Transcripts For CSPAN2 Pandemic Biosecurity Policy Summit - Part 2 20240714

Innovation panel. Weber honored to have dr. Anne schuchat, the center for Disease Control and prevention, and our second panelist is dr. Daniel salmon, Bloomberg School of public school. We are very honored to have the help and security interface from the World Health Organization joint joined us and he is going above and beyond the call of duty as he is alone in from australia through los angeles and took the redeye to be here this afternoon. He has come really above and beyond the call of duty. And then a final panelist is doctor irene koek, acting assistant administered for Global Health United States agency for international development. We will have a similar format of our last panel, and i would also maybe encourage the panelists if they feel the urge to ask one of their copanelist a question that just interrupt me and do it. Ask a wrong question, they just restate the question you would rather answer and go for it. What we are way behind so well probably go to audience q a much quicker because a lot of things to talk about, i know they would like to say, something safari been said so be want to make sure we give you an opportunity to ask some questions of this esteemed panel. I want to start first with dr. Schuchat, and anybody knows the public cdc, and you are our nations Public Health authorities. We are pretty much familiar with the cdc. If you want to restate some of the mission and approach and talk about the great things the cdc, colleagues are doing and many friends of mine, thats great but maybe one way to do that is maybe you can tell us what did we learn from past outbreaks and even a pandemic that i know you in the middle of that in 2009, and other outbreaks we can apply as lessons observed through Lessons Learned for future outbreaks. Sure, thanks. Its a real pleasure to be here and appreciate folks who stuck with the whole afternoon. It is just ten years since the h1n1 influenza pandemic struck, and we have learned a lot from that into some ways are a lot better off, and in some ways theres a lot more to do. I key lesson there was the value of everyday systems. I think sometimes want to have a Fire Department for fires and then whole different Fire Department for bioterrorist events perhaps. But i think the work that we do here in year out with seasonal flu helped us with the h1n1 pandemic, and our efforts since then to strengthen pandemic preparedness will help us with seasonal flu. Whether its the survey lids were, the laboratory work, the communication work the partnerships, the trusted relationships with public and private sector, u. S. And global relationships, exercising every day instead of waiting for the big one, i think thats a critical theme. In terms of learning from the west africa ebola epidemic, as you heard, its not enough to come in when theres an emergency. The three countries that were affected, weakens Public Health systems, and Global Health security agenda was really about making sure every country could find stuff and prevent epidemics, and that the world could surge when needed. What we learned from that is we dont just want to come to drc when theyre in the middle of an ebola problem but we want to be working sidebyside with them to strengthen your system. We are focused on a Public Health system. Just mention the primary care system, but we use the Emergency Operation systems to address trying to eliminate mother to child transmission of hiv. We use them for yellow fever or other conditions. We try to use the Laboratory Networks and the workforce capacity for the problems of the day. I think at cdc we got activities in 57 countries now, very much focused on critical government priorities like pepfar president s malaria initiative, but very much about Global Health security and strengthening everybodys capacity to do with the priorities that have. Thank you. Actually i would like to ask doctor coke from usaid actually, i know the person who is sitting in your seat at usaid recently traveled maybe a month now to the dnc drc and polly came back with some interesting observations that have impeccable usaid, cdc usaid, cdc and other government agencies. Can you share some of the experiences and observations your thinking that at usaid and perhaps have that integrates with an doctor shook it may jump back in with the great work youre doing and collaboration to five necessary support. Was great. Thanks. Would echo her appreciation for the chance to be on this panel and be with you all here today. Usaid roll is with the Development Agency for the u. S. Government. We do work and health is when the ice we work in but sort of work in a number of other areas critical to go in country. As are administered talks our goal is to work ourselves out of a job and that is to build countries capacity to do all of the things whether health, Economic Growth and governance, et cetera. In health we do work across the board. We were close with our colleagues at cdc in a number of areas and you have a lot of programs in dr congo. On the last panel when the big issues with this outbreak is that it is in the middle of a war, a war thats been underway for a long time. It becomes extraordinary difficult to do the kind of ongoing programs that you would be doing in that situation. My predecessor in the current job im in now was there in march i think with doctor redfield and just last week ten seamer who is acting assistant administrator for the human chan assistance work that we do was also there working with the current ambassador and visited the communities affected. Whats really clear is the kind of complex emergency thats underway in Eastern Congress is absolutely getting in the way of the kinds of interventions that we want to do that work in west africa, worked very much in the last outbreak in the western side of the country. Whats also, clear, and theres lot of consensus about the need to do a much more holistic approach, not just the medical interventions with people coming in but doing what are the needs of the community, what does the Community Need and what do they want in order to really bring some of the interventions we need around the Ebola Response, but recognizing as talked about in the last panel its not just ebola that is the issue that is being faced there. People are dying of malaria, tuberculosis. Women are dying in childbirth. Theres lots of fear and distrust of everyone coming in, so trying to engage very, very actively with local committee groups, local ngos, faithbased, the church and other organizations that are active to try to reach the community on a much, much broader scale than simply around Infection Prevention control and going to the etu is host of things. It does need to be holistic and thats impressions by colleagues have come away from visiting there. Dr. Barbeschi, i would like to know, you are heading up the health and security interface at the World Health Organization. I suspect many in this room may be on the phone with the health and security interface may be the first is if you could give us an overview of the health and security interface and how that supports and makes Public Health Emergency Preparedness and your work with cdc and usaid . Thank you all for being with us this afternoon. Health security interface is a result of a failure of the International System to have a definition of Health Security. What for the lack of, or we heard this morning or during the day, for a reflection for this type of platform. Thank you. Dr. Salmon, 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 but very specifically Vaccine Hesitancy and how that may impact epidemic preparedness or response when vaccine will be absolutely essential. Thank you. Thank you for the opportunity to speak youre going today. Its interesting day. The bar is high for us. Its a great question because my experience with h1n1, and im speaking as an africanamerican academic effort at the time i was speaking for overseeing according the vaccine Safety Monitoring Program at the National Vaccine rogan office, and i think the point about the value of routine influenza, control efforts are very important because what we had to work with with what we had at the time. I reminded of what secretary of defense Donald Rumsfeld said that when you go to war, you just with the army you want, with the army you have, not the army you want. Thats just the realities on the ground. When you look at things like vaccine safety, for example, vaccines we use routinely are very, very, very safe and thats very fortunate, and flu vaccines are very, very, very safe. Theres always the possibility of something you dont expect as was the case in 1976 with the swine flu affair. You have to always look for that. If you have vaccine we are blessed experience, the potential for a real safety problem to occur may be greater but you also have a problem which is that he could vaccinate everyone today, every bad thing that happens tomorrow happened within a day of vaccination. And thats a problem domestically but its especially a problem in part of the world where more bad things happen every day. People will naturally assume that this temporal relationship is a causal relationship. They will see look at all these people that got the vaccine and then something happened. We need signs to separate the coincidental from the true, adverse reaction. Science takes time, but the more infrastructure you have, the better, the faster you can respond with good science. And that infrastructure needs to largely exist before theres an emergency because we dont have time to go now we need to put this together. One aspect of this is really important, which is in the report thats been shared is that of trust, and trust specifically in Public Health authorities. This is very complicated, what makes people trust Public Health . Its probably a whole bunch of things from transparency and equity, and a lot of different pieces make up trust, the we dont understand it well. We dont even know how to measure it very well. We need to do that. Thats a cornerstone of Public Health. Its important to measure it, to improve it. We need peoples trust. We need their confidence. We need their confidence in our Public Health measures that the benefits outweigh the risks, that were doing the right thing. Because at the end of the day we need their compliance. You brought up the temporal relationship with receiving the vaccine and something that happened even though theres not a cause and effect relationship. Are we hope theres not. We seem to be in a state right now where the public has some distrust of public figures and Public Health. How do we rebuild that . How do we go about making, we need to address legitimate concerns. We all as ptab legitimate concerns, but how do we rebuild that trust and develop effective education, fumigation system and who is the messenger . Those are great questions. Were at a point where trust in government is at an alltime low. Were in a world of alternative facts where somehow something can be said and within a short amount of time half