Deadliest diseases. Throughout history, humans have been fighting diseases winning deadly neverending wars against rampant contagions. In fact, theres never been a time when humans were not affected with microbes and against them. During the time as a disease detective our speaker has had his ow own brush and own brushi, Infectious Diseases and contagions. For example, in 1995, working with red cross workers for the first ebola crisis and after 9 11, he was called to washington to prevent the spread of anthrax to the Senate Office building. And in 2003 he was called to hong kong. But these are just some of the stories doctor khan chronicles in the next pandemic carried as an epidemic intelligence officer, a disease hunter if you go, his missions for two decades were to read the efforts to prepare the public for disease outbreaks in the Health Emergencies. He has seen it all. While he tells us that it will always be a problem, he also writes as all epidemics and pandemics are inevitable. In fact, most can be mitigated if not prevented. The question is how an did we he enough resources. To help us separate the hype from the fact that diseases pose the greatest risk and what they need to do to prevent the next pandemic, please join me to the four corners of the earth by welcoming doctor khan to the Carnegie Council this morning. Thank you for coming. [applause] thank you very much good morning everybody. As you heard, i spent a career in the preparedness business and usually thats meant for talks. Over time it became getting ready just in time and at this point we are at the realtime speaking. One of the things ive been told is to start with a joke as you can told us nothing about my career but i do promise sex, it will be mosquito sex but there will be lots of it. So im really delighted to have this opportunity to share a bunch of stories within the broader audience of what it means to be a disease due to defend hunting down the diseases. You hear about agent zero and if you read the papers to the movies etc. But what is that from the first of somebody thats been doing it every day with lots of other amazing Public Health practitioners and also tonight if you read the paper this morning whether it is ebola or yellow fever going on in angola it is topical so it makes it easier to start a discussion off of emerging infections, so lets just start there and the idea of why is this always in the paper and why are we always hearing about these type of diseases. Our classical diseases think about smallpox and measles, those all started pretty much around the cultural revolution when people saw this come together because it spreads from person to person. Everybody has their own story of when it starts. And the virus made this jump and same for measles and classic diseases. Moving forward to the Industrial Revolution we realize Infectious Diseases were not due to my asthma was that agents that spread from persontoperson and a lot of enthusiasm that occurred around the beginning of the 20th century with sanitation revolution vaccines, antibiotics people thought okay we are done with this whole Infectious Disease problem all we have to do is put a shot in someones arm, give them a pill and it will be better. If that were true we wouldnt be having this conversation today right now. What is happening is even though we have taken care a lot of these classical we have these continued emerging Infectious Diseases and there are a lot of factors that drive the diseases. Some of the key factors are just about microbes collectively somebody that thinks that they are smart collectively and they evolve. If multiple generations over a single day. A gesture to beat generation and 35 years before we can swap out our genetic material. Microbes, no problem at all, they get smarter over time and e and thats what they do. This will protect me. 100 years ago we changed the risks and the other thing that happens is we change our environment. This is a big driver why we have emerging Infectious Disease. It shouldnt be surprising when i talk about ebola somehow very quickly the animal connection comes into play but with the original cause. The diseases you heard about. But the disease has the potential to cause persontoperson transmission as we see or mers which is what bats and camels, so if you have contact that is how you could get the disease. So it isnt a surprise they tend to come from africa or south america or parts of Southeast Asia where you have a lot of connections with animals. Bird flu is another example where you have people in china and Southeast Asia that live very close to pigs and birds, foul, chickens and its a great opportunity for the viruses this up and eventually infect humans and become global pandemics so those are the environmental conditions that lead to these infections and why we keep hearing about them. I want to d wanted to a specialo Climate Change as one of those environmental factors that lead to emerging infections. First i want to say it is framed as either an economic issue or energy and i think over the last year or two we have been doing better reframing this as a Public Health issue of whats happening with climate currently. April was the hottest record, hottest year on record since 1880 and people ask me how did you know what was going on in 1880 and believe it or not if you are a farmer its important to you with the temperature is so there are excellent records about the temperatures looked like at least for the last 150 years and the same thing with marine temperatures because if youre a captain one of the things you are logging is what the temperature looks like so we have excellent records and to an as they pass through the historical documented record with all sorts of other information that looks at temperatures thousands of millions of years ago but april was the hottest record, hottest year on record and the 12 hottest year in a row. This is not a coincidence that is happening with temperature or climate and if you look at Carbon Dioxide we should be about 240 million, 258 dot 400 parts per million. So the thought that only 100 would like to only cap increases to 1. 