Transcripts For CSPAN2 Ali Khan The Next Pandemic 20240713

And more life conversation weeknights at 8 p. M. Eastern for washington journal prime time. Good morning, everyone. Im joanne myers and only half of the Carnegie Council id like to thank you all for beginning the morning with us. Were delighted to welcome ali khan and cspan booktv to this breakfast program. Ali will be discussing his book United States. As a former director of the centers for Disease Control p ad prevention, he has been on the front lines in the fight to contain the worlds deadliest diseases. But hes not the first to have done so. Throughout history human seven fightingng diseases, waging deay and never ending wars against rampant and violent contingents. In fact, there is never been a time when were not affected with microbes and fought against them. During his time as selfdescribed disease, our speakers had his own brushes with viruses, Infectious Diseases and contagion. S for example, in 1995 he worked among red cross workers in your for the first ebola crisis. After 9 11 he was called washington to prevent the spread of anthrax here in 2003 he was called to hong kong to courting victims of the sars. But these are just some of the stories dr. Khan chronicles in the next pandemic. As an epidemic intelligence officer, a disease hunter if you will, his mission for over two daggett was to lead the u. S. Governments efforts to prepare the public for disease outbreak and health emergencies. He has seen it all. Dr. Khan tells us rogue microbes was the problem come also writes not all epidemics and pandemics are inevitable. In fact, most outbreaks can be mitigated, if not prevented. But the question is how, and to have enough resources . To opus separate hype from the facts, what diseases pose the greatest risk and what we need to do to prevent the next pandemic, please join the in a Public Health journey to the four corners of europe by welcoming dr. Khan to the Carnegie Council this morning. Thank you so much for coming. [applause] thank you very much. Good morning, everybody. Lets put this over here. So as you heard i have spent a career in the preparedness business and usually youre ready in advance the overtime it became sort of hidden ready just in time. And at this point of my career i went to the realtime speaking process which are pretty much make it up as i go along. Now one of the things ive been told when you speak to an audience is start with a joke but as you can tell, theres nothing about my career that, it starts with levity. But i do promise sex, lots of sex. It will be miskito sacks. [laughing] but besideses that, there will e lots of sex. Im really delighted to have this opportunity to share wholes bunch of stories with a broad audience of whate it means to be a disease detective and hunting down these diseases. You hear about patients, read the papers, all popular press, the movies, et cetera but what is a from the perspective of someone whos been doing it every day with lots of other interesting Public Health practitioners . And also tonight to give a talk if you read the paper this morning, if youve if you beeng about zika or ebola or yellow fever going on in angola, so its topical. Lets just start there. The idea of why is this always in the papers and why im always hearing about these types of diseases . Our classical diseases, think about smallpox, think about measles,d those all started pretty much around the agricultural revolution when people sort of came together because you need to have enough people to spread disease from persontoperson. And so thats when i start my story. Everyone has their own storybook for me thats when the world starts whento some rodents that were carrying some version smallpox moved into somebodys home and that fibers made this gel and started to cause smallpoxox in people. Same things for measles, classic diseases. Let me fastforward to the industrial revolution, germ theory. We realize Infectious Disease were notti due to miasma but due to infectious agents that spread from persontoperson. A lot of enthusiasm that occurred around the beginning of the 20th century with sanitation revolution, vaccines and antibiotics and people thought okay, were done with assault Infectious Disease problem. All we have to do is publish autosomes arm, give them a couple pills and that we all better. If thatn was true we wouldnt e having this conversation today right now. Whats happening is that even though we have taken care of a lot of these classical virtues we have his continued in bridging Infectious Disease and a lot of factors that drive this emerging come of those diseases. Some of the key factors are just around microbes, collectively on somebodyly who thinks they are smart collectively and that if all. They have multiple generations with a single day. Humans before lucky, a generationon in what 35 years or something. Before we can swap out our genetic materials. All. Bes can no problem at they swap geneticia material all the time. They get scored all the time. Thats what you read about these drugresistant microbes because thats what to do. They sort of move around, find a good set of genes and they go this will protect me from the set of n of alex and boom, you get your superbugs. Microbes evolve. Humans change a behavior so when it hears ago i could tell you know but had a kidney