Transcripts For CSPAN2 Key Capitol Hill Hearings 20141022

We long anticipated was a gas guest and waiting for a match to it. In a sense if this outbreak is in the past, no its not. Is it the same virus in a different setting . It could be. But i will share more with you and what i think of that. We are making this up as we go but that isnt new to Public Health. Weve done that in the past. Its not a bad thing we just have to be mindful we are making it up as we go. And giving that we have doing that we have to become more uncomfortable huggable with uncertainty. I reject the idea that you cant tell people you dont know because you are afraid youll scare them. There is a complete literature on miscommunication that says people are never frightened by if you tell them you dont know this is what im going to learn or this is something and it might be scary. So the literature shows over and over again there are two things that will turn them to be very concerned if not scared. One is if you tell them with certainty a and candidate with uncertainty be and a and b. Dont happen in the way that you tell them, then they wonder about your current ability. The second thing is if you get the dueling banjo zero get one person that says a and another says youre going to scare people dont say that because it isnt true, literature supports that when people get concerned. So, in that idea let me just say one of the worst enemies we can have today is dogma. It should be at the first thing we jettisoned immediately. Its different than standing behind the science and knowing what we know and how we articulate a do not fall into the trap of dogma and i see far too many people today to be met. Do the math. For the fact that they want to reassure the public about a b. Or c. That is a dangerous path. In the piece i wrote and told eecho over the weekend ago i wrote twice over three plants are planned aone, two and three. Plan a try to stop in the three affected countries using the technique is that we have so well used for so many used it effectively for so many years. And there were reasons for that. First off i want to point out that we did have one oracular save. It was remarkable what happened in nigeria with the one individual, the minnesota resident traveled from liberia to lagos and was infected from the time he got off the plane but if you look at the intensity, over a thousand people and someone whos part of a high socioeconomic status group largely within the healthcare setting where the exposure occurred and the fact that they extinguished that i think that was a testament to the nigerians into the cdc. But if that same person landed in the slums of law goes and had gone undetected couple generations that wouldnt have been the same situation. I am convinced of that. We do know that these things can work but once you get into this setting do they work. In my simpleminded way that i look at this, imagine this critical distance we can go 4 miles an hour, hour after hour after hour but you put them in the river the current going 6 Miles Per Hour downstream and you say some upstream, every hour on the hour he or she is 2 miles further downstream than when they started in the hour before yet they are going like the devil. The question is do our methods work when you have such a situation as you have with no infrastructure, no healthcare etc. So we have to accept the unpredictability. We dont know what will really work. We dont and we have to acknowledge that. Why . Because someone is going to ask did you do what worked and we will say we tried our best. I still recommend it and i still say treatment is the key and you ought to be tried in everything you can or even home detection control kids. Anything you can do but lets not make promises that we know right now we cannot answer because then we are just contributing to the problem. I want to just point out the first set of presentations were outstanding but i want to point out the presentation it was really very good. One of the areas we are hearing a lot of criticism right now is wait a minute. You have the cdc saying 1. 4 million cases by the middle of january for two countries but the who says 20,000 by the middle of november for three countries. How can you be so far off while this is another one of those areas where the hubris and icy hubris not a man on kind way to get us in trouble. My answer which is really simple is theres going to be lots and lots of cases and lots of lots of deaths if we dont what that number is going to be and we just have to accept that. So nobody is right or wrong. We dont know. The precision around these estimates are in fact a big enough to drive an entire convoy through. We also have to understand progress is painfully slow. In the peace and political writeup about the fact that the virus is operating on is a virus time and all the rest of us is on the bureaucracy were programmed by an, and the virus is winning hands down, and it still is. I commend the u. S. Governments response. No other country in the world has put forth the same response as the u. S. It has been woefully inadequate to cause it is up against virus time to read when the president tells us five weeks ago that he is going to send 5,000 troops and until last week there were only 200 on the ground and now theres three under on the ground, the Logistical Support that is my 3,003 at these beautiful slides showing all the donations that have been made arent fair. Its not happening. Nobodys to blame. Everybody is to blame because the world wasnt prepared to respond in a crisis like this. Isnt it rather ironic the only nation in the world actually has an operating Medical Center right now staffed with experts in the medical area is cuba that has an operating medical facility right now in the three affected countries as cuba and they are doing a lot more work where are the rest of us . I know that we are coming into the sunset down the road but this is something that operated in a very different situation and imagine the city of minneapolis at a large fire into the have to call the new York City Fire department. There would be helicopters and it would be wonderful but in the meantime annapolis would burn down. We have to understand that as the new world order when it comes to Infectious Diseases. We have to understand that the Health System in these three countries has collapsed completely. By my best calculation we still have many more deaths in those countries today from hiv, the major Measles Outbreak right now, from pregnant women delivering their children under the most terrible conditions etc. , etc. From the humanitarian standpoint that is a tragedy not reported on right now and that is as desperate as you could imagine because there is no other health care of any kind. And the fact to me is also another storyline that talks about what happens when you have these failed states situations and we have whats going on. The Health System collapse has been incredible so dont just talking over to build up the Ebola Treatment Centers we have to build an entire Healthcare System if we are going to impact even ebola. Its going to be very important. And again i come back to the fact i want to leave no lack of clarity. I believe the only thing we can do is continue to try the treatment to try to to do as much as we can to isolate the infected individuals and quarantine. But im ready to acknowledge, you know, im swimming 4 miles an hour at the current 6 miles an hour. Its not going to be enough. Lets not fool ourselves into dont tell the world its not going to be enough but we have to do what we can. Its just like with dallas its time to reconsider the response. You heard yesterday how federal agencies are willing to consider the response. You know what we should be able to do that and not feel like we screwed up the rate we should be able to do that and not feel like we are to blame and yet we accept the accusations that in fact we screwed up and ive got to tell you a lot of the public thinks we have because we are not willing to get our message out to say uncertainty is reality. I am not afraid to say i dont know. Im not afraid to speculate what might happen. But i always come back to what are the data. We need to do more of that. Plan b. , and this was was a part the part in my article in politico where i said wakeup world, we dont get it. You know, when its over there in west africa its kind of easy just to call west africa. But we are in a place like the school of Public Health for International Help is such a prominent important part of that that is not true and i commend you all for that. But west africa is there and they cant quite tell you isis is in east africa or west africa there are all problems. We have to understand what is likely to happen and this to me is the next black swan waiting to occur and this was very troubling to me when i did this. I actually published in the political piece a very wellknown part, and i know that we have individuals from the affected countries here today who i will come to speak to this. That, every summer, our summer months of august, september, october, a