War ii veterans, key have a receive e social revolution in america. So thats the ultimate legacy of the veterans activism, is the g. I. Bill of rights, which i think most will agree a transformative piece of legislation for average people during that time frame. Military service is a powe politicizing experience for millions of american men in the 20th century. This government wants you to serve, go home, and mover on, but we see veterans becoming a very potent Political Force in American Society in the 20th 20th century and theyre politicized and not just groups like the American Legion or grouped a vow indicating for veteran benefits but we see Civil Rights Movements coming out of these wars. Africanamerican veterans come home and they energize the Civil Rights Movement in an entirely new direction, provide new leadership, and new ideas and that transforms the Civil Rights Movement in the United States. World war i does matter in american history, actually is a pivotal conflict that deserves a lot more love than it tends to get from most readers of american history. For more information go to cspan. Org cities tour. Good evening. My name is bill leggett. Im a book seller. On behalf of the owners, and on behalf of the entire staff, welcome. Its a pleasure to have you here and a pleasure to be hosting sewn sonia shah and her book, pandemic. If you have any noise, making device is if you could sigh silence them. Sonya will read for half hour and then take as menke many questions we can put in one minute. We have one microphone, and for the cspan audience. After the event is over, great help if you fold up your chair and place it against the bookshelf and there will be time for the book signing and the books are for sale up front. Sonia shah is an investigative journalist, author and lecturerrers whose work appeared in the to new york times, wall street journal, and scientific american. Her books include crude the store of holy body hunter body and the the fever how malarias haul ruled human kind for 5 machine thousand years. The tonights book, pandemic she studies the responses to outbreaks and and as a reporter going where pandemickings affect peoples lives and discussing whatey now know and how to use this to predict and contain the next outbreak so please welcome sonia shah. [applause] thank you. Thank you all for coming. This miss fourth book and my third time at this book store, and i think every time i come i have some deep seated understanding that i want to live closer to the store than i do. So, when first started writing the book about six years ago, i certainly didnt expect that we would be living through a pandemic of a novel pathogen right when it came out. But thats exactly where we are with the zika virus washing over the americas, and i just heard the cdc report today that three out of the nine women who were infected with the zika virus who came back to the United States have had abnormalities in their babies this, might have some real verient, not just in brazil. Its a pa g example of what hat been going on generally over the paste decades decades and its e reason why i wrote this book, which is that over the past 50 years we have had over 300 infectious pathogens, either newly emerged or reepledgerrens in the places they havent been seen before. Zika is just the latest. We have had ebola in west africa, never been seen before. We have had influenza out of asia, including one that caused the biggest outbreak of animal disease in the United States history. We have had novel viruses like middle east respiratory syndrome, a virus out of the middle east, and all the antibiotickic resistant pathogens we have, and then we have chiny goodwin ya, and chicken goodwiny and west nile and a wheel bunch of things. What i want to look at as a journalist us how did a microbe that just a tiny little thing that has no independent locomotion how does it become this kind of pandemic causing pathogen . And so i decided to do that, anxious that question, first i looked at the history of pen pandemics and i picked one to focus on, one of the most successful pandemic causing pathogens of all time and thats cholera. So cholera is caused not just one or two pandemics. Its caused seven. It kills half of the people who are infected with it. This can happen in a matter of hours unless theyre rapidly treated, and the latest is just off the coast of florida in haiti. So i studied the history of cal a and then went to places where knew new pathogens were emerging. I went to south china, hong kong, new dehli, portauprince and elsewhere to shed light on what is going to happen to these other new pathogens. What i found is that the history of cholera is indicate of tv what is happening globally with all these other emerging pathogens, too. Cholera came out of the environment. Like a lot of our knew pathogens today. 