of the population questions the birthplace of our president , and so i think the problems are complex and the solutions are also going to be complex. I think we need to make sure we have rigorous objective science. I think it needs to be rapid. If you take the autism example, it took longer than it should have for us to have good data. We have really good data. We have 16 well conducted studies done throughout the world showing vaccines are not associate with autism, but in the time from when the paper was published when science became available, you had a very charismatic, well credentialed person traveling the world creating fiction. So i think rapid is important, objective, rigorous. We need a spokesperson who was really, really trusted, and we need to address it that way. Even if in the United States, certain country or certain areas, to possibly listen to tom brady more than the local ministers health. In the planet that are countries where the issues dealt with giving the politician the states. It will go directly in the other direction. So the message or issue which been researched but not that well yet, because by the time the Research Gets the data, social media can really change the opinion of the public is much faster. Even at the international level, and iteration of the compensation is already matched. Thoughts . I have a lot of thoughts. I need to calm myself. One thing i do want to say, we are at a record right now with more measles cases this year that weve had for 25 years, and larger, longer outbreaks and accomplishments in the country that are quite difficult to control. I think its really important for people to know that here in the United States, most parents make sure their kids get vaccinated against all the things that are recommended. In fact, if you look at twoyearolds, its 1. 1 of them had gotten no vaccines at all. Were not in crisis mode across the country everywhere with everybody opting out of the system but we are at a delicate time of trust which i think building up the last panel is truly local. It used to be people trusted their pediatrician or the family physician. They often trusted their mom or the grandmom. Right now a lot of parents and grandparents havent seen measles and so in sort of a New Territory with that and a lot of pediatricians having either. I think that there are many other influences and some of them are passive and some are active. In the current outbreaks were having, some of the influencers are active with really targeting vulnerable communities with very targeted misinformation. Thats quite challenging but its not a generalizable problem. If we look worldwide theres a lot of different factors influencing confidence in vaccination to confidence in the Public Health system or the government system. This is where we can put all our eggs in one basket of the perfect spokesperson or the perfect role for a spokesperson. You need to look locally and then as a Public Health system we need to make sure we get the best information to all of those partners who might be more trusted than we are. Just to build on her point, because it is really about whos the most trusted voice in any given setting, and getting that goodquality scientific information in a way thats understandable and absorbable to the people youre trying to reach, the complicated studies that you can understand, the lancet is that something by sisterinlaw is necessarily going to understand or similarly in the community. You want to get that information in a way thats understandable but understanding who are the trusted spokespeople in a given area. Theres a lot of evidence from our behavior change colleagues who really look at this, how do you get the information out in way that changes the behavior and can be understood and trusted, and we can look back to some of that, some of those approaches and evidence as a way to get on top of these kinds of misinformation and the misunderstandings thats out there. We need to be careful not to over respond. Theres two places i worry about that in particular. One is theres been a push to eliminate nonmedical exemptions. I understand the desire. My concern is that it doesnt get at the larger issues. The impact based on what weve e in california, which did so in response to a Measles Outbreak in 2015 is that the impact is really small and it reduces parental autonomy and disproportionate for low income people that may not be able to afford the homeschool or shop doctors. My concern is that of trust, and parents feel like were being more draconian, it may have backlash. Also the push on social media. Theres a lot of problems with social media but i recently read a letter written a congressman to that of facebook and twitter, and he said there is no evidence that vaccines cause serious harm or death. Vaccines are incredibly safe but thats not a true statement. The argument is to curtail misinformation but the letter itself is misinformation and its coming from a government leader. I think we can with social b is great. I would much rather see it done between individuals and the Companies Taking social responsibility. I just think we have to be careful not to over respond and feet into the mistrust problems. A lot of our over response is actually probably driving division, device of this we have on both sides of this argument now. We need to avoid it. Id like politics. Need 95 compliance homogeneously across the population indefinitely. We dont want this to be a defining issue. We need to bring people together and we need to sustain that success. Most parents waxing their kids and we need to keep it that way. Let me change gears again. We need to talk about innovation and technology. Doctor shook it, could you share all of it other thoughts about how cdc has advanced innovation and technologies and preferred his outbreak response and how its part of the culture of cdc . Sure. Maybe ill just write a little bit and kind contrast will be our right in 201415 with ebola. There were enormous efforts to get Laboratory Confirmation of ebola cases in 201415 because a diagnosis making it to be separated from everybody, applications on all your contacts, quite a bit of a lift for the Public Health response as well as for your certainty of is this fever due to malaria or due to ebola. 27,000 specimens were shipped via helicopter to a lab that cdc set up in sierra leone for the hot zone lab testing. Today with decentralize labs with the gene expert being used for key piece of people know how to use, you have safely to confirm ebola closer to the point of occurrence. Theyre screening after many death to see what they have to just the diagnostic advanced in a few years is really transformative. In 201415, and hm cdc, debbie joe and partners the trials of experimental vaccines that he cant believe we did these trials because the trust issue s humongous the complex. People thought in sierra leone we were told and ebola vaccine meant to the community a vaccine that gives you ebola. It has been given to so few people by the time these trials were started, but many thousands of individuals in the three countries got vaccinated under study protocol showing the part of pussy and in gaining showing it was effective. And in the usa today, 110,000 people i got vaccinated without which we wouldve had so many more cases. It is a Previous Panel said, these technological advances are not syllables because you cant deliver them without trust. You cant get the staff feel comfortable providing vaccine are giving care if theyre being targeted. If theyre some of the response has become the target of many other agendas. Innovation whether its technologic communication or just the management has a huge role but it doesnt take away the requirement of trust engagement and mobilization. Irene, most people think of u. S. Aid as only involve in international development, providing it. But i are one of seen firsthand the innovation at usaid in many different areas, technology are just the approach to the problem. Could you expand on that . Sure. Much like anne was talking about, innovation is a future important part of a lot of what we do but is not the only thing. Across the work we do in health and every single component there is a certain portion of the effort given to pushing the envelope on new innovations whether it be development. Were downstream, not the work that an h does. Whether it be new diagnostics for tb or the better drug regiment for drug resistant tb or trying to help with advanced market commitment working with the ebola vaccine into the field all the kinds of things were trying to do. It is not a Silver Bullet but it can really make a difference. One of the things were seeing is this revolution in Data Technology can really make a huge difference. How do you feel that in, and the work were trying to do is figure out how to take this Exciting Technology of all of your Health Information system could be on your phone but really make it built into the primary Health Care System so its not just a thousand facts out there for gathering data but it really is useful for people who need use that data. A lot of effort is trying to refine the technology out there to really make it the most useful for getting to the end of, the outcomes you need, which is a healthier population, people have access to the services and healthcare workers about the information or the tools they need to make the difference at the end of the road. And how about the w. H. O. . Just one reflection. Innovation doesnt go semantically in all the world at the same time at the same speed with the same type of caveat or not, lack there of. We should also balance the capacity of the different part, different intellectual parts that are developing, and think about regulating it. All of the research is positive. Theres a debate on dualuse research and which research should or should not or could or could not be used which is not linked with any conversation were having here. Rather than running after the next experiment, we should have an understanding to select which have technology are going to hurt us in the next ten years. Out of them, before the theory or the merge of the two, try to see what is that we need to enhance and manage. Dan, you mention Vaccine Safety Research and sometimes it takes a long time, but i suspect theres some innovative opportunities and, therefore, more rapid realtime evaluation of vaccine safety and efficacy. I know nikki lord who is o a big champion of Operational Research has we were deploying for things. Would you mind speaking to that and your ideas on that . Im happy to. I think there are two places for huge opportunity, and one is large databases and one is containing medical record. Under her leadership were able to build a large active Surveillance System for h1n1 called a prism, and its now a part of the fda its the largest active Surveillance System for vaccine safety. With these large databases you can do very rapid studies and that infrastructure is really helpful. The other place where theres tremendous opportunity through science is in genomics and in particular backs in