Transcripts For CSPAN2 Book Discussion On The Next Pandemic 20160903

Youll also hear a profile of the first ladies since 1960, and booktv visits denver to speak with local authors and tour the citys literary sites. Plus, the science used toism prove the effectiveness and safety of the u. S. Military, trent lott and jon meacham talk about president ial politics, we discuss why the mix has lost faith why the public has lost faith in their political leaders. And finally, Jean Edward Smith discusses his most recent book on the president ial tenure of george w. Bush. Thats just a few of the programs youll see on booktv this weekend. For a complete television schedule, go to booktv. Org. Three full days of nonfiction books and authors this weekend, television for serious readers. And now were going to kick off the weekend with a look at the fight against pandemics. Well, good morning, everyone. Im joanne meyers, and id like to thank you all for beginning your morning with us. We are delighted to dr. Ali khan and cspans booktv to this breakfast program. Dr. Khan will be discussing his book, the next pandemic. As former director of the office of Public Health preparedness and response at the centers for Disease Control and prevention, dr. Khan has been on the front lines in the fight to contain the worlds deadliest decides. Throughout history, humans have been waging deadly and never ending wars against rampant and violent contagions. In fact, there has never been a time when humans were not affected with microbes and fought against them. During dr. Khans time as a selfdescribed disease detective, our speaker has had his own brushes with viruses, Infectious Diseases and contagion. For example, in 1995 he worked in zaire for the first ebola crisis. After 9 11 he was called to washington to prevent the spread of anthrax spores in the Senate Office building, and in 2003 he was called to hong kong to quarantine victims of sars. As an epidemic Intelligence Officer a disease hunter, if you will his mission for over two decades was to lead the u. S. Governments efforts to prepare the public for disease outbreak and health emergencies. He has seen it all. While dr. Khan tells us rogue microbes will also be a problem, he also writes not all epidemics and pandemics are inevitable, in fact, most can be mitigated, if not prevented. But the question is how and do we have enough resources. To help us separate the hype from the facts, what diseases pose the greatest risks and what we need to do to prevent the next pandemic, please join me on a Public Health journey to the four corners of the earth by welcoming dr. Khan to the Carnegie Council this morning. Thank you so much for coming. [applause] thank you. Thank you very much. Good morning, everybody. Good morning. Lets put this over here. There we go. So as you herald, ive spent a career in the preparedness business, and usually that meant for talks, youre ready weeks in advance. Over time it became sort of getting ready just in time. And at this point in my career, were at the realtime speaking process which is i pretty much make it up as i go along. Now, one of the things ive been told when you speak to an audience, you start with a joke. But as you can tell, theres nothing about my career that starts with levity, but i do promise sex, lots of sex. Itll [laughter] itll be mosquito sex, but besides that, itll be lots of sex. [laughter] im really delighted to have this opportunity to share a whole bunch of stories with a broader audience of what it means to be a disease detective and hunting down these diseases. You know, you hear about patients, you read the papers, all the popular press, the movies, etc. But, you know, what is it from the perspective of somebody whos been doing it every day with lots of other amazing Public Health practitioners . Also its nice to give a talk when, if you read the paper this morning, youre either reading about zika, ebola or yellow fever. Its topical, so it makes it easy to start a discussion off about emerging infections. So lets just start there. The idea of why is this always in the paper, and why are we always hearing about these types of diseases . Now, our classical diseases, think about smallpox, think about measles, you know, those all started pretty much around the agricultural revolution when people sort of came together. Because you needed to have enough people to to spread disease from person to person. So thats when i start my story of Infectious Diseases. Everybody has their own story of when the world starts, but for me, thats when the world starts when some row dents carrying prodents carrying some version of smallpox moved into somebodys home. Well, let me fast forward you to the industrial revolution, germ theory. We realized Infectious Diseases were due to infectious agents that 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, okay, were done with this whole Infectious Disease problem. All we have to do is pop a shot in somebodys arm, you know, give them a couple of pills, theyll be all better. Well, if that was true, we wouldnt be having this conversation today, right now, right . Whats happening is even though weve taken care of a lot of these classical scourges, we have these continued emerging Infectious Diseases, and theres a lot of factors that drive this emergence of those diseases. Some of the key factors are just around microbes. Theres collectively im somebody who thinks that theyre smart collectively, and be they evolve. They have multiple generations with a single day. Humans, be were lucky if were lucky, a generation in 35 years before we can swap out our genetic materials. Microbes, no problem at all. They get smarter all the time. Thats why you read about these drugresistant microbes, because thats what they do. They sort of move around, they find a good set of genes, and they go, oh, this will protect me from this set of antibiotics and, boom, you get your superbugs. So the microbes evolve. Humans change their behavior. So a hundred years ago nobody had a kidney transplant, okay . So we change, and our risks to infections change. The other thing that happens is we change our environment, and this is a big driver in why we have emerging Infectious Diseases. It should not be surprising that when i talk about zika, when i talk about ebola, somehow very quickly the animal connection comes into play. Zika, obviously, its with mosquitoes. With ebola, its bats which are the original cause for where this virus lives. It affects somebody, and then you spread the chain in humans. 