Council i would like to think you offered joining with us. We would like to welcome ali khan and cspan book to be to this breakfast program. He will be discussing his book, the next pandemic, as a former director of the office of Public Health preparedness and response at the centers for Disease Control and t prevention, he isn the front line in the front to contain the worlds deadliest diseases. He is not the first to have done so. Throughout history, humans have beento fighting diseases, waging deadly and neverending word against contagious. In fact, there has never been at time when humans were not affected with microbes and fought against him. During his time as a selfdescribed disease detective, our speaker has had hise own viruses, Infectious Diseases and contagion. For example, 1995 he worked among red cross workers in that year for the first double crisis, after 9 11 he was called to washington to prevent the spreadntnt of anthrax in the see office building. In 2003 he was called to hong kong to quarantines victims apart. But these are just some of the stories doctor chronicles in the next pandemic. A disease hunter if you will, his mission for two decades was to read the u. S. Government efforts to prepare the public for disease outbreaks and health emergency. He has seen it all. While he tells us that microbes will always be a problem, he also writes that not epidemics and pandemics are inevitable, and fact most outbreaks can be mitigated if not prevented. But the question is how, do we have enough resources. To help a separate the myths from the facts, what disease posa greatest risks and what we need to do wto prewritte prevent pandemic. Please join me on the Public Health journey to the four corners of the earth by welcoming dr. Khan this morning. [applause] thank you very much. Good morning, everybody. Lets put this over here. As you heard i spent a career in the preparedness business, usually that meant for talks and in advance, over time it became getting ready just in time and at this point my career were into the realtime speaking process which i pretty much make it up as they go along. Now one of the things iak have been told when you speak to p an audience, as you can tell there is nothing about my career that starts within levity. But i i do promise sex, lots of sex, it will be mosquito sex but there will be lots of sex. So im really delighted to have this opportunity to share a whole bunch of stories with the broader audience of what it means to be a disease detective and hunting down the diseases. You hear about patients and you read the papers and all the popular press and the movies and et cetera, but what is it from a perspective of somebody doing every day with lots of another Public Health practitioners. Also its nice to give a talk when you read the paper this morning you are either reading about zeke or ebola or yellow fever, it is topical, so to think its easy to start a discussion of emerging infections. That shouldns start their, the idea of why this is always in the paper and why are we always hearing about these diseases. A classical disease to think about, smallpox, measles, those all started pretty much around the agricultural revolution when people came together, you needed to have enough people to spread the disease from persontoperson. So thats when i start the Infectious Disease, everybody has their own story of when the world starts, thats when the world starts when rodents were carrying smallpox and they moved into somebodys home and the virus made the jump and started to cause smallpox. Let me fast for to the Industrial Revolution theory, we realize Infectious Diseases is from asthma but it spread from person to person and a lot of enthusiasm that occurred around the beginning of the 20th century with sanitation revolution, vaccines, antibiotics and people thought we are done with this whole Infectious Disease problem, all we have to do is pop a shot in somebodys arm and give them a couple of pills and the all be better, if that was true we would not have this conversation today right now. What is happening, even though weve taken care of a lot ofha t these, we have these continued emerging Infectious Diseases, theres a lot of factors that drive this emerging diseases. So some of the key factors are just around microbes, theres collectively somebody who thinks that theyre smart collectively and they evolve, they multiple generations with a single day, humans if we are lucky, generation and 35 years or something before we can swap out our genetic materials. Microbes, no problem at all, they swap genetic material all the time, they get smarter all the time, thats why you read about the drug microbes because thats what they do, they move around find a good setet of gens and think thisll protect me from the antibiotics. So the microbes evolve, human change their behavior so 100 years ago i tell you nobody had a kidney transplant so we changed in our risks to infections changed, the other thing that happened is that we change our environment, this is the big driver and why we have it emerging. When i talk about zeke a and ebola, somehow the animal connection comes into play was eco the and the mosquitoes and ebola itre is bad which is the original cost of where the virus lives in effect somebody and thats we spread out the chain of transmission and humans. 