Transcripts For CSPAN2 Pandemic Biosecurity Policy Summit - Part 2 20240714

Panel of speakers for panel two. Additionally this represents more of an institutional leadership and innovation and we have both were honored to have the center for Disease Control and prevention and our second panelist is doctor daniel professor of International Health and director of the institute of safety at the Bloomberg School of Public Health. We have or very honored to have doctor maurice are busy of the health and security interface and he is definitely gone above and beyond the call of duty as he has flown in from australia to los angeles and took the redeye to be here this afternoon. He has come above and beyond the call of duty. And then our final panelist is doctor irene coates, acting assistant and minister for Global Health agency for International Development. We will have a similar format of our last panel and i would also encourage the panelists if they feel the urge to ask a co panelist a question that just interrupts me and do it and if i asked the wrong question than the last panel then restate the question you would rather answer and go for it. I think what we are way behind so we will probably go to audience q a much quicker because the things we talk about know they would like to say that some things have already been said. We want to make sure we get you an opportunity to ask some questions. I would to start first with Everybody Knows the public cdc and you are our nations public authority. We are pretty much familiar with the cdc. If you want to restate some of that of the mission and approach to talk about the great things the cdc and your colleagues are doing and many of the mind that would be great. Maybe one way to do that is to tell us what we have learned from past outbreaks and even a pandemic. You were in the middle of that in 2009 other outbreaks we can apply as lessons observed for future outbreaks. Sure. Pleasure to be here and i appreciate the folks who have stuck with us this whole afternoon. Its been ten years since the h1 n1 insulin pandemic stock and we are and have learned a lot from that in some ways are a lot better off and in some ways theres a lot more to do. A key lesson there was the value of everyday systems. Sometimes we want to have a Fire Department or fires and a whole different Fire Department for bioterrorist events perhaps but i think the work we do year in and year out with seasonal flu helps us with the h1 n1 pandemic and our efforts since then to strengthen pandemic repair and helped us with seasonal fluids. Whether its the surveillance work, laboratory work, medication work, partnership, trust in relationships with public and private sector u. S. And global relationships exercising every day instead of waiting for the big one we i think thats a critical scheme. In terms of learning from the ebola epidemic epidemic as you heard is not enough to come in when theres an emergency. The three countries affected by the weakest Public Health systems. The agenda was about making sure every country could find stuff to prevent epidemics and the world could search when needed. I think what we learn from that is we dont just want to come in the middle of an Ebola Outbreak but work sidebyside to strengthen their system and worh Public Health systems not just primary Health Care System. We use the Emergency Operations system to address and illuminate child transmission of hiv or yellow fever or other conditions. We try to use the Laboratory Networks in the Workforce Task for the problems of the day. At cdc we got activities in 57 countries right now very much focused on critical government priorities like president s illyrian initiative but very much about global Health Security and strengthening the capacity to deal with the priorities they have. Take you. I would like to ask doctor from usa and will jump to number four, the person who was seated recently traveled maybe over a month now to the drc and probably came back with interesting observations that have impact for both usa, cdc and other governmental agencies. Can you share some of those experiences and observations you are thinking about and how that integrates with and maybe doctor schuchat could jump back in with the great work youre doing in collaboration . Great. No. Thank you. I echo the appreciation to be on this panel and be with you all for today. You say where the Development Agency for the u. S. Government so we do work in health and we certainly work in a number of other areas critical to those capacity as our initiator talks about to build countrys capacity to do all the things whether in health or Economic Growth or economics et cetera. In health we do work across with our colleagues at the cdc and in other areas. We do have a number of a lot of programs in the congo but investors last panel one of the big issues with this outbreak is that its in the middle of the war. A war that spent on the way for a long time and its become extraordinarily difficult to do because of ongoing things you would be doing in that situation. Doctor golden was my predecessor was there in march with doctor redfield and just last week the acting assistant administrator for the humanitarian assistance work that they do was also there working with the current ambassador and visited the community affected. What is really clear is the complex emergency underway in congo is having interventions we want to do that ultimately worked in west africa worked very much in the last outbreak in the western side of the country but what is also becoming clear and theres a lot of consensus about the need to do a much more holistic approach for medical interventions and people coming in and doing what are the needs of the community and what does the Community Need and what do they want in order to bring the divisions we need around the bullet response but recognizing that was talked about that is not just a bola but issues being faced there. People are dying of malaria and tuberculosis and died in childbirth and lots of issues on the ground and lots of fear and distrust of everyone coming in and trying to engage very actively with local Community Groups and local ngos and the church and other organizations active they are to reach the community on a much broader scale in prevention control going to the ep you and other things as well as the vaccine. That is the impression my colleagues have come away from. I would like to now turn to you, if i could. You are heading up the health and security interface of the World Organization and i suspect some in this room are not familiar with health and security interface so maybe the first is if you could give us an overview of the interface and in fact, how that supports the pandemic Public Health Emergency Preparedness and your work with cdc and usa. Thank you. Thank you for being here this afternoon. Its the result of a failure of an International System to have a definition on Health Security. Global Health Security for the u. S. May not be the same definition or understanding of the security of receiving treatment in other parts of the world but there is an issue for doctors most of you intelligence interview investigator may need certain things from the Law Enforcement in many different things. Mixing civilians and civilian may not be the smartest thing to do. The intervention where these understandings are on what the front page for if i let the team that contributed to the investigation in the area where [inaudible] killed almost 1500 people during 2013. That would imply certain security and political us possibilities and health in the un making the case and raising which kind of people or patient sample and how to handle the sample and so on. The use of chemical weapons and muzzle where its not only the clinical epidemiology to get these people in the proper care but how to preserve the fear and maintain fear of the healthcare workers which we run in the camps to drop and run. But also when you have a normal outbreak the league as the question in nigeria without involving they want to landed together with david we ask for the Police Others we never would have gone out because the traffic is impossible to move and have one contact traced without a police escort. Of course, we have to ask which neighborhood to go with the police in which neighborhood not to go with the police. The problem with the cdc [inaudible] so, in essence [inaudible] to exploit all the opportunities that are increasingly for the relevance into the security sectors. Its not just family. If you have a response to the pandemic you cannot do Public Health without roadblock, fire brigade, people bringing the food to the quarantine and is there really a we should start humbly to recognize that we are just a clogged. Last reflection is if a cop skated pandemic. When you cross the border in uganda or other countries like in 2013 there in three different languages and distinct tribes and it wasnt very friendly with each so going back to the [inaudible] to have those messages across many countries and if there is an event which is suspected which country or which close the border will be listened to. They are the loudest so there is a reference for the lack of all we heard this morning during the day for a reflection point that could offer the platforms. Thank you. I want to inject a new but very related topic into this conversation and would like to ask you how you see the role of vaccine safety with very specifically hesitancy and how that may impact and fairness when a vaccine will be absolutely essential spirit yes. Thank you. Thank you for the opportunity to speak today. Its been an interesting day. The bar is high for us. Its a great question because my