75 of the diseases that you hear about, the new diseases, these emerging diseases have an animal connection. And so if you move people out into the environment, into the jungle, you know, they get infected. And that decide has the potential then to cause persontoperson mission as we see we bowl lahr or with ebola or, lets say, with mers. Its not a surprise when we think about those emerging infections, they tend to come from africa or south america or Southeast Asia where you have a lot of connection with animals. Bird flu is another good example where you have people in china and Southeast Asia who live very close to their pigs, their birds or fowl, chickens, and and theres a great opportunity for these viruses to swap their genes and eventually infect humans and then become global pandemics. So those are the environmental, some set of environmental conditions why, that lead to these 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 as an energy issue, somehow energy issues. And i think over the last year or two weve been doing a better time reframing this, actually, as a Public Health issue of whats happening with climate currently. So april was the hottest record on year hottest year on record since 1880. And people ask me, how do you know what was going on in 1880 . And believe it or not, if youre a farmer, its really important to you what the temperature is. So there are excellent records about what temperature looked like at least for the last 100, 150 years. The same thing with marine temperatures, was if youre out as a captain, youre doing your daily log, one of the things you would be logging is what does water temperature look like. So we have excellent records. And be then if you pass through that historical, sort of documented records, you can look at all sorts of other information that looks at temperature, thousands to millions of years ago. But april was the hottest record, hottest year on record, and its the 12th hottest year or in a row. Okay . This isnt a coincidence, whats happening with temperature, whats happening with climate. And if you look at car fox, you know, were carbon dioxide, you know, were now we should be about 200 parts per million, sort of preindustrial level, were now at 400 parts per million. So the thought that by 2100 were going to only cap increases to 1. 5 degrees is highly unlikely. But let me tell this story from a different way. I got into the Climate Change business 20 years ago almost, and it had to do with a mosquitoborne disease in africa. If youre in africa, you dont have a 401 k , okay . You have your cows, you have your goats. Thats your 401 k . [laughter] so if a virus, if a mosquitoborne virus comes around and your animals die and are aborting, that is bad news. So thats rah fellly fever, its a biblical disease, and what weve recognized over the past come of decades of studying this besides the fact that its moving out of Subsaharan Africa and into Northern Africa and the middle east, is it actually depends on climate when these viruses when this mosquito emerges, and you sort of have to have these great, heavy dry periods followed by wet periods to cause this to happen. And to protect your animals and this virus also causes bad disease in humans. It causes abortions in humans, hemorrhagic fever and brain infrom a nation and blindness in inflammation and blindness in humans. But the farmers dont have the money to vaccinate the animals every year. If you had some sort of tool to say, you know what . This is the bad year, get vaccinated, that would really benefit them. People have spent a lot of time what happens with climate so they can help protect these farmers and protect their animals and, obviously, the community. Thats how i got into Climate Change issues, was understanding what the dynamics were. And what became very clear right now is when we talk about Climate Change, everybodys like, whats going to happen in 2100 . No, its really whats happening today. So if we look at diseases, the biggest disease in the United States thats caused by art pods around no pods is lyme disease which everybody in this audience knows very well up here in the northeast. Vectors are spreading over the last 2030 years across the United States where theyre almost in about half of the u. S. Counties. So were seeing that already today. Theres a fungus, theres a tropical fungus up in vancouver causing infections of humans and animals. It doesnt belong in vancouver, it belongs in the tropics. Theres were getting infected oysters from the northwest. So we all know any oyster eaters here like me . Oh, you dont Pay Attention to all the good public be Health Messages about oysters, okay. [laughter] im an oyster eater. Gulf coast, right . You eat oysters in cold month, and one of reasons you eat oysters in months with r in them is to protect yourself from infected oysters, especially gulf oysters. But that shouldnt be a problem if youre getting your oysters from the alaska area, because be they should be nice, cold waters. But we have now started to see outbreaks reported from those oysters in cold waters, because the waters arent as cold anymore. So, you know, contemporary examples of today where were already seeing because of Climate Change. Let me shift you from the u. S. To europe. If you go to sweden they have this Tickborne Disease called, very simply, tickborne encephalitis. [laughter] we doctors, we give it back to you as a medical term, and you think its so smart. [laughter] its called tickborne brain inflammation, and what weve seen in sweden is that this disease has been spreading over the last couple of decades. Theres a lot of factors in addition to where the heck were living, but climate is one of those. Rest pri story [inaudible] virus little kids get infected with rsv which causes this severe respiratory illness. Usually theyre okay, but not always, and what were seeing is those seasons in europe are becoming shorter are becoming shorter and shorter because theres less cold months. So those seasons are becoming shorter. So, again, contemporary examples right now that are only going to get worse when we think about heat waves. Whats happening in india right now . 