50 of the new pathogens are coming out off wildlife, animals and wildlife. And cholera is a marine bacteria and lives in estuaries, special lie bangladesh, where the major rivers rivers of south asia drain into bay of bengal. A huge wetland and the water is half salty, perfect for the bacteria to grow in the water, and it lives in conjunction with plankon and helps the nutrient, a helpful inhabit tenant in that environment. And people this is a giant its tidally flooded twice day. Theres crocodiles, tigers and cyclones. That it changed in the 1923478 century when the british decided to chop down the turns and turn them into rice farms. So quite suddenly over this 90 of the area was settled. So suddenly people are in close intimate contact with cholera in the environment, and that allows the cholera in the environment to spill over into human bodies and adapt to us. And of course what it does in our bodies is quite different than what it does in the environment. So the first pandemic of cholera started in 1817 and then started to spread into russia, into the industrialized cities of europe. And this is exactly what is happening today with our new pathogens. We are invading Wildlife Habitat or disrupting Wildlife Habitat. Either we were allowing animals and people to come into novel, intimate kinds of contact. And when that happens their microbes can jump over into our Bodies Bodies Bodies and become path ogenerallic, so, from that we have ebola. And a number of other viruses, sarsas well. From mon¢ we got zika. Month can hes we got seek campt we got malaria. From bird wed got influenza. So, this is how theyre epledgerring and then were allowing them to amplify in our cities. And our crowds. And that started in 19th 19th century, and cholera took great advantage of that. People were flocking out of the farms to come into the factory jobs. Ran into the streets and over flooded peoples peoples wills and contaminated the groundwater. When cholera enters an environment like that with contaminated waste it just explodes. So that organization of course started in the 19th century is only reaching its peak now so just a few years ago i think that half of the humankind now live in cities that just happened a few years ago. The majority of us will live in cities by 2030. But they will not be like washington, d. C. And San Francisco they will be more like freetown and monrovia and mom mum mumbai. People will live in slums, that is the prediction. So taking advantage of this now, this expansion in the parts of the world in particular. Ebola is a really good example of that. Before we had ebola outbreaks since about the 1970s, but ebola never infected places more than a few hundred thousand inhabitants before 2013. Which was only in 2013 when it came up in danny within a few weeks of that it had infected three Capital Cities of a combined population of nearly 3 million so that is an important reason why it was a huge consecration. And zika is also taking over rehab since the 1940s and maybe even before that, but it was mostly in asia and africa and it was carried by a forest mosquito and it mostly bit animals come it didnt bite people that much so people didnt get a lot of the virus but right now in the americas, zika is being carried and this is a mosquito that specializes in living in human habitations. It can actually breed and breathe in a drop of water in a bottle cap so all of our plastic garbage that we leave around in our urban areas are perfect environment for this mosquito to breed and they only bite humans. So as soon as it got him it started to explode, and it has expanded rapidly in urban areas especially as the tropics have expanded. And then of course we carry these things around and disseminate them and that started in 19th century in earnest with the steam engine we started taking ships across the atlantic really quickly come up and down all of the navigable rivers in the United States and then of course we connected the waterways by using the steam engines to build canals so the canal had opened and it was just in time for cholera to come over into canada down to new york city and into the entire interior of north america and that happened again and again. We do it much better today with our Flight Network we have not just a few Capital Cities with airports but hundreds of airports and tens of thousands of connections between all the airports. In fact, and this is a map i have in the book, you can make a map of all of them corrected by a direct flights and if you run a simulated pandemic on a map like that it basically looks like a pebble dropped into the sea expanding outwards because you couldnt predict where and when an epidemic will strike simply by measuring the number of correct flights between infected and noninfected cities, so thats how Influential Network is on the way the epidemic spread today. So those are some of the ways i talk about in about how modern life really increases the risk of these epidemics and its driving pathogens into human population. But the other part of the book is about what we do about it because of course we dont take these things lying down. We have political differences and medical differences and all kinds of things that we can do to fight back, to contain these pathogens. So its interesting to look at what happened in 1832 in new york. I spend a lot of time and of trying to dissect that outbreak in particular. Now in 1832, cholera came down and the governor from new york sent one of his top doctors to kind of do reconnaissance to see what is going to happen and if it is going to threaten the city of new york and he collected this data that has been mapped and it appears in the book and it shows a very clear picture there are clusters of cases across the hudson river and along the canal and theres even a time series you can see it coming down heading straight for new york city, a very clear picture but nobody wanted to quarantine the rivers or the canal. The canal turned new york city into kind of a backwater poured into the premier part of the country, turned it into the empire state said this is a huge part of the economy and nobody wanted to close the waterway which i would than the obvious thing to do to protect the city at this time, so the doctor said