number of young men and boys basically come home to west africa to help harvest the crops, well established much wellestablished much like the Migrant Workers in this country and in early to midoctober they leave to go back east to work in the plantations and the gold mines in the charcoal operations and even in some cases fishing. I wrote about this in the political piece in several media sources questioned me about it. These people moved by basically the back places that nobody knows and there is no checkpoint , there is no identification parts. I had people call me and asked me where i got this information. I got it from talking to people and sociologists people that have spent a lot of time trying to understand this whole issue and have years and years and one of the things i think that ive learned is theres been a crash course in a very valuable one but what does that mean . If we are worried about this Infectious Disease forced fire in africa burning away and the sparks fly and occasionally into dallas or wherever, imagine what the distracting to the east right now. I dont know how it wont get into those other countries and i can show you the route that we know who these people moved and this is just trying to get out of the infected countries. Lagos is a one and a half day trip for these people, even can shot kinshasa daily more than all these three countries combined. If west africa was a can of gas waiting for a match to hit, the rest of Central Africa is a tanker truck waiting for a match to hit it. We dont quite get it yet. And there is no plan b. There is no plan b. How would we fight this if in fact this were to suddenly in one of these cities along what would we do, could we fight it . We can fight it on the one front. And all a masking for is not to divert anything from west africa but somebody better be thinking about a plan b. Where is it . I will come back to this in a minute, but its not just about ebola. Ive had a number ive done several briefings on the hill for the house leadership and the people that had the most interest beyond the Immediate Health group was the intelligence committees because they see if you destabilize as part of africa publicinterest issue is remarkable. And we are already concerned about the breeding grounds. So as much as this is a humanitarian effort, and it is and lets make no mistake about it this is a selfinterest effort, too. If we were ever going to invest in a timely major way we would invest for that reason alone we do not want to give the world another place where the states are so failed that you can go without impunity in terms of issues around tourism, planning location, etc. Its huge. I would also talk briefly about another plan b. But some were concerned about because i did mention about the transmission. I dont want that to be a focus here. Whats plan c. . For me its one of the hope i think we have ended as a vaccine. I believe this will be an endemic disease and we have to be careful about the trust. Ive worked very closely with mss over the past few months and again, and organization if anybody can win a second Nobel Prize Committee should. They have seen themselves, this splash of cases, elimination of cases, shut down the clinic move, bring it back, shut it down. We dont really understand whats going on in that area. That is a huge piece. So, to me coming at at this point, one of the things that we really have to understand here is that we dont understand whats going on in all of that and thats why i think that this is going to be an anthemic situation and the vaccine will be the answer. Having said that, ive got great concerns about the vaccine situation right now. I think we have great candidate vaccines. At least i was some might say braindead to talk about something that i talked about ebola. Ive been braindead for decades as some of you know, and i got in the trouble back in the 1980s when others made the comment that they would have an aids vaccine in several years and i was quoted in the New York Times that same week saying i didnt understand how that could happen and i didnt have an effective aids vaccine in our lifetime. I couldnt get my mind around how a retroactive vaccine was going to work. Kind of like the beam me up scotty machine. I still have that machine. We can have an effect of ebola vaccine. Im convinced of that i believe that we can. But there is a big disconnect between the work that gets us there and at the time it takes to get us there and then getting it into somebody in africa. And what we are not doing right now, we are not basically gaining this all the time and all the way through. When we are talking of a 57 milliondollar investment in the United States that sounds like a lot of money and i think the United States for that. Thats a drop in the bucket if we are interested in moving the vaccine. And in this regard, actually, we need to be dealing with everything at the same time. The rnd, the potential for measuring how its going to work whether it is the vaccine effectiveness how are we going to make it, how are we going to finish, how are we actually going to get it to africa, how will that be sustained, who is going to get it i want to know that now. I dont want to wait until we get a dime and then we will work on b. And c. We need to imagine that it could be on fire. That means now. Jeremy for our will be cochairing the Team Sponsored by the organizations that will bring together a group of the experts in those areas and we are going to be coming out with a document within 30 to 60 days laying out the challenges. But it must be mapped to get an effective vaccine. It cannot be business as usual. That doesnt mean you take shortcuts and potentially impact negatively on peoples lives, but you dont wait for the program time to catch up to the virus time because it will never happen. So, to me that is a very pertinent part. The other part is we urgently need an International Resource agenda. We have done. We have nine. I understand in a time of dire humanitarian streets but its hard to do research. But we arent doing research for research sake we are doing it for prevention because we have lots of major questions that we have to get answered. And we dont know. I think that it is a travesty. We are now in this outbreak and we have a single set of isolates with genomic data from one location in sierra leone and we have people making pronouncements about what the virus is doing and they dont know what they are talking about. We dont even know what is going on. We need to have that kind of an agenda right now and understand transmission vector. Whats happening there, why is this different . Is adjust the population or are there other things going on . I dont know that there is coming and i sure do not want people to walk away thinking that is scary. But we have an obligation as scientists not to have another event. Ask ourselves what is happening and why. We need much more data and biology. We do not understand that. I see the evolutionary biologists and people commenting often about what is happening there. And we do not have a clue. We are working in the most binoculars that ive ever seen. We need the data and clinical outcomes. I think that today you saw very good information. I think that the presentation was quite outstanding in terms of what they do. What does make a difference is that this is a classic storm weve seen with so many other conditions. What can we do about that . Right now they have one approach that weve taken in liberia because of the dire conditions that we are delivering here. Helping to understand how well that works versus the more intensive care method is true. Finally the issue on those communications i just have to say right now. I think that weve had a number of people in this government that have tried very hard to do a good job, and i think they have. But we have a problem with the fact that we think we are going to scare people and so we are always coaching people which certainty does not exist. We have to start being honest about that. That is different than being scary. We already understand issues. If you solve the sunday la times, you saw the piece. The who report 7 of the cases had a fever but there was a problem with that because you have to have a fever to be part of the Case Definition or to become positive in addition so there was a certain selfselection. I mean im not saying how big it was. Maybe it was minimal, but it was there very i personally have heard from commissions with a whole series of cases where people did not ever present for the entire time from the admission to the treatment that they ever had a document on hundred five or 101. 