the mix and adverse genomics. Most people respond well to vaccines. They get a sufficient and mute response. They are protected. They dont have a serious adverse reaction but some people under respond and theyre not protected, and some people over respond and very rarely have adverse reaction, and why its at and what is the role genomics . This is really an opportunity to not just push the science further but to bring in the skeptical payers. Because what you hear from parents are frequently, i have a Family History of autoimmune disease and im worried that even though for most people the vaccine is good, for my child its not. What theyre saying is they think have genetic miss factor. Thats a place where if we can do science we can address those concerns and the site is hard, difficult and it takes time and it takes money but its an opportunity for us to go through personalized vaccination like personalized medicine to hear the concerns of parents to respond with signs and maybe avoid the very, very rare but serious adverse reaction. Might come back loaded about how the resources going for some of that work. What id like to do now is actually open up to the audience, opportunity to ask questions of the panelists. Its hard for us to see, but if there are any audience okay, and will get a microphone to you. And again, state your name and organization. My name is brandon ball. I work for path. Obviously, we are funded to work in the drc by cdc with usaid. I want to ask a couple of questions regarding strategy. We are pleased to see it release, please to see the content included. One of the things we were pleased about was around the inclusion around understand per the strategy theres an internal working group led by cdc and usaid and am wondering when you think that might be stood up what that like practically to your point, there are so many here, what does that look like for you guys to Work Together on that . And then on the Global Health security strategy, if you look back at the fy 18 on this requirement, congress astra five things and one was future financing. That is a little complicated part because omb doesnt want to put itself on record, but i want to ask, could you give us an idea of what the cost of this Program Might Look Like Going Forward for each of your agencys, the drc, et cetera . Thank you. I actually can do the specifics on the working group. That said, i will seven Global Health security cdc and use it he had been working closely together from the very beginning where our leads talk to each other probably every day, and on the ground the plans that were talked about earlier are done jointly come in response to the joint evaluations, the work that u. S. Government is going to do in any given country is planned up jointly between the two agencies. So sorting out whos going to be doing what, whos taking leak which vary to make sure theres not duplication or what the u. S. Government can do on a cat. Its really important so we will build on the work weve been doing jointly together as well. In terms of future financing, Global Health security is a priority for the administration and has been for the us government, and certainly in the 2020 request there is increased funding for usaid and cdc as well. That does reflect what needs to happen. Also on the financing of what it costs today, the levels vary from country but this is where we do need to look to countries to step up and make investment. It cant just fall on u. S. Government to pay all of the cost or do that. This is where the kind of country commitment we have really seen in Global Health security, country stepping up and realizing however important this is and its very important what you need to do in putting into own investments. Mamaybe just let me expand a little bit. I think its very fundamental to both cdc and use it he called to come building off earlier panels, is we cant measure, we dont know how were doing. And if you want accountability, we need to know how were doing as well. But he think also build on the earlier panel, to really get ownership of Global Health security sustainably, we need this not to be u. S. Governments doing the whole thing or paying for the whole thing. This has to be country owned and partnered, partnerships with multiple countries and the multilateral as well. In some ways you can look at pepfar and say wow, its incredibly impactful and successful. But in some ways its very simple. Its one single disease that youre trying to, a really difficult disease but with great tools right now come one single disease that can have very, very measured tracking, and we can be investing and whats effective can whats Cost Effective and make sure we are accountable. Global Health Security is going to be addressing systems improvements and his final to have an objective way to measure. Were 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 other global initiatives, but building to really Health System strengthening effort, a meaningful way to track. Weve had a fiveyear emergency supplemental dollars that have gotten a lot of improvements and a number of countries as well as in global partnerships and in cross cutting threats. When i done and this is that something thats going to be, youre done. Its a forever kind of thing but it does any u. S. Government will be paying for it at a certain level forever. Theres a question in the back. Burke on cassidy how with the Vaccine Institute and im working on influenza vaccine innovation, particularly universal influenza vaccine innovation. In this work we spoken to stakeholders from a lot of sectors who have all kind of said the government, academic and research and development, architectures are not legal for innovation, accelerate innovation and risktaking. My question to all of the panelists, any of the panelist is how do we the risk the environment to foster these by sector collaborations and encourage the open source, open data cooperation this are to make these challenges and problems accessible to different thinkers, nontraditional experts in genomics and injuring and big data . How do we foster that collaboration and encourage those types of different thinkers to join the cost for Different Solutions . Thats really hard. [laughing] i think im more optimistic about that than it was a few years ago because i do think that people recognize for influenza, we are not where we should be given how much we been investing for decades, and with substantial scientific investment and innovative approaches to it, we could be in a lot better shape. We spent a lot of money every year vaccinating everybody with the best tools we have right now, but you need to give them every year. They dont work as well and many people as in others, and theres some incentives for industry cannot innovate right now in terms of having a pretty good market, not as lucrative as some of the newer vaccines but a reasonable market. Whether its the role of nih or u. S. Government control or some of the academics role, theres a shared sense that we need to do things differently. That doesnt mean i have a solution but i think having agreed that its a problem is a start and i think theres policymaker agreement that its a problem. Just to add on that, i think theres also, every much agree, i think theres been a shift to try to move in a much more open source, more innovative approach. I think theres been a couple of tools of the recently things like the grand challenges which just puts outcome heres a problem, we need a better ebola suit or a better way to monitor the vitals for a patient sitting in an ebola unit. That did bring all kinds of really, really Innovative Solutions from different sources and not the usual sources that we typically look for. Theres some really exciting ways to try to bring in those new ideas from people who are not usually at the table. And on data i think theres also, the Data Revolution is underway. Pushing the envelope, im openly sharing that date is still not quite what we need it to be but given technologies and other, really the pushing to share data puts us closer to a place where we can have a much better way to have that open data. But not quite there yet. I was looking at some of my colleagues back in the room and i know they have certainly tried to be on the front wave of the innovation and ive actually establish a new programs recently in barda. My question is, dan, what advice would you have for barda to make sure that they bring the vaccine safety issues along with their new innovative programs in barda . Im careful in this regard because a lot of the Vaccine Research and felt and a lot of this, the work there is clinical work and Clinical Trial work. I guess one thing i think part of realized was you have the infrastructure, you have when you roll out a product. For example, i was contacted by a Vaccine Company that was the building ebola vaccine and asked me the question, how can we monitor the safety if its rolled up in an african country . The challenge was there was so infrastructure for active surveillance. At least historically dont barda has been quite aware that but in terms of Vaccine Development its just outside of the expertise to try to give advice on that. Just a comment. In general, the Research Suggests people dont like new vaccines. We like new iphones but we dont really like every year. Theres some comfort no of the people of god and we know something about and we will not get surprised. But in the midst of an emergency everybody wants something. One of the challenges in drc is they been doing a ring vaccination and some of the concerns in some of the community are waterloo some people getting the vaccine . What about the rest of us . You know very little about the other vaccine that is proposed to be used in that context. We have a problem that when the Public Acceptance is the highest for something new and potentially untested, we dont have anything. And when we have incredibly well studied products like the nmr or influenza vaccine, people start to kind of wonder about its safety. I did need to also mention that one of the impacts of the 2009 pandemic was a real change in acceptability of vaccination in pregnancies. We went from having 15 15 of wn get a flu vaccine seasonally to about 50 , which might not sound like a lot but that is a lot for obstetrician, Family Physicians and women to decide that this is a good thing, not a risky thing to do. I do think when people see bad events from natural diseases and that there are tools to help them accept the change. Historically, we develop vaccines for developed country and the other one after decades of experience including a lot of safety science there would make it too low and middle income country which obvious is because countries often need vaccines most are not getting them right away. We seen a shift where now vaccines are being developed and rolled up first in low and middle Income Countries which has, which was great in many, many, many ways, but the challenge is the infrastructure for safety and surveillance, the capacity is not there as it is in high Income Countries. The truly