128 degrees or Something Like that, heat wave. And, yes, less people will die from cold, but proportionately more will die from heat. When we think about heart and lung disease from all the air pollution and then, obviously, all the Infectious Disease. Anything that has to do with the mosquitoes and ticks and where things are, climate plays a big role in those and be then theres foodborne illnesses, waterborne illnesses that are an issue as we get flooding, obviously, severe storm ands and mental storms and Mental Health illnesses. Now, the biggest factor after all of these, and all of these are important because whats happening to microbes, whats happening to us, whats happening in the environment is actually more political social factors. And if you look at these outbreaks, these diseases will continue to emerge as i hope ive convinced you over the last 510 minutes. But i think we play a role in keeping them from becoming epidemics and pandemics. A good example would be the recent outbreak of ebola in west africa. It wasnt new, right . Weve known about ebola since 1976. Weve known about the science of ebola since 1976, and i had the opportunity to help support that science in the mid 1990 when i did an Ebola Outbreak in zaire. So what happens . You get infected with ebola, usually probably with a bat, and if youre out way in the bush, you die 8595 of people die. Unfortunately, maybe a Family Member will die with you. But youre out in the bush, youre done. Lets say you change that dynamic and you decide to seek health care in a hospital. Unfortunately, in a hospital that doesnt have infection control. So when youre infected with ebola, you essentially become a virus factory, and you get infected, and your immune system doesnt kick in, youre just increasing the amount of virus youre producing every minute until you die. When do you have the most possible virus in your body . When you die. Well, as you go to the hospital because youre sick, and you dont have more than when you die, okay . And i can give you a ten with lots of big numbers around it means hundreds of millions of billions that happen to be in a milliliter of your blood. Here you are sick, dying in a hospital, and somebody doesnt wash their hands as they go from patient to patient. Whats going to happen . Youre spreading ebola from patient to patient. So hospitals have always served, and weve known this for many years, as a reservoir for how these diseases get amplified and spread. Somebodys sick at home and youre the Family Member taking care of them, youre at risk. They die, unfortunately, and then you decide to wash the body, can kiss the body, hug the body, invite all the loved ones. One of the practices we saw was they would wash the body, and then they would use that water to allow little kids and other people to wash their hands to take on the attribute ares of this sainted person who had just died. This is not a good idea. [laughter] okay . Lets admit, lets admit that. So, but thats the science. We know the science, right . But the science isnt the issue. So when this outbreak occurred, and i think this was the 4th, 25th, Something Like that of ebola weve seen since 1976, many people had thought, oh, this is going to be just like what weve been seeing in east africa. Uganda shuts them down within a couple of days, they have a system in place to identify the case. Teams rush in, they dont even need International Teams anymore. The locals rush in, they test everybody, they follow everybody whos potentially sick, and they extinguish these outbreaks very quickly. And this outbreak occurred in west africa where its never occurred before, so nobody had seen the disease before, and be it very quickly spread to urban areas, large, metropolitan, dense urban areas with slums. And the thinking was, oh, more of the same, you know, rush in, take care of everything, and this Ebola Outbreak will go away. What happened . Thats not what happened, right . So 11,000 deaths, each and every one was a needless death, i would say. An inadequate Global Response. Inadequate local response, obviously, but inadequate Global Response. And be so politics and our Public Health systems play the biggest role in whether or not goes from a handful of cases or small outbreak to whether or not you now what we had was, essentially, an epidemic across west africa with seeding of cases across the world including, obviously, we know what happened here in the United States. And be one of the reasons we had that case in the United States is another factor, social political factor that plays into inpeck white house diseases that we Infectious Diseases that we didnt have in the 1800s. How many people have read around the world in 80 days or have heard of it . How quaint. 80 days. [laughter] to get around the world, okay . So for 22 years, i wore a Public Health uniform. And on my Public Health uniform was an color. I would get an anchor. The Public Health uniform looks very much like a navy uniform, and the reason is we started about 200 years ago providing care to merchant marines. And one of the chores of the Public Health service, which we still have right now, was essentially to fly quarantine flags when the ship came into port and there was somebody with yellow fever or smallpox on it. Well, if its going to take you 80 days, by the time you showed up in new york city, we knew if you had smallpox or yellow fever because the incubation period was always shorter than the time it was going to take to go from point a to point b. Well, weve turned that upside down now. So you could now go to your mothers funeral in liberia, right . So you fly to liberia, go to your mothers funeral, engage in the usual acts that you would around a funeral, you know . Youre distraught, your mothers died, youre kissing her, youre hugging her, and then the next day you get on a plane up through amsterdam to new york city. Okay, so weve got, what . 