Cspan radio app. Klain joint Health Policy experts for a discussion on the u. S. Response to the coronavirus at the centers for American Progress in washington, d. C. Neera good morning everyone. My name is neera tanden. I am pleased to welcome you to the center for American Progress. I am so glad you could join us for this critically important conversation. The death toll from the coronavirus now exceeds 3200 people, with more than 200 cases confirmed inside the united states. As Health Officials warn that the coronavirus ultimately will become widespread in the united states, serious questions have emerged about how the federal government is responding. Around the world, countries are beginning to take significant measures, including restricting travel, closing schools, postponing religious pilgrimages and imposing quarantines. Critics say the Trump Administration has been slow to address the impending crisis. The president and his team have been downplaying the risk, saying last week that everything would work out fine because the virus, will go away by april, contradicting the c. D. C. Itself. Most importantly in a crisis like this, we need to be able to trust the information we get from the government, a trust that the Trump Administration exhausted years ago. There is no question that the president and his a administration are mismanaging this response, unfortunately. President trumps personal frustration has paralyzed this administration with inaction in early days and poor planning, polarized politics and lack of communication has undermined public confidence. The public continues to receive mixed messages with few daily briefings and with public and Health Officials often prohibited from making public announcements. So where do we go from here . The Trump Administrations missteps should not stop us from coming up with a few solutions. That is why we find this discussion today so important. We are joined by a distinguished panel of experts who will discuss how to prepare the country and the world to fight this potentially devastating outbreak. Now, it gives me great pleasure to turn the conversation over the new executive Vice President for policy, mara rudman. [applause] mara thank you, neera. I am very glad to be here and very glad to be having this conversation with all of you because of the terrific experts that we have here today. I am going to be introducing them one by one and asking them to take their seats here, then we will go right into the questions that we have for them. First, dr. Zeke emanuel, senior fellow here at the center for American Progress, but also vice provost for global initiatives chair for the department of medical ethics at the university of pennsylvania, and was also Senior Health advisor in president obamas administration. Ron klain, former u. S. Ebola response coordinator, and earlier chief of staff to two Vice President s and numerous other experiences at senior levels of government. Lisa monaco, former white House Homeland Security adviser, currently distinguished senior fellow at nyu law school, and again, years of experience at the Justice Department in various senior roles. And dr. Jennifer nuzzo, a professor at Johns Hopkins university and an epidemiologist whose work focuses on Global Health and security, virus biosurveillance, Infectious Disease diagnostics, Operational Research to improve outbreak preparedness and response. Cant think of a group that is better suited to help us understand and get to the basic facts and science and explanations about what to do with the situation we are facing today. I should also note that dr. Rachel levine really wanted to be with us today, but because of the current challenges she is facing in pennsylvania, she was unfortunately unable to join us but is following this closely. So, with that [indiscernible] mara we will start with you, nuzzo, jennifer, if we could. I am going to ask you, given your indepth science background, if you could lay out some of the basics for us. We have heard a lot in a lot of places, some science, maybe some less than science. I am being generous. What is covid19, how does it transmit to and between humans . Can you help us understand the words pandemic, isolation, quarantine, and a little bit more about how to interpret the severity of this crisis . Things like mortality rates . Issues like that. Dr. Nuzzo covid19 is a disease caused by a new, newly recognized human coronavirus. Coronaviruses are viruses that circle the planet, that this is anyone for which it is not fault the world has humanity. All genetic analysis of the virus suggested that it started in bats and jumped at some point to humans or to some other animal, likely a mammal, but we dont know what animal it is. It is a respiratory virus. With possibly some exceptions, it is thought to be largely driven through droplet transmission, meaning when someone is sick, they cough or sneeze and expel the virus from their body in large droplets that fall to the ground or surfaces generally within a distance of three feet. I often get questions, can i get the virus when i go running . It doesnt just hang in the air like other viruses and diseases like tuberculosis are known to do. Where we are now is a situation where we are approaching 100,000 cases reported worldwide. Largely confirmed, laboratoryconfirmed cases. I looked up last night how many countries, because it changes literally by the hour, 85 countries as of now are reporting cases. We have very imperfect surveillance going on. Just because a country has not yet reported cases does not mean it doesnt have them. In the united states, we have over 200 cases that have been reported. More than half of them are occurring in people who have not traveled. Likely as a result of local transmission. When we have a situation like that, where we have cases in so many countries where we have local transmission in multiple countries, it is not possible for me as an epidemiologist and not to call that a pandemic. I know there has been some debate over the use of the word. The World Health Organization is particularly reticent to use it, the word comes with a lot of baggage, particularly if it is misinterpreted to be a signifier of how severe the virus is. I am referring to geographic spread when i use the word pandemic. We are very much in a pandemic. The virus has shown itself capable of spreading quickly, particularly as Surveillance Systems struggle to catch up. In my belief, we are in a situation where the idea of fully stopping the spread, i dont think is a realistic goal. I think we are more at a point where we are trying to mitigate the impacts of the virus in our communities. Thank you very much. I have just been told i need to hold the mic closer to my mouth. I will give her the opportunity on that, maybe as you also describe a little more about what kind of surveillance we are currently using, and that we i guess is both the u. S. And some of those 85 other countries. I am guessing there are differences between and among. What kind of surveillance are you using to track and test and learn more, what impact does it have . You used the word mitigate as opposed to contain. Ms. Nuzzo i would say globally, surveillance is not perfect but some countries are better off than others. Part of the reason why, first of all, the fact that we have 85 countries reporting cases, the fact that 85 countries have been able to implement testing for a neverbeforeseen virus is something we should celebrate, there are few opportunities to Say Something good is happening. There is. And i want to give credit to that. That said, many countries for a very long time, surveillance and testing was contingent on travel from china. Until essentially last week, that was the case in the united states, where you could only be tested unless you were a contacted but known case, you can only be tested if you had a lower respiratory infection and traveled to wuhan and were sick enough to be hospitalized and you had traveled to broader china. As a number of other countries were already showing local transmission, we did not update that Case Definition to reflect the fact that the virus could have been coming from those other countries. So our approach in thinking about surveillance, in my view, has been constrained without a view to looking forward to what was likely to come. So if you are only testing people who have traveled to china and you in fact reduce people traveling from china, of course, you are not going to find many cases because you just dont have people in that category to test as much as you could