Transcripts For CSPAN2 Ali Khan The Next Pandemic 20240713

Booktv to this breakfast program. Ali khan will discuss his book the next pandemic on the front lines against humankinds gravest dangers. A former director of the office of Public Health, preparedness and response at the centers for Disease Control and prevention, ali khan has been on the frontline in the attempt to contain the world after these diseases. He is not the first, throughout history humans have been fighting diseases, waging deadly and neverending wars against rampant and violent contagions. Humans are not affected by microbes, during ali khans time as a detective our speaker has had his own russians with viruses, infections and contagion. For example in 1995 he worked among red cross workers in the year for the first ebola crisis. After 9 11 he was called washington to defend the spread of anthrax in the Senate Office building. In 2003 he was called to hong kong to quarantine victims of sars. These are just some of the stories ali khan chronicles in the next pandemic on the front lines against humankinds gravest dangers. As an epidemic intelligence officer, disease hunter, if you will has mission for two decades was to be the Us Government efforts to prepare the public for the disease outbreak and health emergency. He has seen it all. Ali khan tells us rogue microbes will always be a problem he also writes that not all epidemics and pandemics are inevitable. He writes most outbreaks can be mitigated if not prevented. Do we have enough resources. To help a separate the hype from the facts, what diseases pose the greatest risk and what we have to do to prevent the next pandemic, please join me in a Public Health journey to the four corners clear if by welcoming ali khan to the Carnegie Council this morning. Thank you for coming. [applause] thank you very much. Good morning, everybody. Lets look this over here. There we go. I have spent a career in the preparedness business and usually that meant for talks in advance. Over time it became getting ready just in time. At this point we are into realtime speaking process which i pretty much make it up as i go along. One of the things i have been told when i speak to an audience, theres nothing about my career but starts with some levity. I do promise sex, lots of sex. It will be mosquito sex. I had an opportunity to share a bunch of stories, the broader audience what it means to be interviewed. And what is the perspective of somebodys ability. And talking about sica or ebola or yellow favor. And emerging infections. Why is this always in the paper and why we always hearing about these types of diseases. Our classical diseases, think about smallpox or measles, and people came together. It disease spread from persontoperson and that is when i thought my stories Infectious Diseases starts. For me, when rodents that were carrying some version of smallpox into somebodys home in some virus made this something for measles and classic diseases. Let me fast forward to the industrial revolution. Infectious diseases were not due to my asthma miasma, agents that spread persontoperson. And what occurred around the twentieth century, the sanitation revolution with vaccines, antibiotics, we are done with this small Infectious Disease. Given a couple pills and they will be all better. If that were true we would not be having this conversation today and what is happening is even though we have taken care of a lot of them, we have these continued emerging Infectious Diseases and there are a lot of factors that drive those diseases. Some of the key factors, they are smart, collectively. Multiple generations in a single day, humans if we are lucky our generation in 35 years or so, microbes, no problem at all, they swapped in attic material all the time, they get smarter all the time, read about drugresistant microbes, they move around, this will protect me from the set of antibiotics, and and so we change, the risk to infections change. We change our environment. It should not be surprising when i talk about the cover ebola, the animal mentioned comes into play. Zikait was mosquitoes and with ebola it was bats. That is how you spread the chain of transmission humans. 75 of diseases that you hear about, emerging diseases are sora not act meaning an apple connection. If you move people into the environment into the jungle they get infected, there is a potential to cause persontoperson transmission as you see with ebola, bats and camels, to connect contact with camels, it is not a surprise when using of these emerging infections they tend to come from africa, south america or southeast asia, bird flu is another good example when you have people in china, pretty close to their pigs. And a great opportunity for these viruses to infect them. These are the environmental set of environmental conditions and why we keep hearing about them. A special call out to Climate Change as one of those environmental factors leading to emerging infections. I want to say Climate Change is often framed as an economic issue or as an energy issue. Over the last year we have been doing a better time reframing this as Public Health issue of what