5 degrees is highly unlikelunlikely thatunlikely bus story from a different way. I got into Climate Change years ago and this is a mosquito Borne Disease in africa. You have your cows and goats and that is your 401 k. If a mosquito borne virus comes around. And that is bad news. And what we have recognized her for the last couple of decades and beside the fact moving out of Subsaharan Africa into Northern Africa and into the middle east is that it actually depends on climate. There were these great heavy dry. That caused this to happen and it also causes bad disease and fever and brain inflammation and blindness in humans but they dont have the money to vaccinate every year so if you have some sort of tool every five, ten, 15 years that were really benefit them, so people spend a lot of time trying to understand what happens. They protect their animals and the community. To understand what the dynamics were whats going to happen in 2100. If we look at diseases the biggest disease in the United States was caused by arthropod coming up mosquitoes effectually lined disease. Everybody knows if you live here in the northeast we look at the spreading and over the last 20 to 30 years theyve continued to spread across the United States and they are almost about half the u. S. Counties, so we see that already today. There is a fungus up in vancouver causing infections in humans and animals. It belongs in the tropics. They are getting infected oysters from the northwest so we all know. Are there any here like me . A good Public Health messages. Its to try to protect yourself especially from both oysters but that shouldnt be a problem getting them up from the northwestern United States to the alaska area because there should be nice cold water watert they have now started to see outbreaks reported since the waters are not as cold anymore. We think we are all smart so you say but we have seen is the disease has been spreading the last couple of decades and that is in addition to where we are living with climate is one of those and respiratory virus for any who work here to have kids, little kids get infected which causes this illness and what we are seeing are becoming shorter and shorter. Again, contemporary examples are going to get worse when we think about it. Its happening right now, 128 degrees or Something Like that and yes less people will die from cold unfortunately more will die from heat when we think about heart and lung disease from all the air pollution and Infectious Diseases. There is waterborne illnesses at issue with this. I want to make a shout out to Climate Change and one of the factors to keep in mind when you think about emerging infections, the biggest factor in all of these are important with this happening to microbes and in the environment its actually more political social factors and if you look at these outbreaks, these diseases will continue to emerge as i spoke over the last five to ten minutes, but i think that we play a role keeping them from becoming epidemics and pandemics. A good example, for example, would be the recent outbreak of ebola in west africa. So, it wasnt new. Weve known about the science ebola and in the mid1990s. We get infected and usually probably with a bat and if you are out and i 85 to 90 of people die, unfortunately maybe a Family Member or two lets say you changed the dynamic and decide on a hospital. Unfortunately at the hospital to doesnt have infection control. Its producing every minute until you die. You dont have more than when you die and i can give you ten with lots of big numbers around of hundreds of millions of billions in the milliliter of the blood. If somebody doesnt wash their hands as they go from patient to patient, its going to happen you spread from patient to patient so hospitals have always served and weve known this for many years there was a reservo reservoir. Somebody sick at home and you are the Family Member taking care of them, you are at risk. They die then you decide one of the practices we saw during this outbreak is to wash the body and use the water to a file others to take on the attributes of this person who had just died. The science isnt the issue. Its wha what we have seen happg in east africa. To identify the case and a day dont need International Teams anymore. They know what to do for the outbreak to occur which never occurred before and in urban areas and the thinking was more the same. 11,000 each and every one was a needless death i would say. But inadequate Global Response and so politics and the public over systems. What we had essentially was an epidemic across africa with the seeding of cases out of the world including what happened here. To the Infectious Diseases that we didnt have in the 18 hundreds, so how many people, i wont ask because the answer would be yes and ive heard around the world. How great, 80 days to get around the world. So, for 24 years i wore a publichealth uniform and on my publichealth uniform was an anchor looking very much beginning of uniform. It was the service that we still have right now with the quarantine flag and somebody with yellow fever or smallpox. It will take 80 days to go from point a to point b. The incubation took a time it takes to get infecte infected to manifest the system is always shorter than the time it is going to take to get from point a to point b. We turned that upside down now. So now you