before. So this comes up a lot when we talk about, we bought ourselves time with these measures, etc. , it is possible we reduced the number of people coming in with the virus, but we have no way of assessing that from our testing. Many other countries were like that. Because it will probably come up in the course of the other conversations, to define isolation and quarantine, isolation is something we do all the time in medicine and Public Health. It means if somebody is sick, you put them somewhere so that they cannot spread the disease to others. In the context of this response it will be critically important that people who are sick self isolate themselves, stay home unless they require hospitalization. Otherwise, we should reserve hospitals for the sickest people. That, above all, will be the most important thing we can do in responding to this virus and reducing its impact on the community. This is where we should be putting the most attention. There is a lot of attention lately on quarantines. This means separating from society, somehow restricting the movement of people who are well. They dont have any symptoms but you think maybe they have been exposed. This is not something we routinely do in Public Health but the degree to which it is happening now is unprecedented and i dont think we have fully examined the consequences. In particular, when we do things like quarantine well Health Care Workers who may have been exposed to a patient, we are going to find ourselves without sufficient resources to respond if we continue to sort of indiscriminately apply quarantines. Mara thank you. I think that might be a natural lead to ron. You have managed whole government response to mitigate the spread of the virus. You have been less than positive about the white houses attempt to control communications on a variety of issues, specifically by public Health Officials. And you have noted publicly that an effective Pandemic Response requires trust in government. Can you describe a little bit why trust in government is important on this issue, and the issues with credibility in this administration right now on this issue with the American People and with our foreign partners, and how that affects how that impacts an Effective Response . Ron thanks. I think we seeing both a failure of confidence and a failure of competence. Second, on the competence part nuzzo alluded. To, we are far behind other countries in testing people for this virus. When we hear the viruses in x states but not y states, it is largely because we have not tested in y states. The same for the global map, no cases of coronavirus in subsaharan africa, it is not because there are no cases of coronavirus in subsaharan africa, but because we havent tested. That lack of competence is causing us to be blind as to where the virus is, how extensive it is, so on so forth. If our back in my job at the white house i would be pushing to have us do 30 million tests. Test people in nursing homes, people who regularly visit nursing homes, test Health Care Workers. There would be long lines of people we should test. The administration thinks they will hit 75,000 tests by the end of today, maybe one million next week, that is a huge gap. The second competence gap is around hospital awareness. We can talk about what needs to be done to get the system ready to deal with the kind of challenges dr. Nuzzo was referring to. On the confident side, the communications side, the Trump Administration seems to be doing everything wrong, which means the obvious things, like having the president go out there and say things that are untrue that follow under the categories of both misleading and deliberately unhelpful. When he told everyone to go to work with coronavirus, that is not only a bad communication, but a very bad communication. What we are seeing really is that even if you accept, and i dont, that president trumps singular goal here is to keep the stock market up during the coronavirus thing, him saying things that are erratic and irresponsible is not reassuring people, but making people more anxious. His efforts to just tweet the virus away is actually making public anxiety about the virus worse, not better. So what should he do . What he should do is let the Public Health experts be the voice of the response. The idea that they told dr. Tony faucci, who served six president s, probably the nations leading Infectious Disease expert, that he should not go on television, and staff in mike pences office say it is okay, is ridiculous. The idea they sidelined senior officials at the centers for Disease Control is ridiculous. That is with the public should hear from, both to get Accurate Information and to lower the level of anxiety about the disease and at least get it right. That is the biggest problem we have on the communication side. But if they dont fix the competence problems, all the confidence problems will get worse and worse. Mara you mentioned the stock market. How do you think right now we should be thinking about some of the economic challenges we are facing, supply chain issues . Mr. Klain we are already seeing a ripple effects from the anxiety of the coronavirus in the economy. I am not just talking the stock market, the cancellations of travel, cancellations of conferences are going to start to ripple through the economy. We are going to start to see other sectors hit by this. I think it is important for us to focus on who are really going to be hurt by this economically, and that is, as with all things, sadly, the least among us. The hourly wage workers in the hospitality industry, for example, in other industries, who will lose their jobs. We are talking School Closures all over the country already. Some School Closures. That affects people who work in schools. It affects the children, many of whom school is their source of nutrition for breakfast and lunch. If we close the schools, how are we going to feed those children . People who are laid off from work for weeks or months at a time, what is going to happen to their income . What this is going to expose is a lot of weaknesses in our economy already on the lower rungs in particular. But what is really interesting is, as jennifer alluded to, a pandemic suggests something that is global and worldwide, and this is. But like a lot of things that are global and worldwide, it affects all of us but differently. We need to be aware of the fact that there will be some people for whom the Economic Impacts are going to be most severe. Mara thank you. Lisa, for a number of different reasons, including the fact that in 2018, you presciently sounded the alarm about failures to prepare adequately for emerging Infectious Diseases. In an article, i am curious as to whether you came up with that title or somebody else did the title was the next pandemic will be arriving shortly. You argued that the u. S. Needs to treat pandemic diseases, with urgency, with the same urgency it applies to other transnational threats. What should the u. S. Be doing to improve how we treat pandemic diseases like the one that according to jennifer, we are facing right now . Ms. Monaco to your question, i did not come up with the oped title, i should say that i was not alone by any stretch of the imagination. Every person on this panel and legions of experts behind us, used 2018 and the 100th anniversary of the spanish flu pandemic to sound the alarm about the dangers posed by pandemic disease. But, no, i did not come up with the title. Normally, oped writers decry those who put alarmist and inaccurate titles on their pieces. Unfortunately, not so. Could not make that criticism here. So, what do i think we should do . First, i think we should recognize pandemic disease as a National Security threat, as a transnational threat like we do other things like terrorism, cyber threats. First, let me anticipate some concern with that framing. I imagine some folks may say, here we go again, everything is a security issue, we are going to securitize pandemic disease. That is the last thing we should be doing. Let me allay those fears. When i say we should approach this as a National Security threat that it is, i mean that we should apply a whole of government approach of the kind ron just talked about, just to that threat, just like we do other transnational threats. By that i mean diplomacy, intelligencedriven approaches, obviously, Public Health and domestic preparedness. I would lean on the diplomacy piece of this. Howknows very, very well diplomacy played to really help us get our arms around the ebola epidemic. So when i say