it might look like cholera is coming down the waterways and is contagious but actually it is caused by miasma which is a 2000yearold medical theory that diseases like cholera and other contingencies read through essentially stinky air, bad smells, thats what they thought. They decided to blame the bad smells on the drunks, the poor and immigrants, especially the irish in 1832. And this was violent, this wasnt just a bad mouth in the press, there were massacres of irish workers during the cholera epidemics in the 19th century. So, i lost my train of thought where i was going with this. I think im having a senior moment. [laughter] oh my god. Im going to look at my notes here. Okay. The doctors, the doctors. [inaudible] yes, yes. Its funny that is where my mind quite because this is my favorite part of the story. So they didnt want to quarantine the waterways, and in fact, there were companies at the time that were distributing cholera contaminated water and they were making money doing that, so there is a slum in the middle of manhattan and if anybody has seen the gangs of new york and the movie it, the movie it was about five points and thats where the worst parts of the cholera epidemic affected the slump because it was crowded and filthy and the slum had actually been built on what was once a pond. It is the only was the only source of fresh water for a long time. It had been over the course of the century filled with garbage and the slums had been built on top of the landfill. This is the ground underneath was kind of unstable unlike the rest of manhattan that was under lead with dead rock. So, the groundwater was easily contaminated under this slum of quirks and all of the outhouses and everything were, all of the materials were sinking down into the groundwater. While some of the state of new state of new york tried to accompany to deliver Drinking Water to the people of new york and of that company, instead of tapping upstream sources of water committed is the bronx river at the time, which was fresh and clean it up a new would taste better for sure, they thought that would take too much money so they they made an addition like what happened in flint michigan, which they decided not to tap the good water. They decided instead he would sink the well in the middle of the slump and they distributed the water to one third of the people of new york and this was through repeated cholera epidemics. Now this is the good part of the kind of person that maneuvered all of this was aaron burr and Alexander Hamiltons nemesis and murder. On top of that, the company that did this was called the Manhattan Company and the reason they wanted to save all this money is because they wanted to start a bank which they did the data was the bank of the Manhattan Company and that the bank still exists to this day. Do you know who it is . J. P. Morgan chase, yes. So, and i told that story in the book because i think we dont really look at the political and social drivers of contagion in and i think thats an interesting kind of turnaround from the past. A lot focuses on well. Malaria. Weve really got rid of it before we had solid Biomedical Solutions by changing our landuse policy basically. We started building dams of course that we have engineers and scientists on the board of peace to make sure that when we built the dams we wouldnt extend the mosquito habitat. We changed housing practices. Itll started putting screens on their windows and doors. We uplifted people out of poverty in rural areas to give them electricity can give them back in ossetia and in the farms so they would have life and we kind of felt it out and this is well before we had any specific drugs to deal with malaria. But then in the 1940s we started developing these really specific chemical cures. We had insulin, we had ddt and this created a whole kind of medical bio establishment of the king power for and extremely, you know, poet and curing disease very effectively and we sort of gave over Public Health to our biomedical establishment. And so what happens now when we have outbreaks of contagious disease, we dont really look for the social and political roots, we wait for the epidemic to erupt, people get sick and then we hope that we can throw the sufficient drugs and vaccines at it to make it go away, and that can work in some cases. But what im trying to say in this book is that its not sufficient for new diseases because when the new pathogens come up, we dont have the vaccines all made up, we dont have the drugs and yet these things can spread exponentially. So we are talking about exponential growth of untreatable disease. One example of this, not looking at the social and political roots is the outbreak in florida in 2009. So, it came out and it was really centered in key west that it was in south was in south florida generally. In 2009 havent been known in 70 years and immediately it was attacked as a biomedical problem, the tacking the insect and the virus and thats what they did. But of course the mosquitoes that carry that had been present in florida for a long time. Florida has been surrounded by countries where there is dainty around, thats not new so there havent really been any invasion in mosquitoes that needed to be attacked with this chemical onslaught. What had happened in 20 latest weekly for closure crisis and the foreclosure crisis meant we had a lot of band and tones and in florida that means a lot of empty slimming pools custody filled up with water and they became giant mosquito hatchery is. We have this mosquito borne