transplant. Nobody had a kidney transplant. The other thing is we change our environment. This is a big driver in why we had emerging Infectious Diseases. It should not be surprising what i talk about zika, ebola, somehow very quickly the animal connection comes into play but zika its with mosquitoes with ebola its bats which are the original cause of where this fiber sort of lives, infect somebody at that second spread of the chain of transmission in humans. Emerging diseases are anl connection. If you move people out into the environment into the jungle, you know, they get infected and that disease has a potential then to cause person to person transmission, as we see with ebola or lets say with mers from bats and camels. They tend to come from africa or south america or parts of Southeast Asia where you have a lot of connection with animals, bird flu is another good example where you have people in china and other parts of Southeast Asia who live very close to pigs, live close to birds or chickens and great opportunity for viruses to swamp genes and infect humans and become global pandemics. These are the environmental, some set of environmental conditions that lead to infections and why we keep hearing about them. I want to do a special callout to Climate Change as one of those environmental factors that lead to emerging infections. First i want to say often Climate Change is framed as either an economic issue or has an energy somehow issues and i think over the last year or two we have been doing a better time reframing this actually as Public Health issue of whats happening with climate currently. So april was the hottest record on year hottest year on record since 1880. And people ask me, how do you know what was going on in 1880, believe it or not, if youre a farmer its really important to you what the temperature is. So there are excellent records about what temperature looked like at least for the last 100, 150 years, the same thing with marine temperatures because if youre out there as a captain your doing your daily log, one of the things that you will log is what does water temperature look like so we have excellent records and if you pass through the historical sort of documented records and look at 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 its the 12th hottest year in a row, okay. This isnt a coincidence whats happening with temperature whats happening with climate and if you look at carbon dioxide, we should be about 200 parts of million, 238 parts million preindustrial level. We are now 400 parts per million. But let me tell you the story in a different way. I got in the climate business almost 20 years ago and had to do with fever, mosquitoborne disease in africa. If you are in africa, you dont have 401 k , you have cows and goats, thats your 401 k . If a mosquitoborne virus comes and youre animals are dying, that is bad news and so thats fever and its a biblical disease, besides the fact that its moving out of Subsaharan Africa into Northern Africa and into the middle east is that its actually depends on climate on when the viruses sort of when this mosquito emerges and you sort of have to have the great heavy dry periods followed by wet periods to cause this to happen and to protect your animals and this virus, fever also causes bad disease in humans, abortions in humans, fever and causes brain inflammation and blindness in humans, but the farmers, they dont have the money to vaccinate the animal every year so if you catch some sort of tool every 5 to 10, 15 years, you know what, this is the bat year, that would benefit them. People spend a lot of time trying to understand what happens weather and climate to help protect farmers and protect their animals and then obviously the community. So thats how i got into Climate Change issues, understanding what the dynamics were and what became very clear right now is when we talk about Climate Change everybody is like, whats going to happen in 2100, well, what is happening today . If we look at diseases, the biggest decide diseases in the United States which are ticks, its lyme disease. If you look at where lyme disease sectors are spreading, they are actually over the last 20 to 30 years have continued to spread across the United States. Theyre almost in about half of u. S. County, fungus in vancouver, doesnt belong in vancouver, it belongs in forest. Im an oyster eater. Thats to try to protect yourself from infected oysters especially gulf oysters. That shouldnt be a problem if youre getting oysters up from the North Western United States, up from the alaska area because those should be nice, cold waters but we have not seen outbreaks because the waters arent as cold anymore. If you go to sweden they have the tickborne disease. We doctors, when we name stuff, we take whatever you tell us, you think we are all smart, oh, my head hurts, you have we know what it says in latin. What we have seen in sweden that the disease has been spreading over the couple of decades. Theres a lot of factors but climate is one of those. Respiratory virus for those who have kids, grandkids, little kids get infected with rsd, usually they are okay but not always and what we are seeing the respiratory seasons in europe are becoming shorter are becoming shorter and shorter because theres less cold months and the seasons are becoming shorter. Contemporary