National Security threat, i mean that we need to have a whole government approach to this. We have to organize ourselves around it. What does that mean . It means identifying a purchase a identifying it first as National Security threat and approaching and organizing our government from that perspective. We did that postebola on rons excellent recommendations. As you heard, he was dubbed the u. S. Ebola response coordinator. I remember quite clearly that his last recommendation to president obama not displaying any internal deliberations state secrets here his last recommendation on his way out the door was, you should never, ever have to appoint no future president should have to appoint a diseasespecific czar. President obama took that recommendation. The National Security team as a whole took that recommendation. What did we do . We created a Global Health security and pandemic preparedness directorate within the National Security council. To work alongside the other dedicated units within the National Security council that are assigned to and dedicated to other transnational sects. Transnational threats. In a world in which experts and nonalarmist people like bill gates have said pandemic disease is likely to kill the most people in the shortest period of time over the next 10 years, and that is how he has described pandemic disease, in that kind of world, i think we ought to have, and by the way, when our Intelligence Community in its annual worldwide threat assessment put pandemic disease and emerging Infectious Disease as amongst the top threats that we face as a nation, i think it is not crazy to say, we ought to have a dedicated unit of professionals within subject Matter Experts, not talking political folks subject Matter Experts working day in and day out in the National Security council just like we have a counterterrorism directorate or a cyber threat directorate. That seems kind of an elementary approach. We did it and it made a lot of sense. Unfortunately, in 2018, the Trump Administration inextricably dismantled that unit. Mara before or after your oped . Ms. Monaco good question. I have not done those forensics. They dismantled the unit, and its expert career official was reassigned. It is that kind of reinventing of the wheel. Now, of course, we have witnessed over the last several weeks not one, not two, but three attempts to organize the government around our Pandemic Response. This isnt just kind of bureaucratic moving things around in an orchard. How you organize yourselves and prepare before it is an emergency, and before it is a crisis, can make all the difference in the world in how you are able to approach this. I think if we had had a unit and dedicated professionals looking at this issue, gaming out scenarios well before the last week, we might have identified some of these testing issues. We might have said there would have been folks sounding the alarm in december when we saw this coming out of china, hey, what do we need to be doing here in this country to address it . In addition to organizing, and i could reference the erasure and sidelining of my own former role as Homeland Security advisor, in addition to organizing around it, building capacity both locally and in our own Public Health departments to identify and address the gaps jennifer talked about, and importantly, raising global capacity and what i call defending forward, and we can talk about that a little bit more. Mara thank you. In following up on what lisa said, the director general of the World Health Organization pulling out all the stops. Calling on International Leader s for action. You have said americans should not panic at this point. That said, the number of confirmed cases continues to rise. You have been vocal that the current administrations response and the nature of it what would you say at this point are both the things we still dont know about the coronavirus that may bear on how it will spread, how dangerous it will be, and what do you think the government should be doing now, our government, to address the threat and to keep people from panicking . Or should we be panicking at this point . Have you changed your view . Dr. Emanuel panic is never good. Even when you have a very serious situation panic is not going to be good because you are not going to have an organized response that can mitigate the problem. Again, to echo whats been said, when we have the president making a series of either unhelpful or blatantly false claims, this is definitely going away, there will be a miracle, you know, vaccine in three or four months, it does not help. It does not help people calm down. The first thing i would agree with jennifer that we have no idea the prevalence of this thing in the population. We need to have that tested. Ron said 30 million. I have not done the calculation, but in addition to specific groups, we need a Population Survey in places like seattle where you have had a breakout outbreak to see what the rate is out there and to follow it so that we can see how it is spreading and the time force of time course of that spread. That is critical for knowing what to do. There are a whole series of things. I laid out some of them in a Washington Post article but one thing im particularly worried about is Surge Capacity in our Healthcare System both physical stuff do we have beds, and as has already been mentioned, the Healthcare Worker number. Let me play out a scenario for you which i think is not far from reality. 20 Million People in this country somehow get the virus. 20 million. That is less than 10 of the population. 6. 5 of the population get this virus. Its less than get the flu and we have the flu with an annual vaccine that about half the population takes. If the death rate is. 5 , which is a probable guess but its only guess because we dont have the data, thats 100,000 deaths. Now, that is 100,000 people who are going to have severe respiratory infections, 100,000 people who might need to be on a ventilator, might need to be isolated in a health care facility. For those of you who dont eat, breathe this kind of stuff, our Health Care Systems capacity is, we have less than one million beds all throughout the American Health care system in hospitals. 1 million beds. That would be 5 of the 20 Million People who get it. We have less than 100,000 intensive care unit beds. That is all intensive care unit beds. Nicu, neonatal, burn beds, et cetera. We only have about 65,000 ventilators. So we are under resourced already at the getgo and were not talking about a big spread, we are talking a moderate estimate here. Then we talk about the Healthcare Workers. If Health Care Workers get exposed and they are under quarantine for two weeks, we are way underresourced. We only have a quarter million intensive care unit nurses in this country. This is a big problem. We need a Surge Capacity problem. Another issue, and again this is been alluded to, when is it appropriate to close schools, when is it not . When is it appropriate to stop sporting events . When is it not . Political rallies, et cetera. We need a uniform policy or a uniform way of suggesting what the criteria are to states and localities out there. Ron has already suggesting, what it whatlready suggested , is the whole of government approach . Nice phrase. What does it mean . Well, you cant ignore the department of agriculture. All those school lunches, foot d stamps and other things. Cant ignore it. They have to be part of the conversation. They are not a part of the conversation until now. Department of education we are closing schools around the country. They have to be involved. How would we educate the kids . Are we canceling out a whole year . The university of pennsylvania, i have a hard time convincing my colleagues. We go on spring vacation in about five hours. Weve got a week or nine days. We have to think about what happens if god forbid they close Public Schools in philadelphia. It is hard for the university of pennsylvania to continue if Public Schools are closed. What are we going to do on line, in terms of finals . We have to begin planning all of that. The department of education has to be part and parcel. Obviously, defense, health and human services, Homeland Security, we have a big group. We also need to begin developing other tests, serology tests. Who was infected . Because we are not going to have real testing done, there will be a lot of people who got infected, dont know it and will continue. And we need to know who those people are and report them. The list goes on. Mara let me ask you one other planning