18, 24 hours, maybe 48 hours, incue base period of 57 days . Well, its three days after you show back up in new york before all of a sudden you go, you know what . Ive got a headache, ive got a fever, and im not feeling well. You show up at a hospital. If its a good hospital, their number one diagnosis will be malaria, one, two and three. And if its not malaria and they miss this, its very easy to the see how you get hospitalized for something, and you can spread decide within the community. We saw this happen in texas. Exact same scenario. Somebody showed up, came home, infected two local nurses. I have spent a lot of time in places across the world to let you know that our Health Care System is not better than toronto when they had the sars outbreak, singapore when they had their sars outbreak, hong kong or i mean, i just spent some time in seoul. Seoul had an outbreak due to mers which is a stars relative sars relative and, again, excellent Health Care Systems like ours. But theyre not ready for these patients coming in with highhazard viruses. So travel has played a big role in how these diseases emerge currently. So so let me now so now i think ive started giving you a sense of why you always hear about this, but what we can try to do around the associate political social political aspects. I did want to spend a couple of minutes talking about ethics matters. And in this an observation i guess ive recognized it my whole life. If you think about hiv and who gets infected with hiv, its often marginalizedded populations. But as i started to write the book, it sort of dawned on me how almost every chapter you could pull out the marginalized population that was increased risk for emerging infections. Theres a disease thats due to row bents, often to rodents, and the most likely people to get infected was against native americans. Some of you will remember when this outbreak occurred in the early 1990s, there was this group of young navajo kids who had come to d. C. For a capitol tour, and they were denied a tour of the capitol because, oh, you happened to come federal the southwest. From the southwest. There was nothing in anything we knew that these kids were at risk, and they werent. They didnt pose any risk to us. But often these diseases affect marginalized populations, and it helps increase some of the prejudice against them. Ive already talked about hiv, you know . Ive talked a little bit about ebola and the sort of poor, marginalized populations in west africa. And in todays day and age, were talking about zika, right . Poor pregnant women in brazil. Brazil has about 1. 1 million cases i think is what theyre calculating now of zika virus and over 1500 women who have been infected, and their babies have gotten congenital zika syndrome, and this is a severe illness of babies where they get small brains, other Developmental Disabilities including hearing loss and vision problems. And what weve learned now is zika is, essentially, a laserguided missile for neurons. It looks for your neuron cells, and it kills your neuron cells. And be its not just and its not just true in babies. So when zika was first described, what we were told was, yeah, about 20 of people will get sick, and if they get sick, theyll get a fever, theyll get a little headache, some itching, some red eyes, and theyll get better. Be then very quickly it became clear that, you know, this was a problem for pregnant women. But now we know even for adults because of this sort of laserlike focus on neuronal cells, we have this disease calledgy yam beret syndrome gilliam beret syndrome, and it can cause infrom inflammation oe coverings of your brain. So even in what we should think otherwise healthy adults who are not pregnant, this virus is a problem. This virus shouldnt be a problem, okay . The virus is spread by something , a certain type of mosquito. This mosquito is not new to us. Its the exact same mosquito that spreads yellow fever that causes about 30,000 deaths a year. This is the exact same mosquito that spreads dengue, and if we were having this conversation about five years ago, wed be talking about this large dengue outbreak thats occur anything south america. This is exactly and dengue causes i think about 30,000 deaths a year, something around that. This is the same exact mosquito that causes chikungunya virus. That one doesnt seem to cause any deaths. But because of the failures since the 70s to keep up with these efforts to decrease mosquitoes and kill mosquitoes and not paying attention to the people dying from yellow fever, from dengue, now all of a sudden were all up in arms that, oh, we have a disease that seems to be infecting pregnant women. So is its this lack of action over the last 40, 50 years against a known threat that has put us in this current position. At least if you happen to be in south america these days. I heard yesterday that zika now has not just moved throughout the americas, but is now at cape verde. So its essentially knocking on the door of africa to say, hi, im next. Youre next. And so think about whats going to happen as that virus then sweeps through africa and the risk to pregnant women there in africa. Auger chen, whos the head of who, brilliant woman did some amazing work in her time in hong kong has admitted a major policy failure over the last 40 years in addressing this mosquito. Be also she broadened it to talk about major policy failure as we think about protecting women in contraceptive rights because theres a big issue in brazil and other places where they dont have the same sort of contraceptive rights as you take for granted here in the United States and other parts of the western world. So why did it take all this time, people dying of dengue, dying of yellow fever which has a vaccine to say, oh, you know what . We need to Pay Attention because now we may get some cases in europe and north america of women who may have this disease. We will see zika in the United States. So ill preempt that question. Hopefully, we will not see a whole lot of cases, but we will likely see it. Let me the i had oh, thank you. You gave me a lovely comment the other day. The ethics of a delayed response, and i think that goes back to something of what you talk about here amongst your audience. If you think about these marginalized populations, you know, why do we see these delayed responses. And were seeing it today. So the stories the last couple of days is this conversation, theres probably better terms for it than a conversation between, you know what . Lets protect the United States against zika. And nobody can decide whether they want to do it and how much they want to pay for it. And i often get asked, ali, should it be 500 million that the Congress Wants to give, the 1. 