Testimony of Dr. Atul Gawande, Assistant Administrator for Global Health, before the Senate Appropriations Subcommittee on State and Foreign Operations

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Wednesday, May 11, 2022

Chairman Coons, Ranking Member Graham, and Members of the Subcommittee, thank you for the invitation to speak with you today about United States leadership in controlling the COVID-19 pandemic, the key role played by the U.S. Agency for International Development (USAID), and the funding necessary to continue this fight to control the pandemic.

My name is Atul Gawande, and I serve as the Assistant Administrator for USAID’s Bureau for Global Health and as Co-Chair of the USAID COVID-19 Task Force.

I am grateful to the Subcommittee for calling today’s hearing and for continuing to prioritize the global response to COVID-19. Since the start of this pandemic, we have lost almost one million American lives, with the death toll globally now exceeding six million. The effects on worldwide health, development, and the global economy are like nothing we have seen in our lifetimes.

Data recently published in The Lancet estimates that total deaths during this pandemic increased by approximately 18 million worldwide1 —most not directly from COVID-19 but from the indirect effects of its disruptions of healthcare and economies. The result is the first reduction in global life expectancy in more than a century. It is development in reverse. It has pushed back the impact of our decades of bipartisan U.S. global health investments.

Thanks to bipartisan support from Congress and American taxpayers, the U.S. government has mounted a historic response to this global crisis. Since the beginning of this pandemic, the U.S. Government is providing more than $19 billion, of which USAID has provided $9.9 billion in supplemental funding towards the fight against COVID-19. The U.S. government led the world by donating, in partnership with COVAX and bilaterally, more than half a billion COVID-19 doses to 115 countries in just nine months, as part of President Biden’s commitment to donate and deliver more than a billion COVID-19 vaccines.

In December, the U.S. government announced the Initiative for Global Vaccine Access—or Global VAX—a whole-of-government effort, led by USAID in partnership with the CDC and other interagency partners, to turn vaccines in vials into vaccinations in arms around the world through more than $1.7 billion in funding committed to date. Global VAX encompasses all of the U.S. government’s work with more than 100 countries to accelerate COVID-19 vaccine uptake, and involves a surge of technical and financial resources to 11 countries in sub-Saharan Africa where we see the greatest opportunity to increase coverage rapidly. USAID is also making progress to save lives now through programs that provide oxygen, testing, and treatments in order to slow transmission and decrease COVID-19 morbidity and mortality.

But we are now at a precipice. As of May 1, USAID has approved, and when required notified Congress, of 99.9 percent of the total COVID-19 supplemental funds received since the beginning of the pandemic, and we have obligated 95 percent of these funds. We expect to obligate virtually all remaining supplemental funds by July of this year. Under the American Rescue Plan Act—or ARPA—we have so far obligated 90 percent of the funds.

As much as it may feel like we are returning to normal in the United States, the fight against COVID-19 is not over. This is especially acute for those in low and lower-middle income countries (LIC/LMICs), but as long as COVID-19 continues to persist anywhere, inevitably more variants of concern will emerge, putting us all at risk everywhere. Of the more than 10 billion vaccine doses administered worldwide, only one percent has been administered in low income countries. The result is that although almost 60 percent of the world is fully vaccinated—including 50 percent of people in low-middle income countries— barely more than 16 percent of people across Africa are. At the same time, low income countries have begun to delay vaccine deliveries, not because they are not desperately needed, but because the flow of supply is now outstripping their capacity to get shots in arms fast enough. This is why Global VAX’s efforts are so vitally important, and broader U.S. efforts such as the Global Action Plan and the COVID-19 Summit to lead efforts to galvanize commitments and coordinate these efforts, alongside our partners in governments, international and multilateral organizations, and beyond. Lower income countries simultaneously face even bigger gaps in access to rapid diagnostic tests, oxygen, and the new generation of oral antiviral pills that we in the United States have been able to count on to help us so markedly reduce the morbidity and mortality of COVID-19. These gaps create a situation poised to produce further COVID-19 variants that pose risks to not only to other countries, but also to U.S. lives, our economy, and our national security.

In March, the Administration requested $22.5 billion in additional COVID-19 response funding, including $5 billion to support the immediate needs of the global COVID-19 response. This global funding would enable a significant expansion of our Global VAX surge efforts to another 20 to 25 countries and other global COVID-19 vaccination priorities, including the rollout of boosters and pediatric doses. With more than 30 countries qualifying as severely undervaccinated, it remains critical to expand the initiative beyond the 11 surge countries we currently support. This request will also enable us to shrink the severe gaps in global access to testing, oxygen capacity, and antiviral treatments—enabling lifesaving services for more than 100 million people—as well as enhanced monitoring of potential or emerging variants.