about Infrastructure Investment to have capacity. Trying to come anything to add . Im always fascinated by the response. You dont vaccinate if you dont know who to vaccinate. You dont know who to vaccinate if you dont you cannot vaccinate if you dont have the community permission, security environment. This vaccine needs to be kept in time, in congo, think of the complications. The other reflection on the colleague down the, innovation appears to be geographically preferred. The coalition, the appeal of cabbage massachusetts a certain area, across fertilizing appeal to the young scientists. Together sponsor of governments, the same appear in other parts of the planet. The concentration of intelligence, brain, iq, phds, is a phenomenon that was started mit when i was there. Another reflection how to facilitate this movement of neurons will probably follow what else we give to the scientists, its not just money, believe me. Is there one more audience question . I thought so. I forgot, sorry. Earlier darpa was mentioned and i see renee over there and a stink about their diagnostic, local diagnostic industry issue. As somebody who does tropical Public Health research, one of the challenges i sat in partnership with both of your people in the field is trying, trying to do in a Sustainable Way when there is no one other than this one person in nigeria who happens to be certified. It sounds like you two need a capital fund where you come with some support from maybe barda and nih and others, can actually do darpa like spinoffs focus on local Market Development for biomedical science and Health Security. What do you think . You know, im sorry the doctor still here because he spent years at darpa and is very excited about the nexus between innovation and derisk and the kind of problems that we are dealing with all the time. I do think the usual approaches are challenging. We did get congressional support for Infectious Disease Rapid Response fund. We saw so many challenges with the long lag between emergency, that we clearly have exceeded our funding capacities for, and that the resources from h1n1 to ebola to zika. Have a small amount, start, but a very different issue is the innovation kind of investments. And here the translation of this money into the Security Sector with bring uncapped capacities for all the Public Health systems. Because the prize of the ebola fund and our response is possibly onefifth of the mountain of a warhead or something. Not just the technology, the knowledge, the capacity can not just the fund from the security if this dialogue goes well is uncapped. The only other thing i would add very briefly is i think theres also been a lot of interest in Movement Forward bringing the matching with the private Sector Investment in the space, and i think theres a whole lot more we can do in that area. I have one more question and we can keep it brief, and we talked about it before onl earlr in the day but i would like your perspective on this. The question is, and will start, try to come with you. How region today in the Ebola Outbreak compared to 20142016. Different ways you can go about that question but what are the differences today versus 2014, 2016. Not that mitchell, not your specific organization that we as a community. Its complicated question because the anthropology and the history of each outbreak is really different. In 2013 as a second one of the factors is that we all responded to phenomenon that we are local without thinking that the tribe was basically the same family crossing two rivers living in the space of three countries. So we treated the problem geographically or geopolitically because we followed the ministers of health. Thats the only thing we had to while possibly we should be smarter in designing the outbreak. In nigeria, we had a mortality which was 20 less without vaccine than the current one. We enter into the ward to talk to the patient, to speak with them, to joke with them. People are dying of aspirations because they are sad, sick, abandon in these wards. So there is a whole other thinking. Today we have the vaccine so it should be much easier. Doc is one of the most potentially wealth and term of resources, and everybody is having a piece of it or fighting for it. The ambassador, five level at different fighting force for me political to the community, from the mines, protections and plants and so on. This we didnt have it, so it is one of the complicating programs. Last but not least, it flies less. If we would lose the patient from Lagos Airport or the whole response in niger, we would have been a speaking of a different history. Irene . The last panel some of our lot of this. Big fundamental difference i think between this outbreak and when we were in 2014 is quite frankly its the complex emergency setting which makes it extraordinary difficult. The kinds of things weve been talking about, some of the similarities are indeed the need to understand what it issues at the Community Level, how can we possibly reach people given that setting . But that becomes a really difficult thing. The other piece thats talked about is we do have the vaccine which has been said has made a phenomenal difference this time. It is a tool, there is no Silver Bullet, it is an incredibly powerful tool that we do have, but reaching people and trying to overcome some of those really fundamental issues of distrust and concern and a whole lot of other issues in addition to ebola thats facing the people who are most affected will be the thing we have to figure out how to overcome. I would say theres some really disturbing contrasts to make, despite the country, the global community, w. H. O. Responding very rapidly in the country identified the fibers themselves and searched and so forth, despite that it is getting worse, not better. Despite 110,000, some people have been vaccinated, different products been tested and so forth, its getting worse and not bitter. Our ability to change that trajectory is there is very limited as both outsiders and as the context of where its occurring. Beyond the vaccine that something kind of keep it, even though its getting much worse, the vaccine is keeping that at a slope is not as bad as it might be. Theres also this enormous investment in border screening going on with the people, like you say, theres one tribe. People crossing borders into uganda, you know, theres been vaccinations in uganda, rwanda, south sudan i believe. So its really, you know, we cannot stop intensive response and we have to become creative about how to support the Community Level response. Because this could get so much worse and could be in many other communities. Its already and i think 21 or 22 health zones, theres active cases. Dan, as an International Health professor i write anything to add. Its been a great discussion. I want to thank our panel discussions. Its been fascinating and a really appreciate you taking the time to join us this afternoon. [applause] and if we could have our final panelists to come up. Ive already introduced professor trento at the start of the day but he will moderate this panel and ill turn it over to andrew to introduce our panel discussants. Thank you. Am i on now . So were at the final panel today. We have two people who can manage politics. Ron klain was the chief of staff the two american Vice President s, to al gore when he was Vice President in the clinton administration. He was chief of staff to joe biden when he was Vice President under president obama. He is i think a Senior Executive in a Venture Capital fund. The most important thing however is he was the czar during the Ebola Outbreak in west africa for president obama cerise the toppers in the white house which is why we have invited him today. Jim greenwood is the president and the ceo of biotechnology innovation organization, bio come in the middle of the Blue Ribbon Study Panel on biodefense. Hes a former member of the house from house of representatives, the house of representatives in pennsylvania is hosted in that state senate so hes a career politician. I said that as a compliment since i was a career politician myself. Some people think maybe im still a politician. I think actually what were dealing with is political management in these emergencies because were dealing with issues that are not health issues. The lack of trust in government, and not just here but around the world, and the social media now, the misuse of that is a political issue. Its not a health issue per se. Its affecting health. In any case, i want to read something before we start the discussion from john barrys great book, the great influenza, which is probably one of the best histories of the pandemic of 1918. One paragraph, Viktor Vaughn was the dean of the university of michigan medical school, one of the two leading Health Scientist in the United States, and best friends with William Welch who for 40 years was the dean of the Johns Hopkins school of Public Health. Victor von, sitting in the office of the Surgeon General of the United States army and head of the armies division of human diseases watched the virus, influenza of 1918 move across the earth. He wrote this in his own hand and i quote, 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. Now, 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 hands. Thats the sense of panic that existed. We are going to face the same sense of panic. We havent yet. We had to let people get sick with the ball in the United States. You remember what happened. It was all over the headlines across the United States. Imagine 650,00 650,000 americand in six months, which is what happened in 1918. 89 people died and white. 