5 fever. They never did. Now we have focused so heavily on the screening in the clinics and so forth what if the Company Presents but doesnt have a fever . What happens when the media gets a hold and says you told us they would be a fever and you told us that the now this patient has been found to have ebola but didnt have a fever. You didnt know what you were talking about. Now is the time to anticipate that and say you know, most patients are going to have a fever. We saw that but we dont know about this a groovy and we are trying to learn more about it. Tell them what you might have had happened and that is how they will know about it and that is how you will feel like you cannot talk about it and number two, then if it happens, and i believe that it will happen, you dont have to feel like somehow you didnt tell them the complete truth. The issue on airborne i just want to cover this one briefly into say to two comments about this. One, please understand we are covering two different issues. The airborne and the immediate immediate patient space and theres been a series of things written about this recently. Where ive got to tell you that we really have never been into position to judge whether the airborne transmission could have been because it has always been overwhelmed by the host contact. The aerosol is created. I worked on too many infections where somebody at the podium vomited and mailed at the first seven the first seven rows over the next 48 hours. Even though no one ever touched it. We have seen too many things like that. We dont completely understand even the case in dallas. I am not here to speculate and i urge people not to speculate what do we know that there was potentially any issue that has the focus now on incubation . So, there may be in a close space a very limit of the kind of thing. But to say that it doesnt happen bags the question that we should try to understand that. It was never something we could do before the second part of this i raised the issue about the potential for everyones transition being a respiratory agent. And by bringing it up today as more of a classic example of what we shouldnt do. I raised that because ive been talking to to a number of biologists are very concerned about it they been cited in the media talking about it. And its not as great evolutionary we are going to have a mutation happened. Its from carl zimmer nonetheless most people would say a very noted Science Writer and he said the chance of americans getting ebola is tiny and while the viruses are noted for being airborne thats just fear. Thats saying that youre worried about wolves will be born and fly around and attack people. Evolution doesnt work that way. You know what, i was one of those people explain why hiv was never going to be a respiratory passion because we understood which sells and that wasnt going to be an issue. Number one, the transmission of the virus occurred by the respiratory issue. We had one where pigs transmitted to subhuman primates and it was interesting because one of the people that comment a lot on this actually said thats not a problem because we think that we are just putting up which is even worse that they fought through it at the virus was deposited. That is even worse. Okay. But its the point being that some people are concerned because we dont understand why that virus passed in the first place and subhuman primates. Something that we have learned about has concerned me greatly. He actually took one of the strains and a little over a half ago it was like any of the ebola by racist that they have seen and monkeys. As gary said its very worrisome to me about what i saw. Maybe it was a different virus. Maybe there is the possibility. Maybe you might get a cycle. Im not saying that to scare people. Plan b. , what the hell are we going to do if we suddenly see the potential for the transition that might be respiratory in nature. If we can talk about that because people are scaring people come into the blowback has been substantial. I guess im getting old and it doesnt bother me so much anymore because it was all based on what i believe to be the true science. It wasnt an attempt to scare but an attempt to have people think about this. But if we had another black swan event we had another reason to be concerned about airplanes. I dont do much of chance is. But i want a plan. And it isnt based on the idle speculation. Let me conclude by saying we all want certainty in this situation i guarantee that we will not get it. Mother nature will not allow us back. We have to stop providing certainty. We can still provide science and effective Public Health messages and we can still be in control of our own destiny as it relates to how we respond. But the virus is neutral right foot is happening and we have to understand that. But it can conclude in the two final comments that both very, very and important people in my life and being a kid from iowa, one once said if you dont know where youre going to get you there and i worry today do we know what the roadmap is . The who has given us one bit that has already almost been thrown out. We need a Global Response that addresses this uncertainty that we have and does it in a very timely way. We cannot accept any more pledges. We cant accept donations. We cant accept numbers. We need action and thats different. Finally, probably one of the wisest of all times said are these the shadows of things that will be or are they the shadows that may be only the knees or scourge . Thank you. [applause] during this time we are going to morph into the Panel Discussion that they very kindly agreed to be a part of. I would like to introduce right now josh who is the state of maryland secretary of health and Mental Hygiene whose kindly agreed to be the moderator for the Panel Discussion session. And i will invite the other panels to come up right now. Thank you very much. While we are waiting for everybody to take their seats i will just say that im a i am a little disappointed because i have been hoping that the doctor would have told us what he really thinks. [applause] [laughter] but i do hope that we will have the chance in the question and answer period. Okay. Why dont we go down the line im the secretary of the Maryland Department and im looking forward to this discussion. The main point of this period is to go to questions and answers. But in order to prepare people for that i think that it would be helpful for each of the panelists to give a brief introduction into what they do and their interest in ebola. Im an emergency physician right here at Johns Hopkins and im also a professor and vice chair for research and department of emergency medicine. I have done work over the past 20 years that ive been here at Hopkins Program development and emergency settings for rapid diagnosis of the various Infectious Diseases of hiv and influenza for excellence and Infectious Diseases where we have looked at the developing diagnostics for various infectious agents and now i am a codirector on the Influenza Center for excellence here at hopkins. My name is nancy and im a professor at the school of Public Health and also in our university Berman Institute of bioethics. And ive become a little bit involved in thinking about the ethics issues. We have a long history thinking about ethics issues and Public Health in Public Health and including in the infectious outbreaks and we started to do a little work particularly focused on liberia. I am the director of Strategic Communication programs at the center for Communication Programs here at the school. I oversee the teams that manage the fieldwork now in about 30 countries and my main message as a part of the panel today is going to be that communications and social mobilization are at the heart of the response today. Its important for for healthcare continuing both the care continuum communication can help us prevent and help us care safely, treat safely and have safe burials and as was mentioned before, increased vigilance and decrease complacency. And to do that, we have to have better coordination and consistency of the messaging if we do that. We can build trust and reduce fear and address rumors and inspire them to take action and ways to stay safe so that is my main message. Very briefly, what we are doing at the center come in the very first cases through the staff under the usaid funding but recently, weve been asked to ramp up the response in liberia and regionally in liberia including helping the hotline thats overwhelmed and monitoring the evaluation systems where weve put things into the field recently and soon we will be involved in the mass Media Community care. The second part of the response is in the regional preparedness succumbing the staff to unicef in new york and working with them locally and developing the preparedness tools in helping countries created the preparedness strategies in terms of communication. And just finally, i want to say that its an event you listen for on behalf of the staff around the world to mobilize for this and kudos to the staff that have been there for quite some time. My name is derek and im an associate professor in the department of epidemiology here at the school and ive worked in multiple emerging pathogens to characterize the and others i worked to characterize the transmission using National Scale data and they worked to design the systems to characterize the transition clinical outcomes are the units that you heard about being deployed to liberia from the dic. So a couple of