Failure to continue our supplemental global funding would abdicate U.S. leadership even as the People’s Republic of China continues its transactional approach to pandemic response and global health; it would weaken health systems that are crucial to fighting this and future pandemics; and it would amount to a surrender to the inevitability of dangerous new variants. Failing to provide supplemental global funding would also jeopardize our long-term baseline pandemic preparedness, global health, and health security investments. In sum: it would be a geopolitical, ethical, health security, and economic mistake of historic proportions.

The President has repeatedly outlined the stark realities of not passing a COVID-19 supplemental. Variants of concern continue to emerge. Each surge has disrupted the supply chains and the trade we rely on and driven inflationary pressures. U.S. leadership is critical to keeping political momentum and commitment to clear action. Barring additional funding, however, essential work cannot launch and many of our existing programs will begin to grind to a halt in the coming months.

By not helping lower income countries get shots into arms, and not fostering adequate testing, treatment and oxygen delivery capabilities, their populations will be left unprotected and we’ll continue to see more preventable deaths and societal disruptions. New, potentially more dangerous variants may also be more likely to emerge from a long-term infection in immuno-compromised individuals who lack access to vaccination or treatment. That outcome would be disastrous both globally and here at home, with the potential to claim more lives and deliver a serious blow to the economic recovery that all countries and economies seek. We will need additional resources in order to improve our ability to track variants. We were lucky that Omicron was not more lethal. The next time, the variant, or the new pathogen, may be more lethal and may spread even faster; we need to be able to identify the new organism rapidly and respond quickly.

U.S. leadership has led to significant achievements since the beginning of this pandemic. But now is not the time to be complacent or we risk the normalcy and security we are just beginning to experience.

DETAILS ON USAID’S GLOBAL HEALTH RESPONSE TO COVID-19

USAID is supporting more than 120 countries to contain, combat, and recover from this pandemic with more than $9.9 billion in funding. Our activities align with the goals outlined during President Biden’s Global COVID-19 Summit last year and those that will be discussed at the Second Global COVID-19 Summit tomorrow—vaccinating the world, saving lives now, and building back better to prevent future pandemics—and are driven by USAID’s COVID-19 Implementation Plan which outlines USAID’s role in the whole-of-government U.S. COVID-19 Global Response and Recovery Framework (“Framework”). The global community came together around last year’s Summit, making new commitments centered around these global response goals. We continue our work to rally the world to deliver on these goals during the second Global COVID-19 Summit, taking place tomorrow.

Vaccinating The World

Safe and effective vaccines are one of our best tools to end this acute phase of the pandemic. President Biden committed to donating 1.2 billion COVID-19 vaccines—more vaccines donated than by all other countries combined—to the world for free and with no political strings attached. Completing the job collectively with other nations and donors is the Administration’s and USAID’s top COVID-19 priority. As of May 10, the United States, in partnership with COVAX and bilaterally, has donated close to 540 million vaccines, the result of highly successful coordination with our interagency partners, and the White House.

But vaccines on tarmacs are not vaccines in arms, which is why the U.S. government launched Global VAX. This initiative supports countries to scale up their vaccination campaigns and help with last mile efforts, including vaccinating the highest risk populations; planning and logistics; the purchase of ancillary supplies; cold chain infrastructure; and community engagement and public outreach, especially to strengthen vaccine confidence and counter mis/disinformation about vaccines. In the 11 Global VAX surge countries—Angola, Côte d’Ivoire, Eswatini, Ghana, Lesotho, Nigeria, Senegal, South Africa, Tanzania, Uganda, and Zambia——the U.S. Government is surging technical, financial, and diplomatic support in close partnership with the interagency. And we are seeing results:

  1. In Angola, the U.S. government supported vaccination efforts through ultra cold chain strengthening, logistics support to vaccination sites, social media campaigns, and vaccination donations, which contributed to 18.5 million doses administered as of May 2, 2022. To date, around 11.7 million people received their first dose, 5.9 million people received their second dose, and another 440,185 received a booster dose. The U.S. Government is the largest donor of COVID-19 vaccines in Angola, providing more than 8.6 million doses of Pfizer and Johnson & Johnson vaccines, in partnership with COVAX. Of the eligible population, 64 percent have received at least one dose.
  2. In Nigeria, U.S. Government vaccine donations and logistics support, in addition to other implementation support, improved the availability of vaccines at the state level and helped sustain vaccination rates of around 200,000–250,000 doses administered per day by April—up from 30,000 to 55,000 doses daily prior to acceleration.
  3. In South Africa, Global VAX acceleration plans have built on existing health platforms to deliver integrated services. USAID’s partner BroadReach integrated HIV testing services via PEPFAR into a vaccination campaign in February to April 2022 in the coastal region of KwaZulu-Natal. During this campaign, 57 percent of individuals reached were first-time COVID-19 vaccine recipients, and 69 percent of individuals were high-priority populations. BroadReach also conducted 3,000 HIV screenings, identifying nearly three times more positive cases than usual community testing programs.