5 of the worlds population. Were going to deal with a whole series of political issues, which i think we are not prepared to deal with. We have been warned now because of these viruses, the diseases that a spread that we have this new fungus that the spread in hospitals. Its very dangerous point. So i come from my recent perspective the last, going on 15 years now and its been to lead the trade association for Biotech Companies and we have, as membership, about a thousand of them and a goodly number of these are in the medical measure business and a lot of our companies are in the vaccine business. I guess the first thing i need to say is that inventing invading drugs of any kind is extraordinarily difficult. We fail 90 of the time. If we look at alzheimers, weve failed basically 100 of the time. The science is developing, but its complicated. One of the reasons that drugs are expensive is because of the high failure rate. Now, imagine youre a company, particularly a Small Company and what you like to do is make Counter Measures against pandemic and bioterror attack and you know that essentially, your only purchaser, the only person entity thats going to buy your goods is the federal government, so now youre at this highly risky enterprise trying to meet a need that has not been made perfectly clear by the government, not sure that its going to be approved, and then very uncertain about whether its actually going to be acquired, and whether its going to be acquired consistently and whether the funds will be there. So, now imagine trying to attract investors into this enterprise saying, so id like you to investigate in my company. Were going to try to make some important measurements. Were probably going to fail. If we succeed we may or may not get it approved and if we do have an approved, we may or may not have a purchased by the federal government. Its a risky proposition, but nonetheless, companies are busy doing that and in an effort to participate in this effort, i joined this blue ribbon panel, its cochaired by former senator lieberman and a former government and health secretary, tom ridge and tom dachyshyn and donna shillelagh it will she was elected. And the biggest problem is that a number of problems. One of the problems, this is one of those things that the last big pandemic to which you refer it over a hundred years ago. Congress not good at long range thinking. Even though the experts say theres an inevitability to a horrific pandemic, there was an inevitability to terrorist attacks. The thousands and thousands of items on the agenda of the congress, are such at that this doesnt come to the fore. When we wrote our first report, at my suggestion, we began with assimilat a simulated hearing after thousands and thousands of people died. Members of congress were calling members of the federal government basically saying why did you not see this coming . Why were you not prepared . Why did all of these people have to die . And we did that as a message to congress saying let us not wait until the horses have left the born and well prepare. Thats what were desperately trying to do and desperately not trying to be a report on a solve somewhere. This goes to the leadership question. One of the things we zeroed in on is the responsibility for these issues is scattered throughout the federal government and theres no unified budget. Theres no unified chain of command so therefore, its siloed, the lefthand doesnt know what the right hand is doing throughout the federal government. We thought what was important was to have a centralized individual who had ultimate responsibility and we taught that the best way to do that was to give that responsibility to the vicepresident of the United States. Thats not happened. We have not succeeded on that. Right now, the leadership is with the secretary of health and human services, alex azar, a fine man, used to be on my board. The problem he has, as good as he may be, if he has a conflict with the department of Homeland Security or department of defense, he doesnt have the clout to say to one of the other agencies or departments, you can do x and y. Thats why we needed that to be in the white house in the hand of the vicepresident in order to provide the leadership that we think this issue desperately needs. Ron, you in fact were the closest thing to the vicepresident being chosen because you were his chief of staff and president obama appointed you as the czar for this and so, in some ways you had the authority of the vicepresident . I had left the vicepresident s office a couple of years before. Oh, before. Yeah. But you came back. I came back, but i didnt report to the vicepresident. The vicepresident wasnt involved. Okay. Look, i think a couple things just to kick this off, one, first of all, i want to really commend Scowcroft Institute and texas a m and everyone associated with the white paper, its collects powerful information from across the states and puts it together and its a great work and i think the single best thing would be if any policy maker in the United States and capitals around the world read it and followed it because i think its an exceptional piece of work. We are here at the 100th anniversary of the 1918 spanish flu epidemic. As andy said, its startling thing that vast americans dont know, but it took more lives than world war i. But in world war i, world war ii, a lot in the curriculum and you can barely find a word about it. Its forgotten in our country and thats why policy makers dont respond to tn react to it. Theres in a hundred the leadership of other multilateral are important and were addressing this global challenge. Whether its our technical expertise, our resources, our Health Care System. Theres no replacement for the u. S. Being in the forefront of this and were at place in our country wornt the u. S. Is still going to be at the forefront of this and i think weve got to get past those questions and make sure were leading. Third thing i want to say about it is, is this should not be a partisan issue. Im a partisan, im unapologetically a partisan. Im democrat and outspoken on issues and on this issue of pandemic it should not be a republican or democratic issues viruses dont ask, mosquitos dont ask you before they bite you. People should work across party lines. Jim is a good example of that. I think during the Ebola Response, we have a certain politics in the end. Democrats and republicans came together and funded a 6 billion response that we spent here, some around the world and trying to turn around the Ebola Outbreak in 2014. I hope this we can keep it that way and keep it bipartisan. Having said that, its not a partisan issue. And its a political issue. When we talk about Public Health. Were talking about engaging the public and eengage them in our country through politics and whether that means some of the issues and panel talks about antivaccine, responding to antiisolationism, antiimmigrant segments, all these things that complicate our response to Infectious Diseases, i think that politics have to be part of it. And people in the Public Health community have to be unafraid and willing to step into the political arena and provide the kind of force for the kinds of actions that this report and others recommend. Now, last point under the white house leadership thing. I absolutely believe we need leadership at the white house. I do not think it should be the vicepresident. The vicepresident has a fulltime job getting ready for and responding to pandemic threats is also a fulltime job. The idea that the vicepresident would do that in his spare time doesnt seem like a good idea to me. President obama after he brought me in to do the Ebola Response, we were close to zero cases and a Senior Member of the staff to be in charge of Pandemic Response and President Trump continued that. And admiral zimmers leadership on that. That position has been terminated. I hope that either President Trump changes his mind or back with the next president whoever he or she is does that. We need someone for some of the reasons that jim said. I think it should be a Fulltime Position on the staff and not just the vicepresident with a sliver or his or her time. Id like to comment on that, its a debatable point and the thing is, we havent succeeded in placing this in the hands of the vicepresident , indicative of that. But the thinking that weve used here was that of course, the vicepresident is going to be doing the sings that vicepresident s do and the vicepresident is never anticipated to be focused on this all the time, but rather, that the vicepresident would appoint someone who a capable and qualified to do that leadership, but would then be able to, when necessary, simply turn to the vicepresident and say i need some juice, i need to knock some Heads Together here and we think that the vicepresident has the political clout to do so and also influence on the bugetary process in the white house that maybe the nfc may have less clout over. Most Scientists Say that the biggest threat we face that scares people the most is still influenza in its various iterations. Last year was the worst year in 20 years for influenza or the flu. 88,000 people died. I bet most people dont know that. Thats from c. D. C. , 88,000. In 2009 c. D. C. Reports that 1. 9 billion, not million, billion people in the world got the cause there was a pandemic, but had an extremely low death rate. 1. 9 billion people got the disease in six months. Thats how fast it spread. I think, ron, you were the one that said weve created globalization. Our airports are the best thing that happened to a pandemic because they will spread the disease all over the world overnight even where we know its going on because of the nature of transportation in the world. So two questions for both of you, both are related to influenza, or the flu. One is the National Strategic stockpile was established 20 years ago before 9 11. Before the anthrax attacks or sars. Its evolved. Is it the model we should be using to protect ourselves particularly against the flu . Thats one question. And the second question is what could we do to create the incentives for industry to perhaps invest more money and research on this for a universal flu vaccine which of course companies are working on now. Is there anything we need to do to change, as the senator said this morning, senator burke, the architecture of the system and incentives within the system to get some kind of a vaccine before it happens . Before the next pandemic . Those are obviously very closely related questions. Right. I dont think that the problem is so much with the architecture, although ill yield to the senator on that,s been a leader on this issue, as much as it is with the funding and the reliability of the funding. I think unfortunately, if you had 535 members of Congress Sitting here and asked them what the likelihood of a 1918 era pandemic, i would guess that the vast majority of them would not think that was possible. They would think that weve had so many medical advances in the last 100 years that of course that could never happen again and the flu is as regular as anything could be. They see the flu, they see people get sick and see people die and usually they think theyre old people theyre going to die anyway, but they dont recognize an apocalyptic scenario is possible so for that reason they dont feel the sense of urgency and again, this is noahs version on my colleagues and former colleagues in congress, this is not the top of the issue, top of mind issue for the public. So theres no public pressure to do this. So the one thing that i think if the structure were wellfunded and the industry could rely on that, as i said earlier, the investors could rely, the money will be there. The pre procurement will happen. When the ebola first round occurred, companies lost money. They did the patriotic thing, more than patriotic, it was the humane thing to do. They turned they turned away from other projects. They are still behind in some projects because they devoted attention to this and then the epidemic was over and there they were with no one to procure their products and so, they do this at great risk. The so i think if the funding were there, if the sense of urgency were there, the industry would respond. On the partisan issue, youre absolutely right, this is nothing partisan about this issue. But there is a way in which partisanship creeps in, and its this. What is desperately needed is oversight. I chaired the oversight investigation subcommittee of the energy