could take your mothers funeral in liberia and engage in the usual packed yet he was. They get to new york city so we have got the tea team to the 24 hours, maybe 48 hours. Ive got a headache and fever and im not feeling quite well. If its not malaria and its easy to see how that hospitalized and we saw this happen in texas. The same scenario somebody showed up, came home and infected local nurses and i spent a lot of time in places across the world to let you know over Health Care System isnt better than what we have seen in toronto which is what we saw in singapore when they had this outbreak or hong kong and in excellent Health Care System. But they are not ready for these patients coming in with these viruses comes wit to travel has played a big role in how these diseases emerge currently. So now to give you the sense of why you always hear about this but what we can do to make things better around social and political aspects. I did want to spend a couple of minutes to talk about the Carnegie Council. I guess they recognized if we think about hiv and who gets infected with hiv is often a marginalized population but as i started to write the book almost every chapter you could pull out in a marginalized population that would increase the risk for emerging second about the disease that often occurs in the southwestern United States and most likely infected with the original outbreak were native americans into some of you will remember when it occurred in the early 1990s there was a group of young navajo kids who had come to dc and they were denied a tour of the capital because you happened t happen to come fe southwest. Anything that said they were at risk but they were not. But the the effect of the they d population of increase the purchase against the marginalized populations. I already talked about hiv and i talked a little bit about ebola and other marginalized populations in west africa into todays day and age the marginalized population. I think it is what they are calculating now and over 1500 women that have been infected and their babies have got unconscionable symptoms were to get other Developmental Disabilities including hearing loss and vision problems. Problems. What we have learned now is it is essentially a laserguided missile. When it was first described we were told about 20 of people would get sick and get a fever and a little headache, some itching, red eyes and they will get better and there he quickly became clear that this was a problem but now they know even for adults. It causes weakness and they also know it can cause brain inflammation. So even when they think of a small healthy adults that are not present, the virus is a problem. This virus shouldnt be a problem. Its spread by a certain type of mosquito that is not new to us. Its the sam same mosquito that spreads and if we were having this conversation five years ago we would be talking about this large outbreak occurring in south america and it causes about 30,000 a year. The same one that was the big thing in the news two were three years ago that doesnt seem to cause any death. But the failure to keep up with these and not paying attention to people dying from yellow fever we have a diseas the diseo this that are not afraid affecting pregnant women over the last 40 to 50 years against a known threat that has put us in this current position. I heard yesterday that it has now not just moved throughout the Americas Summit essentially knocking on the door of africa to say whats next so its great to have the next is to risk going to pregnant women in africa. The head of who, brilliant woman has done amazing work. Its a major policy failure over the last 40 years in addressing this mosquito and also to talk about major policy failure as we talk about protecting women and comprehensive rights. Some cases in europe and north america remains c. Zika, hopefully im not al not all oft we will see it. You gave me a lovely comments the other day. The ethics of the delayed response and some of what you talk about here. If you think about these marginalized populations and why do we see these delayed responses, and we are seeing it today. The story of the last couple of days this conversation is probably better terms for the conversation between you know what lets protect the United States against zika and deciding whether they want to do that and whether they want to pay for it so should it be 500 Million Congress wants to give or 1. 9 or the 1. 1 to give a version and i dont care what it is, pick a number but why are we having this conversation six months later backs we know whats going to happen and they also know Mosquito Control is not a federal function it is a city and county and district function we need to get the money out of these people so they ca can betn whabedoing what they should be g which is making sure they are identifying cases and have the money to think about hopefully a longterm strategy, vaccine strategy to protect pregnant women with lots of funding and Vaccine Development for the longterm. My analogy is the second story of a building. This is the preparedness infrastructure why are we taking money out of that . And then into the preparedness infrastructure because im all about measures. In the last three years of how prepared for Health Emergencies and it gets a bit better if we want to make sure that they are a threat. And then government is to protect us against threats and that includes Public Health and how do we make sure im old enough to understand you cant completely strip politics from politics decisions but maybe sometimes about what are the health needs of the populations. That is fascinating but you seem so calm. [laughter] but fear is not a Public Health strategy. I know it makes for great press but really it is about education and good science. Now what keeps me up at night what is the next pandemic and what that will likely be. Zeke a virus but not causing hundreds of thousands of deaths your you know that from 1918 so we get the flu every year we get the flu every year it changes a little bit why we need a vaccine every year but unpredictably the flu just takes off now you have no protection against it at all. If we repeat the same thing from 1918 today, seven. 