9 that the president wants to give . I dont care what it is, but why are we having conversation six months later, right . We mow whats going to happen. We also know that Mosquito Control in the be United States is not a federal function, its not 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 doing what they should be doing which is eliminating mosquitoes and making sure theyre identifying cases. And, you know, do you have the money to think about, you know, hopefully a longterm strategy would be a vaccine strategy to protect pregnant women. Do you have some sort of thoughts about funding a Vaccine Development for a longterm vaccine strategy. Why are we still having this conversation six months later, right . Why are we not already doing that . Why are we sort of robbing peter to play paul . So my old program at cdc was essentially responsible for keeping all americans safe from all public threats no matter their nature, chemical disaster, biological terrorism, and as part of that my passion was for the Public Health preparedness programs which put money out into state and local Health Departments. To help pay for the zika response, we essentially pulled back some of that money to help support dire activity in other places including puerto rico where theyve already had 1100 cases, believe it or not. Tragic enough. But why are we taking what ive my analogy is taking the bricks out of a foundation to build the second story of a building. If this is our preparedness infrastructure to support the u. S. , why are we taking money out of that to do Something Like zika . We should be putting money into the preparedness infrastructure, and what ill leave you with is a number because im all about observable measures. 6. 7. So in the last three years, the Robert Wood Johnson foundation has been doing great work looking at how prepared the United States is for Public Health emergencies. And every year it gets a little bit better, i think we started at 6. 3. 6. 7 out of 10. Thats just not good enough for us the if we really want to make sure americans are protected against Public Health threats. 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 now to realize you cant completely strip politics out of policy decisions x its not always about the science, but maybe sometimes we need to be stripping a little more politics and thinking about what are the health needs of our population. Thank you. [applause] well, that was fascinating. You seem so calm though. 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 be it makes, i know be it makes for great press, you know, the sky is falling, but really its about education and good science. Now, what keeps me up at night is what the next pan pandemics likely going to be. And its zika is a pandemic. Needless to say, its 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 be every year. Im going to tell you right now my Public Health message of the day is get vaccinated. It changes a little bit which is why we need a new vaccine every day. But unpredictably, flu just takes off its overcoat, and all of a sudden you have no protection against it at all. And if we repeat the same thing we saw in 1918 today, 7. 5 million americans would die. Okay . 3. 5 . Think about the number of body bags. Think about how this would completely disrupt our society if within a couple of weeks to months we kill 7. 5 million americans. So flu, mers and diseases like mers keep me up at night. I do know, ive seep these Health Systems. Our Health Systems are Getting Better, our ability to respond to diseases are Getting Better. Part of my job in nebraska with the National Ebola Training Center helps hospitals get better. But we know the risk of Health Care Acquired Infections here in the United States. So i worry about mers as another example. A third example, and ill stop at the third example is the next hiv aids. So, you know, hiv aids, another nowadays, you know, you think of it in terms of sexual behaviors or iv drug abuse, but lets remember hiv aids was another one of those nonhuman diseases. It came from be primates, and one time it was the right version that made its way into humans, and then it spread from human to human. I worry about another stealth virus hike that thats like that that has a long incubation period, and by the time you discover it, its already spread be widely. Those are some of the things that keep me up at night about what the next pandemic could be that would have really significant immortality. Well, thank you. Id like to open the floor for a discussion, and when i call on you, please introduce yourself. Well start over here with susan. Susan gedolph. That was too fascinating, especially in the morning. [laughter] 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 an indication a they might be serious. And on the other hand, youre now in nebraska. What is the difference between control measures in an agricultural state with a 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 these outbreaks . Thank you very much, susan, thats an excellent question. How we can do more starts, for me, at multiple levels. And i you always tell people theyre more powerful than they think they really are. So lets start with something very simple, Health Care Acquired Infections and drug resistant microbes. So a paper came out last week that suggested onethird of all the antibiotics were using are unnecessary. Onethird of all the antibiotics were using are unnecessary. So as a patient when you go in and talk to your patient and talk to your doctor, you are powerful to say do i really need this antibiotic for my cold, doc, or is it something we can work out for a couple of days, and then if it doesnt get better, i should take an antibiotic. You have that power. You have that power when you walk into a Health Care Facility and