We need that rapid response fund at an area that we can really robustly respond and not try to make priority choices, how we're going to use the money that we do have. And finally we need to build a robust global health security network throughout the world. I've got a plan to do eight to 12 regional centers that have full capacity so that we can detect, respond, and prevent infections at their source, rather than have to deal with them at home. That to me is the most important, because if we have that all the health departments are going to go up. All the health departments, and all of your own jurisdictions, I guarantee you if you go talk to them, they're underfunded. Congresswoman Roybal-Allard: (52:49) Just to follow up to what you've just said, by the end of 2020 it is estimated that the percentage of health agency employees eligible for retirement will reach 25%. So what level of investment do we need to train and hire the next generation of public health professionals? Robert Redfield: (53:10) That is one of the critical core capabilities. I would like to get back to you with more specifics in that exact arene we were challenged to come up with a very specific budgetary requirements to do with this, but it is critical. We have one program that I just mentioned briefly that my predecessor, Tom Frieden started, which I think is really an important program. It took young people out of college and gave them two years, it's called the Public Health Associates Program, and then put them into health departments all across the country that wanted them. So now you get young, energetic people at the beginning of their career, not quite sure what they want to do, and they see the gift, what it is to do public health. It doesn't necessarily come out that way probably when you read a career magazine, but they get out there and they practice public health and a number of them then say, "I want to go on to medical school or public health school," and a number of them are actually working at CDC today. Expanding those programs to get young people to see the value of a career in public health I think is critically important. And then obviously to be able to continue to retain the individuals that we have. But I think Tom Friedman's Public Health Associate Program is a really important thing for our nation. Rosa DeLauro: (54:25) Congressman Harris. Congressman Harris: (54:29) Thank you very much, Madam Chair. Thanks for taking time to appear here because you're probably a one armed paper hanger right now running around doing things. Let me just ask, let me follow up just on that global health security network issue. We could have all the global health security we want, but when China denies the presence of the disease, for what a month, month and a half, what effect does that have? The bottom line is that we know that the fatality rate in China is probably higher than it's going to ever be here in the United States. What protections do we have against a bad actor like that? Robert Redfield: (55:16) Congressman Harris, I just think if we have these regional presence of strong teams, it's going to give us more eyes on the ground of what's actually going on. Nothing's going to be perfect. This particular outbreak started in a certain area of China. I know I've had direct contact on either New Year's Eve or the day after with my counterpart head of Chinese CDC. I don't think he was in the light that he had a problem in early December, so I can't really comment of how the local health department in Wuhan, and how that was shared. I know that as soon as he knew, I knew. Congressman Harris: (56:04) Well I'll just stop you there. They arrested the physicians who, literally arrested the physicians, who tried to talk about this new disease and how bad it was. Again, we just need to be protective here, but if we think we're ever going to get into that closed system and somehow affect it, no, the communist Chinese are going to have going to continue that system, and we're just going to have to live with it. Now what's interesting though is one of the things that I hope you do as your advocates for the innovation that we're going to need to deal with these kinds of new viruses, both on the vaccine front and the antiviral front, and I know your background is in virology. This idea that we produced an MRNA based vaccine and got it delivery to the NIH in six weeks from conception is phenomenal. But it's an American company that has not had a profit for 10 years developing this platform. If this vaccine works, we will owe it to American innovation. And yet, bills like H.R.3, I think will destroy American innovation. So I'm going to ask you, how important is the private sector innovative process both for this and for antivirals, and for treatment when it comes to these kinds of public health threats? Robert Redfield: (57:28) Yep. Thank you, Congressman. It's obviously fundamental and critical, and I'm going to give you the biggest example for me where it's antibiotic resistance. We have a program right now and you know this, you're a physician, that really looks at surveillance and containment, but we're never going to win that. It's a containment strategy. The only way we're going to win it is new innovation. So innovation's fundamental for us to stay ahead of antimicrobial resistance for us to be able to rapidly respond, NIH and Tony Fauci's group's able to do now in six weeks, which normally would have taken the 12 months or more. So innovation has to drive and if we lose innovation we're going to lose our ability to maintain the advances we have in clinical medicine for antibiotic resistance, they're going to go aside. Congressman Harris: (58:17) Sure, and we made that point when H.R.3 was being considered that, and even the CBO agreed, that there were probably a dozen diseases that we would not be able to develop treatments for if in fact we punish innovators in this country. Let me talk about one last and bring it around back to the testing issue. Because one thing you said, and I'm curious about this just from a public health perspective, is that Quest and LabCorp now are geared up to do this. Could they have geared up sooner? I mean because you imply that we have to have a parallel track, we have to have this one system that is for public health bodies and then this other system for the private sector which it sounds like is you know was ready to go and probably, because there is a profit motive, they're ready to go much quicker. Is that a model we should be looking at in the future in fact to do public private partnerships with some of these companies that have the ability for rapidly gearing up and then make these available to the public health sector? Robert Redfield: (59:16) My point that I wanted to make clear first is what CDC's responsibility was, the public health side. That said as a clinician like yourself, I guess I anticipated that the private sector would have engaged and help develop it for the clinical side. CDC has tried to help because the tests that we did develop IDT asked the FDA if they could now actually commercialize it, and we said it's fine by us, they can do our EOA. But I think those decisions on the commercialized section, I mean, we do have a groups that can fill gaps, BARDA for example, if they see a gap, they can begin to try to promote that. But I think- Robert Redfield: (01:00:02) ... with that, but I think... I can tell you having lived through the last eight weeks, I would have loved the private sector to be fully engaged eight weeks ago. Dr. Harris: (01:00:10) Yeah. I think we have the wrong agency I guess to ask that question here. Thank you madam chair. Nita Lowey: (01:00:16) Congresswoman Lee. Barbara Lee: (01:00:18) Thank you very much. Good morning. Thank all of you for being here and thank you Dr. Redfield for being here and for really your tremendous leadership and all of you. These are very challenging times but you all have stepped up in so many ways. Let me ask you first of all, with regard to hand sanitizers. I'm not sure and I'm trying to unpack how we move forward on this, but I know that and we all know that one of the prevention strategies is to wash hands 20 seconds. If in fact we don't get to wash our hands, we use hand sanitizers, right? That's part of the directive. Barbara Lee: (01:01:03) Now, unfortunately you can't find hand sanitizers, this small one I have... Fortunately I had another one at home, so I just fill it every day. I've been in three cities in the last 10 days. Nowhere can I find hand sanitizer. So what in the world is going on and how do we make sure that hand sanitizers are available? I mean unhoused people need them. There may or may not be water around. So people who just don't have a lot of money, vulnerable populations, if they were around, they probably couldn't even buy hand sanitizers. In fact our healthcare workers, our medical professionals on the front line. So what in the world is going on and how do we wrap our hands around this so that we can make sure that the directions we received from our federal government can be adhered to? Robert Redfield: (01:02:03) Thank you, Congresswoman Lee. Obviously, important and we've seen the shelves. This isn't an area that we drive. But I can tell you the inter-agency working group is looking at a variety of different things to figure out where the shortage is and what they can be done. Whether it's respiratory mask or medicine or hand sanitizers. I can get back to you exactly. But I do from a public health point of view, at least remind people that 20 seconds of vigorous washing with hot water and soap is going to work. There are people looking to track where is the supply issue here and I can get back to you to [crosstalk 00:02:41]- Barbara Lee: (01:02:41) Yeah, could you please? Because a lot of people don't have access to warm water and soap. Robert Redfield: (01:02:45) I understand that. Barbara Lee: (01:02:45) We need to know that. Robert Redfield: (01:02:51) I'll get the information for the inter-agency group and make sure it gets back to you. Barbara Lee: (01:02:54) Okay. Thank you very much. The second question I have is on the Grand Princess. First, thank you for your assistance with regard to this very challenging public health emergency and operation that is taking place in my district. I know CDC and HHS... I think HHS has been in the lead with our governor's office. Could you clarify what role CDC has in this entire operation and what do you think in terms of timeframe, how long it's going to last and what have you learned in the last 24 hours since people have been disembark? Robert Redfield: (01:03:25) So the operational lead, the mission leader is ASPR. It's actually an assistant secretary, Robert Kadlec. He's in charge of the response. We provide technical assistance and support under his direction to the response. We obviously also are going to provide some technical assistance support as these individuals move to housing, either at Travis or Lachlan or in Georgia. But the operation is really under control. Probably most importantly we make sure infection control issues are done right and we are the agency that gives the federal quarantine orders. Barbara Lee: (01:04:08) Okay. But are you the agency that monitors the whole public health criteria and protocols as it relates to the health and safety of the dock workers, the health care workers, the crew, the passengers, the community? Because where the ship is being docked is in an area in my district where historically we had to deal with environmental racism and injustice. So naturally we want to make sure this is not another one of those instances where we will unfortunately feel the impact. Robert Redfield: (01:04:40) We provide the technical assistance to the assistant secretary for response and preparedness. Our