is happening with climate currently. The hottest record, hardest year on record, 1880. How do you know what is going on in 1880 and if you have a farmer it is really important to you, there are excellent records. The same thing with marine temperatures if youre out as a captain doing daily life, one of things he would be logging, what does water temperature look like. We have excellent records. If you pass through that historical, other information, temperature, thousands of millions of years ago. April has the hottest record, hottest year on record and the 12 hottest year in a row. This isnt a coincidence with what is happening with climate, we should be about 200 parts per million, preindustrial level, we are not 400 parts per million. And and it had to do with other fevers. This is a mosquito Borne Disease in africa. We have cows and goats, that is your 401 k . If a virus, if a mosquito borne virus comes around, that is bad news. It is a biblical disease. What we recognized the past couple decades of studying this besides the fact that it is moving in Subsaharan Africa into Northern Africa and the middle east, it depends on climate, on when these viruses, when the mosquito emerges and great heavy periods. To protect your animals, bad diseases, it causes hemorrhagic fever, brain inflammation. They dont have the money to vaccinate the animal every year. If you have a sort of tool, every 5 or 10 years to say this is a bad year, that would really benefit. People spend a lot of time to understand what happens, to protect these farmers and their animals, Climate Change issues, understanding what the dynamics were but what is clear right now when you talk about Climate Change, what happens in 2100, what is happening today, if we look at diseases, disease in the United States caused octopi which are ticks and mosquitoes which everybody in this audience knows very well. If you look at where live disease vectors are spreading. We see that already, theres a tropical fungus in vancouver causing infections of humans and animals. It doesnt believe belong in vancouver, belongs in the tropics. We are getting infected oysters from the northwest. We all know any oyster eaters here . All the good Public Health messages about oysters. Gulf coast in cold months, one of the reasons you eat oysters in months with an are in the ms. Try to protect yourself from infected oysters especially gulf oysters. That shouldnt be a problem getting oysters from the northwest United States from the alaska area. We are not seeing outbreaks, and contemporary examples, let mission from the us to europe. It is encephalitis. What we do is we give it back to you and you think we are all smart. My head hurts, you have several asia, youre so smart. You know what it says in latin. It is called tick one brain inflammation and what we see in sweden, the disease is spreading and there are a lot of factors, climate is one of those. For any of you who work here or have kids or grandchildren, little kids get infected with a severe respiratory illness. And those viruses in europe. They are becoming shorter and shorter. And and and proportionally more will die from heat when we think about heart and lung disease from all your pollution and all the Infectious Disease. Anything that has to do with mosquitoes and ticks and where things are, climate, this waterborne illness as we get flooding, severe storms and Mental Health illnesses. As we think about emerging infections. All of these are important what happens to microbes and all of us in the environment. And and the good example would be a recent outbreak of ebola in west africa. Since 1976 we have known about the science of ebola since 1976 and i had a chance to support that clients in the 1990s when i did and Ebola Outbreak in zaire. What happens . You get infected with ebola and if you are out in the bush you die 85 percent95 of people die. A Family Member or two guy with you. You are in the middle of the bush, you are done. Lets say you change the dynamic and go seek healthcare in a hospital. Unfortunately a hospital that doesnt have infection control. When you are infected with ebola you essentially become a virus vector. You get infected and if your immune system doesnt kick in, you will increase the amount of virus your producing. When do you have the most hostile virus in your body . When you die. As you go to the hospital because you are sick and you dont have more than when you die. I can give you a 10 with lots of big numbers around it, hundreds of millions, billions in a milliliter of your blood. Here you are, sick, dying in the hospital and somebody doesnt wash their hands as they go from patient to patient. You spread ebola from patient to patient. Hospitals always served as a reservoir for how these spread within their communities. Somebody sick at home and you as a Family Member taking care of them, you are at risk. They die, unfortunately, then you decide to wash the body, kissed the body, hug the body, invite the loved ones. One of the practices we saw during this Ebola Outbreak is they would wash the body and then use that water, to wash their hands and take on the attributes of the same dead