examples that are only going to get worse when we think about heat waves. Whats happening in india right now, 128degrees or Something Like that. Heat waves and, yes, less people will die from cold but proportionately will die from heat when we think about heart and lung disease from all the air pollution and obviously all of the all the Infectious Diseases. Anything that has to do with the mosquitoes and ticks and where things are, climate plays a big role, waterborne illnesses that are an issue if we get flooding, so i want to make a quick shoutout to Climate Change as one of the factors to keep in mind as you think about emerging infections. The biggest factor of all of these and all of these are important, what is happening to microbes, what is happening to us, what is happening in the environment is more political social factors and if you look at the outbreaks, these diseases will continue to emerge as i hope ive convinced you over the last 5 to 10 minutes. I think we play a role in thinking of them becoming epidemics and pandemics. A good example the recent outbreak of ebola in west africa, so it wasnt new, right, we have known about ebola since 1976. Weve known about the science of ebola since 1976 and i had the opportunity to help support that science in 19 mid1990s when i did Ebola Outbreak in zair. What happens, you get infected probably with a bat. If youre out way in the bush you die 85 to 95 of people die. Unfortunately maybe a Family Member or two would die with you but youre out in the middle of the bush, youre done. Lets say you change the dynamic and you decide to go seek health care in a hospital. Unfortunately on hospital that doesnt have infection control. So when youre infected with ebola you essentially become a virus factory and you get infected and if your immune system doesnt kick in youre kicking the virus and when do you have the most possible virus in your body . When you die, as you go to the hospital because youre sick and you dont have more than when you die, okay, i can give you a 10 with lots of big numbers around it meaning hundreds of millions of billions that happened to be in the middle of your blood. So here you are sick, dying in a hospital and somebody doesnt wash their hands as they go from patient to patient, whats going to happen . Youre spreading ebola from patient to patient and so hospitals have always served and weve known this for many years as a reservoir for thousand the diseases get amplified and spread within their community. Somebody sick at home and youre Family Member taking care of them, youre at risk, we know that. They die unfortunately and then you decide to wash the body, kiss the body, hug the body, invite all the loved ones, one of the practices we saw during Ebola Outbreak, they would wash body and use that water to allow little kids and other people to wash their hands to take on the attributes of the sainted person who had just died. This is not a good idea, okay. Lets admit that. [laughter] thats the science. We know the science, right . But the science isnt the issue, so when this outbreak occurred and i think this was some 24, 25th Something Like that outbreak of ebola we have seen since 1976, many people thought this is like what we have been seeing in east africa, uganda sees outbreaks all of the time, they have a system in place to identify the case, teams rush in. They dont need international teams. They rush in and test everybody, they follow everybody who is potentially sick and extinguish the outbreaks very quickly and the outbreak occurred in west africa where its never occurred before. Nobody had seen the disease before and it very quickly spread to urban areas, large metropolitan urban areas and the thinking was, oh, more of the same, you know, rush in, take care of this everything and the Ebola Outbreak will go away, what happened . Thats not what happened, right . So 11,000 deaths each and every was a needless death i would say and inadequate response, Global Response. Inadequate local response obviously but inadequate Global Response and so politics and our Public Health systems, play the biggest role in whether this goes to handful of cases to what we had was essentially a epidemic across west africa with cases across the world. We know what happened here in the United States. And one to have reasons we had the case in the United States is another factor, social political factor that plays into Infectious Diseases that we didnt have in the 1800s. How many people, i wont ask, have read around the world in 180 days . 80 to get around the world. For 22 years i worked Public Health uniform and on my Publishing Health uniform there was an anchor and i would get asked about the anchor in Public Health uniform. The public uniform looks like a navy uniform and the reason it looks like a navy uniform we started providing care to merchant marines and one of the shores of the Public Health service is we still have right now is essential through flag quarantine flag when ship came to port and somebody with yellow fever or smallpox on it. If its going to take you 80 days from point a to point b, by the time you show up in port of new york city we knew if you had smallpox or yellow fever because the incubation fever, shorter than the time from point a to point b. Well, we turned that upside down now. You could go to your mothers funeral