question. That is maybe tangentially linked but could become very real. This week, the Supreme Court announced it will hear the healthcare repeal a lawsuit sometime this fall that could rule the entire Affordable Care act, including the medicaid expansion, unconstitutional. You mentioned 20 Million People earlier. This case could result in 20 Million People losing Health Insurance coverage. How would the lawsuit undermine our ability to respond . Dr. Emanuel there is nothing like a Communicable Disease to reveal the problems of a Healthcare System, because not only do we need to get health care, we have to worry about everyone else Getting Health Care because they could spread the disease around, especially in a situation where we can all wash our hands, but there is no vaccine to protect us. This is a very good example of why we need universal coverage, and everyone to be able to get coverage. They cannot be dissuaded from getting a test because of the cost. They cant be dissuaded from going to the hospital because the cost is going to be too high. These high deductible plans, we did do something on the vaccines that is preventative treatment, no deductible, no copay so it will be free to people. That is just a start. Does not mean the test will be free. We have to make that happen. You have to be able to go to the doctor or the hospital to be able to get treatment if you are very seriously ill. So we clearly need not only get from 90 coverage to 100 coverage urgently, we have some stopgaps that will be important in terms of getting the vaccine to everyone and getting testing to everyone. Get from 90 coverage to 100 coverage urgently, we have some stopgaps that will be important in terms of getting the vaccine to everyone and getting testing to everyone. But those are stopgaps. Let me pick up of something, we want people to stay home if they are sick. We dont want them working, as the president suggested. That would be a disaster and it will spread it to more people especially if theyre job involves touching people or interacting in a restaurant. They can only do that if they have paid time off. But in the did economy in the gig economy, we dont have paid time off. We have to solve that gig economy gap. We need to have employers that thee to some pool government runs for these people to give them paid time off in proportion to the amount they work. A stopgap is good but is not a solution. And let me remind the audience just of the frequency of these Communicable Diseases, 2009, we had h1n1. It could have exploded. Thankfully, not that serious. 32004. Ars in 2000 20032004 we had. We had mers ebola, west africa. Now we have coronavirus. About every two or three years were having these episodes, right . Stopgap measures are stopgap, bandaid but they are not the same as structural change that really puts us in a stronger position to address the next one. And dont fool yourself. We are going to have a next one. I dont know when it is, jennifer does not know when it is, but it is out there and it is going to come and we need to be better prepared socially, medically and politically for this. Mara i think jennifer might have an idea when it is. [laughter] i will turn the next question to you jennifer, thanks, zeke. Following up on his point about affordability issues and questions and thoughts, can you comment at all about comment on issues about how we should be thinking about our government, and others ought to be thinking about affordability of vaccines and treatments that would ultimately be developed and how important the question of affordability is in ensuring accessibility for all americans . Ms. Nuzzo i know this has come up in the context of the vaccine. Quite obviously, cost should not be a barrier to getting vaccinated. We depend on people getting vaccinated so we have to take that off the table. I think that conversation is a bit immature because we dont yet have a vaccine, and it is not a good signal to send to companies on whom we will depend to make a vaccine at this point, to figure out if it is worth it for themselves. In 2009, the federal government bought a lot of vaccine. I anticipate that would happen were we to want to find ourselves in a situation of a vaccine. But there has been a lot of conversation about the vaccine, the therapeutics that we have for this virus, which is important because we need to prioritize the research and development process. You heard the timeline of a vaccine might the a year to 18 months . That is provided all the science aligns and works out the way we want, that we get to a point that we have something deemed to be safe and effective. But then we have to produce it. This is not just something you can flip a switch and suddenly it starts cranking out coronavirus vaccine, you have to have facilities fo that are best facilities that are specifically geared toward this. Even thinking about creating vaccine and the quantities for which we would likely need it, assuming estimates of 4050 of the globe potentially affected, that is an extraordinary commercial endeavor that requires enormous amounts of planning that could take years. When we had discovered the pandemic virus, we had a network, companies that were already making flu vaccine every year, multiple companies in multiple parts of the world. They had the ability to tweak the vaccine production process so that they could make the pandemic vaccine. And we still did not get it in time to be able to in the u. S. , there were lots of different issues, but we did not get it until it largely after the epidemic peaked. That is with a Seasonal Market where companies have already invested because they know that it is not going to be just a , it will be something every year, and they already have the infrastructure to not only produce the vaccine at scale, to ship the vials around to the place were it is needed. This is all the planning that needs to happen. ,ut putting that aside, because this is not something that happened anytime soon, there are other medical interventions that we need to be thinking about. When you talk about how deadly is this virus, that is not a function of the virus, it is also a function of our response. If we have the ability to deliver lifesaving medical care or supportive care, we could alter what the severity of the virus is, the severity of the disease. We see this ebola patients treated outside of the epidemic context where it happens and to survive in higher percentages than people treated in situations were Healthcare Research is limited. I agree with the point about the importance of focusing on Surge Capacity, and the point also of ensuring access. There are going to be some will requireom it hospitalization. And if they wait to be hospitalized to the point where they are so severely ill, first of all, it puts more burden on the Health Care System, because the patient is resourceintensive, probably producing a lot of virus which could result in transmission events. We dont want situations where cost is the barrier for which people who would benefit intentionally from receiving medical care, we dont want cost to be the barrier. Mara thanks. Underlying everything you all have said but certainly most recently, zeke and jennifer, is a basic foundation about the import of sciencebased policy decisions. Jennifer, you say, and i am interested hearing waste on that, reactions from others, are the three most important elements that get us to looking at how we get to a sciencebased policy decisions on this issue . Obviously, it carries the assumption that some of this is not happening currently. Ms. Nuzzo i study outbreaks. It is one of the things i have been doing for 20 years. I have always seen the politics enter into the equation. Politics is not by itself a bad thing. Having Political Leadership and political attention is not only it is essential, frankly. But when politics gets in the way of an outbreak response, that is when i think we have problems and can have the potential to exacerbate the total of the outbreak. It is possible for us to do more harm just simply bu by the decisions that we make. The technical experts have to lead in terms of making recommendations for what needs to be done. Ultimately, the call for what needs to be done will be a political one particularly when there is insufficient data. But we have to be honest about what the limits of the data are and honest about the decisions made in the face of insufficient data. That i believe is absolutely important. I just dont see a way around that. I will say, though, that one thing that happened in 2009 