a doctor or nurse or respiratory technician walks into the room to say did you remember to wash your hand, okay . You are powerful, do not forget that. You have the power within your community when you think about personal preparedness issues. So are you if, lets say, a 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 are your vaccines uptodate . How many people in todays cell phone ages actually know a physical phone number . The only phone number ive forced myself to memorize is my wifes number. If somebody asks for a number, i pull out my cell phone. So if my cell phone dies, not so good, right . In terms of numbers. Am i part of a Response Team in the community . Have i taken a cpr course . I could take care of something small myself or help somebody else. Am i a blood donor . And then its things we should expect from our government, and thats where were powerful. So if tomorrow morning in new york city we decide canned, you know what . Lets lay off half the police force. My guess is you will tar and feather that mayor because you think Public Safety is so important. But the same thing is happening invisibly to your Public Health safety work force here in the United States where its not fully funded, and nobody is tarring and feathering anybody when you get a score of 6. 7 in how prepared your community is or how prepare your state is. So to demand the same thing from your local representatives and demand the same things from are your National Representatives that we want a little less politics in what is happening in our health. Why are there still to 30 million uninsured 28. 6 million uninsured americans in the United States right now given the fact that we passed the Affordable Care act . Nineteen states have not passed medicaid expansion. So 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 cdc, i did a tongue in cheek thing about the Zombie Apocalypse to try to get people to be prepared for Natural Disasters, because somehow they werent paying attention to the real Natural Disaster, but you mention zombies, and everybody wants to know what to do for zombies. [laughter] dont ask me. But we took a popular meme and converted it. But one of the things i did use the meme for, i said, you know what . The one thing you can do with zombies is outrun them, so please stay personally healthy so you can outrun those zombies. Again, something you can personally do. And that changes, whether i happen to be in nebraska, an agricultural state, or whether i happen to be in washington, d. C. , what greater risk of importation of international diseases from travel. The local Health Entity needs to take the things into account including, for example, Climate Change. Were not coastal, youre coastal. What is that implication going to be for, you know, flooded Water Supplies and stuff like that. Thank you. Mike [inaudible] long island university. Longtime inveterate news scientist reader. And i remember an article, an opinion piece some years ago to the effect that if only silent springs publication had been delayed for about three years and if ddt use had continued for another two or three years, we wouldnt have malaria. And, you know, you stressed 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. So we were fortunate here in the United States to actually, cdc, so cdc is the only or 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 southwestern United States, and there was a malaria in war areas program. And we were sending our troops down to be getting trained in the south, and they were getting infected with malaria. We dont need that. So this program was set up, and that program became cdc, and malaria was very quickly eradicated in 1945, 46. But lets look at dengue right now. So we see dengue on the texas border due to mosquitoes. We see it in mexico, we dont see it in the United States, and its not due to ddt. Its due to screens and airconditioning, actually, which is one of reasons that will protect us against zika. So youre right. When we think about what does it take to protect us, we need to use every tool. For mosquitoes, its about killing the babies, the adults, and then its about source reduction which means find all the little sources of water out there and get rid of it. So we need to be thinking about every tool that is available to us. And and i think including ddt and others. And people are thinking that way what is the right tool for the right area. What are mosquitoes resistant to, or what are they not resistant to. Im christian [inaudible] thank you for this presentation. Dr. Khan, i wonder, as you know, a number of societies have had prohibitions against consumptioning of certain animal proteachs. In the faith proteins. In the faith be i grew up in, beef and pork were por or bidden. And forbidden. And you made the connection theres a lot of connection between these kinds of viruses that came from animals, and i wonder if any studies have been done to show that societies where the consumption of animal probe teen is protein is limited or not at all, ability to resist some of these illnesses, the ability to take antibioticses 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 an excellent and extremely complex question. So theres let me break it down into these two quick pieces. So one is we to know that people who have a predominantly vegetarian life live longer and do better. Thats pretty much been well established at this point. And let me get to this beef and animal consumption. The other issues are zoo nottic infections, and they have to do more with the close contact we have with animals, not necessarily consumption. Because when you think about it, and i say this all the time since i dont eat pork either which is if you just heat it to the right temperature, there is no risk, right . You hear this about your burgers, you shouldnt be eating burgers that are rare or immediating them medium rare eating them medium rare. All you have to do is just heat it to the right temperature. The risk comes from the daily interaction with the animals, the routine set of interactionsment even if youre not eating them, if youre milking them, if youre keeping them in your houses, that risk is there. The same thing with fowl. A wellcooked chicken fillet isnt