in liberia, right, so you fly to line line liberia, engage in usual acts, your mother has died, kissing her, the next day you get on a plane to amsterdam to new york city. You have 48 hours incubation of 5 to 7 days. 3 days before you show up back to new york. Ive got a headache and fever and im not feeling quite well right now. You show up to a hospital, the number one diagnosis would be malaria, 1, 2 and 3 and if its not malaria and they miss this its easy to see how you get hospitalized for something and spread disease within the community. We saw this happened in texas. Exact same scenario, somebody showed up, came home and infected two local nurses. And i have spent a lot of times in places across the world to let you know the Healthcare System is not what they see in toronto when they had their sars outbreak or hong kong or i just spent time in seoul due to mers, Excellent Health care system. Like ours, Excellent Health care systems but they are not ready for patients to come in with highhazard viruses. Travel has played a big role in how the diseases emerge currently. So let me now so now i think i gave you now i think ive given you a sense of why you always hear about this but what we can try to do to make things better a red social, political of protecting people. I did want to spend a couple of minutes to talk about you at the Carnegie Council that ethics matters. This, an observation which i guess ive recognize that my whole life so if you think about hiv and who gets infected with hiv, its often marginalized populations. As i started to write the book, its sort of dawned on me how almost every chapter you could pull out the marginalized populationth that was increase e risk for emerging infections. Think about honda virus. This often occurs in southwestern United States and the most likely people to get infected and with the original outbreak occurred was amongst native americans. Some of you will remember when this Virus Outbreak occurred and early 1990s there was this group of young navajo kids who had come to d. C. For capital to her and they were denied a two or because you have a could happen to come from the south was. You could be infected. Theres nothing anything we knew that said these kids were at risk and to work. They didnt post any risk to us but often these diseases affect marginalized populations and helps increase some of the prejudice against the marginalized populations. Ive only talked about hiv. I talked about a. Little bit about ebola and the sort of poor marginalized populations in west africa and todays day and age were talk about zika, right, and the marginalized population are poor pregnant women in brazil. Brazil is a 1. 1 million cases, i think what theyre calculating now of zika virus and over 1500 women who have been infected and their babies have gotten congenital zika centrum, thisl severe illness of babies when they get small brains, of the Developmental Disabilities including hearing loss and vision problems. What weve learned is zika is essentially a laserguided missile for neurons. It looks for neuron cells and it kills your neuron cells. Its not just true in babies. When zika was first described what we were told was about 20 of people would get sick and if they get sick and will get a fever, a little, some itching, some red eyes and they will get better. There he quickly became clear that this was a problem for pregnant women. But now we know evennr for aduls because of this sort of laserlike focus on neuron will cells, have this disease called ilio boring system, an illness that causes weakness and we also know even in healthy person zika virus can cause brain inflammation and inflammation of the coverings around your brain. Even in what we should think of normal healthy adults are not pregnant this virus ishe a problem. This virus shouldnt be a problem. The virus is spread by something called aedes aegypti, a mosquito not into a strict exacts a spread yellow fever that causes about 30,000 deaths a year. This is exacts a mosquito that spreads dengue. If thebo ravens conversation abt five years ago we be talked about this large, five years ago this large dengue outbreak thats occurring in south america. This dengue causes i think about 30,000 deaths a year, something something around that. The same exact rescue the causes chikungunya virus. That was a aat big thing in ths two, three years ago. That one doesnt seem to cause any deaths. But because of the failure since the 70s to keep up with these efforts to decrease mosquitoes and kill mosquitoes, and not paying attention to the people dying from yellow fever, people die from dengue, now all of a sudden were all up in arms, we have disease due to aedes aegypti the seem to be infecting pregnant women. So this lack of action over the last 4050 years against a known threat that is put us in this current position. At least if you happen to be in south america these days. I heard yesterday zika now has not just move throughout the americas but is now at cape verde if it is essential nokia door of africa to say hi, im next, your next pixel think about what could happen if that virus sweeps to africa and the risk to pregnant women there in africa. The head of w. H. O. A brilliant woman has done some amazing work come to some amazing work in her time in hong kong has admitted a major policy failure over the