that i thought was helpful, a number of agencies convened sort of bhat they called team v processes where they set up external advisory groups that they would go to regularly, talk about what they were doing, share what they were doing and theyre thinking. Confidential circumstances because many of it was internal the liberations, but there was some level of openness there. The goal is not only making sure they thought of everything, because when you are in the midst of a crisis and i have for the peopley in government right now who are working on these issues. It is incredibly hard work and i dont want to in any way demean a credible hard work going on. It is very hard work when you are in the midst of that and you are just putting one fire out to the next, to have a really long range view. That is why it is essential for people have a little more bandwidth and a bit of a different perspective to weigh in and say, have you thought about this . Why exactly are you doing this . Does it make sense. To make sure we are on the right course and to raise to the surface in issues that have not been identified. The issue of how we are going to do surveillance for when the disease inevitably was found is spreading in the u. S. Could have likely come up in those conversations and thinking about alternatives to technical glitches that influence our ability to deploy diagnostic tests. Thinking about what strategies exist outside a particular agency that could potentially be brought to bear to address the gaps we were seeing. Mara thank you very much. Would curious, lisa and reaction to that having lived through the experience. Often in national emergencies, too often i would say in the united states, we see people revert to their worst rooted in see actions racism and fear as a result in terms of reacting to the other in these kinds of context. As people look to sciencebased decisionmaking and deploy the types of things jennifer is talking about, what should Public Officials be doing to ensure anticipating those issues . Ms. Monaco i will kind of revert to my prior theme of having a prioritized and structured approach to this, looking at it, as a whole of government issue as a transnational threat. As with other such threats, we are intelligencedriven. The policymakers who as jennifer rightly pointed out, are going to be the ones to make the hard calls, and that is appropriate, in other instances, whether it is terrorism, you name it, the policy are asking the subject Matter Experts, the intelligence professionals, give me the data. Help me understand the threat. Help me prioritize what it israel looking at. Unless you have help me prioritize what it is i am looking at. Unless you have a a structure in place and you have leadership wantsays, that is what i to think about this, as opposed to responding to news cycles or responding to irrational fears, if you have a structure in place and you have leadership that says, i want to be driven by the data, you have to send that tone from. The top frankly, with other threats, like this plan b framing, in the National Security world, we call that ming. Teaming red tea you get other experts to say let me take the counter view and really test it. You need leadership that is open to that that is driving a process that says, i want the best, factbased thinking to help inform it hard policy decisions. To your second question, that ought to be permeating our response when it comes to generateded or biased responses. You can imagine a world in our hypothetical scenario, where i as Homeland Security adviser or czar, ife disease you will, is leading the conversation to say, if we are cerned in an uptick concerned about an uptick in crimes, i want my Justice Department who has a role in addressing civil rights crimes, and i want my attorney general, and i want to have statements from the very top being, that will not tolerated, and we are going to deploy our office of Community Relations which operates in these scenarios, with regard to other biasrelated crimes. You have to send the signal from the top that that type of response a is not rooted in any fact or science and it will not be and should not be tolerated. Clean fish three quick points to that mr. Klain i will just add three quick points. I agree that politics is part of this. But the question is, what logical choices are our political leaders making . In the ebola response, president obama made the decision to have science, evidencebased policies be the default choice. Lisa and i sat in a situation room with the president. We were in in a political saying,m with people cut off travel to west africa. Let the people over there suffer without u. S. Help because we dont want to bring the disease back. The president made a decision that the science and evidence did not support that. We send people to west africa to respond and save lives. We allowed them to come home, which was the only way to get them to go, with appropriate precautions after they came home based on science and evidence. So there is always politics in that. That is absolutely right. But political leaders make choices about what values to put at the center of this, and that is vital. Thing, the relationship between this and the testing fiasco we are seeing. There is no question that maybe the lions share of this testing fiasco is logistics, may be a bad choice by the c. D. C. About how to build their own tests. Maybe technical issues. This is a firestorm, people will make mistakes, i understand that. But i have no doubt that part of this fiasco is the president saying as a default, bring me know bad news, do nothing to disturb the economy, dont tell me bad things are happening, i want to minimize the case count, i dont really want to know what is happening. Ok . The bureaucracy risk ons is a signal response is a signal, and when the signal is that if you tell people the truth and it is bad you are going to lose your job or get sidelined, that is the signal. A Political Choice that has an impact on how the government response. The doctor who is a career official at the c. D. C. , who has saved literally millions of lives around the world, stood up and said that any scientist will tell you that the spread of disease in the u. S. Is inevitable and she went into the president s penalty box as a result. Thats not the way you get the bureaucracy and the professionals and experts to respond. Last point i want to make about the issue of discrimination. Lisa is absolutely right. Governmenthole of response, you should have the department of justice stepping up and people stepping up looking for crimes, but also we should step up too. Hate crimes of the most of tim example are happening already. Tremendous drop of business in chinese american businesses. People basically that willing patronize chinatown not willing to shop or buy meals there. Like all of us need to be Civic Leaders and to say this disease affects humans. Its not based on race or ethnicity. You are no more likely to get it eating a meal in chinatown than eating a meal in little italy or any other part of town. We need to set an example and lead and help patronize these businesses and mitigate some of the negative effects this is having already. Whoemanuel the scientists are critical to this response and any Communicable Disease, epidemiologists, biostatisticians, theyre all adjusts, those people virologists, those people are in high demand. Unless the government accepts them and gives them jobs and listens to them, you can find a buyer to station a biased addition in the country. They are so scarce. But if you tell them, were not paying attention, we are not paying attention if you bad news or you have something, or by the way, your predictions, we will ignore them or prevent you from publishing them or prevent you from going to a meeting and presenting them why do i need government . I got 27 job offers outside of government, whether in academia or business or pharmaceutical companies. Unless we populate our government with those kind of people who are supersmart and creative, we will not have the evidence. We know that has been the case. People can also take early retirement. It is partly how they are received, the judgment. It is also the respect they get and the ability to do their best work regardless of where the chips fall because that is what they do. They are fundamentally scientists committed to getting the truth, not committed to whitewashing whatever they have got. Zekes point,nd if you send a signal that you see this as a border issue as opposed to a science issue or an apd realogy