experience with h1n1 and im speaking as an academic i was responsible for overseeing coordinating the vaccine Safety Program international and i think about the value of routine influenza is important because what we had to work with was what we had at the time and im reminded of what the secretary of defense Donald Rumsfeld said about when you go to war you you do so with the army you want but the army you have not the army you want. Thats the realities on the ground. When you look at things like vaccine safety for example vaccines that we use routinely our very safe and thats unfortunate. Flu vaccines are very safe. Theres always the possibility of something you dont expect as was the case in 1976 and you have to look for that. If youre talking about the vaccine or you have less experience the potential for a real safety problem to occur may be greater but you also have a problem which is that if you vaccinate everyone today every bad thing that happens tomorrow happened in the day of vaccination and that thats the problem domestically but especially a problem in parts of the world where bad things happen every day and people will naturally assume that the temporal relationship is a causal relationship and we will see look at these people they got the vaccine and then something happened. We need science to separate the coincidental from the true adverse reaction and it is no not science takes time. The more intersection you have the better, faster you can respond with good science. That infrastructure leads to largely exist before theres an emergency because we dont have time to go now we put this together. One aspect i think of this is in the report thats been shared of trust and trust specifically in Public Health authorities. This is very complicated. What makes people trust Public Health . Its a whole bunch of things from the transparency and equity and a lot of different pieces they trust though we dont understand it well and dont even know how to measure it well and we need to do that. Its a cornerstone of Public Health and important measure and we need Peoples Trust in their confidence in their confidence in our Public Health measures that the benefits outweigh the risks and were doing the right thing because at the end of the day we need their compliance. You brought up temporal relationship with receiving the vaccine and something that happens even though theres not a causeandeffect relationship and we hope not in the trust issue we have seen to be in the states right now where public has distressed so how do we rebuild that and go about that we need to address the legitimate concerns and we all his parents have concerns but how do we rebuild that trust and develop effective education, mitigation system and who is the messenger . Those are Great Questions but and trust in government is an alltime low where in the world of alternative facts where somehow something can be said in a short amount of time half the population questions the birthplace of our president and i think the problems are complex and the solutions are also going to be complex and we need to make sure we have rigorous objective science. It needs to be rapid and if you take the autism example it took longer than it should have for us to have good data. We had really good data and we had 15 while conducted studies done throughout the world showing vaccines are not associated with autism but in the time from when the paper was published to when that science became available you had a very charismatic well credentialed person traveling the world creating fiction. Objection, rigorous we need a spokesperson whose really trustworthy. We need to address it that way. You are itching to say something. Even if in the United States or certain countries or certain areas possibly listen to tom brady more than the local news from health there are countries where you should start with giving up politician on the stage and they go in the direct other direction. The messenger which has been researched but by the time they do the research they social media changed and the opinion of the public is much faster phenomenon. Even at the International Level and whoever but its an iteration of the match. Yeah, i have a lots of thoughts. [laughter] one thing i do want to say we are at a record right now with cases this year more than 25 years and larger, longer outbreaks and a couple areas where they are quite difficult to control. Its important for people to know that here in the United States most parents make sure their kids get back or vaccinated against the things that are recommended. If you look at two yearolds its 1. 1 of them that have gotten vaccines. Were not in crisis mode across the country everywhere with everybody opting out of the system but i think were at a delicate time in terms of trust where building on the last panel is local and it used to be that people trusted their pediatrician or family physician and the often trusted their mom or grandmom right now a lot of parents and grandparents have the measles over in a New Territory with that a lot of pediatricians have either. But i think that there are many other influences and some of them are active and in the current outbreaks we are having some of the influences are active with targeting multiple communities with very targeted misinformation. That is quite challenging but its not a general problem. If we look worldwide theres a lot of different factors influencing competence in the Public Health system and we cant put all our eggs in one backs it of the perfect spokesperson for the perfect role and you need to look locally and then as a Public Health system we need to make sure we get the best information with partners who might be more trusted. Can i build on that point . Its about whos the most trusted voice in a given setting and getting that good quality of information that is understandable and absorbable to the people in trying to reach. Its completed studies that you just dont understand and its not something that my sisterinlaw will necessarily understand or in my community. You want to get that information in a way that is understandable but understanding who is for the trusted people in a given area. There is a lot of evidence from the behavior change colleagues. When you look at this how do you get that information out and it changes the behavior and can be understood and trusted and look back to that approaches and evidence was a way to get on top of these misinformation and misunderstanding. I think we need to be careful to not respond. Two places i worry about and one is theres been a push to illuminate nonmedical exemptions. I understand the desire and my concern is that it does not get to the larger issues. The impact base will be seen in california which he did so in response to a Measles Outbreak in 2015 is that the impact is really small and reduces autonomy and disproportionately for low income people that might not afford school or shop doctors and i think my concern is that of trust. If parents feel like im being more to come in and they have a backlash and also the push on social media. Theres a lot of problems with social media and ive had a letter written from the congress and the head of facebook and twitter and it said theres no evidence that vaccines cause various harm or death. Vaccines are in credibly safe thats not a true statement. The argument is to curtail this information for the letter itself is misinformation. Its coming from government leaders. Working with social media is great and i much rather see it done between individuals and the Companies Taking social responsibility. I think we need to be careful to not overspend and feed into the mistrust. So, a lot of our response is driving the division and divisiveness that we have on both sides of this argument. Thats what we need to avoid. Unlike politics we need 95 compliance indefinitely. We dont want this to be a divided issue but we need to bring people together and sustain that success and as was pointed out most parents vaccinate their kids and we need to keep it that way. Let me change gears again. We need to talk about innovation and technology and doctor schuchat could you share about your thoughts about the cdc and its advanced innovation and technologies and the outbreak response and how its a part of the culture of cdc. Sure, maybe i will prodded a little bit and contrast where we are now 2014, 2015 with ebola. There were numerous efforts to get Laboratory Confirmation of ebola cases in 2014, 2015 because the diagnosis rant that you need to be separated from everybody in the invocations on all your contacts and quite a bit of a lift for the Public Health response as well as for your uncertainty of his this fever due to malaria or ebola. 