The White House's $6.18 billion emergency funding request for the domestic and global fight against Ebola received its first hearing in Congress today, prompting questions from senators on whether the funding and response steps have the right targets and garnering support from dozens of health groups, whose representatives said the funds are needed to build preparedness.
Also in Washington, DC, today nurses from the nation's biggest union held a vigil and press conference outside the White House to call for better personal protective equipment (PPE) for Ebola caregivers. The nurses also voiced concern over eroding patient care standards in the United States and globally.
Events planned by National Nurses United (NNU) included strikes, pickets, rallies, and candlelight vigils in 15 states, as well as in Australia, Canada, Ireland, the Philippines, and Spain.
Senators scrutinize emergency funding request
President Barack Obama on Nov 5 asked Congress for the Ebola investment, which includes $4.5 billion for the immediate response and $1.5 billion in contingency funds. The funding would be part of a $1 trillion spending package that House and Senate members are working on to fund the government past Dec 11 through the end of the fiscal year.
Barbara Mikulski, D-Md., appropriations committee chair, said the $6.2 billion request was in line with emergency requests approved with bipartisan support to battle other diseases: $6.1 billion to address the avian flu threat during the Bush administration and $6.4 billion to respond to the 2009 H1N1 influenza pandemic during the Obama administration.
"We have done this before when we have been faced with emergencies. Now we have to tackle this new development," she said.
Representatives from all of the federal agencies involved in the response were on hand to testify. Also, testimonies of at least 60 outside witnesses were submitted, representing 116 different health organizations. Mikulski said the bulk of the statements said sustained investments are needed for public health and that emergency funds are needed to battle Ebola in the short term.
Richard Shelby (R-Ala.), the committee's ranking member, said the size of the request, the government's slow progress in detailing how it would spend the money, and missteps warrant the committee's scrutiny. He said the Centers for Disease Control and Prevention (CDC) guidance for hospitals has been a moving target and that the Obama administration has sent mixed messages on quarantine issues. He said he is worried that federal Ebola plans revolve mainly around preparing for best-case scenarios.
"Competent crisis planning, however, must include contingencies for the worst-case scenario, as well," Shelby said, urging officials not to rule out any reasonable option for preventing the disease in the United States, including travel and visa restrictions.
Officials who testified today were from the State Department, which includes the US Agency for International Development (USAID), the Department of Defense (DoD), the Department of Homeland Security (DHS), and the Department of Health and Human Services (HHS). In their opening statements, each official outlined agency requests:
- HHS: $2.43 billion focusing on preparedness for US health and public health systems, development of vaccines and drugs, and battling the disease in West Africa
- DHS: $13.2 million, which includes $10.2 million for enhanced medical screening personnel and the rest for PPE, overtime, and other response costs
- State Department/USAID: $2.89 billion, which includes $2.1 billion in base funding to battle the outbreak in West Africa and $792 million in contingency funding as the outbreak evolves
- DoD: $112 million for the Defense Advanced Research Projects Agency (DARPA) to work on technologies to provide immediate temporary immunity and shorten the timelines for vaccine development
Mikulski aired some of the NNU concerns, including a request that Obama use his executive authority to set standardized PPE protocols.
HHS Secretary Sylvia Burwell said federal efforts have trained about 250,000 health workers in Ebola infection control and efforts are needed to continue the training, measure if it's working, and assess if caregivers are comfortable with it. She said the funding request includes money for continuing Ebola training.
Several senators questioned federal officials on why the DoD has a more stringent quarantine policy for troops returning from West Africa than the CDC's recommendations for travelers arriving from West Africa, including healthcare workers returning from treating Ebola patients.
On Nov 7 the DoD announced more details about its mandatory 21-day controlled monitoring for service members returning from Operation United Assistance, which involves seven bases that will temporarily house the troops. So far, nearly 2,000 troops have been deployed to the region.
Maj Gen James Lariviere, deputy director for politico-military affairs (Africa) and the Joint Chiefs of Staff, said that although the approach is more conservative, it isn't based on scientific information that other agencies don't have. He characterized the decision as operationally based, rather than medically based.