issue, you are sending the wrong signals and it is going to affect and hurt the response is you are seeing. I think we lost valuable time in addressing the testing debacle by saying we are going to keep this out. The pandemic, any pandemic and any emerging if anxious disease does not respect borders emerging Infectious Disease does not respect borders and it sure as hell doesnt respect any walls. Mara thank you. Before we open up to questions, which we will do shortly, one last area i wanted to drill down a bit further, jennifer, you and haveand ron you may mentioned this as well, in the category of forward planning and in understanding that we need to have a Surge Capacity, what hospitals,ay either states, what should people be i and at what levels to dont know if triage is the right word, to be planning to make sure that hospital beds, capacity, supplies are reserved for the most sick. Whether you have to the medicine. Who does that, how should it happen question mark how is it happening now, how is it happening . Because that seems to be where we are heading on this. From where i sit, i dont get is ans of where the rules of the road are. Ms. Nuzzo this is something i think we should have learned in 2009 but we did not incorporate into our learning. In 2009, as Media Attention of the pandemic increased, naturally, there were all sorts of additional attentions to the pandemic increased. What you saw, because we track things like influenza, there was a surge of people going to Health Facilities above any kind of historical norms. A surge of people. Shortlyy did the study thereafter, they saw that only a small percentage of those people were actually diagnosed with the flu. What it meant was that a lot of people were showing up for a nonflu specific reasons. They were there for a number of reasons. One, they may have thought they had the flu and wanted to get tested. E hadthey may have an employer who said, they went to mexico or you are in this county that was reporting cases, you need to get a doctors note before you can come back to work. Then they would try to connect to their primary care provider who said, you want to come and flu, go to the emergency room, our office is not equipped to handle an influx of flu patients. We dont want to expose everybody else. Then there were many people who went specifically because they were concerned and he wanted information. This puts an enormous strain on Health Facilities particularly given the numbers zika mentioned, anticipated numbers of people who will require medical attention. It is not a good idea for people to show up anyway because if six, they can expose others. If they are not sick, they can get sick. Nonetheless, we cant put this rooms. On emergency part of the unfortunate aspect of our wanting to expand and improve the diagnostic science, i think we are inadvertently sending the message that everybody gets tested. People here that and think, i have to go and get tested. This is something we should know and plan for. Healththat individual facilities, Health Systems are thinking about how they can triage patients because they are deeply worried about patients showing up in the er, at their clinics and announced. They dont just want them to show up unannounced. It is difficult for this to be done for individual Health Facilities. There should be one number to call to figure out what you should do in your situation, and i think this is something that is a function of government. So many people are seeking information. Any of us who have ever spoken of this are probably being deluged with frantic emails from people seeking information, because there is no information to be found the government. Was he website is abysmal. The New York Times is doing a better job of tracking the pandemic in the u. S. Than any Health Agency i have seen in the u. S. Singapore is doing in its ordinary job. Look at the Singapore Ministry of health website. Incredible transparency. Incredible amount of data available. Realtime. Kudos to them. This is absolutely something we need to think about. I am glad to hear that Health Systems are trying to take this on and they are forwardlooking, but again, i just dont think it is a great idea for there to be 27 numbers to call, nobody knows where to go. There should be one portal for people to understand how to connect. It is not just patients who need this, providers need this. They need to be ready for being know, so that they feel comfortable seeing hospitalization. Patients, particularly patients who dont require they are part of this. They cant just put a sign on their door that says, if you have these symptoms, dont come here. We would be crippled if that were the case. There are other Health Aspects that we should also try to work into our response, like large employers that have Occupational Health services. There is many things after but out there, but it requires planning and coordination. In particular as we are talking about expanding the number of , ices people can get testing am deeply word that we have no plan for understanding who is getting tested where. We will not know what to make of it because it could simply be testing different populations and nobody is tracking that. First of all, that is not even level. Ng on a global just trying to make sense of one countries numbers over another, you have to figure out how they got to those numbers. In the u. S. We should allow flexibility in at the very least willwhat strategies states be using. I dont think they have even developed of those strategies, but when they have, we should be it and understand it. Mr. Emanuel part of it is we have cut back the c. D. C. For those of you who dont know, the c. D. C. Does a lot of funding of state and local Public Health responsibilities by giving out grants. If you dont give out grants, you cut back your pandemic preparedness. You dont give out of the grants, they are not ready with this and creating a modern database so you can do exactly what jennifer suggested, i think it is critical. Of facilitiest that do have disaster plans but there are a lot of hospitals that just have not developed them. Again, this is a place where we can anticipate, we can circulate best practices out there and just have not done it. Let me say that the university of Pennsylvania Health system, we have actually gone to a moderate rationing policy. Medical students dont count. Dont examine patients. You dont have multiple people going into these isolation rooms fully gowning and masks. We have to conserve the number of gowns and masks we have because that supply is not unlimited in the country. And anticipating serious so youre already seeing a lotng of judgments being made at various systems in anticipation of their are going to be shortages, and how do we prevent masks and fullon gowns, gloves, etc. Thats a bad place to be at the start of an epidemic. Very bad. Washington, we have experience at the federal level. Muchnt be overstated how this is about state and local response. , to provide , to help with best, to be a standard setter if needed. The federal we are in washington, we have experience at the federal level. It cant be overstated how much this is about state and local response. To provide, to help with best practices, to be a standard setter if needed. The federal government should be in the role of supporting a robust state and local response, just as we have done to other threats in providing that assistance. I would love to see the type of state and local grant and Public Health preparedness plans and Grant Programs that we provided in the wake of 9 11 to help all of the states and local municipalities raise their level of preparedness for other types of disasters and threats. We need to do the same when it comes to Public Health. The other role of the federal government is to work with our partners around the globe to raise their capacity. With the Global Health security agenda that was started in 2014, a network of multinational approach to raising Global Health capacity around the world to keep those diseases at bay before they get to our shores. Theres a lot more economic and forward thinking to do that than wait to do the type of things we are talking about here. Mara why dont we go ahead and turn to the folks out there. Lets go here first. Theres a lot more economic and forward thinking to do that than wait to do the type of things we are talking about here. Why dont we go ahead and turn to the folks out there. Lets go here first. Thank you so much for doing this. About chinas approach, in terms of containing the epidemic. We