technical assistance is highly respected within the department, but they're ultimately in charge. But we're there to provide that- Barbara Lee: (01:04:57) Who signs off on the health and safety, public health and safety? Robert Redfield: (01:05:01) Ultimately it would go back up to the assistant secretary's office. Barbara Lee: (01:05:05) The assistant secretary does. Okay. Okay, I'll ask my next question go round madam chair. Thank you very much. Nita Lowey: (01:05:11) Congressman Pocan. Mark Pocan: (01:05:14) Yeah. Thank you very much Madam chair and thank you for being here. I got a lot of questions, so if we can be succinct, that'd be great. I did a Facebook live town hall on Sunday and we had several thousand views in the first hour and a lot of people asking questions. First of all, obvious we're not cutting your budget. That's why we brought you here. I just wanted to say that. Now let's go to what everyone's asking about. Are we past containment? Is this strictly mitigation at this point, just yes or no Robert Redfield: (01:05:37) In different areas. We're in a containment in certain areas. I would say in general, we're in a containment blended mitigation, in some areas we're in high mitigation. Mark Pocan: (01:05:49) Okay. When you say nursing homes, does that include assisted living and other senior living housing area? That's a question that people have asked. Robert Redfield: (01:05:57) Yes. Mark Pocan: (01:05:58) Okay. Thank you. Succinct is great. Yes is a great answer. Want to ask the Friday press conference, the president interrupted you and said, anyone who wants to get tested can get tested. Is that true right now? Anyone who needs to get tested can- Robert Redfield: (01:06:12) You can go into a doctor's office- Mark Pocan: (01:06:13) It's a yes or... Really, you don't have to give me a long answer. Just can anyone get tested right now anywhere in the country. Robert Redfield: (01:06:17) Through a physician. Mark Pocan: (01:06:19) You can, yes. Robert Redfield: (01:06:19) Through a physician. Mark Pocan: (01:06:19) But is that a yes through a physician? Robert Redfield: (01:06:20) It's a yes through a physician. Mark Pocan: (01:06:23) Thank you. Great. I wrote you a letter last week. You quit keeping track of how many people were tested on the CDC website. I think that's a bad idea from a number of conversations. You don't know what you don't know, which is why we wanted to keep track of those tests. We had a secretary Azar as of this morning, say he doesn't know how many people have been tested in this country. That was an article at 10 to 10 on CNN. Why are we not keeping track of that and why are we only updating the CDC website now three days a week? World Health Organization does it daily and this is information people really want to know. Robert Redfield: (01:06:57) Yeah, we're doing it every day now and we're actually got a new reporting system that includes CDC, public health labs. We're going to get direct dumps from LabCorp and Quest. So people are going to see all the tests done, where they're done. We'll have a surveillance system that does that. Mark Pocan: (01:07:12) So the answer from yesterday, about three days a week is already old dues [crosstalk 00:01:07:15]- Robert Redfield: (01:07:15) [crosstalk 01:07:15] every day. Mark Pocan: (01:07:15) Thank you very much for that. Appreciate that. Ron Clean and others have said we should be proactively testing Dr. Fauci agreed. Anyone in a hospital with a monomial like symptoms as well as healthcare personnel. Are we now actively proactively testing folks like that and have a policy of proactive testing? Robert Redfield: (01:07:35) We are recommending to physicians at anyone that has a variety of clinical scenarios to be tested. Mark Pocan: (01:07:42) How aggressively though are we [crosstalk 01:07:43]- Robert Redfield: (01:07:43) We're aggressive now. I mean I think- Mark Pocan: (01:07:45) But we are proactively testing. Robert Redfield: (01:07:46) We're proactively in individuals with pneumonia or respiratory illness. It does vary by community where we have significant community spread, it's- Mark Pocan: (01:07:56) The recommendation is proactively testing health professionals as well? Robert Redfield: (01:07:59) Not necessarily all healthcare professionals, if they've had an exposure to in a hospital where we've known cases. Yes. Mark Pocan: (01:08:05) Okay, and how about police officers? Robert Redfield: (01:08:07) Again, we're seeing as we've seen in Washington, that's one of the things in my trip that really surprised me. How many firefighters were no longer available because they were in 14 day quarantine. So again, it goes with exposure. We're trying to... We have increased awareness of how to approach a patient so you don't get exposed. Mark Pocan: (01:08:24) Gotcha. Okay. How about a question on the tests going back. Other countries use the World Health Organization test. Why did we not use that test and who made that decision? Robert Redfield: (01:08:37) Again, as I tried to say, our tests was probably created as fast as anybody's test in the world. Mark Pocan: (01:08:42) I get that. Robert Redfield: (01:08:44) Okay. WHO doesn't actually make a test. They have one of the German universities had made a test so again, and that test would then had to come here and go through regulatory review. I think our tests was a much quicker than they would. I would defer that question though to the FDA and [crosstalk 00:01:09:01]- Mark Pocan: (01:09:02) Okay. I have them in committee tomorrow. I will ask them that. Thank you very much. Another question, there was an article over the weekend, I'm going to pull it up. I don't mean to be rude if I'm not looking at you. As saying that CDC recommended seniors not travel and then it wasn't part of the White House task force recommendations. Vice president Pence said it was never a recommendation to the task force and the story was completely fiction. Did the CDC recommend that older Americans not travel? Robert Redfield: (01:09:35) CDC now recommend- Mark Pocan: (01:09:36) Did they recommend at this point is the question. Robert Redfield: (01:09:37) At this point- Mark Pocan: (01:09:39) Not at this point. At that point, did you recommend to the task force? Robert Redfield: (01:09:43) I don't know exactly when that was. Mark Pocan: (01:09:45) Over the weekend when there was a report that did say it and they're saying that CDC recommended it. At what point did CDC recommend seniors not travel. Robert Redfield: (01:09:53) Probably in the last 72 hours that we recommended. I can get back to you with the exact date and time. We do recognize that not [crosstalk 01:10:01]- Mark Pocan: (01:10:00) I don't want to have to do Freedom of Information Act request. Robert Redfield: (01:10:02) You won't have too [crosstalk 01:10:03]- Mark Pocan: (01:10:03) But I really love to know when it was recommended by CDC because there's a real distrust out there right now and they don't know who to distrust cause we're not getting information. This is one where right now I'm trying to convince my in laws not to travel to Las Vegas tonight. They're both in their 70s and one is health issues. These are the questions we're getting asked in Facebook live town hall. So when someone says it wasn't a request and now I see you are recommending it, I would like to know when it was requested and if I need to make a formal request. Robert Redfield: (01:10:32) You don't need freedom... We'll get the information back to you sir. Mark Pocan: (01:10:34) All right. Thank you very much. Is that my time? Oh, I'm sorry it went that quick. I apologize. Thank you very much. Nita Lowey: (01:10:41) Congresswoman Frankel. Lois Frankel: (01:10:43) Thank you for all for your work. I agree with my colleagues about we should not cut your budget. First of all, I want to just say and I'm sure you would agree with this. You said that this virus is expansive in Italy and South Korea. Now in this country, it is absolutely wrong and inappropriate to call this the Chinese coronavirus. I assume you would agree with that. Robert Redfield: (01:11:08) Yes. China was the first phase. Korea and Iran was the second phase with Italy. Now all of Europe. I mean, if you looked at even just last night, I think if you have a second. Just over the last 24 hours there was almost 1,500 new cases in Italy, 1,500 Germany. Lois Frankel: (01:11:27) Okay. But thank you. You answered the question. Thank you. There's been some other real misleading statements that are wrong. I'm going to read some, if you agree with these statements, just let me know. Our tests have been perfect that the coronavirus, is like the regular flu, that it's a hoax. That anyone who wants to be tested, can be tested. That the number of cases will soon be down to zero. Then magically disappear. You could still go to work and it's okay to shake hands. These will be misleading since I'm not hearing anyone want to correct that. I'm assuming that you would agree that those are misleading statements. Robert Redfield: (01:12:08) I don't think I heard any that I would say is not. Other than that, I do believe that availability of testing in the last two days through Quest and LabCorp is finally getting us where we need to be. Lois Frankel: (01:12:21) Okay. Thank you. There was a new... I just want to ask you, are you familiar with the public charge rule, the new public charge will? Robert Redfield: (01:12:30) Yes, I am. Lois Frankel: (01:12:31) I'm concerned that it might lead people not to go to get the care they need. Could you respond to that? Robert Redfield: (01:12:37) I would concur with you. I've talked to some of your colleagues when we were on the trip in the State of Washington. They brought this and we are looking at it to see its public health implications. Lois Frankel: (01:12:47) Okay, thank you very much. So would you say we were at the beginning, the middle, or the end of this coronavirus fight in United States? Robert Redfield: (01:12:55) I would say I can't predict. Lois Frankel: (01:12:57) Okay. Can you say, what percentage of Americans you think you are predicting will get the coronavirus? Robert Redfield: (01:13:04) I think it depends how effective our public health responses right now. I do want to state one thing. We all have a role to play and it's really serious when we say to practice, the washing of the hands, cough in your elbow, then try not to touch your face. I know I probably... They're going to count how many times I did on this, but it's very hard. But you've got to try not to. And then I think if you're sick, stay home, please stay home. Lois Frankel: (01:13:27) All right. Okay. Well, did any health agency recommend to the White House that people over 60 should not fly on planes? Robert Redfield: (01:13:38) I don't know the exact age. I'll get back to you, but we have recommended that the elderly and vulnerable, including children with chemotherapy and others should really reconsider at this point travel. Lois Frankel: (01:13:49) What is the age of elderly as you many of us leave the room? Robert Redfield: (01:13:55) I didn't define it, but I will tell you that in the discussions we have, the individual brought it up. Did say it was a year older than they were. Lois Frankel: (01:14:04) What is that age? Robert Redfield: (01:14:05) Right now we've been looking at... The data we've been looking at... Really, if you look at the data, the average age in Italy of death is 82, 83, 84 years of age. It's really the data that the ambassador Burkes has gotten from China, Italy, Korea, and our own nation looks like 65 and above is where most of the people are that are dying. Lois Frankel: (01:14:26) All right. One of the concerns I know we have especially in these nursing homes, everybody is getting sick including the care providers. What is the level of your