last 40 years in addressing this mosquito. Also, she broadened it to talk about major policy failure as we think about protecting women in contraceptive rights because its a big issue for brazil and other places where you dont havept the same contraceptive rights that you take the credit here in United States and other parts of thee western world. Why did it take all this time people dying of dengue, people dying of yellow fever which vaccine to say you know what, we need to Pay Attention because now we mayma get some cases in europe and north america of women who may have this disease. We will see zika in the United States but i will create that question. Hopefully we will not see a lot of cases but we will likely see it. T. Let me oh, thank you. He gave me our lovely comment the other day. This goes back to some of what you talk about here amongst your audience is, if you think about these marginalized populations, why do we see these delayed responses . Were seeing it today. I dont care what it is, pick a number but why are we having this conversation six months later . We know whatsgoing to happen. We also know Mosquito Control in the us is not a federal function. Its not even a state function. Its a city and county and district functionand you need to get the money to those people so they can do what they should be doing which is eliminating mosquitoes and making sure they are identifying cases and if you have the money to think about hopefully a longterm strategy would be avaccine strategy to protect pregnant women. Are we funding a Vaccine Development for longterm and why are we having this conversation six months later . Why arent we not already doing that . Why are we robbing peter to pay paul . My old program at the cdc was responsible for keeping americans safe from all Public Health threats no matter their nature whether it was pandemic, biological chemical terrorism and my passion was for the public ts Health Preparedness program which put money out into state and local Health Departments to pay for the z response to hold back some of that funding to support some of the activities in other places including puerto rico where they already had 11 cases believe it or not but why are we taking what my analogy is taking a bridge out of a foundation to build a second story of the building so if this is our preparedness infrastructure to support the us what are we taking money out to do Something Like zika . We should put money into the infrastructure andwhen i leave you with is a number because i am all about observable measures. 6. 7. In the last three years the Robert Johnson foundation has been doing great work looking at how to pay for the United States is a Public Health emergency and every year it gets better. We startedat 6. 3 but 6. 7 out of 10. Thats not good enough for us here if we want to make sure americans are protected against Public Health threats and as far as im concerned the responsibility of government is to protect us against threats including Public Health and Health Threats and how can we make sure , im old enough to realize you cant completely strip politics out of policy and its not always about the science but maybe sometimes we need to be stripping more politics and thinking about what are the health needs of our population,thank you. That was fascinating and youseem so calm, what keeps alyou up at night . I think on call because i decided 20 years ago that fear is not a Public Health aprivacy and i dont mix for great press. The sky is falling but its about education and good science. Now what keeps me up at night is what the next pandemic is ylikely going to be and zika is a pandemic needless to say but its not causing hundreds of thousands of deaths. Whats likely to cause hundreds of thousands of deaths, we know that from 1918 and we did a repeat of 1918 so we get flu every year and im going to tell you right now my Public Health message of the day is get vaccinated, we get free every year and it changes because this is why we need a new vaccine but unpredictably flu just takes off his overcoat and all of a suddenyou have no protection at all. And if we repeat the same thing we saw in 1918 today 7. 5 million americans would die. 2 and a half percent, think about the number of body bags. Think about how this would disrupt our society if within a couple of weeks two months we kill 7 and a half million americans so flu keeps me up. Diseases like mers keep me up at night. I do know ive seen these Health Systems. Our Health Systems are Getting Better, our ability to respond is Getting Better. Part of my job at nebraska etwith the people at Training Center is to help hospitals get better but we know the risk has helped infections in the United States so i worry about mers as a number example. A third example and ill stop at the third is the next itv aids. Nowadays you think of it in terms of sexual behaviors or iv drug abuse. But lets remember hivaids was another one of those do not diseases, it came from nonhuman primates, probably multiple times and one time it was the right version that made its way into humans and it spread from human to human so i worry about another virus like that that spread through sexual transmission of some other mode as a long activation period before you get sick and before you discover its already spread widely so those are some of the things