27000 were shipped by helicopter to a lab at cdc and set up in sierra leone for lab testing. Today with decentralized lab work with the gene expert its been you can have a safe way to confirm ebola closest to the point of occurrence and there are screening community. Dot to see what they have so the diagnostic advance in a few years is transformative. In 2014, 15 and aih, who, partners to trials of experiment so vaccines that i cant believe we did these trials because the trust issue was humongous fleet complex. In sierra leone we were told ebola vaccine to the Community Gives you ebola. It has been given to so few people but many thousands of individuals in the three countries got vaccinated with understudy protocols knowing the product was safe and effective and in the crc today 110,000 people got vaccinated without which we would had so many more cases. As the Previous Panel said, these technological evidence are not you cant deliver them without trust. You cant get the staff to feel comfortable providing vaccines or giving care if they are being targeted. If they are some out the responses become the target of many other agendas. I think innovation whether technologic comic medication or management of responses is a huge role but it doesnt take away the requirements of community trust, engagement and mobilization. Arena, most people think usaid is only involved in International Development in providing a but i for one have seen firsthand the innovation at usa in many different areas and technology are just an approach to the problem and could you expand on that . Sure, like and was talking about innovation is a huge part of what we do is not the only thing. Across the work we do in health and every single component there is a certain portion of the effort to given to pushing the envelope on new innovations and we are down with [inaudible] whether it be the new diagnostics like gene expert for tv or better drug regimen for Drug Resistance he or try to help with the advanced market commitment working on the ebola vaccine and all that were trying to do. Its not a civil bullet can make a difference in one of the things racine is the revolution in Data Technology can make a huge difference so how do you build that into the system . Thats a real question with the work we are trying to do. How do you take this fabulous theory and technology of all the Health Information system being on your phone but make it built into the primary Health Care System so its not just a thousand apps out there for gathering data but its useful in use by the people who use the data so he gets the effort is on trying to define the technology that is out there to make it the most useful for the outcomes you need which is the population and access to services and healthcare workers that have information tools. What about from the who . One reflection. [inaudible] when we speak of innovation we also look at the different intellectual thoughts and think about regulating it because its positive and is based on dual research and could or could not be used which is not linked with any conversation so we have to try rather than coming up the next experiment we should [inaudible] what technologies will hurt us in the next ten years and the merge of the two. Try to see what it is we need to manage. Dan, you mentioned Safety Research and sometimes that takes a long time. I suspect there are innovative opportunities there for rapid realtime evaluation about vaccine safety and efficacy. Laurie was a big champion of Operational Research as we were deploying things so would you mind speaking to that in your ideas on that . To places where we have opportunity. One is large databases and one that contains the medical record and under the leadership we were able build a large active Surveillance System so when anyone called the prison is now part of the fda and largest part of the vaccine safety and with those large databases we can do rapid studies and that if a structure is helpful. The other place where theres two minutes opportunity to science is in genomics and adverse no mix. Most people respond well to vaccines and get a sufficient immune response and protected and dont have a serious of Adverse Reactions but some people under respond and not protected some people over respond very rarely have an adverse reaction and what is the role of genomics. This is an opportunity to not just push the science further but push in [inaudible] what you hear from parents frequently is i have a Family History of autoimmune disease and im worried that even though for most people the vaccine is good but for my child there its not. They think they have a genetic risk factor. Thats a place where if we can do science we can address those concerns and the sciences hard and difficult and it takes time and money but its an opportunity for us to go to personalized vaccination like personalized medicine to hear the concerns of parents who respond to science and maybe avoid a rare but serious adverse reaction. You might come back to how that is going but what id like to do now is open up to the audience an opportunity to ask questions of the panelists. Its hard for us to see but if there are any okay, state your name and organization. Hello. Im bring the ball and i work for path. We are funded to work in the drc by cdc with usaid. I want to ask a couple questions regarding the security strategy. We were great and pleased to see that released and that content included. [inaudible] i understand that for the strategy there is an internal working group and i am wondering when you think that might be set up and practically to your point there are so many complexities here is what does that look like . On the Global Security strategy we look back was asked for five things. Thats a little complicated but partly because omb does not want to put itself on record but i want to ask could you give us an idea of what the cost of this programming might look like Going Forward for each of your agencies. [inaudible] thank you. So, i cant give you the specifics but that said i will say around security cdc and usaid works closely together. Our leads probably call or talk to each other every day. On the ground the plan that were talked about earlier are done jointly. Its in response to evaluations of the work u. S. Government will do in any given country is planned out so sorting out whos doing what to make sure theres not [inaudible] its really important so that will build on the work weve been doing shortly together as well. In terms of future financing global Health Security is a priority for the administration and certainly in the 2020 request there is funding for usaid and cdc as well and that reflects what needs to happen. On the financing what it costs today given but this is where we do need to work through countries to step up and you cant just be u. S. Government to pay all the cost for this is where country commitment we have seen in global Health Security of countries stepping up to realize a very important this is what they need to do in putting of what needs to happen. Let me expand a little bit. Its fundamental to both cdc culture building again off the earlier panel that if we cant measure we dont know how we are doing. If we want accountability we need to know how were doing as well. I think building on their earlier panel to get ownership of global Health Security sustainably we need to not be u. S. Government doing the whole thing or paying the whole thing. This has to be partner owned with multiple countries and the multilaterals as well. In some ways you can look at that bar and say its incredibly successful but in some ways its fairly simple. One single disease if youre trying to of been a really difficult disease one single disease that can have very measured tracking and we can be investing what is effective and costeffective in making sure we are accountable. Global Health Security will address systems and the jee is absolutely fundamental but we are at early stages of knowing the best way to monitor and evaluate. We want to take the best of the metrics from some of the global initiatives but built into a Health System strengthening efforts meaningful. Those we have had a fiveyear emergency supplemental dollars that have gotten a lot of improvements as well as in global partnerships and crosscutting threats. We are not done and this is not something that will be you are done and preparedness is the for everything but it does not mean the u. S. Government will pay for it at a certain level forever. Hello. Kathy howell with the vaccine institute. Im working on insulin the vaccine innovation particularly universal influenza vaccine innovation. In this work we spoken to stakeholders from a lot of doctors who have all said that the government, Academic Research in the moment, architectures arent built for innovation, accelerated innovation and risktaking. My question to all the panelists is how do we the risk the environment to foster these multi collaborations and encourage the open source, open data collaborations necessary to make these challenges and problems accessible to different thinkers and nontraditional experts in genomics and engineering . How do we foster that collaboration and encourage those types of different thinkers to join the cause for Different Solutions . Yeah, thats really hard. [laughter] you know, i will start. I think im more optimistic about that than i was a few years ago because i do think people recognize for influenza we are not where we should be given how much we been investing for decades. With substantial scientific investment in innovative approaches to it we could be in a lot better shape. We spend a lot of money every year vaccinating everybody with the best tools we have right now but you need to give them every year and they dont work as well for many people as in others and there is some incentive for industry to not innovate right now in terms of having pretty good markets and not as lucrative as some of the vaccines but a reasonable market. Whether its nih role or u. S. Governments role or the academics role i think there is a shared sense of need to do things differently. It does not mean i have a solution but having agreement is the problem is a start and policymaker agreement is the problem. Just to add on that, i very much agree that theres been a theres a shift to move in a much more innovative approach. I think there had been a couple tools out there recently like the grand challenges which put out heres a problem and we need a better solution or a better way to monitor the vitals from a patient is sitting in and able unit. It did bring in all kinds of really Innovative Solutions from different sources