dengue virus. So i dont know how they would have helped to calm came to dengue outbreak because nobody tried that. What i do know arguably is that the biomedical model failed. We continue to have dengue outbreaks come, it is considered a permanent part of the landscape. So what i want to say in the book is as great as our Biomedical Solutions are, if we can start to prevent pandemics and we engage in the root causes of them which are more often political and social, in which case it isnt a question of waiting, it is a question of our own political will. Thank you for listening. I take questions. [applause] i am halfway through and im really enjoying the book very much. I have a question about the zika by race because i think that probably came right after with your thoughts on political, economic and every kind of treatment in terms of the olympics and given your theory in the book, what would you suggest . I think that its a difficult situation because the argument they are putting forth in brazil of why they should have the olympics and why people should come anyway is because it is winter and its true that when its dry and cold committees mosquitoes either wont hatch as readily because you need standing water for at least a week or even if they do they wont survive for long enough to transmit the virus because that takes seven to ten days and it actually slows down if its cool, so it is quite possible that that is true that theres maybe less of there is great deal less of a virus around but at the same time, you know, we are living in a time of unstable weather patterns and so all we would need is a good rainstorm a week and a half before people started to come for the olympics and some of the water to remain standing. Those eggs of the mosquitoes that carry zika, they defecate and can last for months. You just need a little bit of water and they will come alive again. So i think it is a risky endeavor but at the same time, there is no stopping the zika. Its going to come and its probably in larger numbers than we know. 80 of the people that get it dont have symptoms. So what we are counting is the tiniest tip of the iceberg. A lot of people that have symptoms think it is irrational or fever and they dont notice. Its limiting for some people so what we are counting is a tiny fraction so its probably already here in a more widespread way than we know if you consider the fact we have 15 or so suspected cases of sexual transmission in the United States, if there is 100 introductions supposedly 100 or so introductions of zika in the United States and then 15 of those have transmitted sexually, those numbers dont match up because sexual transmission is probably a rare form of transmission so most likely theres many more cases of the virus, so olympics are not, its coming and its going to be here and its a matter of time before we see it manifest itself in a more detectable way. So, its hard not to talk about the government on these issues. For 12 years i was one of the leaders dealing with Infectious Disease bioterrorism and in the comment under clinton and bush there were large staffs of the Security Council focusing on bio security. Because there are 25 agencies and you have to have white house control where you have nothing. Obama comes in and wipes it out and its gone. Its not one of the 11 top priority is for the administration in terms of security. And then under bush, we had amazing efforts, tens of billions of dollars to figure out how to get the development of the vaccines and diagnostics and it wasnt very well designed. All of that has been dismantled by obama. And actually the explanation was that we heard why they quoted it was cheney thought it was important and therefore we dont so what is your take of how its possible, given that these are existential threats where the billion people could die, a billion people could die of the avian flu epidemic if it is roughly the same locality lacks we could lose a billion people. Its a contagion. We could have quarantines, panic. How is it possible that this administration has essentially zero interest of this issue . I think youve said it all and im not sure that you have a question as much of a comment, fair enough, absolutely. But i do think that we need to do even more than that because what im trying to talk about in the book is not just lets stop the vaccines and have sort of experts coming and we do need that as well but to get to the root cause is to look at Health Care Infrastructure in the parts of the world like do we have enough primary Health Services and what are we doing about it for the health of our animals and livestock, how are we regulating the way we use land and we are breaking up the land all over the place and those are theres a lot of reasons not to do that and this is another one, they could spill over into our bodies, so i need we need i think we need a candidate all of the above approach and the media expertise youre talking about for sure but i would like it could be to be even a more multifaceted defense strategy. As you probably know, dc has the highest rate of hiv in the United States. So, from a global perspective, what lessons do you think can be learned in approaching epidemics on a smaller scale . Because they have been at the center and so how does that translate or are there any correlations or what can you learn from the global spread of disease as it relates to a smaller population . I think we see this in the history of lots of contagions in the communities over the brunt of it and this is such an interesting