person who had just died. This is not a good idea, okay, lets admit that. That is the science. We know the science. When this outbreak occurred 24th, 25th outbreak since 1976 many people thought this will be like east africa, uganda, sees outbreak the time, they shut them down in a couple days, they have a system in place to identify the case. They dont even need International Teams anymore, the locals know what to do, they test everybody, they follow everybody was potentially sick and take care of these are brakes quickly. For december to start in west africa where it never occurred before, it very quickly spreads to urban areas, large metropolitan areas, urban areas with slums and the thinking was more of the same. Russian, take care of everything in this Ebola Outbreak will go away. What happens . That is not what happened. 11,000 deaths, every one was a needless death. Inadequate response, Global Response to a local response but inadequate Global Response. As though politics in our Public Health system, the biggest role in whether this goes from a handful of cases or small outbreaks to whether or not what we had was essentially an epidemic across west africa and cases across the world, you know what happened in the United States and one of the reasons we had that was another factor, social or political factor that plays into Infectious Diseases that we didnt have any 1800s. How many people . I wont ask. Have read around the world in 80 days. How quaint. 80 days to get around the world. For 22 years, i wore a Public Health uniform and on my Public Health uniform was an anchor. The Public Health uniform looks much like a navy uniform and the reason it look like a navy uniform, we started 200 years ago, one of the chores of the Public Health service which we still have right now with the quarantine flag when the ship came to port, somebody with yellow fever and smallpox. If it is going to take you 80 days govern. 80 point be by the time you show up in the court of new york city, we knew if you had smallpox a yellow fever because the incubation period, the time it takes to get infected, manifest your symptoms was always shorter than the time to go from point a 2 point be. We turned that upside down. You could now go to your mothers funeral in liberia, you fly to liberia, go to your mothers funeral, engage in the usual acts you around a funeral, your distraught, your mother died, youre kissing her, youre hugging her in the next day you get on a plane to amsterdam to new york city. And incubation period, and in new york, all of a sudden you find out, i am not feeling quite well. Number one diagnosis would be malaria. If it is not malaria, in the community, they happen in texas, the same scenario, infected two local nurses, in places across the world letting you know our Healthcare System is not better than you see in toronto when you had the sars outbreak, i spent some time in seoul, and Excellent Health care system like ours, they are not ready for nations coming in, travel played a big role in how these diseases emerge, why you will always hear about this but what we can try to do to make things better. The ethics matter, an observation, i recognized it, often marginalized populations. I started to write the book and it dawned on me every chapter you could pull out, the marginalized population for emerging infections. This is a disease due to rodents. The most likely people to get infected, was among native americans. Some of you will remember when the junta virus occurred in the 1990s a group of young navajo kids who had come to the sea for a capital tour and were denied, you happen to come from the southwest. There was nothing anything we knew that said these kids were at risk. They didnt pose any risk to us but often these diseases affect marginalized populations and increases the prejudice against marginalized populations. We talk about hiv and ebola and the marginalized populations in west africa and in todays day and age we are talking about zika. Brazil has 1. 1 million cases, what they are calculating now of zika virus and 1500 women have been infected and their babies have died of congenital zika syndrome, they get small brains, other Development Disabilities including hearing loss, vision problems. What we have learned is zika is a laserguided self or neurons. It looks for neuron cells and kill your neuron cells. It is not just true in babies. When zika was first described, we were told 20 of people will get sick, if they get sick they get a fever and a little headache, some itching, some redeye, they will get better. Very quickly it became clear this was a problem for pregnant women. Now we know even for adults, this laserlike focus on the ronil cells we have this disease, a neurologic illness causes weakness. Even in a healthy person zika virus can cause brain inflammation of coverings around your brain. Even in normal healthy adults who are not pregnant this virus is a problem. This virus shouldnt be a problem. The virus is spread in certain type of mosquito, this is not news to us. This is the same mosquito that spreads yellow fever, that causes 30,000 tests a year, the same mosquito that spreads dengue