75 of the diseases that you hear about, the new the new diss emerging, if an animal connection, if you move people out into the environment, into the jungle, they will get infected. That disease has the potential to cause persontoperson transmission as we see with ebola or mers which we believe from bats and camels, if you have a contact with camel, thats how you get the disease. It is not a surprise when we think about the emerging infections that 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 good example where as if you have people in china and other parts of Southeast Asia who live very close to their pigs and very close to their birds, chickens and its a a great opportunity r the virus to swap genes and infect humans and that becomes a global pandemic. E. 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 year on record since 1880. And people ask me how did you know whatbe was going on in 188, and believe it or not, if you are a farmer it is important to you the temperature is, so there tre excellent records about what it looks like th for the last 10 to 150 years. You are doing your daily log. Wwhat is water temperature look like. So we have excellent records and then asked you pass through that historical sort of documented record and look at all sortst of other information that looks at temperature thousands of millions of years ago but april was the hottest record, hottest year on record and its the 12th of this year in a row. This isnt a coincidence that is happening with temperature or climate and if you look at Carbon Dioxide we should be above 200 parts per million. So the 2100 year going to only catch increases to 1. 5 degrees. This is a mosquito Borne Disease in africa. So you have your cows and goats and that is your 401 k . It is a biblical disease and what we have recognized the past few decades despite the fact its moving out of Subsaharan Africa depends on climate and when this emerges. To protect your animals this also provides feature and brain inflammation. But they dont have the money to vaccinateni every year so if the is a sort of tool every five to ten, 15 years to say get vaccinated this year, that would benefit so they could understand what happens so they could help protect the community so that is how i got into Climate Change issues understanding what the dynamics were. Whats going to happen in 2100, know what is happening today. So if we look at the diseases caused by arthropods which are tanktanks andthink since mosquis effectually wined disneys. Its continued to spread about half of the county so we are seeing that already today. There is a fungus up in vancouver called the infections of humans and animals. It doesnt belong there. It belongs in the tropics. We are getting infected oysters from the i northwest. Are there any oyster eaters here like the . You dont Pay Attention to the good publichealth messages. Okay. One of the reasons is to try to protect yourself but that shouldnt be a problem if you were getting theyouregetting td states or the alaska area with an ice cold waters. But weve started to see outbreaks reported from those because the waters are not as cold anymore. So, contemporary examples where we are seeing because of Climate Change. Lets shift from the u. S. To europe they have this disease. We take whatever you tell us and give it back. We know what it says in latin. Into where we are nothing but the climate is one of those. Respiratory virus o for any of u that work here, have kids, grandchildren. Kids get infected and it causes this respiratory illness usually they are okay but not always. Contemporary examples are going to get worse when we talk about these ways. And t then obviously the Infectious Diseases and anything that has to do with mosquitoes and ticks and where things are. All of these are important and what is happening to the microbes and whats happening to us and in the environment is actually more political and social factors. If you look at these outbreaks of diseases will continue to emerge as i convinced you the last five to ten minutes but i hope that we play a role in keeping them from becoming epidemics and pandemics. A good example would be the outbreak of ebola in west africa. Weve known about it since 76 and the science since 1976, and i had the opportunity to support a into 1990s when i did this. You get infected anyouve got iy with a bat. If you are out in the bush and w you die 85 to 95 of people by unfortunately maybe a Family Member or two urls in the middle of the bush, you are done. Whalets say you changed the dynamic and seek healthcare in a hospital. Unfortunately they do not have Infection Control so when you are infected you essentially virus factory. You can infected and if your system doesnt kick in your increasing the amount you are producing every minute until you die so you go to the hospital because you are sick and you dont have more than when you die you. Hundreds of millions of billions of them to be in a milliliter of your blood. So here you are dying in the hospital and someone doesnt wash their hands whats going to happen. Theyve always served and weve known this for many years as a reservoir of a spread in the community. Somebody sick at home and you have a Family Member taking care of them, you are at risk. They die, unfortunately, didnt you decide to wash the body, case the body, invite all the loved ones. One of the fact is as we saw during the outbreak as they would wash and use the water to allow them to wash their hands to take on the attributes of the person that just died. This isnt a good idea. Lets admit that. 24th, 25th since 1976 many people thought this isht going o be like what we have seen happening in east africa. They shut them down within a couple of days and have a system in place to identify the case. They dont even need to teams anymore they wont know what to do. They test everybody and extinguish these outbreaks very quickly. Its never occurred before and in urban areas their thinking was one in the same. So each and every one was a needless death i would say and adequate response. Politics in the publichealth system goes from the outbreaks and what we had essentially was an epidemic across west africa with the cases across the world including what happened in the United States and one of the pasons is another factor of social political factor that plays into Infectious Diseases that we didnt have in the 18 hundreds. 