and Commerce Committee and the oversight subcommittees of all the house and the senate have a dire responsibility to look into these programs that theyre funding. The oversight function is the kind of function that it doesnt have to be an emergency in order to occur. Its a kind of function that congress is supposed to do on a regular basis to look into all of these programs that are important and oversee them. As long as both parties, and lets not get into the politics of it, but as long as both parties continue to monopolize the oversight function on political matters, then theres not enough time for things that are important, and theres no need to go into what has been justified and not been justified in the last many years in congress, but it would in many instances, i think it the public is better served when theres time for the oversight committees to do that important work. I just have a couple of things. In 2009, 2010 i was working with vicepresident biden and was involved directly in the h1n1 response and i lived through it as a staffer, but i will say a bunch of talented people working on it and we did everything wrong and 60 million americans got h1n1 at that time and its fortuity that it wasnt one of the largest mass casualties. Pure luck. If anyone thinks its not going to happen, dont go back to 2009, 2010 and do the math on that. What did that tell us . It told us the vaccine will arrive late. It told us if its not prepared in advance, it will arrive late. We dont have the answer before. Were not going to get the answer in time. It told us that our systems for deciding how to distribute and administer a vaccine in the time of crisis are going to be badly, badly tested. It also told us one other thing, that we really lack a Global Policy mechanism for dealing with these untested vaccines in an emergency situation. Now, we saw this a little in 2014 just as towards the tail end of that outbreak. We got some of these new experiment vaccines and had some phase one testing and phase two. And immediately had issues about who would be liable if the vaccine made anyone sick. Who would be liable if they had claims. Who would own the intellectual property. Its pretty clear in the United States, theres no global prep act, theres no global structure. A lot of the constituent companies were very worried about their exposure in that circumstance and you can imagine the scenario. It kind of faces a little in 2010 with h1n1 where the vaccine didnt arrive for us in time, it got in time for europe and there was a big controversy whether or not it could be administered. What was the Regulatory Approvals and so on, so forth. This has been a life and death situation. Policy would have killed people. The absence of policy would have killed people. One thing that we can do now is try to get together. Try to figure out a solution on this liability issue that works worldwide and not just in the u. S. And that deals with this. One thing we know for sure is, if we have to deal with it in the moment, its going to be very bad. And i disagree with a little of that. You know, on the Global Nature of this, as fully prepared as we are, i dont think theres a country in the world thats better prepared and so, thats not good news. Whats really frightening about it, should you have an outbreak somewhere else, that could readily arrive here and we have, lets say, Counter Measures that could be responsive, who do we tell our fellow earthlings in other continents that, im sorry, that we have to ward ours in case, to protect our own people. Thats a difficult humanitarian decision to make, but its one that i think we probably would make and so it really does require a lot more global coordination and a lot of work by other nations as well. But i would say the development professional, the first line of defense is not the borders of the United States. Theres no way were going to prevent this from getting into the United States. If the factor, in other words, the infectious nature of whatever the virus is, like measles, has a very high infection rate. Ebola actually has a low rate. Influenza has a high rate. Its going to get into the United States. The first line of defense is the rest of the world not here. To me we need to respond immediately to stamp the thing out before it gets out of the country that it starts it. And thats a hard sell in for people in the United States. Why dont we worry about ourselves. The reality is, if we want to worry about ourselves we need to extend help to the rest of the world. Let me just fill in. This is an eye opening comment. The isolationist sentiment in our country right now is one of the most dangerous dynamics we have. We cant have Public Health safety in the United States out of the context of Global Health security. And as andy said, in the event of any kind of pandemic or whatever, certainly in cases of h1 h1n1, we had cases before we knew it was here and thats going to be true for whatever comes down the road. And the only way to keep our people safe is to engage globally in making other people safe. Thats what u. S. Leadership is so important and u. S. Engagement is so important. This is an area where the Public Health Community Needs to speak out. Ill just be very honest about it. We saw it when we had zika in 2015 and 2016 ch. Very slow action in the congress. In funding the response that president obama sent to the congress, ten months away, and again, ill be honest, i spoke out a lot about it, i do a lot of events, and hey, zika is an immigrants disease. Why not keep the immigrants out. We shouldnt pay for all this, keep the immigrants out. That mindset really impacted our response. I fear that that mindset a little bit colors our reaction now to different Global Health challenges and how we engage in the world and i think that weve got to get past that. Weve got to rally people in both parties. Weve got to rally peoples goodwill across the political spectrum to understand that we understand this with terrorism, with terrorism, the on thing keeping the American People safe is to engage on issues around the world. By the time the threat gets here its too late. You have to have the same mindset, obviously, much more positive attitude about it in terms of building Global Health security around the world is the best way to keep people safe here. Even if the sentiment is, the europeans and the asians have to pull their weight and make their contributions, scientifically and financially and so forth, lets assume that thats the case, you dont get there by retrenching, you get there by leadership, by having those conversations around the world, contributing, but also encouraging the participation by the rest of our neighbors. Can i get both of you to comment on something weve spoke of in our first white paper three years ago which we released at this conference, the first one, which is the fact that who did not perform well in west africa. I think its performed much better since then, but its not quite there yet. What needs to be done to finish the process of reforming and strengthening is who because they need to play a role in terms of International Coordination in case much an emergency. Could both of you comment on that . Not very well. Let me start that. [laughter] okay. To be honest, i dont know. Who did a very bad job on ebola in 2014, i think ive been outspoken. Theyre superb in response to drc, offing everything they were not in 2014. Theyve been fast, transparent, candid and theyve been quite responsive and their leadership is exceptional. I think what this outbreak is showing is the limitations of who. Its not a response organization. If the biggest problems we have right now in drc is the security instability, is the attack on Health Care Workers, the attacks on responders, the Community Resistance and the Community Resistance getting violent and dangerous, the who has no capacity to respond to that. Thats not their mandate. And theyre never going to have that capacity. We always have a big debate how many more bigger checks that the countries right the who, that would help in the drc. Thats not going to solve that core problem. Since 2015 ive been a public advocate of having a white helmeted Security Battalion upped the leadership of the eu that could provide in the case of an epidemic response. 2014, 2015, president obama did something hes never done before which is he ordered u. S. Troops into the field to help with an epidemic response. Operation united assistance. 300 troops in kentucky airborne over to liberia. It worked in liberia where american troops were welcomed as friends and as a blessing to have that solution is not going to work in congo. Okay. That solution is not going to work in other places in the world. Wed have to fight our way in, a bad way to do epidemic response, but some sort of Global Security force is needed. What were seeing in congo is n new, but likely to be the new normal. The combination of Infectious Disease outbreaks and regional conflict, fighting over resources, fighting over control, 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 because if we dont solve this thing in congo, you know, it is going to spread. Its going to spread to some places much more populous and much more connected to the outside world and were going to lack that we dont have the tools to deal with it as is. Let me add to that, almost everything happening in the congo has happened before, but not in the context of epidemic disease. Its happened with famine and civil wars in south sudan. In somalia, yemen, its been going on for 30 years. Theres literature on it, but none of it deals with complications of Infectious Disease. Thats new and the u. N. Is not using the Emergency Response function of the rest of the system to help who deal with niece instability issues, which weve been dealing with for a long time now. And we have put in place some things, youre correct, the biggest factor in my view is the lack of a powerful the mechanism for putting together a peacekeeping in the u. N. , i would never use that for this at all, without going to the details of this. It does not work. It does not work. Ive been involved in this for 30 years and we need a different model. I think your idea of having the eu do it is a very good idea because they would be exposed to that. Its philosophical in many respects. I would say that i i am largely critical of the organization for a couple of reasons. I think if they are its very political in ways that result in lack of good science revealing. I think that they are very political in that they, for instance, really seem to be the enemy of intellectual property, which is easy to do under certain ways of thinking, but without an intellectual property there wont be any innovation to meet the help meet the needs of the world. So i think that the World Health Organization needs a lot of work. Again, i really say i was unsparing in my criticism of dr. Shan in 2014. I think that what the doctor has done with who has been a dramatic change. Not saying that theres no room for improvement. Theres always room for improvement. What theyre doing right now in congo is amazing and heroic and again, i think we have to toe it up. Were falling short. And i think the u. S. Is not doing its part right now and i think and that means both in terms of resources, but also in terms of helping to put together some of the Diplomatic Solutions that might help address some of the security issues, but i do think we need a dramatic improvement in who in the past five years and a lot of credit needs to go to dr. Tedros in my view. Let me raise another issue, which is the role of social media which is complicating all of that very substantially. It is clear that social media is being used for very good things in the world, openness and accountability, however, its being used for rumors and antiscientific and its not just in this field, in the gmo field and a whole bunch of other fields, theres a lot of stuff on the internet thats complete nonsense. So the question is what we do about it. I might add theres a new study out in one of the health journals, peer reviewed, done by engineering scientists looking at tweets to see where a lot of the antimessaging is coming from and its not coming from random people just and there is a legitimate when i say legitimate, people are genuinely concerned about it among the people. I dont think theyre right, theyre wrong, but we need to understand the domestic sources that go back to the american revolution. However, its now a function of great power politics and what the study shows is that tweeting is now being used to spread antivaccine messages. 