have seen some countries, like italy, locking down the city. Approach . Cessary will we see something similar in the u. S. . Are there any approaches the may or other countries learn or copy from china, in terms of stopping the outbreak . As we think about what measures to take in response to the virus, it is important for us to evaluate not only what the Health Impacts will be, and that is not just looking at case broader but also the social and and comic and Economic Impacts. We need to hold those in balance. Its possible to take measures that do more harm than good. I think what we have seen in china is a result of the situation that got very much out of control, where there was limited understanding of what was going on. Im sure a lot of the uncertainty fueled those aggressive actions. I also think we have not fully virus, iged this dont think its amendable to containment. It is spreading too quickly and too fast. It is not like ebola or the flu. No one would even attempt that. Theres been a lot of celebration over a recent decline in case numbers in china as a result of extraordinary unprecedented actions. Skeptical remain about the case numbers just because i havent fully understood how they are testing and looking for it, im not suggesting they are not being honest. Thats not what im trying to say. I believe there have been other impacts we have not fully accounted for, such as people who are sick with other things like cancer and hiv have been unable to receive care from a response so focused on driving the number of cases down to zero. I also dont believe we are fully accounting for the social and Economic Impacts. Any decline in incidents we are seeing now, if it is true, is temporary. Work as weet back to absolutely need them to do, less we run out of equipment we know we are going to need, the virus is circulating on the planet, china is a growing economy. The virus will continue to circulate and come back. Even places like singapore, which have reduced cases, and i believe they have, is acknowledging the fact the reduction will be temporary and will come back, because they cant wall themselves off. U. S. , i very much want to stress we need to proceed carefully and not act just because of chaos. On top of my mind what i am worried about is School Closures. I dont think we have adequately thought through i think we to sayry limited data they are going to alter the trajectory of this pandemic, but i also dont think we have thought through the contingencies, like what it means when Healthcare Workers cant show to work, what it means for the nutritional needs of children, the Economic Educational and social needs of the children. I have spoken to those under lockdown in china. Life. Escribing their one reporter had twins at home. He said it wasnt healthy for them to be inside the house for months on end. We have to account for those things in our decisionmaking. Im an epidemiologist, but its not just about the epidemiology, its about a broader view. I very much want to stress the need to fully evaluate measures. Two thingsant to add to that. It is very easy to say we should quarantine these people. Any Health Care Workers having exposures should go home for two weeks, we will close the schools, we will do all of this. Surfacetand the level appeal of that, but a lot of those measures will make us less healthy, not more healthy. Think about Healthcare Workers. We already have kind of a shortage of Health Care Workers. To quarantine large numbers of Health Care Workers, not only will that impact our response to coronavirus, people will show up with heart attacks, breach birth, or other things, and the system will not deal with that. The precautionary principle, which is so attractive to us as human beings, actually winds up doing more harm than good in these kind of circumstances. I would say there is one thing they are doing in china that we need to think about, the ability to construct quickly surge health care capacity. Governor, a mayor or or a major Health Care System administrator and you dont have a plan and 500 beds on three days notice, you are not ready for this. Whether it is through construction or finding some facility, whatever, not everywhere in the country, not every city, but we will find a major city where every bid is filled, every hospital is filled, it will become an outbreak, and we will need that Surge Capacity. We need to think about where it is and how you are going to construct or repurpose it to get that kind of Surge Capacity. You can see this in seattle where they had to buy a hotel. That is a sign of desperation. The fact we havent thought this through and have a backup plan. It is very expensive to have beds mothballed, and hospital beds, only 60 of them are occupied. We shouldnt be doing that. We should have a plan for Surge Capacity. Whether it is putting up quick hospitals, which the military has a lot of experience in. We need that. It is not clear how much that is being done. I do have to say, and maybe i will be a little bit more forward. There is some doubt about the chinese numbers and whether they have gone down, whether they have gone down because they changed testing protocols. Without open transparency, with a history of trying to suppress this, one has to be skeptical. We do need to have belief, i think there are procedures you can have. Much more believable that you have been able to turn a corner. The chinese are trying to get their factories back to work. You cant have a negative Economic Growth of less than 6 Economic Growth for the country. Stability. They are trying to get factories back working. That may be premature for their situation and provide a focus for much more rapid spread of sick people going to go to work and spreading it around the whole factory. Worryas to be a serious in this circumstance. I would go to the woman here. I dont mean to point. Excuse my pointing. What is the incubation or just ration period of this virus . It is a term for the period of what you have been infected and in some cases to develop system symptoms. The best estimate is somewhere around three to five days, but two to 14 days. We want to make sure people get to hear every word. You will hear a lot about 14. When you do things like quarantine, we take the full range and thats where we get the 14 days people get quarantined. There are ongoing debates about the incubation period. There have been some questions raised is whether it can be longer than 14 days. As of now, that is the current thinking. One of you mentioned there is pandemics that are inevitable, and some are caused by transmission from animals to humans. Downere a way of slowing that transmission process from the animal to the human . Should anticipate future spillover events jumping from animals to human. If it feels we are having more merging Infectious Disease outbreaks, because we are, about two thirds of them have originated in animals. The challenges we often dont detect when that happens, but we should be doing more to understand what causes it to happen. There was a Great Research usaidm being funded by called predict that funded researchers to work in the field to understand not only of urologic drivers, but also social and behavior drivers, trying to understand risk areas and hotspots, etc. Strange thate bit it was a research program, but i think they did really interesting work. Unfortunately, it just ended. There is one more thing we can do to reduce the risk of spread from animals to humans, combat climate change. Climate change is driving this problem. Not necessarily coronavirus specifically, but disease spreading vectors like mosquitoes have wider range of habitat. Next time we have ziegler in the u. S. , we will not just see it in the southern part of the u. S. , but the mosquito can now live further north. That is one effect. Human, animals, closer proximity due to habitat destruction, gratian patterns. Climate change is also forcing refugees off of places into places where they are vulnerable. The ebola epidemic finally coming under control in congo. One of the risk factors was always across the border in south sudan. One million refugees in a camp. That would have been a disaster. Has a lot of bad effects. What we dont think about very often if it is a driver of the epidemics. It certainly is making the risk go up as a planet. All of these things mentioned underscore while we cant view this as something we can deal with domestically as only inside our borders. Increasing the capacity to detect these issues overseas with programs like predict, raising the capacity of