aspect of the 1832 epidemic of cholera is that we have slums in the middle of the city and that was such a driver of epidemics because there are neglected communities and that was something kind of knew at the time because in the past usually people were put out on the periphery of communities and with urbanization they were starting up in a middle of the city and that became kind of an epicenter that would just spark out to the rest of the city again and again and i think theres a lot of parallels right now we are seeing even ebola is a great example where intervention could have controlled about. Even soap and water could have helped control the spread of a virus like that. But we dont even have the most rudimentary services for some of these remote communities and marginalized communities and that puts everyone at risk so that is something that i think is a big lesson of the history of the contagions. My name is scott and i work for the Global Health organization lobbying to focus on Health Systems and the developing world. So, i think its not ridiculously hard when you take a given country that you know whats killing people in that country like kenya with hiv and malaria are big killers, its not ridiculously hard to find what investments you can make that will make the greatest difference in saving lives and have the greatest impact. But that gets a lot harder when youre looking at the pandemics where you dont know what the disease is or where it will emerge or come from. So the question of the priority setting is important because we will never have all the resources that we want and so we need to set priorities should we invest in strengthening versus building vaccines and investing in labs. Theres a ton of things we could do to prevent the pandemics but i just dont have a lot of ability to say which things are going to have the biggest bang for the buck so i would like your thoughts on that. I think youre right we need all of it. To me, the most glaring is primary Health Healthcare services for poor people in remote places. I was in haiti during the epidemics epidemics going on after six years but i was there a few years ago and we traveled maybe 15 miles from the capital but it took about eight hours because this place was so cut off but the thing that was so ironic as they werent so cut off that they couldnt get cholera. So it had come into this village but they were cut off enough that they couldnt get any resources to help them and it just really struck me this Uneven Development where they had one type of water coming down from the hills that the belgians have built 20 years ago as a project and never gave them any support for maintaining it. Theres no services or resources or know how to maintain this thing. So when i came there, they brought the Drinking Water to this Remote Community and it was supposed to be up on the cliff and because there is so much erosion it is slowly falling all the way down to sea level and you know, the storms are coming in and hitting the pipe and they had about 32 holes and nothing to patch it up. They were literally using cloth just wrapping it around. The water was dripping it out and they had a tiny trickle of freshwater coming into the town and thats all the reason they get cholera because everyone was getting buckets and leaving it out and when you only have a bucket of water you dont give up eating and cooking, you give up watching as much. So to me that this really simple things like clean water and aid thats sustainable over time, empowering local communities. Those are all vague things. Im not a policymaker. Im looking at how these things spread and what are the approaches we can take to help empower the communities to come up with their own solutions of it is the biggest lesson of all when you go into the communities, do we ask them what do you think we should do and do they say i would really like 500 treated bed nets . No, they say we would like better a better water in the towns or whatever it is. I would like to thank you for this. Although im from a different part of it but nonetheless it is a huge problem because of the tremendous poverty there and marginalization and it happened in the talked about the fact that the public has sanitation issues that are more important than the medical issues for stopping a lot of the stuff from happening but having said that, the first question is both from europe and the United States of america and other countries attempts to please people in different places. Africa is an example to try to figure out potentially new coming pandemics and so that is the first thing maybe you want to talk about. The next thing is the context of zika starting to spread into caribbean and happening at this point in time, not my island but its only a matter of time. Its a matter of time before they get there. Also, it is complex they are coming out of brazil. This whole issue of consequences for kids that people are saying that yes potentially certain people with certain genetic profiles with this lead to catastrophic consequence. But it was also seemingly a problem no one was talking about and a lot of the neighborhoods where a lot of this is happening especially with the kids to the consequences for the kids the neighborhoods that are bombed with a lot of pesticides and other stuff and is it zika or these other things . Its more the other elements that led to that. So have you heard about that, and i would like to tear from you. Thank you. Thereve been lots of alternate theories about why weve had this rash of microcephaly