and not the usual so there are some exciting ways to bring in those new ideas from people who arent at the table. On data there is also the Data Revolution and pushing the envelope on sharing that data is still not quite where we need it to be but given technologies and other approaches pushing to share data puts us in closer to that place where we have a much better way to have that but not quite there yet but progress. I was looking at my colleagues back in the room and they have certainly try to be on the front wave of the innovation and that is established new programs recently in florida but what advice would you have to make sure that they ring the vaccine safeties with innovative programs . Im careful in this regard. Its a lot of research and development and the work there is clinical work and i guess one thing i think barta realized was that you have the infrastructure when you roll out a product. For example, i was contacted by a vexing company that was developed the evil of vaccine and was asked how can we monitor the safety if its rolled out in an african country and the challenge was there was no infrastructure for active surveillance. Barta has been quite aware of that but in terms of vaccine its just outside my expertise to give advice on that. There is some comfort in knowing that another people have gotten that and we know something about it and we will not get surprised. But in the midst of emergency everybody wants something. So one of the challenges is that they been doing fox nation and some of the concerns are why are some people getting it but what about the rest of us. You know very little about the other vaccine that is proposed. But we have a problem when the Public Acceptance is the highest for something new and potentially untested. We dont have anything. And when we have incredibly steady products people start to wonder about its safety looted me too mention one of the impacts of the 2009 epidemic is a change in fox nation during pregnancy about 15 of women got a flu vaccine to about 50 that my not home like a lot but thats a lot of women to decide that this is a good thing not a risky thing to do when people seem bad events with natural diseases and told to help them. I think this is the problem in low and middle Income Countries. Historically we develop vaccines for developed countries first and then after its a problem because those countries that need the vaccines most are getting them right away and weve seen a shift where they are being developed and rolled out first to low Income Countries which is great in many, many ways but the challenge of the infrastructure for safety and surveillance is the capacity is not there as it is in high Income Countries. That is about Infrastructure Investment to have the capacity im fascinated about the vaccine issue. It is only one moment you dont vaccinate if you dont know who to vaccinate and you dont know who to vaccinate if you dont have the information. A coaching to the logistics. Ladies to be kept at any given moment in time. Think of the publications. The other reflection it appears to be particularly sexist. In the smaller growing firm and of a certain area being a crossed appeal to the outside. The concentration of intelligence, brain, iq, phd is phenomenal since i was there in law school. In a reflection of how to precipitate the movement we are probably follow what we leave to the scientist, its not just mind believe me. Is there another audience question . Earlier they mentioned and i think about the diagnostic and local diagnostic and industry issue. Somebody who worked as a tropical Public Health issue, one of the challenges ahead with both your people in the field is trying to do it in a Sustainable Way when there is no one other than this one person in nigeria who happens to be certified to o for these kinds of issues. It sounds like you to meet a capital fund. Where you with some support from barta and nih and others can actually give spinoffs on local to markman for biomedical science and Health Security. I am sorry that doctor is not here because he spent years there and was very excited about innovation and you risking in the kinds of problems that we are dealing with all the time. So i do think that the usual approaches are challenging and we did get congressional support with Infectious Disease response one, with a long ride between emergency that we clearly have exceeded our funding capacities four. Your mentor resources from h1 and one. We must all trans mall amount start but the issue is innovation investment in interior to the unity sector that would bring capacities. Because the prize and now the response is supposed to be one fifth in the warhead of something. And not just the quality, the knowledge, the capacity if it goes well. One other thing i would add, i think there has been a lot of interest in movement with the private sector. I think there is a whole lot more we can do in the. One more question in the making keep it brief and we talked about it before but i would like your perspective on this. The question is when i was to review, how are you doing today with the a bullet outbreak compared to 2014 and 2016. Are there different ways you can go about the question, what are the differences today versus 2014 and 2016. Not who or through specific organizations but we as a community. These complicated questions, it is really different, and 2131 is we all responded to phenomenon without thinking that it was the same family crossing leaving in the space of three countries. So we treated the problem geographically because thats only thing we had. Possibly in designing outbreak. In nigeria we had a mortality which was 20 less without vaccine than the current one. We entered into the word to talk to the patient and to speak with them and to joke with them and people are dying because theyre abandoned in these words. So there is a whole is thinking about vaccine. So it should be much easier. There one of the most potential wealth in terms of resources. And everybody is having a piece of it or fighting for. There are five level a different fighting forces. From the political to the community and so on. It is one, it flies less. If we were to lose a patient from the airport with a response in nigeria we would not be here speaking of the story. So i think the last panel in some different between heartbreak and where we were in 2014 and quite prickly its emergency setting which is extra nearly difficult in the kinds of things weve been talking about from the similarities to understand of the issues of the Community Level and how you can reach people given that setting we do have the vaccine and has made a phenomenal difference at the time. It is a tool that is an incredibly powerful tool that we have and the fundamental issues of distrust and concern in a whole lot of other issues in addition to a boa that is facing the people. It will be the same district figure out how to overcome. I would say there is some disturbing contract to make. Despite the country, the global community, the bho responded very rapidly and identified the environment. Despite that it is getting worse not better, despite 110,000 people having been vaccinated and getting worse and not better. And the ability to change her trajectory is very limited as outsiders in the context of words occurring. And even though its getting much worse, the vaccine is keeping that at a status that might be. There is also an warmest investment owing on with the people, people crossing the borders into uganda so it is really, we cannot stop intensive response we have to become creative on how to support the Community Level response because this could get so much worse and could be in many other communities. It is already in 21 of 22 help zones. Of active cases. Dan is an International Health professor. I dont have anything to add is been a great discussion. I want to think or panel discussions, it is been fascinating and i really appreciate you taking the time to join us this afternoon. [applause] [inaudible conversations] if we can ask our final panelo come up liberty introduce the professor he will moderate this panel and i will turn over to andrew to introduce or panel. Thank you. So, we have the final panel today. We have two people who can manage politics, ron claimed was the chief of staff due to american Vice President to al gore, and he was chief of staff to joe biden when he was Vice President under under president obama. He is a Senior Executive in the most important thing is he was in the top person in the white house and why we invited him here today. Jim greenwood is the president and ceo of bio. And a member of the blueribbon study panel on bio defense. He is a member of the house representatives, he was in the house of representatives of pennsylvania and in the state senate. Hes a politician and i say that as a compliment since i was the career politician myself. Some people think im still politician. I think what were doing with his political management and these emergencies because redoing with issues that are not health issues. The lack of trust in government and not just here but around the world and social media has misuse of the and applicable issue. It is not a health issue. At any case i want to read something before we start the discussion from the great book the great influenza which is one of the best histories of the pandemic of 1918. One paragraph, victor ro von was the two leading health signs and the United States and best friends with William Welch who for 30 or 40 years was the dean of the John Hopkins School of Public Health. Victor vaughn sitting in the office of the general of the United States army and head of the Army Division of diseases watched