other when thatto detect jump happens. It can greatly improve our ability to get ahead of it. While it is really unfortunate the original request for an emergency bill, emergency money from the administration to congress contained no International Aid funding. Thankfully congress and a number of really smart thinking Committee Chairs and ranking over 100t a little billionin this 8 emergency supplemental that just got passed. But we have to be thinking about this as a global issue that requires programs like predict funding, such as the stuff just added. Straight back, lets get to the back of the room for the folks who have been patient. Thank you. I was wondering if you could shed any light on the response structure within the administration. The lead is still with hhs, but the Vice President is in charge, Deborah Burks is the coordinator. With theit contrast situation when you were tsar in the white house . It is confusing, isnt it . Earlier on in january, i said they should put someone on blast. The problem isnt that they dont have a coronavirus coordinator, although maybe now they do, but it is that in july of 2018 when john bolton took over, he abolished the unit that lisa set up after i left. Team, no one in charge to coordinate on the preexisting basis. Then they went on the structure and created a committee that alex as are shared, a task force. It did not occur to me if there were tasks, if they were getting done. When things got bad, they put Vice President pence in charge. They didnt disband the task force. A day later, they brought in debbie burks. Parttime, still doing what shes doing in africa, but parttime working for Vice President pence. She is on the task force, the coordinator. The point of this is what you need in this situation are clear lines of accountability, clear lines of authority, clear lines of coordination. This is a big, hard problem. We didnt get everything right in ebola, we were right on many things, and we made some wrong choices. But what we did was have a process that everyone in the government understood how it worked, where decisions needed to come to, understood how decisions were getting made, pressed through the system. They understood were to bring problems and how to get them solved. Science and medicine as a guide. A lot of this is just logistics. A lot of it is about making things happen. Solving problems. The test kit thing is partly a science problem, partly leg no one knew how many you needed. Badlyk that is very confused in the Trump Administration. Thats why a lot of things seem like they are moving like molasses. Thats why you can say we will have one million tests on monday or friday, and the actual test is 75,000, a lot less than one million, i think you are seeing the consequences of a lack of acountability, coordination, lack of really Clear Management for this challenge. One thing that is clear is that can only happen at the white house. The ability to get all of the departments and agencies to Work Together and unify, that has to start at the white house, because thats the only place that can oversee the whole thing and create accountability in each place coming back to the center. Say that is really critical that the white house work well and with all the agencies. That is indispensable. We have time for one less question. The woman right here in the back. Im an intern. I am student at the university of pennsylvania. About supplys chain disruptions in china and how that will affect manufacturing of a potential coronavirus vaccine, or even other essential drugs crucial to our Health Care System, and whether or not the supply chain disruptions will have longterm impacts on the Drug Distribution and manufacturing process, both in the u. S. And worldwide. Have been deeply worried about this, but one of the things i have been frustrated by is i dont think we understand the problem at the level we need to understand it. Supply chain is incredibly complicated, and no one seems to have a handle on where it is, the issues, the vulnerabilities. I dont think we have truly examined it in the context of not just a hurricane taking out a plant against medical celine and thinking about where to source it, but to think of it in the context where every country is affected at once and every country will be clamoring for the same things at once. For the companies, it will be hard to think about the product in a country. I know there are folks in the government working hard on the issue, but i dont feel a small group of people inside the government have the appropriate view on the issue. This is one area where we need more work and more individuals involved, particularly from a private sector, to figure out the issues, the problems. I know from the Health Care Delivery side that they are very worried about the issue, but they have no intelligence on what to expect and whats coming down. You may have heard the fda recently announced a critical drug shortage, but did not announce what it was. Its hard for Health Facilities to hear about supply chains. They are told to conserve, but they are also told to evaluate patients with airborne precautions, which is a way to burn all the the supplies you have. This is not one area we have given enough attention. I think the attention has to be multisectoral, has to involve not just the government, not just the private sector. I think it is an area of critical work. Just think about the flu vaccine. It is 11 countries that produce the flu vaccine, thats it. 11 countries out of 190 six, whatever the latest number is. That has to supply the world. We are definitely going to need capacity field. Its not like you can just hijack theres not a manufacturing facility you can just switch over to. On the drug shortage problem, a High Percentage of drugs are made in china, but the raw materials, it is Something Like 90 . That was a good idea for driving prices down, it is a really bad idea to solesource. Such a large proportion of the raw inputs. Toneed two things, we need diversify. Those chemicals can be made in a lot of places, china doesnt have a lock on the chemistry. Second of all, we need to diversify the sources, but also facilities,on especially for generic drugs. This is going to become a big problem. It will not be one of these things that we can waive away. There are 20 drugs on the fda watchlist. We already know we had a preexisting drug shortage problems in many different areas. Generics for cancers, which i know very well. I think we will have to diversify. That is not an overnight problem, it is not even a sixmonth problem. Start, we have to make sure the fda stays on this route and doesnt lose track of it, because it will affect all of us. Our problem is Something Like having the generic diabetes problem, but there is no supply. That would be a real disaster. T shows how interconnected it might be coronavirus, but you can be affected if you have cancer or diabetes, or something else, through no fault of your own, because of the interconnectedness of the system. I think thats a really good point. We have agencies responsible for this, they just need to stay on it and get the work to solve this problem, and we might need to create new authorities. I want to thank everyone for coming, i want to thank our questioners. I think we had some very thoughtful questions that were also evident of the terrific panelists we had here and your incredibly thoughtful answers and comments throughout. Thank you so much for being here. In a time, eric, an issue when there is a lack of evidencebased and calm and thoughtful discussion, you help to make up for that in major parts. You are providing what you did. Thank you very much. I think we are all better prepared for being here. Appreciate it. Cspan, your unfiltered view of government. Created by cable in 1979 and brought you today by your television provider. Up, we will discuss the u. S. Response to the coronavirus and potential impact on children with dr. Roberta debiasi of Childrens National hospital. We will talk about the shortage of lifesaving drugs and its impact. With rosemary gibson, author of. China rx washington journal is next. Host good morning and welcome to washington journal. With fears of the coronavirus the stock market has seen huge swings in the last few days. With vacations at public gatherings being affected by worries of the virus many travel, chris pratt, restaurant and has been telling the companies are seeing plunges in Stock Companies are trying to figure how they will keep going if people are ordered to stay at home. Some investors are seeing an upside w