going to tell you, but handling these chickens that have chicken flu will potentially kill you. [inaudible] could you just wait for the microphone to come . Thank you. Marlon madsen from wild cornell medical college. I appreciate the clarity of your presentation and the impressive work 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 and response . And then something maybe about the World Health Organization in terms of whether it plays a part in this area. Thats a great question which links back to the earlier question about what can you do. So the u. S. Government has embraced something called the Global Health security agenda, and so should we with. That is a way for us to work with countries internationally to make sure that they have right tools and systems in place for the early diagnosis. You know, you want to find the first set of cases. Theres a number of countries that have bought into this including who. And, remember, cdc is a Technical Agency that does this work, and cdc has people all over the world to help with this, but who has a global mandate to do this. They are the world health agency. And they have been very introspective and have recognized the failures of ebola and what happened in ebola, especially not just the failure from the early detection, but, you know, six to nine monthses before they called it an international, a Public Health event of International Concern which is their official term to say, oh, my gosh, this is a problem. In the spring of 2014, they misread to think that things were Getting Better when they really were just a lull before they got worse. So theyre in the midst of a complete reform process right now to be able to better respond to these emerging infections including for the first time putting some teeth into the International Health regulations to actually go and do countrylevel assessments. And if theyre ready. And you showed the me the lovely article from the world bank today. The world bank is setting up a brand new pan dem cantic Response Fund 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, and he had no resources to do so. He just wanted a handful of cards and some dollars to do some work, and there was no ready sense of resources. So we cannot a afford for an outbreak to get out of control because somebody cant get their hands on a couple hundred thousand dollars to go do some surveillance and put systems in place in hospitals. Im Helen Thurston with the Bryn Mawr Club of new york city. One of my clients has city mosquito inspections, and they put traps out. New york city is actually looking for mosquitoes. You know, you mentioned the political aspect of the health situation. We have two candidates that are, i think, diametrically opposed on a number of Health Issues more care, more insurance care for many people and also on the issue of womens reproductive rights which are really, in my opinion, not womens but all peoples rights because everything that happens to a family happens to everybody in the family. Be could you comment a little bit on that and how this issue can be brought up in a way that affects the political outcome . So you know im the Health Person and not the politics person, right . [laughter] [inaudible] [laughter] opened the door. I opened the door. Im going to look for the expertise in this audience maybe for the that answer. So mosquitoes in new york. New yorks my home. I grew up in brooklyn, went to ps130, went to college and med school before i realized i could leave brooklyn. I actually have aunts and uncles who have never gone to the city, because why would you go to the city . Everything you want is in brooklyn. [laughter] so i know a little bit about the city from having grown up here mosquitoes though, you are very fortunate in having some of the best Public Health practitioners in the world here. And ill do a shoutout to Marcy Leighton and annie fine. In 1999 west nile started where . Right here. West niles another good example. West nile, it belongs in the west nile. It doesnt belong in new york, okay . Another example of a disease somewhere else that sort of came and decidedded america was home. Decided america was home. So you need, we need as individuals as we make choices about who we elect and who we support and the op to eds we write opeds we write to find people who say that health is an important factor. And youre much more eloquent than i can ever be about reproductive rights. Youre right, its an everybody right, its not just pregnant women, and we need to make sure women have the appropriate reproductive rights. We talked about brazil, but lets not forget the United States, you know . Theres a lot of things going on across the United States, and we need to make sure that women really do have a full set of rights. Ron baronpersian im. I want to ask a question about a developing global problem and also potential developing response to that problem. And the problem, of course, is refugees, and ill just leave it at that. And as far as the Global Response and what has been overlooked has been the role of pharma and the hack of incentives the lack of incentives in the pharmaceutical business for responding to these kinds of emergencies and to make a really wild suggestion that perhaps its time for pharmaceuticals to be considered pretty much as a public utility, a public good like the military, like the water system and like all the other things we have that we take for granted and that are not incentivized by profit. Thank you. So i assume the refugees was an issue to Infectious Disease issues yes, absolutely. And so my comment to that always is i know people often in terms of what risks do i have because of refugees, i like to reframe that in terms of how do we protect the refugees, right . I dont want them getting measles, thats a horrific disease. What are we doing to make sure the refugees are are protected themselves. How do we make sure theyre protected. And in any screening and other processes we do to make sure these people are protected. Pharma. So theyre actually people have recognized this problem for a very long time, so ill bring it to you from some of the stories i tell about anthrax. There is zero incentive for anybody to build a medical countermeasure against