in brazil. Some of them are easy to say no that is definitely not happening. The pesticide theory to me theres a lot of evidence thats probably not the best. The pesticides have been used in other parts of the world and there hasnt been a spark of microcephaly. Still, could it have been used in different places and somehow because of cultural reasons or some other reason, could those people have gotten a higher dose or Something Different happened . I dont know. I think it is a mistake to dismiss the theory is as conservative theories and its a mistake to dismiss them out of hand. I think that is the sort of conventional response especially in the Global Health establishment to say stop spreading these conspiracy theories but there is a reason why these alternate theories come about and its important to look at that and useful. If they come about because of a lack of trust in our biomedical establishment and where does that come from . If you trace that back and this is something i try to do in the book. I look at why were Health Workers during the crisis in west africa attacked . This happened in cholera epidemics, too. They would burn down cornyn teen hospitals, and we saw this again and again. If you go back, there were transgressions that have occurred between the biomedical establishment and local people and maybe through the best of intentions, but its still there and it needs to be addressed. Its real and i think when we just dismiss peoples alternate theory we are dismissing the feeling that they dont trust the messages and it makes it worse. They may say youre just a stupid ignorant. Its the same with the antivaccine argument people say those people are so stupid and ignorant. Of course it doesnt cause autism, have evidence and of course we do but where does the mistrust come from . People are are frighted about the contaminants and about secrecy. All these things. Corporate control of medicine. These are issues that are worth addressing why people feel they cant trust these messages and we needed that. Need that. We need to do that work now. We need more of us to trust them. We need to all be on the same page but we are not there yet. We have a lot of pockets of mistrust and conspiracy theories that come up almost immediately. The virus moves within days there was the mosquito, theres all kinds of theories about why this is happening. Im studying Public Health at George Washington university and my concentration is Environmental Health science and policy but right now im taking a class could the social determinants of health and so my question is how would we work towards creating a policy that would be effective in addressing the Environmental Issues and also perhaps other causes ike social issues as mentioned before . Spigots a huge issue like how do people experience disease and what does that mean about the intervention thats going to make sense in their life where we were hatching a lot of plans to help people in the countries that didnt necessarily match up in their own priority is and the bedding and its for a good example about where we created insecticide treatments and was a great idea because it would be cheap and easy commute to need refrigeration or hospitals or anything. These people can be in the most poor settings and we can give them this intervention and it will save them. Well, okay so we did that, we spent hundreds of millions and that was a huge effort and a lot of good intentions and money and resources spent doing that and then they were not used right away. Like 20 of them are were being used or something, really low. Then they sent the anthropologists and to see whats happening and people dont consider it a killer disease, they consider it a normal problem in their lives. They live around the nicest material theyve ever had a severe saving it for when our guests come. All kinds of reasons that just really were not considered and its because the people on the ground that have the most think of it in a totally different way than we think of it and part of it is anybody. If you survive the first two years of life and have your 12 episode and you survive that then you have some immunity to it. Its the way that we think of the flu. If we had a bunch of scientists that came over to the United States and said you people use 40 billion a year for the cold and flu all you need to do is wear a little mask when you go to school and work for six weeks out of the year its so simple. We dont need anything fancy we will just give you these for free. What we do it . [laughter] we dont even wash our hands during flu season. I have a question about the contrast between this book and ted koppels book about the doomsday events like the power grid outages. So what are your personal actions you have done to prepare for pandemic or what do you do in your daily life to avoid the epidemic disease . I do commonsense things like i keep up with vaccinations and wash my hands because each is different but i do beneath that we live in a microbial world and disease is part of our relationship to nature and this idea that we should live in some kind of a germ free environment and never have it is anomalous if you think about it for the long history of humankind battle with microbes or interactions with microbes we have the first antivirus, and by the 1980s we started having hiv and blind disease and all these pathogens we couldnt treat it that well anymore. That well anymore. So that period of time when we had this sense and this is the period that i grew up and im the daughter of two doctors, so