that keep me up at night about what the next pandemic could be that would have really significant morbidity and mortality. Like to open the floor to discussion and when i call on syou please introduce yourself. Susan get off, that was too fascinating especially in the morning. But about what can be done and here you are the most stexperienced person so the question is first of all, what is the cdc doing to educate people and control the diseases as soon as theres anindication that they might be serious, and on the other hand, were now in the brassica. What is the difference between control measures in an agricultural state with a small relatively small population and washingtons or new york, the large urban areas. How can the us do more and cdc do more to preventthese outbreaks . Thank you very much, thats an excellent question read how we can do more starts efor me at multiple levels and i always tell people that their more powerful than they think they are. He so lets start with something very simple. Healthcare acquired infections, drugresistant microscopes so a paper came out last week that suggested one third of all the antibiotics are unnecessary. One third. Of all the antibiotics were using our unnecessary so as a patient when you go in and talk to your patients, talk to your doctor you are powerful to say you i really need this antibiotic for my cold . Is there something we can work out for a couple of days and if it doesnt get better i should take an antibiotic. You have that power when you walk into a healthcare facility and a doctor or nurse or technician walks into the room to say did you remember to wash your hands . You are powerful, do not forget that. You have a power within your community and you think about personal preparedness so lets say a pandemic runs through your community or Natural Disaster, are you prepared personally for that . Not just in terms of having a kid in your home andbeing ready but are your vaccines all uptodate . How many people in todays age are no physical phone number, the only one number i force myself to memorize is my wifes number. Somebody asked for a phone number i pull out the cell phone but if my cell phone dies not so good in terms of numbers. And my my part of Response Team within the community, have i taken a cpr course so something bad happens i dont need to call 911, i can take care of something small myself for help me out my blood donor so theres also the things we can personally do and then its things we should expect from our government and thats where we are powerful so if tomorrow morning in new york city we decided but lets lay off after the police force. I my guess is you will are feather that man because you think Public Safety is so important but the same thing is happening invisibly to your Public Health safety workforce here in the United States where its not fully funded and nobody is targeting tar and feather anybody when you get a score of 6. 7 and help prepare your community is to help prepare your state is. So the demand the same thing from your local representative and the same things from National Representatives that we want a little less politics in what is happening in our l health, why are there 30 million uninsured, 20. 6 million uninsured americans in the United States right now given the fact that we passed a healthcare act, 19 states that have not passed Medicaid Expansion but i think you are powerful and you need to expect more and ask for more at everylevel including your own level. When i was at cdc i did a tongueincheek thing about the Zombie Apocalypse to try to get people to be prepared. For a Natural Disaster but somehow they werent paying attention to the real Natural Disasters but you mentioned zombies and everybody wants to know what to do. Dont ask me but we took a popular meme and converted it. But one of the things i did use the mean for i said the one thing you can do with zombies is out run them so please make sure you stay personally healthy so you can out run those zombies so one thing that you can personally do and that changes whether i happen to be in nebraska and agricultural state or whether i happen to be in washington dc with the greater risk of importation of diseases from International Travel so we need the local Public Health entity needs to take the appropriate things to account including for example for Climate Change. When were not coastal, what is the implication going to be flooded Water Supplies and stuff like that mark fax mike carnegie, long island university. Longtime new scientist reader and i remember an article and opinion piece years ago to rt the effect that if only silent spring publication had been delayed for 3 years and if ddt use and continued for another two or three years, we wouldnt have malaria. And you stressed Mosquito Control. So i waswondering what your take on that thesis is . We need to use every tool available to us when we think about Mosquito Control. We were fortunate here in the United States to actually cdc, cdc is the only one of the only federal agencies outside of washington dc and it always took me a while to figure out why that is the reason is malaria. Malaria used to be in the southwestern United States and there was a malaria and work Areas Program and what was happening as we were sending our troops trained in the south and they were getting infected with malaria, young women getting ready to go to war to get infected with malaria so this swas and became cdc and malaria was eradicated. 