points on that but i would like to make is i think that the burden due to the other passage pathogens is something we need to be concerned about now and in the future and i think theres an opportunity because of fever and symptoms that will be cases of ebola where people might present to the clinics and right now this might be the only sort of capacity to treat them. And the number one cause of the mortality morbidity and all three of these countries. And also reduce the burden of the cases that might show up later because of the potential of disturbing the broad response. I think taking up something that was said the International Research agenda, some of the details in this response and where it is failing and where it is exceeding is a target of research. We have tools that have contained the epidemics in the past and i think we have a problem of scale that ebola really makes it as it spreads it makes it harder and harder to contain because you are taking up all of the capacity and reducing that capacity to respond in ways that control the small epidemics. But i think that working out the details of where we are failing in his response and seeing a simple accounting we dont have the hospital beds to perform the isolation that we need to respond, and that just is calling the response. My name is michael [laughter] i often gets that wrong. I chair the emergency medicine and i have an appointment at the Bloomberg School as well. I am here today probably in my role as the director of the Johns Hopkins school of vertical event preparedness and response and organization that was given birth in 2003 to manage the overall response of the institution including the Health System and the university. My name is Lenny Bernstein and im a reporter with the Washington Post and i have no expertise on this matter whatsoever terri is [laughter] i spent a lot of my time calling folks on the panel into sitting in the french couple front couple of rows asking them to explain this to. But i did go to monrovia for two weeks in september and saw virtually all of what he spoke about in my assessment is that it is even worse than he described and i would be happy to get into that on these questions. This is a tremendously talented panel and family and its been believably interesting so far. I think that we are going to be answering questions in a minute i first wanted to ask you to get a give a little bit more detail about the experience since you have been recently in the area thats affected. Sure. Cut me off whenever you want to. I got there on september 12 and on september 13 very early in the morning we started by going to the Treatment Centers. I went to two of the three Treatment Centers in the hospital that had been turned into a chance for points. At any point in the next two weeks that i wanted to i could go to any of those places and i would always find the same thing. There were people sitting, standing, lying on the ground outside of the gates of all of those facilities trying to get in there yet they generally do not get in. If their symptoms are particularly dire like if they are being taken out of the taxi cab on a stretcher they might jump the line. That is a chronic condition the shortage of beds. When i left the opened another Treatment Center on the sunday before i left called ireland clinic. It opened on a sunday with 150 beds and on wednesday that he before i forgot it had 173 patients. Thats just the way it is. They have begun a program in liberia before i left to simply isolate the sick. They said okay we will never be able to treat everyone with the fluids and all the other things they need so maybe we can bend of the reproductive curve by simply taking the sick and putting them in schools away from other people so at least not infecting two people each and every person hasnt affected the two people maybe we can get it down to 1. 5 or Something Like that. Most of liberia isnt working. I could never get a really good number on this that many people will tell you 80 or 90 of the people are unemployed. Schools are closed. Theres a lot of people in the streets. They are just kind of milling about aimlessly. You dont have a sense of purpose. Before ebola, the monthly income was about 400 a month median income. I have no idea what it is now but im sure that its much lower. People are beginning to have trouble feeding their families. In the two big slums in monrovia just to show you the kind of thing that Public Health folks are up against, most people have no water or electricity, sanitation, cars or refrigeration. The city of monrovia that has 1. 5 million residents there are probably 12 ambulances. You can call for an ambulance if you get ebola or Something Else for days and days into the ambulance will not come. Your chances of finding an ambulance or next to zero. If i had to break down the population into two very broad categories it would be the people that understand that ebola is real and are trying to take precautions that are basically not equipped to do so and the people who dont yet really that evil ebola is real and the stigma associated with it or because denial is a coping strategy. And those that do understand that i saw people bringing in sick and dying relatives to the Treatment Centers and they would take those little plastic bags that you get at the Grocery Store and they would wrap their hands into sometimes they would try to put them on other parts of their body because they knew that when they brought this person to the Treatment Center in the taxi cab they were going to have to take that person out with their own hands and bring them to the gate. Most people just pull up in a taxicab and try to get some help for their relatives. They have the money and they cant get in. They drive off to the next Treatment Center or the next. A lot of people dont have enough for more than one trip and they would just leave the person there was that there. I saw a lot of people very sick and dying outside Treatment Centers. I think that is tremendous. [laughter] it really shows the incredible tragedy thats going on. I wanted to ask, having heard that from a respond to the Emergency Department physicians. What do you see as the key to your ready for the Healthcare Infrastructure and to the serious point are we in a trajectory to begin to meet those or what else should we do . While i very much like the message of not writing to say more than you actually know. The main priorities as you are hearing it in the news is to try to prevent even the remotest likelihood of transmission in the healthcare setting and its scary to the point that we think that theres a mechanism of transmission and if you take care of that event youre fine. But i dont recall an Infectious Disease respiratory or otherwise where the tiniest amount possible on your ppe equipment as you are taking it off but it might brush against some other part of your skin and you touch her nose and eyes and you are done or you have a tiny scratch we dont actually know. But to train everybody that might come into contact in the healthcare setting, we have four, five, 6,000 people any given day that might come into contact with patients. Thats a pretty big deal. On the front line that is an even bigger deal because you have residents come you might have students, nurses, nurses who are coming in from an agency because somebody called in sick or what not and so to get everybody trained properly is a problem. Based on and reacting as you suggested things change and reacting to some extent based on dallas but we did have a plan b. Maybe not so much plan c. We are getting teams to take care of potential ebola patients so we have a highly trained and highly drilled team that takes care of people rather than figure out a way to train four or 5,000 people that might come in contact with the patient is. I would echo those points. I think that improving and ramping up the infrastructure training across the country and the hospitals and if you are speaking to the u. S. Situation, those in building that infrastructure i think the point about effective screening approaches is a good way to make note of and to gather that information and create infrastructure understanding of the transmission and the most effective methods for screening. One of the things we worked on over the years at the various programs is developing diagnostic tests and i think that wasnt specifically mentioned, that the bedside tests that could be used to more quickly isolate patients at risk and more quickly make decisions about the need for isolation. And treatment im going to ask a couple more questions if that is okay. One of the things that came out pretty clearly this morning is the vulnerability of the very week acute care system and the countries as ebola has really preyed on that, you think of the Public Health as prevention, education, field vaccination, the absence of the hospital infrastructure has really made it very difficult to contain ebola. And the question that i have probably for doctor cummings and doctor osterholm is what are the interventions that are going to happen and how