Burwell added that the differences in approaches is influenced by the desires of the groups involved, and said that although the quarantine decisions should be based on level of risk and science, "it's also important to respect those who are serving and the desires of those who have taken the step to serve."
Other medical concerns
Mike Johanns, R-Neb., asked federal officials if funds should be included to help cover costs for treating Ebola patients, since the cost of treatment can be extremely high, with private insurance not likely to cover all of the costs. Nebraska Medical Center in Omaha is one of the high-biocontainment units that has treated some of the US-based Ebola patients. Johanns urged federal officials to consider, given the challenge of treating Ebola patients, a more regional care model.
Burwell said federal officials are taking a phased approach to beefing up biocontainment capacity and for now are focusing on facilities that are near five airports that are funneling all of the travelers arriving from West Africa.
Some senators raised concerns about whether there is enough in Obama's request to build up health systems and disease detection capacities in the wider West Africa region. Chris Coons, D-Del., said he spoke with Liberia's President Ellen Johnson Sirleaf, who relayed her gratefulness to Americans for the US response efforts but urged the country to not ease off on its efforts.
CDC Director Tom Frieden, MD, MPH, said the CDC already has teams in each of the surrounding countries, and he said the cluster of Ebola infections in Mali (see related CIDRAP News story today) is a great concern.
A handful of legislators pressed federal officials about why the United States hasn't limited visas for people traveling from West Africa, similar to what Australia and Canada have done.
DHS secretary Jeh Johnson said there are already mechanisms in place for denying visas to people when officials determine that travel would be too risky. He said, however, that putting a broader ban in place would set a dangerous precedent and hamper the response effort.
"The biggest concern about limiting the number of visas is that other nations would follow, and that would isolate [outbreak] countries," Johnson said. "I don't want to see our country become a leader in isolating those countries."
Health groups weigh in on Ebola funding
Trust for America's Health (TFAH), one of the groups that submitted a witness statement, said it supported the request, especially the funds that will go toward building long-term public health capacity in West Africa, assist state and local public health departments, and beef up the Strategic National Stockpile and hospital preparedness.
Jeffrey Levi, PhD, TFAH's executive director, said in the group's statement that infectious disease control needs constant vigilance, requiring both emergency and ongoing funding. "Quite simply, we will never have a reliable public health system if it is constantly scrambling from crisis to crisis and from emergency funding stream to emergency funding stream with no continuity."
In testimony submitted by the Infectious Diseases Society of America, the group's president, Stephen Calderwood, MD, said it and the Pediatric Infectious Diseases Society strongly support the Ebola funding request, both for response and to build capacity to address infectious diseases. "We urge that that this funding not come at the expense of other infectious disease programs, so that preparedness and response efforts for future outbreaks are not undermined."
Liberian man's family, hospital reach settlement
In other US Ebola developments today, the Dallas hospital that cared for the Liberian man who was the nation's first Ebola patient said it has resolved matters with the man's family.
Thomas Eric Duncan, who got sick with the virus after arriving from Liberia, was hospitalized at Texas Health Presbyterian Hospital, where he died on Oct 8. After he died, his family called for an investigation into the care the man received, especially why he was released from the emergency department during an initial visit 2 days before he was isolated at the hospital.
In a statement today, the hospital's parent company, Texas Health Resources, repeated its condolences and said it regretted that the Ebola diagnosis wasn't made during Duncan's first visit to the emergency department, 2 days before he returned by ambulance and admitted. The man's travel history to Liberia wasn't fully communicated to his care team at that visit, and some experts have said a quicker Ebola diagnosis could have improved Duncan's prognosis.
Texas Health Resources said it is honoring Duncan by creating a memorial fund in his name to assist Ebola victims in Africa. It said it appreciates acknowledgment by the family's attorney that Duncan received excellent inpatient care. "We are grateful to reach this point of reconciliation and healing for all involved," it said in the statement.
Financial details of the agreement were confidential, but Duncan's family will benefit, the Dallas Morning News reported today.
Senate appropriations committee background materials and testimony
Nov 11 NNU press release
Nov 12 TFAH news release
Nov 12 Texas Health Resources statement
Nov 12 Dallas Morning News story