45, 46 but lets look at we see that day on the texas border through the mosquitoes. We see it in new mexico but not in the United States and is not due to ddt. Its due to screens and airconditioning which is one of the ways that will protect us against zika. We need to use every tool available for us for mosquitoes about killing the babymosquitoes. Its about killing the adult mosquitoes which is called an insecticide and then its about source reduction which means final all the little source of water and get rid of it so we need to be thinking about every tool that is available to us and i think including ddd and others and people are thinking that way, what is the right tool for the right area, whatare mosquitoes resistant to, what are they not resistant to. Thank you for this presentation. Doctor kahn, iwonder as you know , a number of societies had prohibitions against consumption of certain animal proteins. The state i grew up in it was forbidden and you made the connection that theres a lot of connection between these kinds of viruses that come from animals. And i wonder if any studies and then done to show that societies where the ipresumption of animal cruelty is limited or not at all, the ability to resist some of these illnesses, ability to be able to take antibiotics and have it effective, theres a connection between our consumption and the likelihood of other continued ability to cope with the consequences of these illnesses, i wonder if you can comment on that. Thats an excellent and complex question so let me break it down into these 2 quick pieces. One is we do know people who have a predominantly vegetarian diet live longer and do better. Thats pretty much wellestablished at this point and that may get to beef and animal consumption, the other is around zero not infections and those have to do more with the close contact we have with animals, not necessarily their consumption because when you think about it and i say this all the time because i get challenged about that since i dont eat pork which is if you heat itto the right temperature there is no risk. Your eating burgers that are rare, eating the medium rare so the risk comes not from the consumption because all you have to do is heat it to the right temperature, the riskcomes from the daily interaction with those animals, touching them, the routine set of interactions, even if youre not eating them, youre milking them , that risk is there. The same thing with the foul. Well cooked chicken burger isnt going to kill you but handling these chickens have chicken flu will potentially kill you. [inaudible] Marlon Matson from marlin medical college, i appreciate the clarity of your presentation. One of the things that came to mind was the delay in identification and response to evil and so my question really is what does the cdc do to try to increase collaboration with countries Health Departments and countries around the world to begin to do something about early identification and response and then something maybe about hethe World Health Organization in terms of whether it plays a part in this area . Thats a great question which links back to the earlier question about what can you do . The Us Government has a embraced something called the Global Health security agenda and so should we and that is a way for us to work with countries internationally to make sure that they have the pright tools and systems in place for the early diagnosis. You want to find the first set of cases. Theres a number of countries that have bought into this including the who and the cdc is a Technical Agency and cdc has people all over the world help with this but who has a global mandate to do this, they are the World Health Agency and they have been very introspective and have recognized the failures of the bola and what happened in people especially not just the failure from the Early Detection but 60 9 months until they called it a Public Health event of International Concern to say oh my gosh, this is a problem. In the spring of 2014 they misread the data to think things were Getting Better when they were just a little before they got worse so there in the midst of a complete reform process right now to be able to better respond to these emerging infections including for the first time in some keep into the International Health regulations to go and do country level assessments and if they are ready, theres an article from the world bank today setting up a new brand, a brandnew Pandemic Response on. I have a story in my book from a really good friend of mine who was asked to come to respond to the evil outbreak early on and he had no resources to do so. He wanted a handful of cars and some dollars to do some work and he was already a sense of resources so we cannot afford for an outbreak to get out of control because co somebodycant get their hand on a couple hundred thousand dollars to go do surveillance and put some since comes in place. And Helen Thurston with the Bryn Mawr Club of new york city, one of my clients as the city sent out a inspection and put tracks out so new york city is actually looking for mosquitoes. You mentioned the political aspect of the health situation. We have two candidates that are i think