5 million americans will die. Two. 5 percent. Think of how this would totally disrupt our society within a couple of weeks or months diseases kicking up one keep me up at night i have seen these health systems. They are Getting Better at the ability to respond with the National EbolaTraining Center the hospital is better but so i do worry a third example is hivaids now we think of it in terms of sexual behavior but that is another zoonotic diseases came from primates and one time it was the right version that made its way to humans then spread from human to human so i worry about another virus like that that spread through sexual transmission with a long incubation. And then before we discover it has spread widely. Those are some of the things that keep me up at night. I would like to open the floor to discussion. That was to fascinating. Especially in the morning but we have to worry what has to be done. What is the cdc doing to control the diseases and educate people . As soon as there is an indication that might be serious . On the other hand now you are in nebraska. What is the difference between control measures and a relatively small population or the large urban areas . How can the us do more and cdc do more to prevent these outbreaks . An excellent question. And we always tell people they are more powerful. Talk about drugresistant one third of all antibiotics we are using our unnecessary. So as a patient and go to talk to your doctor do i really need this antibiotics is a something i can work out after a couple of days then take an antibiotic . You have that power. You walk into a healthcare facility and then to say did you remember to wash her hands . You are powerful do not forget that if you think of personal preparedness issues. If a pandemic runs through your community are you prepared personally for that . Not just in terms of having a kid in your home but are your vaccines up to date how many you actually know a physical phone number if somebody asks for a phone number what do i do . Of my phone dies not so good. In my part of a Response Team within the community . So if something bad happens i have to call 911 i can take a something small myself or help somebody out. And im a blood donor. And then things that we should expect from our government. s of tomorrow morning new york city we decide lets lay off half of the police force, my guess is Public Safety is so important. But the same thing is happening to the Public Health and safety workforce that is not fully funded. When you have a score of six six. Seven or how prepared your stay is so to demand the same thing in a local representative and International Representative a little less politics why are there still 20. 6 million uninsured americans in the United States right now not passing Medicaid Expansion with the Affordable Care act . So you need to ask for more at every level including your own level. At cdc i did a tongueincheek thing about apocalypse to get people to be prepared for a Natural Disaster but some are not paying attention to the real Natural Disaster like the zombies. [laughter] dont ask me. We took a popular meme and converted it but the one thing you can do is out run them so say personally healthy something you can personally do. And that changes whether i am in nebraska or washington dc with a greater risk of importation from International Travel the local Public Health entity needs to take those things into account including Climate Change what will that implication be for the water supply and stuff like that . I remember reading an article some years ago to the effect that if the only publication had been delayed about three years and if ddt use continued another three years we would not have malaria. You stress Mosquito Control so what is your take on that thesi thesis . We need use every tool available to us when we think about control we were fortunate here in the United States the from the cdc it is one of the only federal agencies outside of washington and it took a while to figure out because of malaria used to be in the southwestern United States what was happening we were sending troops to be trained in the south. We dont need young men and women getting ready to go to war being infected so then that became the cdc and then malaria was quickly eradicated. But right now we see dinghy fever on the texas border we see it in mexico but not the United States is due to screens and airconditioning. So you are right when we think about what does it take to protect us we have to use every tool available its about killing the baby mosquitoes are the adult mosquitoes which is insecticide and get all those sources of water out there and get rid of it so we have to think of every tool available to us including ddt and others people think what is the right tool for the right area what are they resistant to or not resistant to. Thank you for this presentation. The number of societies that have had prohibitions of certain animal proteins and you have made the connection between these kinds of viruses that come from animals and to show the presumption is limited or not at all the ability to resist some of these illnesses to have the antibiotic has a connection between consumption and the likelihood of the continued ability to cope. So to break it down into the