anthrax, you know, due to bioterrorrism or against smallpox which is Something Else that i worked on. And the u. S. Government actually established barta, biological advanced research and development agency, for that specific purpose in the department of health and Human Services to make sure that somebody understood how to work with big pharma and make sure we have these excellent products that now are available to us against things like anthrax and, you know, we have enough smallpox vaccine for everybody in the United States if somebody decide cans to reengineer decides to reengineer smallpox and make it in a lab. So we do have some mechanisms that are available to us, but youre right, its a challenge. Drugresistant antimicrobes, how do you make sure you continue to have new drugs available for these bugs that just get smarter and smarter all the time . Thank you. I guess you have addressed the biological threat issue just now, i was going to ask you about that. I would just like to thank you for an exciting journey you took us on. It was a wonderful talk. The book is available. Thank you. [applause] thank you. Thank you. Really, it was terrific. Thank you. Thanks for the opportunity. [inaudible conversations] ralph nader recently recommended 13 books for Summer Reading. Heres a look at a few to evade and or avoid paying taxes. Former nightline host ted koppels lights out examines the vulnerable of americas power grid. And john mar covers machines of loving grace reports on the current and future relationship between humans and robots. For the full list of ralph naders Summer Reading recommendations, go to blog. Nader. Org. Booktv has covered many of these authors, and you can find them on our web site, booktv. Org. This photo was sent to me in an email in 2012 just weeks actually, days after president barack obama was reelected in 2012. It was at the top of an email from the Christian Coalition of america, and i was struck with it at the time because it came right on the heels it was in between the election and thanksgiving, and it had this caption underneath it. It said family at prayer, pennsylvania be, 1942, right . Its the image here. Of course, its a black and white photo, its a white family saying grace before a meal, and then it had this line of text further explaining kind of the transition from the photo to the message of the Christian Coalition of america. It said this excuse me. It said we will soon be celebrating the 400th anniversary of the first thanksgiving, and god has still not withheld his blessings upon this nation, although we now richly deserve such condemnation. We also need to pray to our heavenly father and ask him to protect us from those enemies outside and within who want to see america destroyed. And, you know, at the time i wasnt really work on the book quite yet, but i immediately saved it, because it seemed to me a symbol of this visceral reaction to the reelection of barack obama in 2012. So part of the book is about unpacking, like what is that about when we see this kind of reaction. And this kind of throwback energy, whats behind that sense of nostalgia and loss and grief . The book is called the end of why is christian america, and i want to say to kind of prevent some confusion be, what i mean by White Christian america really is a metaphor for the whole cultural institutional edifice that was built not exclusively, but primarily by white protestant christians in this country. That really did set the tone for our National Conversations and really shaped a lot of american ideals. I mean, it wouldnt be hard, you know, many of you may have walked here, to walk very far without tripping over an institution that was started by White Christian america. The ymca, the boy scout, you know . It would not be hard or to kind of find these things. And yet these kinds of institutions and the world that they were really a part of has really passed from the american scene. And so thats really what the book is about, and you can see this in a number of demographic ways, you can see it in architecture. Im going to focus on demographics just for the set up of the conversation here. If i can show you one chart and unfortunately, im going to show you a few more [laughter] but if i could show you just one chart, it would be this one that really shows us some real changes that happened just oh the last just over the last eight years. Ive got shaded in light gray the period of Barack Obamas presidency. This is all White Christians together, the prang that all white crisp chans the percentage that all White Christians lump together comprise of the american population. So in 2000, 59 of the country. By 2008 when president barack obama was running for president , that number was 54 . Today that number is 45 president. 45 . It was 47 in 2014, and just in the next year our latest data shows it at 45 . So just during the last two election cycles, during Barack Obamas presidency, we have crossed this amazing threshold. We have moved from being a majority White Christian country to a minority White Christian country in just a short amount of time. So this is, in fact even if people dont know these stats that well, i think many White Christians, particularly White Conservative christians feel this shift in their bones, right . And this is part of some of the reacttivity that were seeing. Just to kind of put one more kind of symbolic issue across this same time period and putting up here support for gay marriage over this same period of time. And, right, so if you just, again, go back to 2008, what you see is only about 4 in 10 americans supported gay marriage when barack obama was running for president in 2008. That number today is 53 . So similarly, weve gone from a country where only about 4 in 10 supported it, to being a country where a majority support thats a major cultural shift on a pretty big bellwether issue in a short amount of time. To part of the story that the book is telling is really about unpacking the reactions and the grief and the anxiety around the reactions to these kinds of demographic ask cultural change and cultural change that weve seen really in the last decade of our nations life. You can watch this and other programs online at booktv. Org