concern about us having enough care providers to take care of people as this disease spreads? Robert Redfield: (01:14:45) Yeah, this is the important of what we've talked about before. Being over-prepared. If you're over-prepared, the ability to protect the healthcare professionals and not just the healthcare professionals. I think the congresswoman knows that in Washington, one of the places, they don't have firefighters, their firefighters are on quarantine, self isolation. So we have to be over prepared to respond to these outbreaks, not try to catch up. Time matters and infectious disease. We have more time in environmental disasters like hurricanes and flooding, than we do when it comes to an infectious disease. Infectious disease, if you're a week late and some of you have criticized about the testing or whatever, it matters. Lois Frankel: (01:15:29) So let me... I'm running out of time. We have another round coming. Okay, one more question on this round. So I have some friends or people who are self quarantined hating themselves. We've read about it in the paper and so forth. So you get exposed, you self quarantine for 14 days. Is that right? Is that because you can have the... Is that how long you have the disease for, 14 days? Robert Redfield: (01:15:50) Yeah. Right now the average incubation period from infection to symptoms is 5.2 days. Lois Frankel: (01:15:55) Okay, but how long does the disease last once you get it? Robert Redfield: (01:15:58) Well, it varies. If you do get it... But you'll... If you get exposed, you will develop symptoms within those 14 days and be able to then either be diagnosed. If you stay in asymptomatic, we have no evidence that you still shed virus longer than that. Lois Frankel: (01:16:15) But if you self quarantine for 14 days, you come to work and then you meet somebody who else and you get exposed again. Then you might have to self quarantine yourself again, which means that we may all be in a process of self quarantining. Robert Redfield: (01:16:32) You sound like what my wife said this morning. We fully intend... I do believe if we're all in this together from individual citizens all the way up, we have a great public health department. We still want to stay with our early diagnosis, public health isolation and then aggressive use of mitigation strategies. We're in a fight to basically stop this outbreak, at least for now. Many of us are hoping, not knowing, hoping that this will follow the pattern of flu and other respiratory viruses. That means the transmissibility in our environment might change. Robert Redfield: (01:17:09) It is interesting that when I look at the cases around the world and I sensor out all the exports cases and I sensor out all of the contacts of exports and you look in the southern hemisphere, there's very few cases in the southern hemisphere right now. It's a great possibility that might change just like as flu changes. So I think we need to stay the course, be aggressive. This is again why I think being over-prepared is where the posture we want to be in. This is why the supplemental you did in such a fast way, on a bipartisan way. It's so important to us because it gave us resources now to scale up. Nita Lowey: (01:17:43) Congresswoman [inaudible 01:17:48]. Cheri Bustos: (01:17:47) I think you're getting garbled there. Dr. Redfield. Thank you for your willingness to hop on the phone yesterday with me. I know the White House called you away, but I do appreciate your willingness to take a little time. So, I'll start with some of the questions that I was going to ask you yesterday. Oh no, obviously the White House was calling, so I got bumped. That's all right. Is this a pandemic? Robert Redfield: (01:18:14) No, I think the word I think is really not important. Usually the WHO is the jurisdiction that makes that call, this is clearly a massive global outbreak. Cheri Bustos: (01:18:25) Okay. So I know that chairwoman Lowey started out focusing on where she's from, New York city. I'm from a very, very different part of the country, a very rural district that I represent in the Northwestern corner of Illinois. In fact, 11 of the 14 counties in my district are almost entirely rural. So as you can imagine, my office is taking the necessary steps to prepare for cases and we're doing what we can to make sure that we're filling in people with what we know. So we have been in communication with all of our hospitals, our community health centers, our county health departments, et cetera. So one of the concerns that has been shared with us through this outreach is how the virus could increase provider shortages, especially in rural areas. So let me just give you an example to back up a little bit. Cheri Bustos: (01:19:20) One of the counties in my congressional district is called Henderson County. We have a patient to physician ratio of nearly 7,000 to one. If you want to compare that to Cook County, that's about 1200 to one. So you can imagine if rural doctors need to isolate themselves due to coronavirus exposure, there are limited options for our people. So I'm just wondering if you could offer in anybody at your table there will maybe give other folks that opportunity to answer this as well. But what steps can rural communities take to continue treatment if their providers get sick and cannot see patients? If you have any advice specific to more rural parts of our country. Robert Redfield: (01:20:00) Any of you want to make a comment? I'm happy to make a comment. Cheri Bustos: (01:20:02) Please. Robert Redfield: (01:20:02) This is an issue. This again is why we've heightened the area of infection control. Because as we've seen now in Washington and we've seen now in California, we got 600 healthcare providers out of work in both of those environments. That's causing strain. The source for most communities. If this is going to happen, it's probably going to be a nursing home. And then they go into the hospital and then the hospital... You don't have diagnosis. Someone gets sick from the nursing home because someone came in and visited who just came back from Italy. They visited their sick mother in the nursing home and then they got sick and went in the hospital and then boom. Robert Redfield: (01:20:43) So I think we just have to be aggressive in the infection control and work hard because this is what happened in Wuhan. That's why the mortality was so high. They had 130 infection beds when they started. They had over 20,000 within about four weeks. But do you know what they didn't have, they didn't have doctors and nurses and equipment to staff this 20,000 beds, their health system fell apart. That's why the mortality was so high. Cheri Bustos: (01:21:09) Are rural areas more at risk for something like this? Robert Redfield: (01:21:12) Well you may have the benefit of being more isolated from a large population. So, you pray that the virus doesn't really get into a community transmission zone, if it does, it's going to come through a nursing home. I would bet. Cheri Bustos: (01:21:23) Is there anything from anybody else at the table who would have anything to add to what Dr. Redfield just shared? Dr. Ileana Arias: (01:21:30) Thank you for the question. I mean rural health has been an ongoing issue for a long time and with a lot of other things that we've been talking about here, the coronavirus and the COVID-19 issue is just sort of shining a light on a number of deficits that we've had in our healthcare system and in our public health system for a while. We have been involved in have some resources. They're very small in terms of how it is that rural communities generally not in this situation specifically can have resources that they normally wouldn't have. That might be helpful and we can follow up and send you some of that information and talk to your staff about what's available and what are the kinds of things that we have supported generally that may come to bear for COVID-19 as well. Cheri Bustos: (01:22:11) We'd appreciate that. Anybody else have anything else to offer? Okay. Something else that we've heard from nearly everybody that we've contacted as far as health providers is the respirators, latex gloves, eye shields. They all expressed a need for more of this equipment and I don't think anybody's asked this yet, but kind of the plan to make sure that this protective gear is out there for our healthcare providers. Robert Redfield: (01:22:43) Thank you for the question. This really is the important role and I'm sure you'll have a hearing there for ASPR to really look... They manage our stockpile, they manage... I will say that the inter-agency group has done critical analysis, as I mentioned before, all the different things we need mask, protective gear. I know the vice president went out to 3M the other day to visit them with mask and try to see... They're making about 35 million mask a day, but unfortunately only four million of those are for medical use and about 31 million are for industrial use. You'll probably hear more about that because I think ASPR, others will be coming up with a plan to try to see how maybe some of that could be modulated, but it's an ASPR issue and we can make sure they get in touch with you, so they answer that question. Cheri Bustos: (01:23:35) That'd be great. Thank you very much. I'll yield back. Thank you. Nita Lowey: (01:23:42) Congresswoman Watson. Watson Coleman: (01:23:42) Thank you Dr. Redfield. Thank you for the information you're sharing and I associate myself with all of my colleagues to say, we're not cutting your budget any way, shape or form. I do have some questions in this. Do you have any idea how many people have been tested? Robert Redfield: (01:23:59) Yeah. Yes, I have an idea. We're now getting all the health departments [inaudible 01:24:05] to collect the data and we are going to put it out every day. As I mentioned to Congressman Pocan. Watson Coleman: (01:24:13) Can tell me how many. Robert Redfield: (01:24:14) Right now I have as of yesterday, 4,856 from public health labs only, so that doesn't include the clinical labs. That doesn't include the private labs. We're trying to get it all together so you'll have a single point in daily that surveillance should be out soon. Watson Coleman: (01:24:35) Do the individuals who get their tests at the private labs still have to have the diagnosis confirmed by the CDC? Robert Redfield: (01:24:45) If their lab is not independently approved by the FDA, we do still do a confirmation of those state labs. So the clinical labs have been reporting their test as is. Watson Coleman: (01:25:02) Okay. I have a New Jersey specific question. Fortunately, we only have, I think 10 is the number today, presumptive cases. But there are six people with presumptive positive cases that have yet to be tested by the CDC. So New Jersey I guess did this preliminary, whatever it is, it does. I understand that this is a rapidly evolving situation, but can you confirm with us why there has been a delay in the confirmation from the CDC on these six cases? Watson Coleman: (01:25:38) Our staff have checked and CDC staff confirmed that there's not currently any delay due to volume on previous media calls. CDCs, Dr. Messonnier, french, it takes about a day to ship tests to CDC and then we have confirmation within 48 hours. She also said the CDC does have a secondary test for quality control measures. Why is it now taking more than one week for verification? Why is it... Why do we have this delay as relates to the six presumptive cases in New Jersey? Robert Redfield: (01:26:13) Yeah, I'll have to look into that. But I will tell you if they've confirmed in New Jersey and I have that, there's 11 confirmed cases in New Jersey as of now, they're considered a case. All right. And then we follow up and confirm it. Watson Coleman: (01:26:27) Do they know that? Robert