two quick pieces those that have the predominantly vegetarian diet lot live longer and do better that has been established at this point. Also the zoonotic infections have to do not necessarily their consumption but i say this all the time if you just heat it to the right temperature there is no risk you shouldnt be eating burgers that are rare or medium rare anymore so the risk doesnt come from the consumption so just heat it to the right temperature it comes from the daily interaction you have with these animals touching them and the routine set of interaction milking them, keeping them in your houses the same thing like a well cooked chicken burger will not kill you but handling chickens with chicken poop will potentially kill you. I appreciate the clarity of your presentation and the work you are doing. One of the things that came to mind was the delay in identification of the response to ebola. So what does the cdc do to increase collaboration with countries around the world to begin to do something about early identification and response . Something maybe about the who in terms of fit plays a part in this area. What can you do . The Us Government has embraced Global Health security agenda. That is a way for us to work with countries internationally to make sure they have the right tools and systems in place to find the first set of cases a number of cases the cdc is the Technical Agency that does this work but who has a global mandate to do this they are the World Health Agency and they have been very introspective and have recognize the failures of ebola and what happened especially not just from the Early Detection but between six and nine months and then to say oh my gosh this is a problem and then that things were Getting Better. So in the midst of that process to better respond to these infections and not to do country level assessments. And then the world bank is setting up a brandnew pandemic response. I have a story in my book from a really good friend of mine and he had no resources he just had some dollars to do some work so we cannot afford for the outbreak that you cannot get your hands on a couple hundred thousand dollars to put something in place for the hospitals. One of my clients has mosquito inspections putting out traps of actually look for mosquitoes but you mentioned the political aspect. Where two candidates were diametrically opposed and also on reproductive rights that in my opinion but all peoples rights because everything that happens to a family happens to everyone. Could you comment on that and how this issue could be brought up in a way that affects the political outcome . Im the Health Person and thats a politics question. [laughter] i open the door . I will look for the expertise in this audience new york is my home i grew up in brooklyn when i went to ps 130. So actually have aunts and uncles who have never gone to the city because why would you go to the city . Everything you want is in brooklyn. [laughter] so i know little bit about the city but mosquitoes. You are very fortunate to have the best Public Health practitioners in the world here. Giving a shout out in 1999 west nile it started right here. West nile is another good example. It doesnt belong in new york its another example of the disease somewhere else decided america was home. We need to have individuals as we make choices and the opeds that we write to say health is an important factor it is everybody rights not just pregnant women we need to make sure they have their rights we can talk about brazil but dont forget about the United States theres a lot of things going on across the United States. I want to ask a question about our developing global problem in a developing response to that problem and that of course is refugees. I will leave it at that. As far as the Global Response is concerned one of the things that has been overlooked is the role of pharma and the lack of incentives in the pharmaceutical business for responding to these type of emergencies and to make a really wild suggestion that perhaps its time for pharmaceuticals to be considered as a public utility like the military or the water system and like all the other things that we have that we take for granted and that are not incentivized by profit. So i assume of Infectious Disease . People say what risk do i have but how i make sure . Measles is a horrific disease so what are we doing to help make sure that the refugees are protected themselves . How do we make sure they are protected with any screening or any other process that we do. So people have recognize this problem for a long time. Talking about anthrax there is zero incentive for anybody to build the medical countermeasure against anthrax or smallpox the Us Government establish the Research Agency with the department of youth and one dash hhs that somebody understood how to work with big pharma that we have these excellent products that are available to us that we have enough smallpox vaccines everybody in the United States if they decide to reengineer that and make it in our lab. We do have some mechanisms available but its a challenge so how do you make sure you have new drugs available but just get smarter and smarter all the tim time. I was going to ask about the biological issue thank you for this journey you took us on. [applause] thank you. [inaudible conversations] last november remarked the centennial and in november 1918 people thought relief the years of warfare and death were over. So the influenza pandemic of 1918 killed more people worldwide and was killed in combat during the war. Here in the Washington Area and other many field locations document and patient record books and telegrams and photographs of the 1918 influenza epidemic to all parts of the nation. To open