important is that on the capacity that they leave behind in meaningful care capacities were ability to take care or is this a sort of discrete problem that can be solved through, you know, a very focused effort on ebola . So, i think there are two very laudable goals. I think if you have the capacity had the capacity that you could put in place even temporarily there would be the utility to it. Obviously, less utility than the capacity that would build upon the longterm resources in the country. But coming you know, we are just behind the curve and i want to address the productions. Thereve been questions about the projections and sort of models. We dont really need a complex model to produce good forecasts of what is going to have been in the short timescales. Time scales. This has been doubling the number of cases over roughly 28th to 50 days depending on the setting. That would be very odd for us to see in the next 28 days, something dramatic would have to have been that we dont see the cases doubling 28 to 50 days. So, the 15,000 case estimate i think is extremely optimistic. Probably not doable because we already have 8,000 we are going to be doing things all that differently. Surprising that the projections are on your question because now every 28th to 50 days weve doubled what we have to do. At the model that you are working on to translate how does that relate to this end is that and is that something that you hope would happen . So, its very much right now focused on the shortterm to provide some resources to get ahead of this. I can get us help longterm capacity because the outbreak is with everyone from every six months that it goes on its way to reduce all sorts of factors which will impact the longterm capacity and each of these affected countries. First of all let me build on what he just said i think thats a very important point. One of the observations that very striking is we are getting more and more intelligence from the ground up that this is not like a fire line that is burning. This is a little explosion. And we are seeing clusters of activities that tend to flame and cause a big problem and then they kind of died down and they come back again. And one of the questions is wouldnt it be nice if we had the virus is to see what was happening and how similar and dissimilar are they and what is going on and how much of it is behavior etc. The other part you asked about the infrastructure. You know, i know that you have some really good neurosurgeons in this place but if you give a sledgehammer and h. Is o and that is all you have to work with, they would have some problems, too. And what we have done in Public Health as we have given the equipment of that of trying to deal with ebola on top of Everything Else that is going on. Very articulately of his late hour was going on over there and trying to overlay the comprehensive medical care on top of that is just so difficult. Thats why Doctors Without Borders has come under some criticism for at least one group but they are not doing more in liberia in terms of the therapy etc. I have to say they are on the mark because they are doing the best they can with what they have under those conditions and to me it is miraculous that they are doing what they are doing. So i think that is the undermining issue. We dont have an assessment of just how bad things are. And i think the thing that worries me is that if you look carefully across the equatorial africa, not just in there anywhere in the developing world, the same conditions are everywhere. They may not be as bad as they are in liberia or sierra leone or ginny did this got him to mumbai antiworker to get there and got into kinshasa or nairobi, i dont know that it would be any different and in fact i think is the message we have to start to understand. The last question i want to talk on the idea of the therapeutics. You mentioned that it would be a critical part of this and we heard about the diagnostic tests. In order to test and scaled the vaccine, there are a whole range of different ones that come up, two of which are what are the ethical issues in terms of getting it out there into the data that you need to base the policy decisions as well as how do you communicate about doing the research in the middle of a crisis like this . I would like to ask a brief comment from the professor on that. So, echoing so much of what you said about what they are trying to do with the messaging and i think that we have all seen in the Public Health response at least some media reports come across as sort of whats wrong with these healthcare workers when clearly people are responding from a place of fear and maybe messages not having been locally crafted etc. In a way that might make a big difference in the Public Health response. We have that sort of on steroids of a challenge with regards to the research and research and so there certainly are the Research Ethics challenges about when we are going to start rolling out vaccines cant go get them first into the test ban and do we do this design lacks this is a place where the sophisticated methodology and Public Health compassion and ethics can all be online but it takes a sophisticated thinking. The conversation that he had with a methodologist yesterday specifically about this question really made me convinced about the adaptive diesel signs are going to be the way to go so that we feel confident that we are learning whether the vaccine treatments work while being able to maximize the people that get access to something that seems to be defective. We know from the history of Research Ethics including in africa where we and lots of other people worked the last 15 years on the Research Ethics challenges that there is so much suspicion about medical research when it comes from the west. We saw what happened with polio and we saw what happened with meningitis. You go in with the best of intentions thinking youre going to help and whether the research is just taking blood for all of these studies which would make a tremendous difference and again, we all know what happens when you take blood and people die in the rumors start into the messages have to do with trying to help people understand what a placebo is and what you were even getting something if youre coming from the United States and giving people nothing simply to learn i think there is more and more people in africa trained on the ethics but a lot of it is challenging. Anything that you want to add . I just want to take an opportunity to talk about the kind of research that we are doing in liberia. As i said, about being a part of hopkins, people look to us in terms of behavior change and the communication as the experts in the research and being able to attribute the effect of the programs to the interventions that we are designing. Cicada kind of things that we are trying or the Media Monitoring system to look at the Electronic Media to see how the messages are trending. We are involved in a knowledge attitude and Practice Survey that is being mounted in collaboration with the government and the multilateral agencies. And we are also trying an innovative very quick system that we are developing to look at a few indicators over phones to get information from the Key Informants very quickly back to the comment was made before about the virus time. We are having to adapt our methodologies in order to get the very quick information, and all of this is trying to uncover the key factors in terms of the norms and behaviors that are affecting peoples risk behaviors and confidence to act. What is your level of confidence that we would have a vaccine that we would be able to develop an approach that could be used in the division and ethically that we could test it . Well, first of all i want to be clear i dont think that it is going to be an easy issue. I think that if you are in the middle of a crisis, people will tend to overcome other issues of fear and so forth if they think thats what they have but i think weve also seen coming in again, one of the issues im having to learn very quickly and i think that we all need to learn is social and culturally and i invite people in the audience to know more about this than i do, we are talking about these three countries as one kind of place but its not. You have very different populations. Why are those individuals killed . And if you understand the background to that it is actually quite hard to understand how they could these were not foreign nationals that were attacked. These are needed and it had to get into a number of different issues. So i think that it would be complicated and i think that this is where malcolm and i talk about the vaccine im actually talking about inviting and almost mandating that any program have not researched component to it now and start understanding that. I mean come if we have a big outbreak in nigeria with this coming your right we would talk earlier about the polio vaccine issue in northern nigeria. Why would we expect we are not going to have some kind of issue there. So i dont think that it is going to be just build it and