the virus, and pull into a 1918 move across the earth, he wrote this and is on hand. If the epidemic continues its mathematical rate of acceleration, civilization could disappear from the face of the earth within a matter of a few more weeks. This is not some crazy person. This is one of the two top medical scientists in 1918 in the United States. He wrote that in his own hand. At the sense of panic that existed. We are going to face the same sense of panic. We have two people get sick with ebola in the United States, you remember what happened. The headlines across United States, imagine a 650,000 americans died in six months which is what happened in 1918, 80 Million People died worldwide 5 of the population. We are going to deal with a whole series of political issues which i think we are not prepared to deal with. We have been born because of the viruses and diseases that have spread. We have fungus that is spread in hospitals that is very dangerous. And so we want to talk about leadership and vaccine and epidemics impending mix which is a political issue. If i start with you jim, given your leadership role right now and your previous and politics, could i ask you to begin by looking at the question of the complexity of the enterprise or the public sector, the government, Nonprofit Sector and corporations in developing the bio defense capabilities of the u. S. To meet one of these crises in the future . I come from the recent perspective going on 15 years now with the association of companies as membership by the thousands. In a number of those are in the panel major and a lot of our companies are in the vaccine business. I guess the first thing i need to say, inventing and innovating a drug of any kind is extraordinarily difficult. We fail 90 of the time. If you look at alzheimers, we feel basically 100 of the time. Scientists really, could, one of the reasons is a high failure rate. Now imagine youre a Small Company and you would like to make countermeasures for and against pandemic and bioterror attack and you know that essentially you are purchaser and its going by the federal government. And so now youre at this highly risk and a price trying to meet a need that is not been made perfectly clear by the government, not sure that its going to be approved and then very uncertain about whether itll be acquired in weather is going to be acquired consistently in the front will be there. So not imagine trying to attract investors into this enterprise saying and like you to invest in my company, we will try to make some important measurements and we will probably fail if we do succeed we may or may not get approved and if we do get a approved we may or may not have it purchased by the federal government. Its a risky proposition. Nonetheless companies are busy doing that and in an effort to participate i joined the Blueribbon Panel which is cochaired by senator lieberman and governor and Health Secretary tom ridge until she got elected to congress and weve been studying this for four or five years and we made great contribution. The biggest problem is, this is one of those things that the last big epidemic which is 100 years ago, congress is not good at longrange thinking, even though the experts will say its inevitability to horrific pandemic inevitability to a terrific attack, the thousands and thousands of items are such that this is not come to the floor. And we wrote the first report, at my suggestion we began with a simulated hearing. It was a congressional hearing after the fact when thousands and thousands of people had died and members of congress holding the hearing were calling representatives of federal government saying why did you not see this coming, why read not prepared and why did these people have to die. And we did that as a message to congress saying let us not wait until they have left the barn to prepare. And so thats were desperately trying to do and desperately trying to be not another report that sits on a shelf somewhere. One of the things, this goes to a leadership question, one of the things we zeroed in on is the responsibility for these issues is scattered throughout the federal government. There is no unified budget, no unified chain of command and therefore in silo and contradictions nose with the left industry with right hand. And we thought what was important was that of a centralized individual to ultimate responsibly. The best way was to give the responsibility to the Vice President of the United States. That has not happened, we have not succeeded on that. And the leadership is with the secretary of health and human services, hes a fine man and used to be on our board. The problem he had is that he had a conflict with the department of defense for homeland security, he does not have the clout as one of the secretaries of his peers he doesnt have it to say to one of the agencies that you will do x and y. Thats why we felt in and needed to be in the hands of the Vice President in order to provide leadership that this issue desperately needs. Ron you are the closest thing to the Vice President being chosen because your chief of staff and president obama pointed you in some ways you have the authority of the Vice President. I left the president s office a couple years. But you came back. I came back but i did not report to the Vice President , he was not involved. I think a couple things, first of all i want to commend texas a m and everybody involved the white paper associated with this. Its an exceptional document that collects powerful recommendations from across the space and puts them together and integrate work and i think the single best thing would be a if every policymaker read and followed it is really exceptional piece of work. We are here at the hundredth anniversary of the epidemic and it is startling to think that few americans know about and yet, hundreds of memorials and americans in world war i and world war ii loss itself in the creek them and you can hardly find a word about it. It is a forgotten memory in our country and as jim said, that is one reason pulsing makers do not respond and do not react. In 100 years a lot of technology and a lot of things that make us safer than we were 100 years ago globalization and the Rapid Transit of people means of Something Like this happens again it will go around the world a lot faster than in 1918, other complicating factors then then. What to do about it, first the recommendations of the report are spot on and essential. Second, i think there is no replacement in this global problem for u. S. Leadership. This is a multilateral global problem, leadership of the who is very important, no question about it. But for better or worse we are indispensable in the nation in addressing the Global Challenge whether its expertise, resources of the Healthcare System, there is no replacement for the u. S. Being at the forefront. I think where to place in a country where there is a lot of questions of whether or not the u. S. Is going to be at the forefront of this and i think weve got to get past those questions and make sure we are leading. Third thing i want to say, this should not be a partisan issue. I am partisan, unapologetically a partisan. A democrat, proud of it and lots of issues and outspoken on that. On this of epidemic that should not be a democrat or republican issue. Viruses dont ask for political affiliation before they infect people. Mosquitoes dont assess your voter id card before they bite you. This is not something we should divide its something people should work across party lines. Talk about some of the bipartisan leadership on the commission. I think during the bully response we had politics in the end, democrats and republicans came together and funded 6 billiondollar response that we spent some here and some around the world and help turn around the lower break in 2014. I hope that we can keep it that way and keep it bipartisan. But having said that is not a partisan issue, it is a political issue. When we talk about Public Health, or talk about engaging the public. When we engage them in our country through politics. Whether that means some of the issues before us discussing about responding to antivaccine in responding to isolationism, responding to instant immigrant sediment, all these things that complicate our response to Infectious Diseases, i think politics is a part of it and people in the Public Health community have to be unafraid and willing to step into the political arena and provide a force for the actions that this report and others recommend. Last on this, white house leadership, i absolutely believe we need leadership at the white house and i dont think it should be the Vice President , he has a fulltime job getting ready for and responding to pandemic threats is also a fulltime job. The idea that the Vice President would do it in his free time doesnt seemed like a good idea. President obama after he brought me in to do the bully response, we got close to 0 cases, pointed a 0 member to be in charge of Pandemic Response and President Trump continued that for the first year of his presidency. In the leadership on the nsc staff. It is been terminated and i hope that President Trump changes his mind or bring 70 back or the next president , whoever he or she is. We need someone leading this unit should be a Fulltime Position on the nsc staff not the Vice President which is a sliver of their time. I would like to come on that, its a debatable point. We have succeeded in placing this in the hands of the Vice President. But the thinking that we used here was the Vice President is going to be doing the things that the Vice President is doing and he is never anticipated it would be focused on this but rather the Vice President would appoint someone who is capable and qualified to do that leadership. But them would be able to when necessary simply turn to the Vice President and say, i need use and i need you to knock Heads Together and i think the Vice President has a political opportunity. An influence on the budgetary process in the white house that maybe the nic might have less over. Most people say the biggest out there we face is gears people most is influenza of the spirit generation. Last year was the worst year in 20 years for influenza or the flu, 88000 people died and most people dont even know that. Thats from cbc, in 2009 they report that 1. 