and if we were having this conversation five years ago when we talk about this large dengue outbreak that is occurring in south america, this causes 30,000 of the year. Its the same exact mosquito that causes chikungunya virus. That was the big thing in the news 2 or 3 years ago. That 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 dieing from yellow fever and dieing two people died from yellow fever and people dying from dengue now the sudden were all up in arms that we have disease due to aedes aegypti the soontobe infecting pregnant women. This lack of action overn the last 40, 50 years against a known threat that is put us in this current position. At least ifme you happen to be n south america these days and i heardte yesterday zika now is nt just move throughout the americass but is not a verdict. At the center did not get on the to say hi, im next. Your next think about what could happen if that virus goes to africa and the risk to pregnant women there in africa. The head of w. H. O. Brilliant woman has done some amazing work, did some amazing work anytime in hong kong has admitted a major policy failure over the last 40 years and addressing this mosquito. Also she brought it to talk about major policy failures as we think about protecting women and contraceptive rights for women because theres and big issue in brazil and other places where you dont have the same contraceptive rights as you take for granted here in the United States and other parts of the western world. Why did it take all this time people die of dengue, people dying of yellow fever with just a vaccine to all of a sudden say we need to Pay Attention . Because now we may get some cases in europe and north america, women who may have this disease. We will see zika in the United States. Ill preempt that c question, hopefully we will not see a lot of cases that we will likely see it. Let me thank you. You gave me a lovely, the other day. The ethics of delayed response and this goes back to some of what you talk about here. If you think about these marginalized populations, why do we see these delayed responses . We are seeing it today. The stories the last couple days is this conversation is probably better terms what the conversation between lets protect the United States against zika. Nobody can decide whether the what to do and how much they want to pay for it. I often get asked, ali, should be 50 billion the cogs wants to give . The 1. 9 president asked or the 1. 1 against the city wants to get. I dont care what it is. Pick a number but why are we having this conversation six months later . We know whats going to happen. We also know that Mosquito Control in the United States is not a federal function. Snide even a state function. Its a city and county and district function, and you need to get the money out to these people so they can be going with the should be doing which is eliminating mosquitoes and making sure they are identifying cases. Do you have the money to think about public longterm strategy would be a vaccine strategy to protect pregnant women. To get some sort of thought of a refunding of Vaccine Development . Why are we having this conversation six months later . What do i would not already dog that . What are we robbing peter to pay paul . My old program at cdc was responsible for keeping americans safe from all Public Health threats to matter what the nature, it was spent in the extent of biological chemical terrorism. As part of that program my passion was for the Public Health Preparedness Program which putta money out interested in a local Health Departments to help them for the zika response we pull back some of that money to help support some of the dire activities in other places including puerto rico with it at 1100 cases, believe it it or not. Tragic enough. Analogy is taking taking the brt of a foundation to build second story of a building. If this is our preparedness infrastructure, why are we taking money out of zika and putting money into the preparedness infrastructure and what i would leave you with is the number because im all about measures, 6. 7, so in the last 3 years the Johnson Foundation has been doing great job looking at how prepared the United States and every year gets better and i think it started 6. 3 and 6. 7 out of 10. Thats just 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 and that includes Public Health and Health Threats and how can we make sure. You know, im old enough to know you cant completely strip policies out of policy decisions and not always about science. Maybe strip more politics and thinking what are the health needs of our population. Thank you. [applause] well, that was fascinating. You seem so calm. What keeps you up at night . [laughter] yeah, i think im calm because i decided 20 years ago that fear is not a Public Health strategy and i know it makes great press, the sky is falling, but really its about education and and good science. Now what keeps me up at night is what the next pandemic is likely going to be and zika is a pandemic needless to say but not causing hundreds of thousands of deaths. Whats likely to cause hundreds of thousands of deaths in the future is flu. We already know that from 1918. So we get flu every year. Im going to tell you every year Public Health message of the day get vaccinated. We get flu every year and changes a little bit which is why we need a new vaccine every year but unpredictably flu takes off overcoat and all of a sudden you have no protection against it at all. If we repeat the same thing we saw in 1918 today, 7. 