Redfield: (01:26:28) Yes. Watson Coleman: (01:26:29) Okay. Because I got the impression that they're still waiting for confirmation, which suggests to me that they don't necessary know that. Robert Redfield: (01:26:36) Yeah. Yeah, we'll clarify it for sure and we'll get back to you so you know exactly what the reality is. Thank you. Watson Coleman: (01:26:44) So I have a question about what happens if you are confirmed to have this virus and your isolated, you're in a hospital, you're whatever. Right? You're in the hospital. What is the treatment? Robert Redfield: (01:27:02) That's very important for everyone to hear this, very clearly. A majority of people who get infected with this virus, particularly those that are under the age of 60 are quite relatively healthy and they would go to home isolation. We'd ask them to restrict their movements, stay at home for 14 days. Watson Coleman: (01:27:22) And do what? Robert Redfield: (01:27:23) Basically, do everything they can to not infect anybody else that lives around them. We have very good- Watson Coleman: (01:27:29) There's nothing that they can do. Robert Redfield: (01:27:30) There's nothing that they need to do other than what we used to say when I was a doctor, rest, drink a lot of fluids, take some orange juice and please, please- Watson Coleman: (01:27:41) Is that what happens? Robert Redfield: (01:27:41) ... please, honor the home isolation. But I will tell you for people that are very sick and we have a number that are very sick, there is an experimental drug called Remdesivir that's available right now in compassionate use. This country's used in a number of people in the state of Washington had been treated with it and there is clinical protocols going on by Tony Fauci at NIH comparing that to placebo, both here and overseas in Asia. We're going to know probably by April whether that drug works or not, and that's important because that's a drug that can save lives if it works. Watson Coleman: (01:28:19) Should we expect the CDC to not confirm state health lab results? Robert Redfield: (01:28:25) I think we're moving in that direction. Watson Coleman: (01:28:33) Why is that? It's not primarily what you all do in this situation? Robert Redfield: (01:28:39) What's going to happen is a number of these laboratories are going to come out with their own regulatory approval to do the test. Right now they're all [crosstalk 00:28:45]- Watson Coleman: (01:28:46) I'm sorry. Are we going to be sure that all states have the same sort of standards, that we're apples to apples across this country, not apples to oranges and peaches and pears. Robert Redfield: (01:28:57) Well, we put out our standards for the public health labs. Obviously, as you know, each state has their own, but we do put out our standards. Right now, all the state labs are working under our emergency operation. Our emergency authority. We are in the process of getting each lab to get their own with the FDA and that's ongoing. Watson Coleman: (01:29:23) Thank you. I yield back. Thank you. Madam chair. Nita Lowey: (01:29:27) Congresswoman Clark. Katherine Clark: (01:29:29) Thank you madam chair, and thank you all for being here today. As you know, we have been warned about moving from containment to mitigation. I think the lack of testing that was done has hastened our move out of containment phase into mitigation. Would you say that's true across the country? Robert Redfield: (01:29:53) I would say congresswoman that I think one of the biggest drivers of what we're going through right now is the movement of this outbreak risks from travel from China... Robert Redfield: (01:30:03) Is the movement of this outbreak risk from travel from China to travel from Europe. And individuals are coming back from Europe and they're seeding communities. We will have to determine and we will know quickly how much of is that driving it or how much was there a community transmission before that wasn't recognized because of less testing. We will figure out that answer because we're going back and looking at let's say blood samples that we can go back a month ago and do surveillance and see what was there through. But I will say my own personal opinion right now, the new cases that we're seeing in the United States are probably disproportionately driven from people that have returned from Europe and then gotten into a community. And then we've seen secondary cases and tertiary cases. That's my own personal opinion, but I'm not going to die on my sword on it. I'm open to the data to show us that no, that's not true. There was more transmission that we missed. Katherine Clark: (01:30:57) Well, we want to make sure that we remain data-driven so I appreciate that, but I think that we can, as we look at what's happening, I think we are going to continue to see totals doubling and more of a move to broad scale actions that we need to take to mitigate this because our testings behind where the virus and infection rates really are. Are you, how are you working with sort of the front lines on this, which is going to be our local public health officials managed by the state and hopefully supported by the federal government. How are you working with them to give opinions on large scale gatherings, should they be canceled? Is there a role for the CDC in that sort of work? Robert Redfield: (01:31:55) Thank you very much for that. We initially deployed teams into California and to Seattle to work over the last several weeks just on this issue. And I will tell you today the Vice President's office will be releasing a mitigation strategy for all states and territories in this country. Guidance that we've worked on for the last couple of weeks. Katherine Clark: (01:32:18) Can you give me any preview? Robert Redfield: (01:32:20) Well, what it is is it's a framework for each of the states to look at a number of different areas and they've put into low risk, moderate risk and high risk and different examples of what they need to do. I will be probably reaching out directly to Massachusetts in light of the recent cases that they've had. They now are basically one of the top five. Last night we had a long call with the health leaders of the top four and we've asked them now to take this template and edit it very carefully, which they're supposed to have completed by 12. We'll incorporate their edits, it will go global and then we want them to fill it out specifically with the questions you just asked. Robert Redfield: (01:32:56) Okay, what are they going to do about the Mariners game? What are they going to do about working from home? What are they going to do about the schools? All of that's in play as an example so that not only will we give them the framework, we're going to have a couple of the groups that have actually been dealing with sustained community transmission for the last four weeks say how they're going to do this and because I do think this is critical and they do need, we're here to give technical advice to all of the groups. I will be reaching out to Massachusetts in light of the last couple of days and see if they want to engage more directly with CDC. We have sent people to New York, to Seattle and to California and to Florida to help them and I think Massachusetts is the next one if that health department wants assistance. Katherine Clark: (01:33:40) Are you making recommendations that people don't have gatherings over a hundred people or have you set that sort of criteria? Robert Redfield: (01:33:47) We're currently working in partnership with the current state health departments to come up with what we believe is an effective mitigation strategy for that... Katherine Clark: (01:33:58) Is that part of what the Vice President's going to be releasing? Robert Redfield: (01:34:00) He's going to release the framework. Right. It will tell them how to do this and then we will be following up with the specific jurisdictions like I did last night and the day before or actually for the last couple of weeks to work in partnership to see how they are now operationalize that framework in their community. They're all going to be different, but yes, we're very involved. Rather than CDC give a blanket recommendation, since this is community by community, we're working with the local health departments head on to come up with obviously expressing our technical assistance and recommendation. Katherine Clark: (01:34:33) I'm almost out of time and I don't want you to interpret this as a flip question, but is there anything in those recommendations that say sort of structural barriers at our borders would be of any use in mitigating the outbreak of this virus? Robert Redfield: (01:34:51) Not that I've seen. Katherine Clark: (01:34:56) Thank you. Rosa DeLauro: (01:34:56) Thank you. Dr. Arias, I've a quick couple of questions for you and I want to get in a question to Dr. Houry as well. This is about public health data and I think what we've heard here this morning is that the Coronavirus outbreak further confirms the need for modernizing our public health data system. Dr. Arias, I understand you worked directly on the public health data initiative. So let me ask you a couple of questions. If the data initiative had been implemented over the last five years and CDC had a modernized public health data system, how would the current public health response be different? Dr. Ileana Arias: (01:35:38) So in the spirit of conjecture, it would've been different in two ways. One is, well in two different ways possibly. One is that we would have detected it much, much sooner and been able to contain it further and more effectively. The other is even before detecting, depending on relying on different sources of data, which we do not now and we want to do more of and analyzing that information along with health data, we could have start seeing that there might have been a problem even before getting scared about the number of cases that were being detected. So it's a both detection and very quick prediction. Rosa DeLauro: (01:36:14) And are there examples of things you cannot do right now but and you'll be able to? What can't you do right now? Dr. Ileana Arias: (01:36:21) What we can't do right now is twofold. One is, and they're related. One is the delay in finding out what actually is happening and who what's happening to. And a lot of that has to do with unfortunate barriers that the current systems have with getting that information from healthcare providers, getting it from states, getting it from, that we can use then to engage in that response earlier. Rosa DeLauro: (01:36:42) In that regard, what we did was to provide in the supplemental to improve surveillance and reporting. Are CDC public health data system up to the task of handling all of the data coming from state and local jurisdictions in such an emergency? And I make the reference to the 4,856 number that you gave us, Dr. Redfield. Are we where your... Dr. Ileana Arias: (01:37:07) Not 100% and not what we would like now that we know is possible. And so the initiative... Rosa DeLauro: (01:37:16) What's the percent? Dr. Ileana Arias: (01:37:16) 75. And the initiative would then get us to a hundred and not only get us to a hundred but then allow us to maintain that over time and be able to keep up with. The difficulty that we're running into that you probably can appreciate is that methods are changing significantly faster than they ever have been. Tools are showing up faster than they ever have been and if we can't keep up with that, then we're going to fall back even more. And so if we talk five years from now and don't make those changes, it may be 50% instead of 75. Robert Redfield: (01:37:43) I just want to add one quick thing. And it's fundamentally critical that every state and local territorial and tribal health department has that capacity too. Rosa