80 days to get around the world. On my publichealth uniform was an anchor and i get asked about it. The publichealth uniform was very much a navy uniform and we started about 200 years ago providing care to the merchant marines and one of the chores was to be so hot right now essentially to fly the flags and there was somebody with yellow fever or smallpox. We knew if you had smallpox or no fever because the incubation. Coincubation. Co. And the time it takes to get the systems was shorter than the time to go from point a to point b. We turned that upsideps down now so now you can go to your proter mothers funeral in liberia, fly to liberia, go to your mothers funeral, engage in the usual act that the word if you are kissing her and hugging her and the next day you get on a plane up to to amsterdam to kneejerk city. New york city we give me 48 hours, incubation period of five to seven days. Its three days aftethree days k up in new york and say ive got a headache and a fever and im not feeling quite well right now. Ive spent time in places across theno world. They are not ready for these patients coming in with these viruses so travel has played a big role. What can we do to make things better around social political aspects. I guess they recognized if we think about this and who gets infected as i started to write the book is sort of dawned on me how most every chapter you could swap a marginalized population that was the increased risk. So this is due to rodents and often occurs in the southwestern United States and the most likely people to get infected and when thehe outbreak occurred was among the native americans into some of you will remember that when this occurred in the 1990s there was a group of kids that had come to dc and they were denied to her you could potentially infected. And todays day and age we are talking about zika and others including that what weve learned now is zika is a laserguided missile it kills your cells and its not just truee in babies so when it was yfirst described you were told about 20 of people get sick and get a fever if they missed to be a cook at a little headache and some red eyes and they will get better and it quickly became clear that this was a problem for pregnant women but now we know even for adult in this laser like focus we have this disease that is a neurological illness that causes weakness and we also know that even in a healthy person that can cause brain inflammation. So what we should think of as normal healthy adults that are not present it as a problem. The virus shouldnt be am, problem. Its spread by a certain type of mosquito. It isnt new to us. Its the same that spreads yellow fever. It causes 30,000 around that. And not paying attention to the people dying of yellow fever now all of a sudden we are up in arms that we have the disease due to these that seem to be infecting pregnant women. So it is a lack of action over the last 40 to 50 years against the known threa threats that hat us in this current position. Its essentially knocking on the door of africa whats going to happen is it then sweeps through africa and the rest on pregnant women. The head of who whos done amazing work in her time in hong kong has admitted in addressing this mosquito, although to talk about the major policy failure as we think about protecting women and contraceptive rights is a big issue in brazil and other places to all of a sudden say we need to Pay Attention because now we may get some cases in north america women who may have this disease. We will see zika in the United States, hopefully we will not see a lot of cases that we will likelbut we willlikely see it. What they you gave me a lovely comment the other day. You think about these m populations. In this conversation is probably better terms between lets protect the United States against zika and no one can decide if they want to do it or how much they want to pay for it and should it be 500 Million Congress wantses to give, some version and they are like i dont care what it is, pick a number of way ar that way are wg this conversation six months later. We know what is going to happen and we also know us keep those controlled in the United States is not even a state function. It is a state and city and county function and we need to get the money out to these people so they can be doing what they should be doing which is eliminating mosquitoes making sure the identify the cases. Why are we still having this conversation six months later. Why are we sort of robbing peter to pay paul. So we were responsible for keeping americans safe from all publichealth threats no matter what their nature if it was biological chemical terrorism. The program puts money out into state and local Health Departments. To pay for this week essentially pulled back some of that money eto help support some of the activities and other places including britne theyve alreadd 1100 cases believe it orup not. This is the preparedness infrastructure why are we taking money outut a of that when we sd be putting money into the preparedness infrastructure and what i will leave you with is a member because i am all about these measures. 