5 million americans would die, okay, 2 and a half percent, think about the number of body bags and think how this would disrupt our society. Flu keeps me up at night. Mers and diseases like mers keep me up at night. I know ive seen the Health Systems, our Health Systems are Getting Better, our ability to respond to diseases are Getting Better. Part of my job at nebraska with National Ebola Training Center is help hospitals get better but we know the risk of healthcare acquired infections here in the United States and so im worried about mers as another example. A third example and i will stop at third example is next hiv aids, hiv aids is nowadays you think of it in terms of sexual behaviors or iv drug abuse that give you hiv aids, hiv aids was one of those diseases, came from nonhumanitarian primates, probably multiple times and right version that made its way to humans. Spread through sexual transmission or some other mode has long period and by the time you are discovered it its spread widely. Those are some of the things that keep me up at night about pandemics that would have mortality. Lets start over here with susan. Susan, that was too fascinating and especially in the morning, but we have to be concerned about what can be done and here youre the most experienced person, so the question is first of all, what is the cdc doing to educate people and control the diseases, as soon as theres indication that they might be serious and on the other hand, you are now in nebraska. What is the difference between control measures on agricultural states, small relatively small population and washington or new york, the large urban areas, how can the u. S. Do more and cdc do more to prevent the outbreaks . Thank you very much, susan, thats an meant question. How we can do more start for me at multiple levels and you always tell people they are more powerful than they really are. Lets start with something very simple, healthcare acquired infections and drugresistant microbes, onethird of antibiotics that we are using arent necessary. Onethird of all the antibiotics that we are using are unnecessary. As a patient you go in and talk to your doctor, you are powerful to say, do i really need this antibiotic for my cold, doc or if it doesnt get better, should i take an antibiotic. You have the power to walk into a healthcare facility, doctor or nurse technician walks in the nurse, did you remember to wash your hands, okay, you are powerful, do not forget that. You have the power within your community when you think of personal preparedness issues. If lets say pandemic runs through your community or Natural Disaster runs through your community, are you prepared personally for that, not just in terms of having a kid in your home and being ready but your vaccines up to date . How many people in todays cell phone age know of physical number. The only number i forced myself to memorize is my wife. If my cell phone dies not so good, right, in terms of numbers. Am i part of Response Team within the community, have i taken the cpr course so if something bad happens i dont need to call 911 for tinny things and blood donors and things that we can personally do and then things that we should expect from our government and thats where we are powerful. If tomorrow morning in new york city we decided, you know what, lets lay off half of the police force, my guess is you will call the mayor 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 tarring and feathering anybody when youre get a score of 6. 7 in how your community is and how prepared your state is, so to demand same thing from local representatives and demand same thing from National Representatives that we want little less politics and what is happening in our health. Why are there still 30 million unsured 28. 6 million une ensured americans in the United States right now given the fact that we passed Affordable Care act. 19 states that have not passed medicaid expansion. I think you are powerful and you need to expect more and ask for more at every level including your own level. When i was at cdci did tongueincheek thing to get people to be prepared for Natural Disasters but somehow they werent paying attention to the real Natural Disasters and everybody wants to know what to do for zombies, dont ask me. [laughter] we took a popular meme and converted it but one of the things that i did use the meme for, the one thing you can do with zombies is outrun them, please be sure you stay personally healthy to outrun zombies, something that you can personally do and that changes whether i happened to be in nebraska in agricultural state or whether i happened to be in washington, d. C. With greater risk of importation of diseases from international travel. So we need the local Public Health