90 of antivax messages and 10 pro, to cause more conflict around the world and its not just its directed against the United States. Its from russia, actually and it doesnt appear that its from russian civil society, the opposite. It appears that its a public source and this study you can read in the Public Health journal that just came out a couple of months ago, and its based on a comprehensive study with algorithms that were used to look at mass numbers of tweets to see what the source of the information was. Huge disparate between the tweets in the west and the tweets coming from russia. On the Measles Outbreak. So the question is, what do you do about it . If this is being used of geo a tool, a geostrategic competition, the reason we got rid of small pox because soviet scientists and american scientists made a deal to wipe out the diseases. One thing that we worked on that worked heroically, heroically. And so, the fact that now this is happening in the opposite way for strategic purposes is very disturbing, i think. So can you comment on social media and how do we deal with this issue of social media being used for very destructive purposes, for geostrategic purposes and pandemic disease . Ill make a comment. I think most of us at the earlier stages of the internet were filled with hope that, what a fabulous tool this will be to educate the world and to unify the world and to bring knowledge to all and now we find ourselves in a strange moment in history where virtually everyone in the world has a device in their pocket that enables them, handled well, to find the truth and real science and real facts and reliable information. But at the same time, were getting dumbed down by it at an alarming, alarming pace. And when its one thing to think ow destructive it is in antivaxers and antigmo and fake science out there. The real terror, what happens in the midst of a pandemic or a bioterror event when people are desperately looking for, what do i do, where do i go, and imagine the flow of bad information, disinformation, and malinformation that could occur and people would be almost better off throwing their devices in the river. So how do we deal with that . I think lord only knows. You can talk about teaching Critical Thinking and teaching people how to find their way through the miasma of disinformation. Weve been talking about it for decades and getting nowhere in public and private education. How to get a handle on this and teach people to go beyond the first tweet or facebook posting that we see and actually find their way to the real facts, i have no idea. Its a real challenge. A couple of things on this. One, in the west africa Ebola Response, it was a multilateral respon response. The front line responders, a lot of them, from west africa and people in the free country deserve the lions share for turning it around with their courageous work and willingness to change. They were from a lot of countries. That included, france, england, a lot of focus on that, cuba and china. I sat in the situation room. We saw photos of Chinese Military planes landing on runways, being unloaded by american troops. Its an amazing example of local cooperation. While that was going on we believe russians were on the ground in west africa spreading this information, telling people know the to go to the ebola treatment units that they would die there, telling people not to trust the Health Care Responders and so, this issue of the russians using uncertainty and fear about disease as a geopolitical tool has been around for a while and now, were seeing it on social media, deliberate attempt to spread diseases, spread uncertainty, spread resentment, spread social strive. Now, what are the solutions . Look, i think it goes back to the discussion in the last panel about voices of authority and where that Authority Comes from in a crisis. And wed like to think it comes from up high, way up high, love to think its president , oval office, Surgeon General or Surgeon General, u. N. Services. What we saw in west africa in the middle of this was an authority came locally, came local clergy, came local healers, local native healers, local community leaders, local tribal leaders, so on, so forth. And social media is its own kind of community so i think we have to work on in Public Health is really a very, ironically in a world of Global Connected social media, local social media authorities that take, at that persuade people of the right information. Locally prominent doctors. Locally prominent religious leaders. Locally prominent social leaders that people know and trust off the platform, who they know outside of the twitter world who hopefully theyll listen to and have confidence in and we have to build a network of local leaders who can use social media to drive messages to drive these messages effectively. But this unquestionably in the face of a deliberate effort to disrupt a response, this is going to be a big challenge. We are going to have authorities that people really know and trust to push back that information and thats probably more likely the local than global on national. It sounds gratuitous, but it has to be said, when you have a president who says that real news is fake news and fake news is a real news, sure doesnt have. An a democrat on the panel, trying to keep myself out of trouble here. Can i open it up to questions now. Do you have a question or a comment . [inaudible] please identify yourself. Again, okay. I am a doctor from world health a World Health Organization which i have the but the capital of two or three to complement what has been said. Any International Bureaucracy is a bureaucracy. Internationally. Which is with all the problems that come on excellence that nations can avoid with good politics. So i wouldnt the u. N. In general as the matter comes and fix everything. There is room for improvement. There are draconian in place as we speak. We learn our lesson in ebola and it shows. So as far as perfection, its a work in progress and it is the sum of the contribution and political contribution to all of its members. So each of the members can bashing on the head of a poor child, is like treating a child with parents and each of us are havi having, married, i know how difficult it is i hope that can be edited from the on line. [laughter] the small pox education have been a different era. The way our where you kick the door open, take the child, vaccinate the child. In todays world you dont vaccinate anybody without a lawyer, a legal agreement, and grandmother, inlaw who says yes, lets do it, let alone in any part of the world. Exposing onetoone to the planet at times may be more costly for remedies than having a bottom up approach, moralistic from the beginning. Thank you, to close today with your comment today was re insightful. Other questions. Yes, sir. [inaudible]. Im the executive director at Harris County Public Health, which is in houston, texas and i just flew in from houston so i missed almost the entire day. So anything i say, if its completely off, i completely apologize, so just wanted to say that right upfront, but i actually have a question for you. Im also associated with the National Association of county and City Health Officials and represents across the u. S. Were interested in this really, Global Learning that really impacts domestic local Public Health and best Public Health practice in the u. S. As were going through this process were learning that a lot of organizations that were getting to are very much, very interested in the Global Health space. Theyre doing Global Health work, but not interested in Domestic Health or doing Domestic Health work and not interested in the Global Health aspects. So as we talk about pandemics, it seems this is really that gulf between, as the three of you have been speaking about, between Global Health, Domestic Health and how they come together. Do you have ideas how to really bridge that gap in terms of models of practice and practice at that local level . Not at that national or federal level, but really, at that local level where we can really share across the system that would help us for pandemics and beyond . Thank you. Let me just tell you something that started in the early 1980s, its still going on. Its a school run by the office of foreign disaster assistance, naid, to train First Responders in latin america and its the trainer program. And its been going on for what, almost 40 years now. And its dramatically reduced the need for the United States to do Emergency Response in latin america. There are a couple of exceptions without mentioning countries. There are some countries that are so dysfunctional you need assistance from the outside. Most latin american countries dont need the help anymore. And almost unknown outside of usda to run the center. Its all done at the local level. There are people with the National Health ministries and the police and all that, mostly it was the Community Level and a 40year effort to do it. I dont know why we cant do the same thing in africa. Why we cant do you set up the school in africa, you dont have it in the west, you fund it over a very long period of time and do a train to trainer approach. Weve done one thing. They dont train for pandemics, they do it for natural disasters like earthquakes and storms and all that. Theres no reason it couldnt be expanded to this Larger Community and i went down there and saw it 30 years ago and i took over the directship of that office under bush 41. So there are models. Let me just quickly say, andy introduced me as the ebola czar. Theres