Saving Lives Now by Strengthening Health Systems And Countering Emergency Impacts

Success in stopping the catastrophic damage of COVID-19, however, has required more than a vaccination strategy. Omicron makes clear that we must sustain and expand support for activities that minimize spread and prevent the emergence of new viral strains, decrease severe illness and death, and limit the burden on health systems, including health workers who are on the frontline of this battle. We must save lives now while we continue our efforts to vaccinate the world.

At the first Global COVID-19 Summit in September 2021, President Biden emphasized the importance of reducing morbidity, mortality, and disease transmission. With the constant threat of emerging variants and many lower income countries still facing low vaccine coverage rates, increasing global access to COVID-19 testing, therapeutics, and countermeasures is critical to saving lives among those who experience a breakthrough infection or who are yet to be vaccinated. Two of our efforts with greatest impact have been increasing oxygen capacity and providing resources for emergency response.

Oxygen. USAID has become a world leader in supporting increased access to lifesaving oxygen in health facilities that lack it. An estimated 50 percent of facilities with inpatient services in LMICs lack reliable access to oxygen—even before COVID-192. Thanks to more than $100 million in COVID-19 assistance funding, USAID has built systems to provide oxygen to facilities in more than 50 countries—including India, Haiti, and Ghana, to name just a few—and is in the process of building oxygen systems for facilities in 13 countries across Africa, Asia, and Latin America and the Caribbean.

When expanding access to oxygen, USAID acted quickly to strengthen oxygen ecosystems and is currently a leader in bulk liquid oxygen investments for LMICs, the standard for oxygen delivery in high-income countries. To promote sustainability, we are exploring market-shaping opportunities so that oxygen markets can work more efficiently in LMICs, and lower prices and increase distribution. Our leadership is also informing other partners’ investments, including those of The Global Fund to Fight AIDS, Tuberculosis and Malaria. All of these investments have the potential for long-term impact on countries’ health systems—strengthening their capacity to respond to not only this pandemic, but also other critical health needs, such as child and adult pneumonia, safe birth, safe surgery, and new infectious disease outbreaks.

Emergency response. Since the beginning of 2021, USAID has supported rapid responses across the world as COVID-19 hotspots developed. To date, we have provided $429 million to support urgent health care needs and critical commodities (including PPE, diagnostic tests and treatments) in South Asia, Latin America and the Caribbean, and sub-Saharan Africa.

COVID-19 has also continued to exacerbate humanitarian crises around the world by increasing food insecurity, reducing access to lifesaving services, and fueling a shadow pandemic of gender-based violence against women and girls. In response, USAID has provided more than $2.658 billion in COVID-19 supplemental funding focused on preventing famine and mitigating food insecurity, supporting protection and gender-based violence programs, and strengthening critical public health initiatives to reduce transmission of COVID-19 in humanitarian settings. For instance, in Ukraine, we are supporting the World Health Organization (WHO) to expand delivery of COVID-19 vaccines to internally displaced people, and to expand hospital oxygen supply to improve health system readiness to manage COVID-19 cases.

USAID has also been investing in the capacity of the humanitarian assistance community to respond to outbreaks. The READY initiative (currently in its fourth year) has been focused on building and retaining capacity among non-governmental organizations (NGOs) and other stakeholders in priority regions and countries to more quickly and effectively respond to major outbreaks. Risk Communication and Community Engagement continues to be a priority as well, with USAID partnering with the International Federation of Red Cross and Red Crescent Societies (IFRC) in building community trust, social cohesion, and public solidarity to pave the way for uptake of emerging lifesaving COVID-19 biomedical measures.

A NEW AREA OF FOCUS TO SAVE LIVES NOW: TEST-AND-TREAT

Recently authorized oral antivirals have been shown to significantly reduce the risk of hospitalization or death by almost 90 percent among people who are at high-risk for severe disease. These treatments are becoming a mainstay of treatment in the United States and limiting the COVID-19 hospitalization rates and risk of death, especially among the unvaccinated and the medically vulnerable. But lower income countries have little to no access to the new therapies and have limited access to rapid diagnostic tests. In collaboration with other agencies and global stakeholders, USAID is working to increase the supply, availability, and use of low-cost, generic versions of these oral COVID-19 antiviral drugs for lower income countries.