entity to take things into account. Climate change, coastal, what is that for flooded Water Supplies and things like that. Thank you. Mike, long island university. New scientist reader and i remember in article, opinion piece years ago to the effect that only silent springs publication had been delayed for about 3 years and if ddt use had continued for another 2 or 3 years we wouldnt have malaria and, you know, you stress Mosquito Control, so i was wondering what your take on that thesis is . So we need to use every tool available to us when we think about Mosquito Control. We were fortunate here in the United States to cdc is the only, one of the only federal agencies outside of washington, d. C. And it always took me a while to figure out why that is and the reason is malaria. Malaria used to be in the south western United States and malaria in war area programs and we were sending troops to be trained in the south and they were getting infected in malaria. We dont need young men and women getting ready to go to war infected of malaria. The program was set up and became cdc and malaria was eradicated in 1940, 45, 46, but lets look at dengue right now. So we see dengue on the texas border through the mosquitoes. We see in mexico, we dont see it in the United States and its not due to ddt, its due to screens and airconditioning. Its one of the things that protects us against zika. When you think about what does it take to protect us, we need to use every tool available for us. For us its killing baby mosquitoes, killing the adult mosquitoes which is calledded insecticides and source reduction which means final, sources of water out there and get rid of it and we need to think about every tool thats available to us and including ddt and others and people are thinking that way, what is the right tool for the right area, what is mosquito resistant to, what are they not resistant to. Im christian, thank you for this presentation. Dr. Khan, i wonder as you know a number of societies have had prohibitions of consumption of Animal Proteins n. The faith i grew up beef and pork were forbidden. Youve made the connection that theres a lot of connection between these kinds of viruses that come from animals. I wonder any studies have been done that society where is the consumption of Animal Protein is limited or not at all the ability to resist some of these illnesses, the ability to be able to take antibiotics and have it effective. If theres a connection between our consumption and the likelihood of our continued ability to cope with the consequences of these illnesses, i wonder if you can comment on that. Thats actually excellent and extremely complex question, so let me break it down into these two quick pieces, so one is we do know that people who have a predominantly vegetarian life live longer and do better, thats pretty much well established at this point and that may get to beef and animal consumption. The other is infections and really have to do more with the close contact we have with animals not necessarily their consumption. When we think about it and i say this all of the time because i get challenged about this which is if you just heat it to the right temperature theres no risk, right, you hear this about your burgers, you shouldnt be eating burgers that are rare anymore, medium rare. The risk comes from the consumption, the risk comes from daily interaction you have with these animals, touching them, you know the routine set of interactions even if youre not eating them, if youre milking them, keeping in houses, that risk is there. The same thing with the well cooked chicken burger, handling the chicken that is have chicken flu will will potentially kill you. [inaudible] thank you. Marilyn matson from cornell medical college. I appreciate the clarity of your presentation and impressive work that youre doing. One of the things that came to mind was the delay in identification and response to ebola and so my question really is what does the cdc do to try to increase collaboration with countries, Health Departments in countries around the world to begin to do something about early identification and response and then something maybe about the World Health Organization in terms of whether it plays a part in this in this area . Thats a great question which links back to earlier question about what can you do, so the u. S. Government has embraced something called 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 right tools and systems in place for the early diagnosis. You want to find the first set of cases. But you an international Public Health event, an international concern, the official term to say my gosh this is a problem. In the spring of 2014 they misread the data to think things are Getting Better when they were just a low before they got worse. In the midst of a complete reform process right now to be able to better respondd to thee emerging infections including for the first time putting some teeth into the National Health regulations to actually go and do country levelg assessments f you are ready. The lovely article from the world bank today, setting up a new brand, a brandnew Pandemic Response