nothing as unczar like as being involved in the response in the u. S. Health care system. You know, when we had one case of ebola in texas where we had, under the texas system, most of the key decisions were made by a state court judge, clay jenkins, a great man, but commissioner essential will i that saw a county, and governor perry as the governor, and there was a health director, county Public Health director and very, very unczarry in washington is how this works. One thing that i took out of that is one great way for local and i think the plurality, the pluralism in our Health Care System in the u. S. Is a great strength and a great weakness. Its a great weakness there isnt that kind of command control that youd love to have in a crisis. During the ebola, i did a column with my counterpart in the u. K. And every week we bench marked who was sending more Health Care Workers to west africa to respond and i would report on the 52 calls id done to 52 different Health Care Systems begging them to send people and he would tell me he called the National Health service and get 60 more people and took him five minutes and i gotten vee yus got envious of that system and a nurse came home with it and there are strengths and weaknesses to the patch work system that we have in america. One thing with the Ebola Response was that it would be great if people on the local level organized exercises where you put everyone in the room, the local Public Health people, the local providers, private providers, public providers, First Responders, the community leaders, political lead estate political leaders and you saw what would happen in the event of one of those, of some kind of instant like this in your community and nothing is going to make the people this that room more connected in Global Health than going through the exercises, understanding that by the time it gets to houston, its too late. And the kind of problems youre going to have are too late. I think at the end of every one of those sessions, said you know what we ought to do, go get on a plane and go to washington and get involved in health. Its one of those things think locally, act globally, in the sense when you see how hard this is to manage, city by city in the u. S. , county by county, town by town, you realize we need to take the different players and plug them into a Global Health awareness. One of the concepts that we used at bios is one health. By that the interrelatedness of one health in Domestic Animals and crops and domestic community. Again, as the world shrinks and is increasingly interconnected, the ability of pathogens to pass through the boundary is greater than ever. Its a lot of thinking to do and its hard to get out of your local responsibilities, but a number of us have to be thinking that way about all of that, all of those interconnections. Another question here. Thank you. Monique had the privilege with working with dr. Parker. Im going to ask you about a world in which we have the trusted relationships and trusted communication and Health Care System that, would for us and focus on the medical Counter Measure component piece assuring we have the aspect that we need to save lives. And ask the question, if we could view the suppliers of that asset as a critical element of our Industrial Base, the way we think about the Defense Industrial base and all the components that make the jet fighters and the aircraft carriers. It doesnt seem like we view it that way. Its a series of transactions, we have a threat, we have a requirement, we enter into a transaction, but we dont have industrialbased policy. We dont have industrialbased assessment. Dont look at the fragile nature of some of the supply companies and supply chains. Would i ask you your sort of perspective on that lens on the medical Counter Measure enterprise and also this idea, mr. Klain, you remarked on, exercising. Can you imagine exercising making a vaccine, actually making having a system where that Industrial Base in the biopharmaceutical sector is tested and evaluated on a regular basis so if we establish at that capability, even if that event doesnt emerge until the next outbreak, major outbreak or pandemic that weve tested that capability thank you. By the way, we did a simulation in our conference in october of last year of ph. D. Across the texas a m. They wrote a paper in your folder, in addition to the white paper. Frankly as good as the white paper, the students recorded after they did more research what their conclusions were. I actually think simulations are very valuable. One little story, i went on a simulation, this is about ten years ago, in north korea, and there was an admiral, a friend of my retired admiral and i said how many of these have you been through . I said 22. And how did they end . He said all of them ended in nuclear war. I said really . I said do you know why were in south korea its because of the simulations. Its so scary the policy makers who see the simulations prevent the country going to war again because what it means, it escalat escalated. And it escalated in the one i was in to nuclear war, not a real one. What the dod does all the time, do simulations of war Time Training exercises. I think that aid and c. D. C. Ought to manage it because they both have roles on this and do it on a regular basis with the community, but also in the developing world in the u. N. System on a regular annualized basis with a regular budget and get the reporting out to polyma polymake policy makers. I would respond. Just as i said early on, the federal government responses as well as the Big Government responses are siloed and not interconnected and not coordinated. The private sector, the companies that are members members of my organization, do a grand job, but what is needed is a level of coordination that is bigger and boulder to create new platforms, to have the capacity to surge, to have the capacity to share manufacturing facilities and turn around in realtime and very quickly have a more unified system of diagnosis capabilities around the country and around the world. And on the bioterror thing, you know, we have these systems that were developed right after 9 11 where we had the sensors all over the place and supposed to be able to pick up when events are occurring, is a complete shambles. Its virtually useless, no matter how many times youve all been banging on the heads of the federal government to modernize and update the systems and woefully neglect an incompetent. The only thing i would add to that, i agree. We need to think more strategically about this, i agree with the idea that taking counter medical as a critical sector. I think one of the things we should be doing in that sector. I think that barta is supposed to have this role in some respect, but i think they need more funding and they need more strategic leadership and more strategic empowerment to do that and again, while i do think there should be someone at the white house whose job is every day, seven days a week, ten hours a day to get up in the morning and think about how to build a plan to do this and how to make it happen. You know, had a lot of great teachers, one thing tom he can fa sized is youre going to respond to these by flexing the system. What you cant do is hope youre going to build some magical capacity in the emergency moment. Youve got to have strong, Robust Health care had systems with a lot of capacity doing well and then, you know, try to amp that up in the event of a crisis and it really starts what the daytoday looks like and there are things about our Health Care System right now that are very strong on daytoday basis and things that are less strong, but investing in the Health Care Systems is the best way to have a capacity you can flex up in a time of crisis. Capacity is a critical issue. Everyone says to me, why dont we have hundreds of hospital beds where we can push people who have the Infectious Disease. I said can you imagine building hundreds of beds and keeping them empty just indefinitely . Can you imagine having vaccine manufacturing capacity and not using it so its sitting there. You know, we have so Many Health Care needs that you have full, Spare Capacity is it a hard thing to imagine, a hard thing to consider. And if thats true in our country. Think how true that is in other countries. Doubly and triply true in other countries. Its in the course of making a Health Care System and the ability to dial it up and amp about up in the event of a crisis. I would like to thank the staff of the Scowcroft Institute and veterinary hospital and leadership, and texas a m students here, checked everyone in for all their work. Please. [applaus [applause] well, we have come to 1700 and thats 5 00 and this has been an outstanding day. We have, i think, learned a lot. Unernl to unfortunately some of these issues are not new issues as ive said in my opening remarks. Weve got to find a way to turn these longstanding lessons observed into Lessons Learned. Our nation and the International Community deserves it. I want to thank our last panel for getting in some of the strategic issues. [applause] and everybody thats made this possible. The scowcroft, and others here in washington d. C. This concludes the third annual forum, thank you very much. November 1112, please join us at the president ial Conversation Center at bush school of Government Service at texas a m university for our pandemic and biosecurity summit that again will be in Chatham House rules and begin our policy process once again. Thank you very much. [applaus [applause]. [inaudible conversations] wednesday, the House Judiciary Committee convenes for prevention bills. Watch on cspan, cspan. Org or listen live on the free cspan radio app. The u. S. Senate comes back into session on monday, september 9th with two important issues on their agenda. Avoiding a Government Shutdown and antigun violence legislation. But before senators return to washington, get a behind the scenes look with cspans history program, the senate, conflict and compromise. Here is a preview. The various government under which we live was created in a spirit of compromise and mutual concession. Thomas jefferson questions the need for a senate. The framers believe what follows the constitution. The framer established the senate to protect people from their rulers and as a check on the house. The fate of this country and maybe even the world lies in the hands of congress and the United States senate. The senate, conflict and compromise, using original interviews, cspans Video Archives and unique access to the senate chamber. Well look at the history, the traditions and roles of the u. S. Senate. Please raise your right hand. Sunday at 9 p. M. Eastern and pacific on cspan. Well, the u. S. Senate is about to gavel in on this tuesday for what is expected to be a short pro forma session with no votes scheduled. Senate lawmakers have been meeting every three Business Days during this summer state work period. Legislative work is expect today resume on monday, september 9th. And now to live coverage of the u. S. Senate here on cspan2