diametrically opposed on anumber of Health Issues , care for more insurance therefore many people and also on the issue of womens reproductive rights which are really in my opinion not womens but all peoplebecause everything that happens to a family and everybody in the family. Could you comment a little bit on that and how this issue can be brought up in a way that affects the political outcome . You know on that and that the politics person. I opened the door, im going to look for the expert in thisaudience for that answer. Mosquitoes in new york. New york is my home, i grew isup in brooklyn and went to ps 130, went to college and then school and i realized i could leave brooklyn though i have aunts and uncles who have never gone to the city because why would you go to the city bus and mark everything you want is in brooklyn. But i know a little bit about the city from having grown up here mosquitoes. You are really fortunate in having some of the best Public Health practitioners in the world here and ill do a shout out to marcy lakeman and annie find 1999 west nile started where russian mark right here so you know a lot about mosquitoes west nile is another good example. West nile belongs in the west nile. It doesnt belong in new york ng another example of thedisease somewhere else came and decided america was on. So you need, we need to have individuals as we make choices about who we elect and we support and off as we write, the people who say that health is an important abfactor and youre much more eloquent and i can ever be aboutreproductive rights, its an everybody right. Its not just pregnant women and we need to make sure that women have their appropriate reproductive rights across, we talk about brazil butlets not forget the United States. Theres a lot of things going on across the United States and we need to make surewomen have a full set of rights. Ron barenboim, i want to ask a question about a developing global problem and also potential developing response to that problem. And the problem of course is refugees. And ill just leave it at pthat. And as far as the Global Responseis concerned , i think one of the things thats been overlooked has been the role of pharma. And the lack of incentives in the pharmaceutical business. For responding to these kinds of emergencies. And to make a really wild suggestion that perhaps its time for pharmaceuticals to be considered pretty much as a public utility. A public good like the military, like the water system and like all the other things we have that we take for granted and that are not incentivized by profit. Thank you, so i assume refugees was an issue Infectious Disease issues. So my comment to that always is we want, i know people often say it in terms of what c risk do i have to because of refugees, i like to refrain that in terms of how do we protect the refugees, how do i make sure, i want them in measles, measles is a horrific disease so what do we do to make sure the refugees are protected. We dont want people to have tv so how do we make sure they are protected and in any screening and other processes we do to makesure those people are protected. So there actually are people who recognize this problem for a very long time. Offering to use some of the stories about anthrax, there is zero incentive for anybody to build a medical countermeasure against amtraks due to bioterrorism or in smallpox, Something Else i worked on and the Us Government established athe biological advanced research and Development Agency but that specific to the department of health and Human Services to make sure that somebody understood how to work with big pharma and make sure we have these excellent products that now are available to us against things like anthrax. We have enough smallpox vaccine for everybody in this everybody decides to reengineer smallpox and naked in a lab so we do have some mechanisms that are available to us but its a challenge to rid its a drugresistant antimicrobial audi make sure you continue to have it in your drugs available for these smarter and smarter all thetime. I guess you had directed the biological issue just now, i was going to ask you about that and i would like to thank you for really an exciting journey you took us on area. [applause] terrific, thank you. Weeknights this month we are featuring book tv programs showcasing whats available every weekend on cspan2. Tonight we will feature bestsellers, first journalist Nicholas Kristof and sheryl wu done on their book tight rope about issues facing the working class in rural america. They were interviewed by oregon democratic editor jeff merkley. Then Charon Westover recalls growing up in the idaho mountains and her introduction to formal education at age 17 in her book educated a memoir. After that turning point usa founder charlie kirk and his book the maga doctrine on the new conservative agenda. Cspan has roundtheclock coverage of the federal response to the coronavirus pandemic and its all available on demand at cspan. Org coronavirus. Watch white house briefings, updates from governors and state officials, track the spread throughout the us and the world with interactive maps. Watch on demand any time unfiltered at cspan. Org coronavirus. Gina kolata, author of the flu, the great influenza pandemic of 1918 and is the search for the virus , why did you write this letter mark