fund. I have a story in my book from a really good friend of mine who was asked to come to respond to the Ebola Outbreak in sierra leone. He had no resources to do so. He just wanted to hand out cards and talk to do some work and there were no extensive resources. We cannot afford for a break to get out of control because somebody cant get their head on a couple dollars. To go do some Surveillance Systems in place in hospitals. I am helen thurston. One of my clients sent out mosquito inspection that they put traps out, new york city is looking for mosquitoes. You mentioned the political aspect of the health situation. We have two candidates who are diametrically opposed on a number of health issues, care, insurance care for many people and the issue of womens reproductive rights which in my opinion are not womens but all peoples rights because everything that happens to a family happens to everybody in the family. Can you comment on that and how this issue can be brought up in a way that affects the political outcome . I am the Health Person and not the politics person. I opened the door and looked for the expertise. Mosquitoes, new york is my home, i grew up in brooklyn when the ps 130 went down the street, i realized i could leave brooklyn. I have aunts and uncles who have never gone to the city. Why would you go there . Everything you wanted in brooklyn. I know a little bit about the city from having grown up here but mosquitoes, youre very fortunate having the best Public Health practitioners in the world. A shout out to marcy and annie, 1999 west nile started where . Right here. So you know a lot about. West nile is a good example. West nile belongs in the west nile. It doesnt belong in new york. Another example of the disease somewhere else became and decided america was home. We need to make choices about who we elected, who we support, the oped we write, find people who say health is an important factor. Your more eloquent than i could be about reproductive rights. It is not just pregnant women. We have to make sure women have reproductive rights. We talk about brazil but lets not forget the United States. A lot of things are going on across the United States. The soviets have a full set of rights. A question about developing global problem and potential developing response to that problem and the problem is refugees. As far as the Global Response is concerned, one of the things that has been overlooked is the role of pharma and lack of incentives in the pharmaceutical business for responding to this kind of emergencies and to make a wild suggestion that perhaps it is time for pharmaceuticals to be considered a public good like the military, like the water system, like all the other things we have that we take for granted that are not incentivized by profit. I assume the refugee was an issue to Infectious Disease issues. My comment, in terms of what risks we have because of refugees. I like to frame that in terms of how to protect the refugees, i dont want them getting measles. Measles is a horrific disease. What are we doing to make sure the refugees are protected themselves . We dont want people to have tb. How do we make sure they are protected . Screening and other processes make sure these people are protected. Pharma, they have recognized this problem for a long time. Offering it to you for stories to tell about anthrax. There is 0 incentive for anybody to build a medical countermeasure against anthrax, bioterrorism or smallpox. The Us Government established the biological advanced research antigovernment agency for that specific purpose, the department of health and Human Services to make sure somebody understood how to work with big pharma and make sure we had excellent products that are available to us against things like anthrax was we have enough enough smallpox vaccine in case somebody decides to reenter smallpox in a land. We have some mechanisms that are available to us but it is a challenge, drug resistant microbes, how do you make sure you continue to have new drugs available but get smarter and smarter all the time. You addressed the biological threat, i would think you for an exciting journey you took us on. Thank you. Thank you. Really terrific. Thank you. [applause] [inaudible conversations] [inaudible conversations] [inaudible conversations] you are watching a special edition of booktv airing during the week while members of congress are in their districts due to the coronavirus pandemic. Tonight, the presidency. First u. S. News world report Kenneth Walsh looks at how different president s have looked at crises. Enjoy booktv now and over the weekend on cspan2. This weekend on booktv saturday at 6 p. M. Eastern richard cordray, former director of the Consumer Financial Protection Bureau. Its about consumers and the problems they face. Its not Consumer Finance and how its changed. That is about the new Consumer Financial Protection Bureau and the role and importance of the work that it engages in to protect people across america. Sunday at 12 30 p. M. Eastern, h. R. Mcmaster conformer Trump Administration National Security adviser. 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