9 billion people in the world there was a pandemic but had a low death rate. 1. 9 billion people got the disease in six months. Thats how fast this bread. You are the one that said we created globalization. Our airports of the best thing that ever happened to pandemic. We will spread the disease all over the world even before we know what is going on because the nature of transportation in the world. So two questions for both of you, both were related to influencer or the flu. One is the National Strategic stockpile was established 20 years ago before 9 11 and before the anthrax attacks, it is involved and is it really the model that we should be using to protect ourselves particularly against flu, that is one question in the second question is, what can we do to create the incentives for industries to invest more money and research on this for universal flu vaccine which companies are working on now. Is there anything that we need to do to change, the architecture of the system and the incentive within the system so we can get a vaccine before it happens before the next pandemic spivak those are obviously very closely related. I dont think that the problem is so much with the architecture although all yield to the senator on that. As much as it is with the funding and the liability of the funding. Unfortunately if you had 535 members of Congress Sitting here and they asked them what the likelihood is of a 1918 air pandemic, i would guess the vast majority were not think it was possible. They would think that we have had so many medical advances in the last 100 years that that could never happen again. And of course the flu is as regular as anything can be. They see the flu and see people sick an and no people die and usually think its all people that are going to die anyway. But they do not recognize that in apopkapocalyptics scenario s likely. This is not the talk of the issue for the public. There is no public pressure to do this. I think that if the structure was wellfunded in the industry could rely on that as i said earlier, the money will be there the procurement will happen, its worth the risk, when ebola first occurred companies lost money. They did the patriotic thing, the humane thing to do, they turned away from other projects, there still behind in some projects because they put attention to this in the epidemic was over and there they were with no one to procure their products. So they do this at great risk. So i think of the funding were there a sense of urgency were there, the industry would respond. On the partisan issue, youre absolutely right, this is nothing partisan about this issue. There is a way in which partisanship creeps in. It is this, what is desperately needed is oversight. I carried the subcommittee and the oversight subcommittee of all of the committees in the house and the senate have a dire responsibility to look into these programs that their funding in the oversight function is the function that does not have to be an emergency in order to occur. It is the function that congress is supposed to do on a regular basis to look into all these programs that are important and oversee them. As long as both parties and this might get into the politics, as long as both parties continue to monopolize the oversight function on political matters, then theres not enough time for the things that are important. And theres no need to go when to what has been justified and what has not been justified in the last years in congress. But in many into and making sure that it was time for the oversight committees to do the important work. I just had a couple things, i was working for Vice President biden then and i was not directly in the h1n1 response but i was in the white house and what i will say a bunch of really talented and really great people working on it and we did every possible thing wrong. It is 60 million americans that had h1n1 in the period of time and is purely a fortuity but this is not one of the mass casualty events in American History and had nothing to do with us doing anything right. If anyone thinks that this cannot happen again there to go back to 2009 and 2010 and the virus and you can do the math on that. What did that tell us, the vaccine will regulate we dont have into before and we will not get in time and it told us her system for deciding how to distribute and administer vaccine at the time of crisis are going to be bad about the tester. It also totals one other thing, a Global Policy mechanism for dealing with the vaccines in an emergency situation. We saw this in 2014 and most africanatthe tail end of the ext had phase i testing and they wanted to get them into the field in west africa and immediately had issues about who would be liable if the vaccine need anyone sick, who would be liable if theres claims and who had any intellectual property for the test of the vaccine. Trying to find a way to bandaid but its pretty clear where is the United States we have the act and theres no global act and no global structure and they were very worried about their exposure in that circumstance. And it kinda faces a little bit in 2010 with h1n1 where the vaccine did not arrive for us, it got time to europe then theres a big controversy over whether or not it can be ministered or what was the approvals so on and so forth. This is a life or death situation and policy wouldve killed people. So i think one thing we can do now is try to get together, try to figure out a solution and not just in the u. S. , one thing that we know for sure, if we have to deal with it in the moment its gotta be very bad. I agree with a lot of that. On the Global Nature of this, i dont think theres a country in world that is better prepared. Thats not good news, whats really fighting is should have not break somewhere else, it could readily arrive here and we have countermeasures to be responsive. How do we tell our fellow earthlings that i am sorry but we have to hoarders in case to protect her own people. That is a very its a very difficult decision and one we probably would make it requires a lot more global coronation and a lot more work by other nations as well. I would say the development is the first line of defense is not the borders of the United States. There is no way we will prevent this from getting into the United States. In a factor of the infectious nature of whatever the viruses, like measles has a very high infection rate, ebola has a very low rate. An influenza has a high rate. It will get into the United States. We need to respond immediately to try to stamp the thing out before gets outside the country and thats a hard sell in the United States because people say why do we worry about ourselves. The reality, and we want to worry about ourselves we need to extend the help to the rest of the world. I have this in my opening comments. The isolation is sentiment in our country right now its one of the most dangerous dynamics we have. We cannot have Public Health safety in the United States out of the context of global Health Security. As andy said in the event of a pandemic, and certainly we sell this with h1n1, millions of cases before we knew it was here. And that is true for whatever comes down the road. In the only way to keep our people safe is to engage globally in making other people safe. That is why eunice leadershi u. S so important. This is a scenario where the Public Health Community Needs to speak out. I will be very honest about it. We saw when we had zika in 2015 and in 2016. Very slow action in the congress. In funding the response that president obama spent to the congress ten months away. I gotta be honest, i spoke a lot about this, a lot of reaction was the cut is a immigrants disease, why should we keep that out and out paper all that stuff. And that mindset really impacted the response i fear that the colors are reaction to different Global Health challenges and how we engage in the world and i think that we have to get past that and rally people both parties and rally people with goodwill across the spectrum to understand that we understand this with terrorism, and the American People is to engage on issues around the world and time the cricketer its too late. Its in the same mindset for positive attitude from building global Health Security around the world and the best way to keep people safe. Even if the sentiment is the europeans and the agents have to pull their weight and make their contributions scientifically and financially and so forth. Lets assume that is the case, you dont get there by retrenching, you get there by leadership, by having those conversations around the world. Contributing and encouraging the participation by the rest of the neighbor. Can i get you to comment on something that we spoke on three years ago which we released at this conference. Which is the fact that who did not perform well in west africa. It is performed much better sense and but its not quite the area. What needs to be done to finish the process of reforming and strengthening because they need to play central role in this in terms of international