they will come but on the other hand i think that we have an opportunity here to maybe put our best foot forward if we start thinking about it now and dont handle it like a bunch of Public Health at the genealogists only that we handle it as a social and cultural event it needs all of us on board. But you have to have the vaccine to do that. And i want to make sure that i get the vaccine first if we get at him. I think that we will go to some questions and maybe we will start either way. Go ahead. Thank you very much. This is a very informative workshop. I am from liberia and i happened to be president the president of the Liberian Association and i think that we are set with information that we can use with our community and with our people back home. My question has to do with one of the presentations one of the presenters in this series of axioms that have been developed or are developed and tested primarily on animals and prove to be not for the humankind. Recently there was a report of a doctor in liberia who was mandating one of the Treatment Centers. He had 15 petitions in his care and just studying and trying to understand it for himself without medication into the right tools to work with come he discovered that ebola acts in the story and the internal organs in the same way so he decided to use what he had. Of the 15 patients, 13 of them survived. There were two who died and the two that died were taken five or six days after they had contracted the disease. Those who of those who were taken earlier than five days survived. My question is have you given that report is there a possibility that we already have a vaccine that could possibly help fight this crisis and would you be willing to consider testing the vaccine as possible at this time . Thank you for asking that. I think that we heard it is best addressed to you that some of these dogs have been tested without activity if i heard correctly but i dont know if theres anything further that you want to say or anyone on the panel would want to comment. Did i get that right . Let me just say we were aware of those reports and although that we suspected the drugs would not work and its the reason that we did the testing and i show the data three tc and i forget that trade name but nevertheless, those drugs drugs had have zero efficacy and in one case they actually had pro virus activity in its presence than in its absence and that isnt to say other drugs in widespread use shouldnt be tested. Thats part of the repurposing program. But from our standpoint we are unable to confirm that those drugs might have worked. I would be interested. One of the challenges were seeing right now coming from the twin cities with the largest liberian population outside of the country liberia a community that has been concerned and organized to address this issue and have gone through a great deal of pain but knowing what is going on back home and the issue we have run into in the private sector job situation someone wanted to go home to help because their mother and father are dead they have to yonkers siblings and want to go back to that issue then come back to the United States. It is a heart wrenching experience then what will happen to you and we dont have answers for that. That is one of the concerns. Businesses are looking at furloughed 21 days after returning said he will find out theyre not going most likely and the policies are a debate and a dollar short if they know it goes into the other countries we have the same thing where other countries want to go back and help rooting into the fire not away from it. There is a significant level. They need Health Care Workers even more but it is hard to believe but it is only the second worst problem one is once they are built is inadequate they dont have the people to staff them. So in other Health Care Worker who feels they can do something they should try to find a way to do so because that is the numberone issue the hope is the resources and training that liberians are taking those jobs as a matter of the economy they need money but also they take those jobs to combat the crisis we need folks with expertise to train people on that is probably the most serious. Of also empathize critical need to. Just to add one thing the Liberian National Health Care Workers all went on strike because 80 to not have masks or gloves or goggles. What the hell is wrong with that . Why is that happening . We can deliver iphones from asia in 24 hours why cant we deliver masks or goggles or gloves in one week . I dont get it that is the part that frustrates me because losing that group is huge it is the backbone but i know how hard it is to strike but that is the part that is of a disconnect we have to get those together. You may know this better but it is not the equipment that before the various governments made the institutions to get over there there is a tremendous amount of with back from august of that p p e because that was the Opposition Leader not the government or the president so that distribution model that exists in these fail states is horrendous so we need Health Care Workers that is the plea. Johns hopkins has been trained to go to the disasters we are left with a gut wrenching decision would be really sent to our team into a dangerous situation where pp cannot be assured for one week you have one type and then the next week you have another little late now the intensive training will start to ramp up with security arrangements a huge number of logistics but everybody is working for Health Care Workers. You may have a fighting chance with other ngos and groups working for Health Care Workers it is not quite as simple as it seems on the surface. I think the recent discussion that the department of defense talking about the financial pledges but if i heard correctly no personnel would be in contact with patients we can all understand that complexity but i wanted to hear the thoughts that we keep hearing about that shortage that we will all be involved to help with that . First of all, the historic nature itself has urged the military involvement basically with the detached position for all the reasons giving an idea how far we have come, we just need a Logistical Support and also with command and control. And i agree but we need a mission to give half a command and control structure with the chinese and the cubans and the russians and the home countries to have one command and control structure. But the key thing is Logistical Support to bring that person know that is great but you have to understand so often we get into a Public Health crisis like this and it tends to be shortterm but this could go on for a long time so we also have to realize were not a sprint but a marathon. If you get one recruitment or to howard you get people to stay and support psychologically . I have not thought that far down road we need a bigger commitment and a just want to echo the fact i am proud the u. S. Has done as much as they have for the philanthropic standpoint why do we not see that . Saying that over and over where is the rest of the world . Secretary kerry said that whereas the rest of the world . If you dont care about the humanitarian side in shame on you but this is in your selfinterest you have to worry about terrorism and collapse infrastructure why are you not there . That i can understand. To pick up maybe it is worthwhile as the professors are still here, a think the question and your answer raises the issue of Global Leadership fair are Different Things toward who and its role and other important points. I have had a completely different strain. Reticulate from the broader perspective to the Global Health care system so feel free and come up to speak to that sinecure raised the question that cannot be answered in 10 seconds but by all evidence what needs to be there the day are pleading and it hasnt been there with the linn has created a mission for the Ebola Response that is the first time this has been done for a Public Health event and that is meant to serve as the structure to bring the different players together to work towards the same goal but that is what is meant to happen. Un serve several as a leadership function the u. S. Military does not need to say that rule in fact, there in support of that mission even within the u. S. Government but they do provide a critical Logistical Support that was mentioned so there is a lot more to do to get the resources where they need to be and when they need to be there space that. I agree we are in an that situation as the epidemic is ongoing youll have to look at how this is done though this is set up a physically now in terms of command and control we are long way from the book and approach there is a lot of leadership emerging the example as those that are attacked there will be a role with a prepared list and response to these epidemics. To add one little piece at the risk of being controversial but i am convinced this outbreak is said to be made joe 9 11 and i think the future of wa joe is in question of how it lacked in the future but there will be a lot of talk is it