DeLauro: (01:37:50) Yes. And folks that come, we heard from them and we talked about electronic medical records. They were talking about fax machines, individual Excel worksheets and data entry, etc., which holds up the process. So making your point, we need to invest in this effort. Dr. Houry, let me just move to you for a second. First time in 20 years, 2020 appropriation included funding for CDC firearm injury and mortality prevention research. Enthusiasm from researchers everywhere to move forward. What steps has CDC taken with the new funding? What areas do you see as promising opportunities to address this public health emergency? Dr. Debra Houry: (01:38:32) CDC really appreciates the appropriation and we have moved very quickly on this funding. February 21st we issued our first funding announcement for our R01 grants. And pleased to let you know we had an informational call for potential applicants yesterday. Had a record number for our injury center of interested applicants. Letters of intent are due next week and then we hope to issue these grants by September to really look at areas like mass violence, how does it, how are some prevented, why are others not. Self-defense of use of firearms, when is it used against a person or what does it help thwart a crime. And then things like school programs, are they effective in preventing this firearm violence. And then safe storage. What are the best circumstances for it? Rosa DeLauro: (01:39:23) Are there any applicants looking at homicide versus suicide? Dr. Debra Houry: (01:39:27) So we don't know yet. Our hope is that we get a wide variety of applicants. We have really greatly disseminated this information to a diverse group of stakeholders and we do think it's important. We appreciate the suicide funding as well to look at primary prevention and community level interventions for that. Rosa DeLauro: (01:39:44) Thank you. I will, let me yield to my colleague. Tom Cole: (01:39:49) Thank you very much madam chair. You actually anticipated one of the questions that I had for Dr. Arias on the importance of health care information, which we've all frankly mentioned one way or the other. I would just ask you this, could you work with our committee? So we obviously have a very substantial supplemental that we hope will be helpful in this area and you mentioned that what you had requested might well get you to 100% of where you need. Tom Cole: (01:40:19) What we also need is a look forward as you mentioned yourself and I know you can't estimate every new piece of technology that's going to come along or what might be useful, but when you think through these things you really have to have a multiyear plan. Even though we only budget one year at a time. Really helps if you can tell us particularly on technology because we tend to to invest once and the speed of change is much faster than we usually anticipate and so you end up with equipment that's out of date pretty quickly if we don't have at least some way of thinking proactively about what you might need going forward. Dr. Ileana Arias: (01:40:55) Thank you for that invitation and we are working on a longterm plan that includes all of that and so we're building as we go along the way. Part of that plan is doing what we have not done as much before and that's working with the private sector where those advances are really showing up and introducing them into public health way before we're doing now so that we don't fall behind in the way that traditionally we have done. Tom Cole: (01:41:15) And this is direct to your Dr. Redfield and I don't ask you to make a judgment here. We have the system we have, but I am struck, honestly, it was one of the things I learned when I was chairman about how heavily states and locality are absolutely dependent on CDC. And again, I want a robust partnership and I want that. But I don't want people to think that there's not a role here for states to actually step up and do a little bit more in localities to do a little bit more. I mean, in my own state, the lack of investment here is, so I'm not throwing stones at anybody else. I'll just pick my own home. And when you're providing 60% of the healthcare budget or the public health budget, excuse me, for the state of Oklahoma, that's something we ought to be worried about as Oklahomans as well. And we shouldn't be waiting around for the best equipment or the best ideas. You could give it template advice, but we need to do a lot more in this area across the board, don't we? Robert Redfield: (01:42:09) Yes, I agree with you. I also just want to add, because we're all impacted by the degree of preparedness of any state. So if we have one state that's under prepared, we're all under prepared. We've, if anything I would have loved, and the state of New York is great. They've got a great lab, they've stepped up, they got there, they're actually doing their own. They got their lab tests going up. So it's not just CDC now it's at the state level, it's CDC and the state developed their own. Well I like every 50, I'd like all the jurisdictions to be able to bring up their own tests. We could have a race to who gets to test as quick. So this goes back to that core investment in public health. Tom Cole: (01:42:48) Yeah, point well made. Let me ask you this, and again, I want to be careful for two reasons. I'm going to ask you two related questions, the first one does relate to China. And look, I recognize the delicacy of your position here. We've got to work with China. This wasn't the best result, but it was better than we've seen in the past. So, but hopefully there's some candid discussion going on with them. I mean not letting our folks in as rapidly as they should have. I think we could have been helpful to them and it certainly would've been helpful to us. Tom Cole: (01:43:23) And this kind of closed system does invite, one out of five people on the planet live there and they can't just put everybody, I'm glad it's coming down where they're at, but it's going up every place else now in a more rapid response from them would've made a big difference to every place else in the world. They have a special responsibility, they're a superpower. They have world-class science and they have very capable people. So I would just, what are you doing to invite them to sort of integrate themselves more fully into the world health organization? Robert Redfield: (01:44:02) Congressman, we've had more than 30 year cooperative relationship and the reason it's called CDC China, it was built by CDC America. I actually have a small group of individuals in CDC China and you'll see in my global health footprint plan expanding that is part of it. At least in China. We did offer directly to provide amplified assistance to the outbreak back in early January, our CDC colleague, my counterpart actually requested and wanted that. It had to go up through higher channels and that was not done until the WHO did the GHO report where we did have one CDC individual and one NIH individual from the United States on it. But we do believe we could have been very helpful early on and it would've helped us in our own policy decision. Tom Cole: (01:44:52) Exactly. And I'll just make this plea and I'm out of time here. This isn't directed to you or your counterparts because I suspect they wanted to do it. This is a discussion that needs to happen between our political leaders and their political leaders. This was a matter of global, it's actually an area we should be able to cooperate with one another on, probably help the overall relationship. So I just hope it's on the radar screen of our state department. And our President as well. They need to have this kind of conversation privately. Tom Cole: (01:45:24) We're not trying to embarrass our friends or anything else, but again, they're, they're a big part of the solution or a big part of the problem. They can choose to be one or the other. I know that all of you have urged your counterparts to do that and I suspect they would want to do that because they're professionals. They dedicate their lives to defending people just like you do. But this is one where the political leaders need to get involved, I think for the good of all. So that was my sermon madam chair. Rosa DeLauro: (01:45:51) Take it to heart. Congresswoman Lowey. Nita Lowey: (01:45:53) Thank you very much. The vaping epidemic as we know as a public health crisis that must be met with every level of government. That's why the CDC's office on smoking and health is so crucial and why Congress provided an increase of 20 million in the FY20 bill, so all levels of government can have the resources to combat vaping before we lose a generation of children to the harms of nicotine addiction. Nita Lowey: (01:46:20) Last year's vaping related respiratory illness resulted in at least 64 deaths, nearly 3000 hospitalizations and we know that many but not all of the cases were attributed to Vitamin E Acetate. Dr. Redfield, why can't the CDC say with certainty what caused these illnesses? Do you consider vaping regardless of the existence of Vitamin E Acetate to be a risk to public health? And my key question, are you concerned that compromised lung health could exacerbate risk for those who contact Coronavirus? Robert Redfield: (01:47:04) First, the last question is yes. The first thing I like you learned about this from my grandson who told me I was the CDC Director and I needed to stop it because he has a brother with cystic fibrosis. I would like to have Ileana tell you more and then answer anything that she didn't clarify. Dr. Ileana Arias: (01:47:23) Sure. Thank you for this question. Anything that can actually go into somebody's lung through vaping or anything else is of concern to us. Vitamin E Acetate is part of that. We are concerned that we've shone the light on that and that may go away, but other things are going to take its place. So one of the things that has become very, very important for us to do is make sure that although the response has been the activation for the response has been ended, the activities continue and especially the surveillance activities, looking at what kinds of symptoms people are presenting in emergency room departments and what is it that they're using in those substances that may be related to that. For like we were talking about before to catch it before it gets to the point where we were with a Vitamin E Acetate. So that is continuing. Dr. Ileana Arias: (01:48:09) In addition to that, we're continuing to work on making sure that we understand how it is that adolescents, we're not adolescents anymore and how it is that they're thinking about these substances. Just very different from what adults think like. And then make sure that we reach out to them and make them understand what the choices that they're making and try to redirect their choices so they can make more healthy choices. So that not only continuing the progress that we made with adolescents on combustible tobacco, but that we're replicating that for vaping as well. Nita Lowey: (01:48:42) But you know it's not working. And you know because I've been to college campuses, not only with my own grandkids, but I even met with the President at one of them and I said, what are you doing? And Dr. Redfield as you and I discussed, I learned about it from a grandchild who told me this is before she was in college, must've been five years ago. And she was upset because she was saying 65% of fifth and sixth graders. I mean these are crazy statistics. Do you think perhaps now that we know what can be connected with Coronavirus, maybe that'll shake them up. Robert Redfield: (01:49:19) This is a very important priority for us and Dr. Arias and the team is the bigger picture of adolescent nicotine addiction. When the decision was to take flavored products off, menthol was not