coronation. Can both of you comment on that . Not very well. [laughter] i have been quite outspoken on that. I think theyre doing a superb job in drc. They have been everything that they were not in 2014. They have been fast, transparent, candid and they have been quite responsive in their leadership is exceptional. I think what this outbreak is showing is the limitation of who, it is not a response organization. If the biggest problems we have right now in drc is the security and stability in the tax on responders and it getting violent and dangerous. That it would help in the drc since 2014 ive been a public advocate to have a white helmeted security under the leadership of the eu in to provide the assistance and epidemic response page 2014 and 2015 president obama did something he never done before. The order of the troops in the field to help with an economic response. Over liberia. It worked marvelously in liberia. Where market troops were welcome as friends. And as a blessing to have. That solution is not going to work in congo. That solution will not work and a lot of other places in the world. We have to fight our way and, its a bad way to do an epidemic response. But some stored u sort of globae the forces needed. What we are seeing in congo is new but likely to be the new normal. The combination of Infectious Disease outbreak and regional conflict fighting over resourc resources, thats more likely to be the scenario in the future than what we saw in west africa in 2014 and we have to have the tools as a planet to deal with that. If we dont solve this thing in congo, it is going to spread it will spread to places much more populous and much more connected to the outside world and we will regret we lack the tools to deal with it. Let me add something, almost everything is happening in the congo has happened before but not in the context of epidemic disease. It happened with civil wars in sudan, somalia, yemen, its been going on for 30 years. But none of it deals with a couple occasions of Infectious Disease. That is whats new and what is not happening is a you and is not using the response functions of the rest of you in system to help who deal with these instability issues which we been dealing with for a long time. We have put in place some thin things, you are correct the biggest factor is the lack of a powerful mechanism for putting together peacekeeping operation and is very dysfunctional i would never use it for this at all. But i wont go into the details. It does not work. Ive been involved in it for 30 years and we need a different model. I think your idea is very good idea because theyd be at under dispose. I didnt feel qualified to respond to the spirit i would say i am largely critical of the organization for a couple of reasons. It is very political in ways that result in lack of good science prevailing and i think theyre very political and for instance they seem to be the enemy which is easy to do under certain ways of thinking but with that there will not be any innovation. I think the Organization Needs a lot of work. I was unsparing in my criticism of the bho in 2014. I think what theyve done with the bho has been a dramatic change. There is room for more permanent but what theyre doing right now in congo is amazing and heroic and again, we have to turn up where were falling short. The u. S. Is not doing his part and i think in terms of resources but in terms of helping put together some of the Diplomatic Solutions that might help address the security issues. But i do think we need to recognize a dramatic temperament and who in the past five years and a lot of credit needs to go to them. Let me raise another issue issues the role of social media which is complicating all this substantial. It is clear that social media is being used for very good things in the world, openness, accountability but its also been used for rumors, gmo field and a bunch of other fields, theres a lot of stuff on the internet that is complete nonsense. And so the question is what do we do better, there is a new study out in one of the articles done by Computer Engineering scientist looking at tweets to see where this is coming from. It is not coming from random people. When i say legitimate, people are generally concerned about it among the people. I dont think the right, they are wrong but we need to understand the domestic sources and go back to the merkin revolution. It is now become a function of politics and what the study shows is that tweeting is now being used to spread antivaccine messages, 90 are antivax, 10 in a study were protocols more conflict around the world and is not instructed against the United States, it does not appear its from russia civil society. It appears as a public source. This study you can read at the Public Health journal that came out a couple of months ago and its based on a copy of the study logarithms that were used to look at mass numbers of tweets to see what the source of the information was. Huge disparity between the tweets in the west and coming from russia. On the Measles Outbreak. So the question what do you do about it. If this is being used of a tool of geostrategic competition of all diseases, the reason we got rid of smallpox was because soviet scientists in american scientist made a deal in the 1960s to wipe out the diseases. One thing we cooperated on that work to heroically. So the fact that this is happening in the opposite way for strategic purposes is very disturbing so can you comment on social media and how we deal with this issue of social media being used for destructive purposes for geostrategic purposes to stabilizing pandemic disease. All make a few comments. Most of us at the earlier stages of the internet was filled with hope of a fabulous tool this will be to educate the world and to unify the world and bring knowledge to all and we find ourselves in a strange moment in history where virtually everyone in the world has a device in the pocket that enables them handled well to find the truth in real science and real facts and reliable information but at the same time we are getting gunned down by at an alarming pace. And its one thing to think about how destructive it is in the world of the antifactors, antigmo and all kinds of fake science but the real terror, what happens in the midst of a pandemic or a bioterror event when people are desperately looking forward for what we do, word wego. Imagine the flow of that information. People would be almost better off going to the river. How do we do with that, i think lord only knows that you can talk about teaching Critical Thinking and how to find their way through the information and we been talking about that for decades and getting nowhere in terms of Public Education in private education as far as im concerned and how we get a handle on this and how educate people to go beyond the first tweet or facebook posting and actually find their way to the real facts. A couple things, and the respondent was a multilateral response, a lot of them returning disease around with a courageous work and willingness to change but a lot was from other countries that includes not just United States, france and england but also in china. And i sat in the situation room as we saw photos of Chinese Military planes landing man on american troops. It was an amazing example of global cooperation. That was all going on, we believe russians were on the ground in west africa spreading this information and telling people not to go to the ebola treatment unit that they would die there telling people not to trust the healthcare responders. The issue of the russians using uncertainty and fear about disease as a geopolitical tool has been around for a while and now as you said were seen on social media a deliberate attempt to spread diseases, spread uncertainty, resentment, social strife. What are the solutions. I think it goes back as discussed on the last panel of voices of authority and where that Authority Comes from in a crisis. We would like to think it comes from a part in love to think as president in the oval office and the Surgeon General but we service all west africa that authority came locally and came from local clergy, local healers, local community leaders, so on and so forth. Social media is its own kind of community so i think we have to work on and Public Health is a very ironically in global connective social media authorities that persuade people of the right information, locally prominent doctors and religious leaders that people go and trust off the pot from. People who they know outside of the twitter world that hopefully they will listen to and have confidence in. We have to build a network of those local leaders who can use social media to drive these messages effectively. This in the face of a deliberate effort to disrupt a response, this will be a big challenge we will have time authorities that people really know and trust to push back the information. That is more likely to be local and global or national. I think this should always be said when you have a president of the United States telling people that real news is fake news and big news is real news does not help. I dont know if the democrats said that. Im trying to keep myself out of trouble. Can i open it to questions. The reflection complement of what is being said in the international they made their excellent that nations can avoid so the you and in general comes and fix everything. There is improvement with the transformation in place now as we speak. So we learned our lesson and it shows. So its far from perfection and its a work in progress and its a contribution and political contribution to all these numbers. So for each of the members bash on the