currently allocated for its time with civilian response and Financial Support all of these with the Health Regulations came through that this was an organization i doublea3 here for years now the same degree rachel will be there i think thisll be a very important time for Global Health and how we respond to those prices. [applause] i missed the a Global Leadership with the emperor structured just briefly wanted to conduct on the issues dated peters was talking about with the importance of local leadership and just one hopeful sign where the cases there from 790 cases in august and going down since when there was said debriefing about what worked they highlighted all those issues those local leaders tour committed and mobilizations your womens groups and burial teams so there are some hopeful signs focusing on the local level intervention and leadership and mobilization to uncover those resources that the community level. Ebola, it is personal for me that people from these countries of how to help the black man. With the issue starts data send troops they send doctors. So those from the villages ever since 1822 talk about infrastructure this is since fighting world war ii it has not been beneficial wasting my time talk about everything you have produced but you need to know something about it. That is all i have to say. [applause] figure. First of a bite to think the speakers with the situation and the Science Behind it. So with those 3,000 people we have 690 beds and so far only 40 of the recovered so there is not enough beds there is not enough of everything. So there is a need. To take into account to stop taking care of the patients we need more people but that is not enough. So for the time being we really need more people involved with the commitment is saying the science to approve what were doing now for the short term. We need treatment and vaccines we need way to do the Clinical Trial and that is understandable so we need much more and they give for organizing this meeting but i am asking for more. Before you go, if people are watching on the web cast and they want to know how they can help the efforts specifically they can go to your web site to contribute money . What else should people be doing . But also people pushing of politicians that we dont see thats led is the rule of everybody in the school of Public Health revaluate quickly to make them available and affordable. With access issue and affordability issue. Just very briefly what people are listening can do can help the entire response it is a shameless plug last week launched a website called ebola communication. Org is still had 4,000 hits and 170 materials but the whole purpose is for people to share experiences that they have been using so quickly since people are listening looking for concrete things they can do to share your experiences if you can go to the site so thanks for that chance to shamelessly plug. The question on vaccines vaccines, what is the pathway to the passenger and how do regulatory agencies reason respond to that risk . I will give you a little answer to that i worked with the fda hands there are a good and creative people to think about the trials necessary and what could have been based on the evidence along the way. But if you have different types of Public Health challenges you need the best people who understand how tears set the standards with Creative Designs which have to know as quickly as possible it is the challenge to know the people there and the commitments to live open to further comments on that. And mention briefly but i will say it again about to launch a comparison with hepatitis says the third arm what is being rolled out as a Clinical Trial will last speak to the fda but that will facilitate licensor. I will tell you a quick story about eight to one and one there was the push at that time with the experimental vaccine purses pushing to get that data and the agency felt very strongly if it could be licensed then you dont have to get conformed informed consent so the street work of licensor exceeds the risk is very important less than thinking this might work the risk is on new whether it makes sense then hopefully the agency can be comfortable enough to where we stand behind the product for people in west africa. So huggies a vaccine that as evidence of efficacy with 15,000 doses . And to engage Country Partners having 100,000 doses it is not that easy to think how you would use those. It is an Interesting Group to target as well it is issues of equity and to figure out which could be used to curtail the a break. This is the last question. I have two questions the first is with the Trauma Centers in any specific Health Care Facilities at first institutions that they may be overwhelmed of suspected cases of ebola . Initially the recommendation was to do a shelter in place and in a hospital felt they should come up to take care of patients people are questioning that regardless and that changed a whole spectrum but to give you some insight the biocontainment unit is a concept completely sealed off of all patient areas and is standalone have for 100 beds and some are virginia hospitals. And we are likely to go in that direction actually we should have a designated site for one of the hospitals we have not finalized exactly where but in the short term building that has to broker to meet those search and specifications with nebraska and the nih that have preemptively done this talkedabout having a public Health System better now faced with a one to play and contribute because we think that is our responsibility now how to do it quickly and pay for it . And now what about my other patients . Where will they go . To the ebola hospital . We face these same issues with hiv and that was a major hiv Treatment Center and today we see the benefits of that but back then oh my god where is the designated area . What happens to the Business Model . It is very complicated but we will walk in that direction it is probably the right way to go with the highly Trained Group of people who take care of these. Ims Family Medicine and dr. Said curtly a resident here at the school of Public Health. On september 13 us zero leone dr. Passed away from ebola and there was a hospital in germany ready to receive her but the divvy ratio declined transportation vichy was said garrisons irreplaceable asset for the doctors on the frontlines are the panelist in support of considering transporting local doctors to outside facilities given where transporting foreign aid workers in the area if they become sick . It is a great question and i want to say a couple things about it but separate questions if that is wa chose responsibility to take them out. First of all, the fact that employers have made commitments to their own employees International Employees if they get sick is not something that is unusual but if it is essentials is Johns Hopkins will send people over they have to guarantee their welltrained with enough equipment and air lifted out it is the same someone from abc news was covering the war in afghanistan the lake is blown off you assume abc news will airlift them out so the fact that happened is the responsibility the employers have but it seems to me that i am making this up but there are groups right now to contribute an extraordinary amount of money to ebola there are foundations trying to figure out what they can do to be helpful particular those that are not interested in going but that is the kind of thing that could be potentially set up this gets into the role of a who are not that was their role and it was complicated and a slippery slope that has to be anticipated of the number of Health Care Workers that were getting infected and what the budget would be it would be a lot of people but it is an important conversation to raise and jews think about addressing but i will not separate that let me give you some context it was dramatically impacted and there was a problem occurring at the time of certain aircraft plus u. S. Contract we even had a problem to delay that aircraft to seal off from a ready and upon the hill one of the first briefings that i did a very senior congressmen and it is interesting because i realized i had as high wire in the nation rocco right now but the pitcher said so to send something into harms way can we bring them back if they give their life . The biggest problem is to get people to go there because if they get sick it wants to know somebody will bring them home he said i never thought about it like that we do have some education to do here in terms of policy makers it is about a standard of whoever they may be and that is one of the few Fringe Benefits you may give it and we should make that a hallmark and i think that is a huge. One thing i have been surprised about to move this beyond Health Care Workers is to talk to people over there they no health care is available outside of liberia because the only check is the infrared thermometer period clear the fever checked so what is holding most people back is the money for the plane flight not talking just about Health Care Workers but