taken off at that point in time. And we're tracking very carefully to see if now underage are shifting and we're going to really be seeing the data. We've gotten a commitment. If we have evidence that some adolescents are shifting now to menthol, then we'll put that public health evidence back up for action. And from the regulatory perspective, the FDA. But my biggest concern as is yours, mine were actually in middle school and telling me 50% of their class was using e-cigarettes on a regular basis. Nita Lowey: (01:50:09) Well, let me, since I have 46 seconds left, you know it, I know it, our grandkids know it and so far they've been reporting, rather than talking about the impact themselves, they're reporting what's happening to their friends. Are we making any progress? Is anything we're doing working? I hear the statistics of the same, whether it's in junior high or now in college, they're all vaping. Robert Redfield: (01:50:36) Anywhere in the country, man or woman. It's any age. It's all the same. Nita Lowey: (01:50:40) So what are we doing? Anything? Dr. Ileana Arias: (01:50:42) It is increasing and as you know when things are increasing, it's very hard to start turning around and it's going to be a while before that starts to happen. However, what we are doing is focusing on things that happen effective in terms of communicating and how it is that adolescents understand those communications in order to understand that no, don't just look at the pretty colors on the package, which they respond to. Think about what's inside the package, even if the packaging doesn't change. And then of course there's what other sister agencies are doing in terms of regulation that are going to make it a little bit easier to sort of control the environment so that they basically are protected from that side as well. But a lot of it has to do with finding out why they're using it, how they're using it and how it is that we can get them to stop. We showed progress, I'm sorry... Nita Lowey: (01:51:29) I'd like to pursue this Madam chair because we're talking about it, everyone's concerned. You're concerned, you're concerned, I'm concerned, but we failed. We haven't done anything. We're trying to do something but we're not successful. Thank you. Rosa DeLauro: (01:51:42) Ban it. Congresswoman Roybal-Allard. Congresswoman Roybal-Allard: (01:51:49) Dr. Houry of the FY20 final appropriation included $10 million for the first ever dedicated funding for suicide prevention at the CDC. And as you know, there are unique populations that are at higher risk for suicide such as Latina adolescents, veterans and nurses. I'm co-chair of the maternity care caucus along with my colleague Jamie Herrera Butler, and I'm particularly interested in recent statistics that indicate suicide may be a significant contributor to the unacceptably high incidents of maternal mortality in this country. Can you speak to the connection between postpartum depression and suicide etiology and tell us what efforts your center is leading to track and address this problem? Dr. Debra Houry: (01:52:42) Certainly I can start and then turn it over to my panel if anybody wants to add to it. With regards to suicide, the 10 million appropriation, we're going to fund applicants to look at data within their communities to identify who are the most vulnerable and which communities have the highest risk really rates, and then work with them to focus effective interventions on those areas. So it might be rural populations, it might be veterans. To your point, it might be young mothers. And to then really look at some of the evidence-based community level strategies to drive that. Dr. Debra Houry: (01:53:14) With regards to maternal mortality and suicide, I believe it's about 6% of maternal deaths that are due to suicide. We do know that the age of 10 to 44, I believe it's the fifth leading cause of death is due to suicide in that group. So we do see that that is the increased age for suicide deaths, but we're really focused on primary prevention of suicide deaths. Things like making sure that there's good programs in schools around social emotional learning, that we're improving connectedness and if those are at risk for suicide, make sure that they're linked to care. Our vital signs found that more than 50% of people who died by suicide did not have a known mental health diagnosis. Congresswoman Roybal-Allard: (01:53:58) Can you tell me if you're coordinating your efforts with other agencies on this problem such as SAMHSA and the Veterans Administration? Dr. Debra Houry: (01:54:06) Very much so. And we've been working closely with the VA around some of the veterans service organizations to look at things like, why are some veterans not accessing VA when they are having suicidal ideation to look at what we can do more in the community. We also work closely with SAMHSA for their mayor's challenge. We went out and talked about our technical package and some of the strategies that were done at CDC to really help cities really implement those strategies. Congresswoman Roybal-Allard: (01:54:32) Dr. Arias, over the last two decades, we have seen significant gains in the life expectancy for people living with Spina Bifida, with adults who are living into their sixties and their seventies. This creates new challenges because when young adult patients age out of pediatric care and the national spinal bifida registry, there is no system in place to follow and care for them. The CDC Spina Bifida program has been flat funded at 6 million for the last six years and is currently down two staff members. Do you have concerns that progress and investigation into critical life saving issues such as the cause of sudden death in midlife and prevention of sepsis related morbidity are possible within the current staffing structure. Dr. Ileana Arias: (01:55:23) We're working with in the confines of the resources that we have to address these issues. It has been significantly difficult. I think that we need support in order to branch out and address the problem in its full complexity. So right now it has been very limited in the kinds of things that can be done. It's not just true of Spina Bifida. It's true of other conditions as well, such as Alzheimer's and Multiple Sclerosis and other kinds of things that have been very difficult for us to make as much of an impact as we think we can because the resourcing really hasn't been there and we've had to work with what it is that we have. A lot of that means measuring it. A lot of that is getting information to the extent that we can about either prevention but in most cases sort of managing and then a lot of information, which is we're getting more requests now for dealing with the caregiving community in each of those situations. Congresswoman Roybal-Allard: (01:56:18) Well, then what funding level would you need to ensure that the national Spina Bifida program covers the lifespan of individuals living with a disability and what are your plans to track people as they age out of the pediatric system? Dr. Ileana Arias: (01:56:32) We have been working on a plan, sort of looking for where it is that we need to go and we can get information to you about what that plan would look like and then what would be necessary in order to support the implementation. Congresswoman Roybal-Allard: (01:56:42) In terms of the resources. Dr. Ileana Arias: (01:56:42) Mm-hmm (affirmative). Congresswoman Roybal-Allard: (01:56:43) Okay. Thank you. Rosa DeLauro: (01:56:46) Congresswoman Frankel. Lois Frankel: (01:56:47) Thank you again for being here. You would agree that this is not a time to cut any of our global health budget? Robert Redfield: (01:56:57) As I said, I think one of the most important things we need to do is to build a robust longterm foundation of global health. I think CDC is the tip of the spear and I think this is a time to get that foundation built. Lois Frankel: (01:57:12) All right, so the answer is yes, we should not cut or no we shouldn't cut or yes. The answer is yes, we shouldn't cut the global health budget. Are there enough, I don't know if I want to ask this, but are there enough masks now for our first responders and our health care workers and if not, where do we get them? Robert Redfield: (01:57:29) We can, again, this is something that Asper is in charge of looking through and and making those calculations so we can get back to you, but I refer that to Asper. Lois Frankel: (01:57:40) So I have a couple of practical questions. So I have an older mom, my mom's actually older than me. That's obvious. Okay. She's healthy. Knock on wood. She was supposed to go to the doctor for a checkup. Now she says she's afraid. She says, I'm not going to go for a checkup. That can be a room of sick people. Of course it's a room of sick people. What do you say to that? Robert Redfield: (01:58:09) I think your mother has a lot of wisdom. Lois Frankel: (01:58:11) Okay. I always thought that. Okay. Robert Redfield: (01:58:14) Unless she really has a requirement to do things right now, we are trying to get the elderly and vulnerable to kind of just step back and try to avoid being in crowded places. Avoid travel. This is where we are right now. Lois Frankel: (01:58:28) Okay, got it. Another practical question. So we're told to wash our hands, all that. Don't touch our face. People are coming in contact, even ourselves with our clothing, with our furniture and all that is, is it spread that way? Robert Redfield: (01:58:46) Congresswoman that's a very important question. This virus clearly can live in the environmental surfaces for some period of time. With the ship in Japan, very aggressive studies are being done to see how much virus they find on railings in different places. Finding the virus doesn't mean it's infectious, but we can detect this virus for prolonged periods of time and surfaces. And the role that we call fomite transmission is still unknown. That's why it's important when you put your hand on the handrail as you're walking down, you probably need to wash your hands afterwards. You don't think about it. Lois Frankel: (01:59:23) What about if you put, you touched the hand rail and then you touch your clothing, but you can wash your hands but you can't wash your clothing. Robert Redfield: (01:59:31) It's probably more touching the rail and putting your hand to your face. Lois Frankel: (01:59:34) Okay. All right, so is the information coming from the World Health Organization reliable? Robert Redfield: (01:59:44) I would continue to say the World Health Organization is a very well respected public health organization. Lois Frankel: (01:59:51) So right now, can anyone go to the doctor and get tested for Coronavirus or do we still have a delay in having enough tests for that? Robert Redfield: (02:00:02) As of... Lois Frankel: (02:00:02) For that. Robert Redfield: (02:00:02) As of ... I don't even remember what today is. Is today Monday? Tuesday. Okay. As of Monday, Quest Labs and LabCorp Labs have made this test available in doctor's offices. When you go to the doctor and you get your blood drawn, the test isn't done there, it's done by LabCorp or Quest, and now that same thing can happen if your doctor wants to order a coronavirus test. Lois Frankel: (02:00:28) I want to just go back to ... This as another common sense question, though. It seems to me that some of the reasons ... Not shaking hands, washing hands, self quarantining is not just about not getting the coronavirus. Well, it's about that, but the fact is we don't want everyone to get in at the same time, because we can't take the stress on the healthcare system or the stress on the economy. Is that right? Robert Redfield: (02:01:01) Yes, and we don't want them to get at the same time they're getting flu. Unfortunately, this virus is very similar. In a sense, it's a respiratory