6. 7. In the last three years the foundation has been doing great work looking at how prepared the United States emergencies we started at 6. 3 or 6. 7 out of ten. That just is not good enough for us if we want to make sure americans are protected and as far as i am concerned, the responsibility is to protect us against threats and that includes publichealthhr and threats and how can we make sure its not always of the science but maybe sometimes we need to more politics. [applause] that was fascinating. I think because i decided it 20 years agoat that here is not a publichealth strategy. I know it makes foror great pre. The sky is falling but its about education and good finance. What keeps me up at night is knowing what the next pandemic is going to be. It is a pandemic needless to say that its not causing hundreds of thousands of deaths. What is likely to cause hundreds of thousands we already know that from 1918. A publichealth message of the day is to get vaccinated. The changes which is why we neee to do the vaccine every year but unpredictably all of a sudden you have no protection against. From 1918, 7. 5 million americans would die. 2. 5 . Think about the number of body bags and how this would completely disrupt the society if we kill 7. 5 million. If the diseases like mersa keeps me up at night. Ive seen these health systems. They are Getting Better at the ability to respond. Part of my job in nebraska was to help the hospitals get better, but they know the risk of these infections in the United States and its ally worry about this as another example. A third example and i will stop there and that is hivaids. Another you think of it in terms of sexual behaviors or drug abuse and lets remember it was another one of those. Its spread from human to human so why worry about another like that that spread through some other mode is a long information period before you get really sick and by the time you discover its already spread widely, so thoset are some of e things that keep me up at night about for the next pandemic could be. That could have significant mortality. Whe when i call on you, please introduce yourself. Death was fascinating to. Here you are the most experienced person t so the question is first of all what is the difference between thehe controlled measures for the smaller population and washington or new york the large urban areas. How do they do more to prevent peace outbreaks . How we can do more starts at multiple levels and its how powerful they really think they are. So lets start with something very simple. Healthcare acquired infections and drug microbes, the paper came out of last wee last week t suggested one third of all antibiotics we are using are unnecessary. One third are unnecessary. So when you talk to the doctor you are powerful to say they might need this antibiotic or is this 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 healthcar healthcay and a doctor or nurse or a technician walks into the ring m to say did you member to wash your hands you are powerful. Do not forget that. Lets say a pandemic funds for your community are you prepared to personally put a . Notou just in terms of having a kid in your home and being ready that are the vaccines uptodate and how many people in todays healthth ages have no physical phone number. The one number i can force myself to remember is my wife and he asks for a phone number i plop a cell phone so if you guys, not so good in terms of numbers. I can take care of something small myself. The results sorts of things we can do and that is why we are powerful. As of tomorrow morning in new york city w we decided lets lay off half of thee police force, y guess is you will do there that may or unless because you think Public Safety is so important at that the same thing isni happeng to the publichealth safety workforce here in the United States. But in how prepared your state is so to demand the same thing from your local representatives and National Representatives we want a little less politics in what is happening. Why are there still a 19 states that have not passed the Medicaid Expansion so i think that you are powerful and need to expect more and ask for more at every level including your own level. When i was at the cdc cited a tongueincheek thing about the people to be prepared for the natural disasters. But somehow they were not paying attention to the disasters and everybody wants to know what to do about zombies. Dont ask me. We took a popular meme and converted it. The one thing you cant do is outrun them so please make sure you stay healthy so you can out run those zombies. So something you can personally do. But the greater risk is from International Travel they need to take the appropriate things for example Climate Change from the Water Supplies in things ans like that. Longtime scientist reader and i remember an article some years ago to the effect is only silent springs publication had been delayed for about three years and if it had continued for another two or three years we wouldnt have malaria so i was wondering what your take on that thesis is. Its one of the only federal agencies outside of ndc and it took me a while to figure out why that is into the reason is malaria. It used to be in the southwestern United States in the area program we send troops down and they were getting infected with malaria. The we see this on the texas border due to mosquitoes and new mexico, we dont see it in thes United States. Its through the airconditioning act. You are right when we think about what does it take to protect us, we need to use every tool available. So it is about killing