if that were to happen from the ivory coast were something that is another situation. I am not at all an expert in that essex but i would go back there are relatively simple things to approve our medical response so i do think it is important to change that discussion how much we should offer people in the field even with helpful interventions we could improve the outcome so when i think from a public review that this has to be part of the messaging we need to change the paradigm to think about how we can decrease mortality because weve not have the funds to bring everybody out. Maybe just follow up what would you like to see available to everybody . Seven of this is done with Doctors Without Borders that you give people a few years they have cholera like diarrhea see you have to aggressively hydrate with the electrolyte replacement this is even within the steady to look bad electrolytes or how we would do that anymore developed setting. You can manage the not russia so there are things that were doing in the developed countries to be part of the bundle of care than the other thing is we can prove that the aviation of people that are dying and how to a incorporate into a bundle of care that is part of it dated is out there suggesting antibiotics something very simple as an important component during the illness. It is not terribly expensive than the other huge debate going on is when youre in this part of the world and a patient comes in and should reach three people for malaria while waiting for the diagnostic test . Were not talking about fancy stuff for xray machines but treating it as a diarrhea elvis to maintain basic hydration with electrolyte replacement. This question is about what you said earlier in your remarks around cases with fever that what i heard back in july for a malaria project i have heard the comment a couple times since then. The deal lets get the literature from other organizations you dont see that but it is the fever and other symptoms. Can you shed some light to help me understand what is going on . Thanks for that question but it is something we have to understand better we can not be afraid to ask the question but it is tied so closely to a policy that is so rigid that i have heard ems people that we know is so immaterial but keep an open mind to with think most patients resemble the fever . Absolutely is it days of group . Yes the implication is they are real but what i worry about was of one patient presents in the u. S. Hospital and doesnt have of fever but has ebola the emergency room is exposed then is a Public Health did not solicit truth they did not have a fever we should prepare for that now i dont understand it the with that article i was not part of it but i have gotten the same feedback from various groups of physicians and have a real significant subset but theyre not presenting a fever. They have been calling around the states with the question everyone to be open with whatever happens without too many preconceptions with anything that could come but i want to thank the panelist for their insight for organizing this and for showing incredible resources that is an incredible task right now we have heard from international Health System for the ability to scale of support but not just here understand the illness and it is the tough road to implement those Community Projects in a way that are effective battle local level with that ability of the Health Care Workers idled think we have any chance to be successful certainly there is a lot of reasons for concern and i think we have learned a tremendous amount. I can only imagine how busy you are. To take the time as the state Health Officer we appreciate it. The Panel Discussion was incredible so my notes say as part of the days discussion really have two minutes so we have to save that for another day but i would point people to the twitter feed from the School Letter summarizing the participants at the School Website real archived up presentations. I heard so many insightful comments the best metaphor is if you give a great neurosurgeon a hammer and chisel they will not do a great job and those Public Health workers and frontline workers have been given as a hammer and chisel the man from iberia that told us he has lost 12 the members and cuba is there and were not and i apologize for that. We tried to get people and it did not work out but when we send out the agenda yesterday we tried but we failed and apologize i think that this happened basically in six days was just incredible and it takes a salas from one josh said it is a test but mike said who will be changed no doubt think about when now have vaccines from Clinical Trials in a short amount of time that we are moving maybe not a virus time but not to with three years ago and we saw that with what makes our system better. Thanks to andrew who works nonstop. [applause] interoffice of external affairs i was watching the live feed we have 25 people watching us live in the sound quality was excellent and that is important because it shows how hungry we are for information so we get better insights from our speakers. Many speakers were inhouse but several travel. Peter it was said to were divorced of vaccines and drugs. Mike came all the way from minnesota. And of course, just came all the way. [laughter] when he came back from liberia he brought those insights. But our magazine they dont have a copy on behalf of the school so please pick up a copy and in fact, were having a meeting until 5 00 so we will talk about those articles and their i hope choosier their. So we will look back as school rededicate itself through the emerging disease is thank you very much. [applause] [inaudible conversations] finn gift for the fifth. [applause] good morning. I know you can do better then that. Good morning. Now i know it is and thinks. He said retired . What is that . When mom said she raised her last breath then retire. The theme of the program is geared to act by we have dear to lead we have all these stairs i want to take a second summit is there to act or dare to leave this morning there to impact their to include darr to engage the darr to innovate in here is one that i love darr touche transform. Got it . To darr to improve. Darr to empower and my word darr to educate and dare to create so how many are a part of your life . I can run through the list and i have been in darr all my life. I hope as a go to a new age of fulbright youre not afraid to do but be committed to darr. Yes . You know, i came back with many tears as the entire country was changing my has been changed my kids change my Community Change it extended family members so for 15 years we took 500 people with us. Says those totally change meet and we have senator fulbright to say thank you. Darr touche transform so then we change our world. I expect lots seeing you in the ladies room or coffee hour to say i am ready to darr. All rights . I will look at you and talk back to me. To introduce to individuals i am delighted to have this opportunity to first introduced our winner for the fulbright prize the recipient and we are absolutely thrilled to have him. Then i will introduce tom the first was start with dr. A swedish diplomat and a politician for the liberal Peoples Party was a swedish minister for Foreign Affairs 1978 through 79 and later became part of that International Atomic agency. The first representative to inspect the consequences of chernobyl and led the Agency Response to them mr. Blix was also head of the monitoring Verification Commission for march 2003 june 2003. He was succeeded in 2002 began searching iraq for weapons of mass destruction. We know that story. Were so proud to have him as a recipient. Next a managing director vice chair of Morgan Stanley a leading Global Service firm of the other key constituencies around the world and served as a member of the Management Committee and reports to Morgan Stanley chief executive officer. Prior to rejoining the firm of his curveball was deputy secretary of state serving as chief operating officer of the department and tonight a graduate of the university of minnesota so please help me to invite our guest to the stage. [applause] [inaudible conversations] good morning everybody sometimes get the question are you going to retire sometime . I say what you mean . Then i say i have done that three times and will not do it again. [laughter] it is a great honor to give the first speech to this conference. The Fulbright Association here in the United States and many sister organizations all over the world. And those that need to be supported by governments. The admirers of senator fulbright are demobilized. Through that senators wisdom no excuse to take on the soft power. I woke up in 1945 when Nuclear Bombs were dropped on nagasaki when the United Nations came then immediately placed on the new world organizations Atomic Energy and atomic weapons and they are still there. One crucial question is how we can harness the enormous potential to harness Atomic Energy safely that could predict a humanity with a suicide. The one that i warned about already in the