virus. So if you look at hospital capacity right now, much of it is full up to 95, 96, 97%, so we really don't have a lot of resilience in the capacity of our health system. Lois Frankel: (02:01:20) Are there test shortages as any other part of the world? Do we know? Are there test shortages in any other part of the world? Robert Redfield: (02:01:29) No, I don't know exactly, but I can tell you, obviously, in areas like Subsaharan Africa where they have really underdeveloped health systems, clearly they've been spared right now. The reason for that is unclear. If it is seasonal, obviously we're going to have some challenges, and more importantly, the most important, you asked me medical interventions before, the one medical intervention you need if you go into the hospital is oxygen, and there's many health systems that don't have the capacity to deliver oxygen to its people. Lois Frankel: (02:01:58) Is that in this country? Robert Redfield: (02:01:59) Not in our countries. Lois Frankel: (02:02:00) But in other countries. Okay, thank you. Yield back. Lois Frankel: (02:02:04) Congresswoman Lee. Barbara Lee: (02:02:05) Thank you very much. I apologize. I had to step onto the ad committee, and so if this is redundant, I'll ask what the answer was in terms of pandemic versus epidemic. Has anyone asked that question? Where are we in terms of describing this? Robert Redfield: (02:02:26) I said it's really ... The word is not that important. This is a major global outbreak, but the WHO is usually the organization that formally declares something a pandemic, but clearly this is a wide-scale global outbreak. Barbara Lee: (02:02:41) Let me also ask you about sickle cell. The sickle cell trait, it's been estimated, and CDC estimated that over 4 million Americans have the sickle cell trait, and the incidence of sickle cell trait in newborn screening was found to be about 7% for overall black births and about 1% for a Hispanic births. Now, are there any standard methods, and I've been trying to get to the bottom of this for 20 years, standard methods or protocols for alerting families or healthcare providers to the presence of sickle cell trait, educating them about the potential health outcomes and might be associated with the trait, or counseling them about the impact that the trait's status might have on families' future reproductive decision making? I ask this because once a child is tested at birth, by the time they're 18 or 19, who knows if they know or not whether they have the trait, and I have personal examples of that with regard to the interaction between the A1C test and the sickle cell trait. If you don't know you have the trait, the doctors aren't required to test for the sickle cell trait if you are from the specific target population. So how in the world do we deal with this, because it's really a problem. Dr. Ileana Arias: (02:04:03) So we can send you information about the sickle cell program at CDC. A lot of that work is done in conjunction or in partnership with providers and with the healthcare community to make sure that they get that information to families and point out resources that are available to them. Robert Redfield: (02:04:21) You can see that as we operationalize this data monitorization and predictive analysis for the whole nation, we could actually have data that actually could be in a system, a public health system this nation could have access to. Barbara Lee: (02:04:34) But why when an adult gets a blood test, if this adult is of a specific population, why isn't part of that panel a test for sickle cell trait? If I have the traded birth, at 20 if I'm getting married or at 25, there's an issue there, and I don't even know I have it. Dr. Ileana Arias: (02:05:01) Sure. I can get back to you and find out what are the systemic things that stand in the way of that happening. I would imagine a lot of it has to do with the fact that it's known at birth, the assumption being that that is known to the individual and there's no point in ... But you're right. Barbara Lee: (02:05:22) If it's known at birth, how do I know at 18 or 20 or 30 [crosstalk 02:05:26] I have the sickle cell trait. Dr. Ileana Arias: (02:05:28) No, you're right. The assumption is that if it's part of the birth record, you'll have it, but you're right, but it's an assumption. Barbara Lee: (02:05:32) There's nobody in this country, I guarantee you, who's an African-American who knows that they have the sickle cell trait based on the birth record. Robert Redfield: (02:05:41) We'll definitely get back to you. That's something we need to address. Barbara Lee: (02:05:43) Thank you very much. Now, let me just ask you, going back to the REACH program and the whole issue of health disparities, which my friend Congressman Cole raised, in terms of just the budget, the REACH program has been really a critical program in eliminating racial and ethnic disparities, but it's been eliminated from the budget again, and I heard your response in terms of how you're going to make some moves within the CDC, but with this budget eliminating and being eliminated in the president's budget, I don't think you can compensate for addressing racial and health disparities. Barbara Lee: (02:06:22) You indicated some kind of moving the aspects of the program around to address this in terms of not disease-specific, but community-specific or whatever, but this is unacceptable. When you look at people of color, when you look at the native American community, when you look at every community in this country that exhibits health disparities based on race or ethnicity, to eliminate this program is, to me, unethical in terms of health and medical standards, and it's a shame. So are you all weighing in on this? Is CDC saying this is not a good healthcare decision, a good decision to make? Public policy decision? Robert Redfield: (02:07:15) What I can say, I think you all know that we're constrained right now in this environment. That's why I've tried to put so much focus on core capability. It's going to help all programs, all programs, including the health disparity programs by building this public health capacity. I do believe that block grant flexibility will give local communities to be able to invest the money they want, and we're not turning our eyes off to the health disparities in this nation, and we will continue to try to navigate how we can continue to address those. Again, I'm going to come back, I've done it multiple times. I do think the core capability that goes beyond CDC, with all the public health structures that we have at state and local, tribal and territorial, that gives enormous ability for these public health departments to function on multiple areas, including health disparity. Barbara Lee: (02:08:15) Yeah. Thank you very much for that response, but unless directed by the federal government with some major protocols in place, with some major research in place, with some major investments by our government in terms of the REACH program, we're going to be set back, and thank you, Dr. Redfield. Robert Redfield: (02:08:34) Yeah, thanks. Rosa DeLauro: (02:08:36) Thank you. I have an additional question, and I know the ranking member does, and then we will hear from the ranking member to close, and then I will close up. This is about global health security, Dr. Redfield, and you just mentioned Africa, and I just got an email again from my dear friend, who was the former health director, health commissioner in South Africa, the shadow commissioner, just said that they've now had the first cases in South Africa. So these are my questions, because the viruses don't have borders, and Africa can easily be overrun. What is CDC and global partners doing to assess the risk for immune suppressed clients with HIV and other infectious diseases? What resources are available to support diagnosis and clinical care, and can this be scaled up with other partners? Is CDC able to send health specialists to support the Africa CDC and its regional collaborating centers? We provided 600 million in the past, and as supplemental, we include 300 million for global health. If you could just answer those three questions. Robert Redfield: (02:09:59) Thank you very much, chairwoman. I clearly hit on one of the real concerns in Subsaharan Africa. In general, obviously, how immune compromised individuals are going to react to this virus. One would predict it would be more likely to cause more severe illness, and in Africa, that obviously causes the other problem, because more severe illness needs greater likelihood of dependency on oxygen, and many of these nations don't have that capacity to the degree they may need it. Robert Redfield: (02:10:32) We have, from the beginning, and as you know, because of the PEPFAR program, CDC has country offices all through Subsaharan Africa. We have them providing technical assistance to their counterparts in the countries they are. We have worked with ... Actually, the director of the CDC Africa, it was actually a CDC colleague that has gone on loan to the ... Actually, he's now hired by the African union. He's one of our best. We've helped him build testing capacity, so there is testing capacity now in West Africa, in the African CDC in South Africa, but Africa is a great vulnerability. It's been one of my biggest concerns on a global scale, because if this virus gets into Africa like it's into Italy, there's going to be a lot of casualties. Rosa DeLauro: (02:11:23) Mm-hmm (affirmative). Let me ... Yeah, that's my ranking member. Tom Cole: (02:11:30) Thank you madam chair. Obviously we've talked a great deal about coronavirus healthcare security, and I'll get to that in my close, but I actually want to shift to another area, and this would be addressed to you, Dr. Houry Probably when I'm home before all of this, I hear more about drug overdose deaths than any other healthcare cry, that more family, more people affected. Obviously, I suspect the death toll there this year will be worse than anything we see in coronavirus. It's just year in and year out. Finally, last year we saw it come down a little bit, first time in 28 years. Congratulations for some of the great work at CDC to help us in that area. So going forward, what can we do and where do you need additional help? I've seen ... It's not always opioids or different substances that seem to be more common, even, so give us some view of this continuing problem and what we ought to be doing as a congress to try and provide the resources to help our fellow Americans in this area. Dr. Debra Houry: (02:12:43) Absolutely, and thank you for that question. What I would say is the resources that we have received from congress have really helped us build that infrastructure. We are now able to collect syndromic surveillance data, and with our current grant, we actually added in a category to look at meth and other psychostimulants, because we didn't want to be, three years later, when our grant is over, saying, "What is going on with the trends?" So we're able to really pick up that in more real time. Dr. Debra Houry: (02:13:09) We also realized that linkage to care is really important, so we built that into our current programs as well. In addition to what more can we do to help provide health providers, for the past 15 years I worked in a county ER and have really watched this evolve, and that's one of the reasons why I came to CDC. It was because I knew it was not just about the individual patient, but what can we do at the population level. I still work in an MAT clinic once a month just so I can see that integration of the CDC successes that we're doing with things like electronic health records. We're now, as you mentioned, seeing that surge of methamphetamine and other substances. What I think is important is not to lose sight of how we got here, and we need to