the baby mosquitoes and the adult mosquitoes and insecticides and then its about the force reduction between fine i will get rid of it and we need to be thinking about every tool that is available to us and i think including ddt and others. Yhat is the right tool for the right area and what are the wert resistant to. Thank you for the presentation. As you know a number of societies have had suspicions against certain animal proteins. I grew up where beef and pork were forbidden and they make the connection that theres a lot of connections between these kind of viruses that come from animals. And i wondered if any studies have been done to show thehe societies where the presumption of this is limited or not call the ability to resist and the ability to take antibiotics and have an effective if there is a connection between our consumption and the likelihood of our continued ability to cope i wonder if you can comment on that. That is an excellent and complex question. We do know people that have a predominantly vegetarian diet to do better and live longer. That is wellestablished at this point. The others have to do more with close contact as we think about it and i say this all the time if you heat it to the right temperature there is no risk. So it comes not from the consumptionco that from the daiy interaction you have with these animals into the routine interactions with the id is the same thing with the foul. Well cooked chicken burger. Handling chickens with chicken flu will potentially kill you. From why old cornell college. I appreciate the impressive work that you are doing. One of the things that came to mind is the delay in the identification and response so my question 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 andnd response lacks and then somethin indepeng maybe about the World Health Organization in terms of whether it plays a part in this area. Back to the earlier question of what can we do. That is a way for us to work with countries internationally to make sure they have the right tools and systems in place for the early diagnosis. Theres a number of countries that have bought into this including who. They have people over the world to help with this but they have a global mandate to do this. They have the World Health Agency and they have been very introspective and have recognized failures of ebola from six to nine months until they called the international Public Health event they thought it was Getting Better before it got worse so they are in the midswere in themidst of a proceo better respond to these infections including for the first time putting some teeth into the International Health regulations that actually go into the country level assessments. Theres a brandnew Pandemic Response fund. I have a story in my book from a good friend of mine thatro was asked to come to the response of the outbreak and he had no resources to do so. So to go do some surveillance in the system in place in hospitals. One of my clients has the city inspections and they put traps out so they are looking for mosquitoes. You mentioned the political aspect of. We have two candidates that are opposed on a number of Health Issues and those that are not womens but all peoples rights because everything that happens to a family happens to 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 im the oldest person a and not the politics person, right . New york is my home i grew up in brooklyn. I realized i could leave so i have aunts and uncles that had never gone to the city because why would you go to the city if everything you want is in brooklyn. [laughter] you are fortunate in having some of the best Health Practitioners in the world and i will give aou shout out in 1999 west nile started right here. West nile belongs in the west nile, not new york. Another example of the disease somewhere else that came into america and decided it was home. The you are muc much more equipt than i couldld ever be. It is an everybody right, not just pregnant women and we need to make sure that women have the appropriate reproductive rights. I want to ask a question about the developing global problem and also potential developing response to that problem. And the problem of course is refugees and i believe that data. As far as the Global Response is concerned, i think 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 kind of emergencies and to make a really wild suggestion that perhaps is pretty much a as a public utilitbusy publicutility in a pe the military, like the water system and like all the other things they have that we take for granted and that are not incentivized by profit. I assume the refugee. People often frame it and i would like to reframe that and how do we like to protect the refugees and how do i make sure. It is a horrific disease and so what are we doing to help make sure that they are protected themselves. How do we make sure they are protected. Theyve recognized this problem for a long time so i will bring this to you. There is zero incentive for anybody to build a medical countermeasure. Its Something Else ive worked on and actually established the advanced Research Development agency but that is the purpose of the department of health and Human Services to make sure somebody understands how to work with big pharma against things like anthrax and somebody decides to reengineer smallpox and make it in the lab so we do have some mechanisms that are available to us. But it is a challenge. You have addressed the biological threat issue. I would like to thank you for an exciting journey he took us on. The book is available. [applause] [inaudible conversations]