With additional resources, USAID can work to build a “test-and-treat” approach and the capacity to deliver it to those who need it the most. This work would build on successful test-and-treat approaches for HIV and malaria and will require educating communities about the importance of prompt testing (including use of self-testing) and availability of treatment. It will also require the expansion of health systems’ capacity to quickly identify new infections and initiate appropriate treatment in high-risk patients. USAID can support these strategies to ensure that test-and-treat programs are integrated into existing health infrastructure and community systems. In addition to reducing morbidity and mortality, these activities would also help stem transmission and reduce the likelihood of health systems being overwhelmed by patients suffering from severe disease by promoting early diagnosis and intervention.

Diagnostic testing remains a critical part of the public health response, not just for diagnosis of new infections and linkage to care, but also to help identify emerging variants. The President’s Global COVID-19 Summit laid out ambitious goals of reducing the cost of diagnostic test kits to $1 per test and achieving global equity for testing. But rapid diagnostic tests are largely not accessible in many LMICs. Only five rapid diagnostic test kits have WHO Emergency Use Listing. When Omicron spread more rapidly than had been anticipated during the Omicron surge, manufacturers could not keep up with surging demand, and many countries did not receive the testing supplies they ordered until after the Omicron wave had passed. Available laboratory testing can be slow, and extremely costly, with a diagnostic test costing as much as $99 in some countries. As a result, testing rates in lower-middle income countries remain low, and low income countries account for less than 0.5 percent of the tests performed, despite having almost 8 percent of the world's population3. The WHO has now committed to accelerating test approvals, but low income countries have limited capacity to drive demand. For them to effectively roll out new test and treat strategies, investment in purchases of low-cost, rapid diagnostic testing is essential.

Much of the world also lacks excess laboratory capacity and is unable to respond to a dramatic rise in testing need; therefore, we have invested in laboratory strengthening activities that will pay benefits beyond the current COVID-19 crisis. To support national laboratory networks, we have funded sample transport networks to ensure timely and safe delivery of samples within 24 hours so results can quickly be returned to individuals. Future surges are likely to encounter the same challenges without additional financial support.

THE COST OF INACTION: AN URGENT NEED FOR COVID-19 RESOURCES

We have made huge strides since this pandemic first began, and we are witnessing the end of the acute stage of this pandemic here in the United States. But we simply cannot ignore that in many parts of the world—where countries face low vaccination rates and lack of access to tests and treatments—this pandemic is far from over. And as long as that is the reality, we face a world in which new and more dangerous COVID-19 variants will be able to continue developing and endanger the recovery we have made so far.

Without additional COVID-19 resources, we will be unable to mount the response needed to end this acute stage of the global pandemic. That is why the White House has requested $5 billion to support the global COVID-19 response, which includes:

  • $2.55 billion to resource our efforts to vaccinate the world through Global VAX programs that are strengthening countries’ vaccine deployment and readiness capacities, including $1.8 billion for USAID and the State Department and $750 million for CDC. These additional resources would enable us to support an additional 20-25 countries to get shots into arms; support multilateral partners providing critical assistance; and prepare for pediatric doses;
  • $1.7 billion to finance our efforts to save lives now, covering activities that are critical to ensuring adequate global supply and technical assistance to support COVID-19 testing, treatments, access to oxygen, personal protective equipment (PPE), and support for health workers to reduce morbidity and mortality and mitigate transmission. This would provide lifesaving testing, treatment, and care for more than 100 million people; and
  • $750 million for lifesaving humanitarian assistance as global humanitarian needs have skyrocketed, with COVID-19 adding an additional layer of suffering upon the world’s most vulnerable. This humanitarian funding will help us to continue to scale up to meet new and growing needs, while sustaining our ongoing complex emergency responses in places such as Ethiopia and Afghanistan.

Without additional funding, we will be forced to scale back the expansion of Global VAX into 20-25 countries and our existing programs will begin grinding to a halt this fall. Many countries that finally have received the vaccines needed to protect their populations will risk seeing them spoil on the tarmac because they can’t be distributed in country and/or administered to the population. And at the same time, we will not be able to expand the critically needed testing and treatment programs that we would have otherwise been able to support and continue our leadership in expanding access to oxygen. All the while, COVID-19 will continue mutating and growing, endangering populations abroad and the health and prosperity of all Americans.

Throughout this pandemic, Congress has come together to pass supplemental funding that has saved the lives of millions abroad and protected millions more here at home. Once again, we are urging you to come together in support of continued U.S. leadership to control and end the acute phase of this pandemic.

Thank you for the opportunity to represent USAID. I welcome your questions.


1. Wang, et al. Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21, The Lancet 399, no. 10334 p. 1513-36 (2022).

2. PATH, Oxygen Is Essential: A Policy and Advocacy Primer, PDF p. 7 (2017).

3. FIND, SARS-COV-2 TEST TRACKER (2022).

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Last updated: May 11, 2022

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