head the poor child is like having a child in each of us which are having i hope that can be edited from the line. [laughter] the reflection in the smallpox has been in a different era. You keep the door open and vaccinate the child. In todays world you do not vaccine anybody without a lawyer and legal agreement let alone in any part of the world. So again it may be more costly than having an approach. Other questions . My name i am the director of houston teshouston, texas and iw in so i missed the most entire day. Anything i say if it is completely off i completely apologize. I want to say that off from. I have a question for you. Im associated with the National Association which represents 3000 local Health Departments across the u. S. We are very much interested in a really Global Learning that impacts domestic, local Health Practice in the u. S. As we are going to this process we are learning that a lot of organizations that we are getting to are very interested in the Global Health and doing Global Health work but not interested in Domestic Health or the doing Domestic Health work and not interested in the Global Health aspects. So as we talk about pandemics it seems this is really the gulf between the three of you of real Global Health, Domestic Health and how they come together. Do you have ideas of how to bridge that gap in terms of models, practice and practice at the local level, not at the national or federal level, the local level where we can share a crossed that would help us for pandemics and beyond. Thank you. Let me tell you something that started in the early 1980s and is still going on. If the school run by the office of foreign disasters called osta and id to train First Responders in latin america. And as to Trainer Program and has been going on for almost 40 years now. Leaders dramatically reduce the need for the United States to do Emergency Response a lot of makeup. There are couple exceptions in a couple countries that are so dysfunctional that you need Emergency Response from the outside. Most dont need help anymore. I attribute to the quite program almost unknown to run and fund the center and it is all done at the local level. There is people that participate at the National Health ministries in the place and all that. But its mostly at the Community Level and a fortyyear effort to do it. I went down there and saw 30 years ago and took it over, that office of bush 41. Let me say, theres nothing like being in charge of the u. S. Healthcare system. We had one case of ebola in texas where we had most of the key decisions remains by the state court judge, he was the commissioner who oversaw the county and county that was with governor perry and pulse director and county Public Health director. Very much in washington with how this worked. So one thing i took out of that was one great way for local the pluralism in our Healthcare System, u. S. Has a great strength and weakness. Its a great weakness in there isnt that kind of command control to love to have enterprises. Everyone who benchmarked who was sending more healthcare workers west africa to respond. I would report under 52 calls in 52 different Healthcare Systems, making them to send people. Would say they were sending more and it would take about five minutes. They were very envious of the Healthcare System. They found one of the nurses came home with ebola and they voted to send no one else. And we were still sending people if they werent in the uk. Their strengths and weaknesses to that system we have in america. One thing i took with me, would be great if people on the local level organized exercise. You put everyone in the room, the local Public Health people, local providers, private and public responders, the community leaders, political leaders, state political leaders and you saw what would happen in the event of one of these, some kind of incident in your community. Nothing will make it more connected to the Global Health and going through that exercise, understanding that by the time it gets to houston, its too late. The kind of problems you have are to play. At the end of every one of those sessions, we need to go to washington. I think if we, its one of those things think globally, act globally in the sense that you see how hard it is to manage. County by county and town by town, we need to take all of these different players and put them into Global Health awareness. One of the concepts we use is called one health, we talked about the interrelatedness of Domestic Animals and crops and Global Health community. The world refuses, the ability to travel all over is greater than ever. They have to think that way, its a lot of thinking to do it hard to get out of local possibilities. I have to think that way and all of those interconnections. I have the privilege of working for him for nine years. I will ask you to envision a world where we have these relationships and Effective Communication in Healthcare System that works for us. I want to focus on entering the aspect to save lives. I want to ask if we can view the suppliers as a critical element of our Industrial Base way we think about the Industrial Base and components that make the aircraft carriers, it doesnt seemed like we view it that way. We have a threat and requirement but we dont have Industrial Based policy, we dont look at the rates for companies and supply chains. I would ask you your perspective. Also this idea, exercising. Can you imagine exercising making a scene . Having a system that Industrial Base in the pharmaceutical sector is tested and evaluated on a regular basis so if we establish that capability even if it doesnt emerge into the next outbreak or pandemic, that we tested and evaluated that capability. We did a simulation in october last year and they wrote a paper on the folder in addition to the white paper, its very well done. Went through this accumulation and reported after they did research on the conclusions. I think simulations are very valuable. There was an admiral, a friend of mine and they said how many of these have you been through parts he said 22. I said, how did they he said they all ended in part. You know why we are in south korea . Because of these simulations. They are so scary that the policy makers seek the result accumulation. It will escalate. I have to say one thing we could do thats not politically impossible to do what they do all the time, simulations of work Time Training exercises. I think the cdc are to manage it, they both have rolls in this and do it on a regular basis with the community and also the developing world on her regular annualized basis and get the reporting out. Thats my response. The federal government responses as well as State Government are silent and interconnected and coordinated but the private sector, they do a grand job of what is needed, and level of coordination that is bigger and bolder and create new platforms to have the capacity to search and share manufacturing facilities and turnaround in realtime and quickly to have a unified system of diagnoses capabilities around the country and the world. On the bio terror thing, we have these systems that were developed after 9 11 or we have these centers all over the pla place, picked up on the complete shambles, it doesnt matter how many times the heads of the government, they were willfully neglected and incompetent. I agree. We need to think more strategically about this. I think about what are the things we should be doing governmentally to increase that sector and responsiveness . I think it is kind of supposed to have this role and some respect but i think they need more funding and more strategic leadership and empowerment to do that. I do think there should be every day seven days a week, ten hours a day, get up in the morning and think about how they plan to do this and how to make it happen. One thing tom emphasized was that youre going to respond to these crises by flexing up your existing system. Hope you will build some magical capacity in an emergency moment, youve got a strong robust Healthcare System with a lot of capacity doing well and try to amped that up and it starts with the day today looks like. There are strong limited databases but investing in the Healthcare System i think is the best way to have the capacity. The capacity is a critical issue. Everyone says why dont we have hundreds of hospital beds in place where we can put people who have this disease . Can you imagine hundreds of beds and keeping them empty indefinitely . Can you imagine that and just not using it so its sitting there . We have so many healthcare nee needs, thats a hard thing to imagine, a hard thing to consider. If thats true in our country, think of how it is in other countries. Its really about investments in the court system, having the ability to dial in amp it up in a crisis. I would like to thank the staff. For their efforts and students who are here for all their work. Please. [applause] this has been an outstanding day. We have learned a lot. Unfortunately, some of these issues are not new issues. We simply have to find a way we can turn these longstanding lessons observed to lessons learned. Our nation and International Community deserves it. I want to think our last panel for getting into these issues. [applause] and everybody who made this possible. In our federal Nations Office here in washington d. C. This concludes the third annual form, we will keep in touch and continue this dialogue. Thank you. On cspan2, military leaders and Current Issues facing service members. Watching live coverage on cspan2. Shes always had our backs and puts in lots of time to make sure she is successful. Id like to introduce to you the chair of the service leadership