look at the whole range. We are starting to see a decrease in high risk prescribing, but still, many of the people who go on to use other drugs got started with prescription opioids. Many of the patients I see in clinic are wrestling with cocaine use now, but they are also wrestling with heroin, and we can treat that with MAT. So having that linkage to care is still crucially important, and then looking at vulnerable populations like tribes. We are working closely with many tribal organizations and giving direct funding to tribes this year, and groups like the Cherokee nation in Utah have really been able to integrate prescription drug monitoring programs now, so we can identify those high risk patients and link them to care to prevent them from having overdoses. Tom Cole: (02:14:27) Dr. Redfield? Robert Redfield: (02:14:28) Just want to add one point. I really think it's important to aggressively engage in innovation here. This is a chronic, recurrent medical disease. It should engender the same aggressive research that we're doing to get new cures for cancer or new cures for heart disease. This is going to be a medical disorder that will have effective therapies. We have them now that are a little bit for opioids, but we really need to have effective therapies at all to recognize this as the disease that it is. This is not a behavioral choice. This is a medical condition that needs that innovation, that medical research, private sector's got to get engaged to develop the same passion that they have for cancer cures that they do have for addiction cures. Dr. Debra Houry: (02:15:19) I would just add to that too, as we look at the full picture of substance misuse, looking at what led to that misuse in the first place, and primary prevention such as the funding that y'all gave us for adverse childhood experiences, when a childhood trauma can lead to suicide, deaths and overdose deaths. So really looking at that linkage in the whole spectrum is really key. Tom Cole: (02:15:37) Terrific. Thank you very much, madam chair. Do you want me to go ahead and close? Okay, thank you very ... Well, first of all, I want to thank all of you. I thought frankly last exchange was a splendid example why we all admire you so much, because of your commitment to our fellow Americans and all of humanity in the search for cures and defending people and therapies. It's an extraordinarily noble profession that you're all engaged in, and we appreciate what you do. We, I hope, have made it very clear, not to you, but to the powers that be, that we intend to continue to make these investments on a bipartisan basis, and I will just say to my friends, and they are my friends at OMB, and I mean this with no disrespect, when somebody in Congress tells you, and when they tell you on a bipartisan basis, we're going to spend money in these areas, you can either help us figure it out by by letting your people to work with us to, where does the money make the most difference or not, but we'll do it anyway. So it's just much better. Tom Cole: (02:16:42) Again, I've had that discussion when I was chairman. I'm sure the chairs had that discussion as well. This is just something Congress has decided to do, and it's decided to do it in a pretty substantial way over multiple agencies, NIH, CDC, strategic stockpile mechanisms that help you sort of get into the fight as quickly as you possibly can for all of our benefit. We all agree, I agree very much with my chairman, this isn't a Republican or Democrat thing at all, and we've just made that collective decision. It's not triggered by this particular event. As a matter of fact, this event is sort of vindication of the bipartisan judgment over the last several years that this was really an area we needed to make investments, and we want to work with our best people that we think are in these agencies in a very collaborative way so that we don't make mistakes. Tom Cole: (02:17:39) That's not your requirement. Your requirement's to come and do what you all do, and that's defend the presidential budget, but I would just submit for the record that administrations would be lot better off had they listened to us several years ago in this area, and we would all collectively be better off, and I hope you all learned a lesson from that. There are some things to have a very sharp pencil about and a very keen eye. Look, I am a conservative Republican. There are other areas where you really need a substantial public investment to protect the American people. I think this area, probably more than any other single one, although there's certainly a range of activities that we're involved in, but here, you're literally talking about the health and wellbeing of people in a very individual way, in a very immediate way, and in a way that can come out of nowhere when you least expect it, as something like this has happened. Tom Cole: (02:18:32) So I think it's sort of been the collective of wisdom of congress over many years. Again, because Congress had doubled this NIH budget, and I will tell you, just as a member, you learn more over sitting through these hearings. They were very helpful. I appreciate it when you guys are up here, and learn a lot. I've had the opportunity to go down and visit CDC on a couple of occasions when I was chairman. I learned a lot just sitting down and talking to people and getting an idea of the range of capabilities, and I think we all reflect that over time, so I want to thank the chairman for the hearing. First one, as she said, since 2016, it's certainly very timely, madam chair. Tom Cole: (02:19:11) But more importantly, I just want to thank my chair for the bipartisan commitment here, because this is not something that's likely to go away, and I think that's something, again, I hope the executive branch realizes over time, regardless if it's there, this is a kind of enduring commitment, and so there's no sense sending us a budget that cuts things that we're not going to cut and doesn't work with us in areas where we want to make investments, but recognize that you have enormous expertise that your institution, that we ought to be listening to as we fashion what those investments are going to be. So we look forward to working with you, and telling you this, I wish you very good luck, all of us very good luck in dealing with the coronavirus right now. Suspect things get worse before they get better in this area, but at some point they will get better, and at some point we will turn the corner, but I hope the lessons learned here are enduring lessons. I have no doubt they will be for this subcommittee, because they have been, but I hope they are for the American people, as well. Tom Cole: (02:20:18) We take a lot of things for granted around here. These are investments that matter. These are investments that, if they're not made for years ahead of time, can't be sort of parachuted in at the last minute. We can't make the difference without a sustained plan for investing in what each and every one of you do, and madam chair, you've had that commitment for your entire career, so I appreciate that very much. We're very fortunate to be led by you at this particular time. [inaudible 02:20:45]. Rosa DeLauro: (02:20:47) I thank the gentleman, but I'm fortunate, which is why we have been able to produce, I think, quite remarkable labor HHS bills over the last several years. There's a compatibility here that I think at the outset, someone would say, "Well, it's not going to work," but because of the competence and professionalism and deep compassion and caring and the values of the ranking member, and our ability to work together, yes, there are differences, but those differences don't cloud the goals and the challenges that we see, and it's been in the past, the history of this country, that members on both sides of the aisle that crafted the responses to the serious challenges that we have had, they were not naive, but they understood that the challenges were that great, that from wherever you come from, that our obligation and our responsibility is to see that we address this issue, and that's the kind of cooperative relationship that I find on this committee with my ranking member, and I think it's true with the subcommittee as well. Rosa DeLauro: (02:22:05) So I thank you for being here, very, very much to all of you. There are a couple of things. I did look up PEPFAR, which has been so critically important, and that's been cut by half. We will address that issue as well. On the vaping issue, Dr. Arias, the fact of the matter is that the e-cigarettes never had an FDA approval, which is why I made my comment on ban until we know I want to go on science. Stop it until we figure out whether or not and where we go for. Rosa DeLauro: (02:22:42) I will just ask you, Dr. Redfield, because you talked about the masks, and I say this to the ranking member, what I heard yesterday was that yes, 3M, it's 35 million. It's four million in terms of the hospitals or public health workers. 31 million is for the commercial sector, but it's only four million because that's all the insurance that 3M has, and without some notion of indemnification or so forth, we need the strength of the administration to say get more insurance and let's move forward with what we need for the public health. That's something that I'm asking to do. It's wrong to stop at four million, because we can't get there, and there's no answer to this, but I don't know for the life of me who was monitoring the self monitors, who are out there and what they are doing, and that's a hard task to push. If you want to say something about that, go ahead, and then I'll wrap it up. Robert Redfield: (02:23:52) I only say one word, because we did this with the Ebola outbreak a number of years ago, and it's just heartening to see the cooperation of the American public when they understand what we're asking to do. I think about 97% of them basically did what they were asked to do. Not everybody, but it's heartening to know the American public, when they understand, that they will in fact abide to these clear instructions. Rosa DeLauro: (02:24:21) And again, I thank you very, very much. You heard the concerns of you. There are serious concerns. We'll keep asking the questions. We want to make sure that the statement is accurate, that anyone who needs a test gets that test immediately, and we can allay fears. The crisis is here, we know that. We are all dependent on the strength of our public health infrastructure. If we are not strong, you said it, if we're not strong in all 50 states, we are not strong. Let us help you with the core capabilities, and I wrote those down. Rapid response, predictive analysis and data modernization, global health security, and a public health workforce that is second to none. We want to do that, and please let us know, because you have listening ears here to what you need, and we want to get you where this country needs to go during this crisis. Thank you all very, very much for being here this morning. Let me bring this hearing to a close. Robert Redfield: (02:25:42) Thank you very much chairman. Rosa DeLauro: (02:25:42) Thank you. Rosa DeLauro: (02:25:42) Thank you. Tom Cole: (02:25:42) You said you'd be part of this conversation. Robert Redfield: (02:25:42) Thank you. Tom Cole: (02:27:18) Fist bump, elbow bump, whatever I need. I was immediately trying to take it somewhere. [inaudible 02:27:18] Thanks for what you do, and thanks for coming out here. I know we've got, obviously, I deep [inaudible 02:27:55] coronavirus and some of the other things, and that we would like to discuss in one way. Tom Cole: (02:27:49) You were great. You were great. Rosa DeLauro: (02:28:08) You did. Thank you. Very concerned about aces and what happens. Tom Cole: (02:28:08) Well done. Rosa DeLauro: (02:28:08) Take care, guys.