Were in their height, the number of private security contractors outnumbered the us troops. How did that come to be . Again, i think we are like that one of the unintended consequences of relying on the all volunteer force and allowing the country to slide into a condition of permanent war. We ended up with too much work, too few warriors and so policymakers and the pentagon turned to the notion of defense contractors to try to fill the gap. At a very high cost. At a very high cost and i would argue with little evidence that they that they were worth the money. I know youre going to stay around and sign some books i want to thank you, colonel, professor,. You know, we barely scratched the surface of this book, so i really encourage you to pick up a copy and you will have a very indepth although somewhat pessimistic understanding of the wars of the middle east. Thanks again. [inaudible conversations] [inaudible conversations] this is book tv on cspan 2, television for serious readers. Heres our prime timeline appeared tonight starting at 7 00 p. M. , Richard Sachs reports on mark twains trip around the world and at 745, three war correspondents share their experiences and the challenges they faced in the field. On afterwards at 9 00 p. M. Eastern, former inmate shares his experiences during his 19 years in prison and his thoughts on prison reform. Then at 10 00 p. M. , a panel on and we wrap up the tv in prime time at 11 30 p. M. With Charles Kesler of the claremont review of books. That all happens tonight on cspan twos book tv. [inaudible conversations] welcome, everyone. Can you hear me . Im rebecca from the university of virginia and im delighted to be moderating this panel today, dark tales of contagions with two outstanding journalists and authors who are both currently living in baltimore, and have come down to share their stories with us. We are going to be on a tight schedule, which i am responsible for keeping. We will look forward to about 15 to 20 minutes presentation from each other and then there will be ample time for questions. I would like to remind, request that everyone silenced their cell phones. Would also like to especially since i would like to remind everyone that the virginia festival of the book is pleased to keep most events free and if you would like to help with that , please, consider a donation. My third request is to please evaluate this session as the festival is always working to improve its offerings and finally, we will have books for sale here and in local bookstores throughout the festival and we hope you will be interested. So, without further ado i would like to introduce sonia shah to my far left. Sonia shah has written the book under discussion today, pandemic as well as other books. She is a prizewinning author and a science journalists. Her has appeared in the New York Times, wall street journal, Foreign Affairs and she has and a stout outstanding talk on eliminating malaria. If you want to take a look at that also. She focuses on the intersection of science, politics and human rights and will be discussing her new book with us today. We also have Karen Masterson who is former political reporter for the Houston Chronicle and the Washington Bureau of the Houston Chronicle and she actually left newspapers to pursue a interest close to my heart into the hearts of many in this room, microbiology. She won in 2005, the knight journalism fellowship to study malaria at the us centers for Disease Control and prevention in atlanta in rural tanzania. She has a masters in journalism from the University Maryland and also a masters in science writing from hopkins, where she is now a teacher of science journalism. She we are delighted to have you here, so again welcome. Please remember to keep those cell phones quiet. I know we will have a fascinating discussion and i would like to turn the microphone over to sonja. Is this on . Know, okay. So, when i wanted to do with this latest book this is my fourth book and i wanted to look at how it is that microbes, which are these little microscopic things that have no independent locomotion cause these highly disruptive deadly events that we call pandemics so the past 50 years we have had about 300 infection pathogens that have either newly emerged or reemerged into new places where they have never been seen before. We have had in bullet in west africa, never seen there before. We have the zika virus now washing over the americas and has never been seen here before, novel kind of influenza, new kinds of tickborne illnesses, highly antibiotic resistant pathogens, thought id try to do is track the origins of these things and what i found is a lot of them are coming out of that environment. About 60 of the pathogens that are coming up today come out of the bodies of animals. Over 70 of them are coming from wildlife and so its happening is as our population expands, as our industrial activities expand we are disrupting and invading and destroying a lot of wildlife habitats. So, this of course, means we lose a lot of wildlife species, but the ones that remain coming to ever closer contact with us. With this novel intimate contact allows the microbes that live in their bodies to spill over into our bodies. So, from bats we got it bore the need the virus. Rumba rodents we have monkeypox and lung disease. From monkeys and chance we have hiv, malaria, probably zika virus. From birds we are getting west nile virus etc. So, these pathogens are moving into human populations and then wear allowing them these great opportunities to amplify in our cities. The process of urbanization that first started in the 19th century is reaching its peak now , so by 2030, the majority of the human population will be urban. We are going to be living in a giant cities and they want to be cities like lovely charlottesville. It will be more like monroe the country town with a lot of ad hoc developments, a lot of slums , poor of the structure. And we had already seen new pathogens take advantage of this. Ebola is a great example where we have had people are breaks since at least the 1970s, but they were always rather small and selflimited. One important reason why is because of those viruses never infected a place with more than a few hundred thousand inhabitants. What happened at the end of 2013, is that you bullet virus emerged in guinea and within a few weeks was able to reach three Capital Cities with a combined population of nearly 3 million. Thats an important reason why it became such a huge competition where we lost 11000 or more people. More people died in that outbreak than all of the previous people outbreaks can mind. Similarly, the zika virus. We have had the zika virus around since it needed at least the 1940s possibly before, but it was in the equatorial forest of africa and asia. Carried by mosquito that most of animals, so we didnt have a lot of infections in humans. But, what has happened recently is the zika virus has arrived in the americas where we have massively expanding urban populations in these tropical areas and that means we have massively expanding territories of 80s egypt, this mosquito that thrives in cities. Is an urban mosquito, not a forest mosquito. To listen human garbage and can breed in a drop of water in a bottle, so all of our plastic garbage around a little rain gets in them and this allows the mosquitoes to breed end of this mosquito is a very efficient carrier. It only bites people. But, we are not only crowding our cities together, we are also crowding our animals together. So, its not just about people. Its also about our livestock and right now, we have more animals under domestication them out last 10000 years of domestication until 1960 combined. This is because i populations are getting more wealthy, bigger and as we do that we demand for protein and more meet our diets. A lot of these animals are living in the equivalent of islam. So, we have 2 billion People Living in slums by the year 2030. But, we already have millions and millions of animals living in slums and those are factory farms where we have a million or more animals crowded close together, exposed to each others fluids and excreta. This is one important reason why we have this increase in frequency novel kinds of influenza. These influence of viruses near normally live in wildlife lower and dublin because animal sick at all. Windows viruses are able to reach these factory farms full of captive chickens and birds, they can replicate quickly. They can spread faster and they often become more virulent this is why we have seen eight increasing frequently of more forms of influenza a curried most at a major wear what must part waterfowl live. They are advancing way too fast. We are like five slides ahead. Im not sure why. Yes, thats why want to be. Thank you. The last one, just last year we had Avian Influenza patched in the giant Poultry Farms of asia regional america for the first time, cause the biggest outbreak of animal disease in us history. So, along with the crowding of our animals we are also getting how do we go next your . Okay. This is what happens when using macbook all the time. It becomes stupid. Thats my rule selects thank you. My goodness. Its that one. Number five. So, we have we still have a sanitary crisis of human waste in our planet right now with 2. 6 billion people around the world with no access to modern sanitation. They are still living in the equivalent of 19th century slums. But, what we also have now is a new kind of sanitary crisis and it is with our livestock excreta our livestock are now producing 7 billion pounds of waste every year. This is far more than our croplands could possibly absorb. So, whats happening is farmers are collecting them in things like this, mineral lagoons, essentially giant unlined pits of untreated amylase. So, when it rains or there are storms all this material can leak out into the environment. We dont have just a few airports in a few towns, but we have hundreds of thousands of connections between thousands of airports which means when a pathogen breaks out in one part of the world, it can rapidly spread to the rest of the world. This is a simulation of a flu pandemic on a geographic map. So you can see how quickly us disburses across. But the if you plot that same pandemic on all the cities connected by direct flights, you can see when it comes up that a pandemic will resolve into a series of waves, because you can actually predict where and when a city will get infected just by looking at the number of direct flights between infected and uninfected cities. Okay, this is slide is going fast. Is there something we can do . Okay. So one of the things i did in my book is not only do reporting to look at where emerging pathogens were coming from, and i went to haiti and south china and new delhi and elsewhere, but i also looked at the history of some of the our most powerful pandemics. And the i one i focused on was cholera because its one of our most successful ndemiccausing pathogens, its caused seven global pandemics since it firsted first emerged in the 19th century. We think of it as a disease of poverty, and it is that today, but when it first emerged [inaudible conversations] oh, there we go. Okay. So this is, this is a map of epidemic in 1832 of cholera in new york city. Thousands of people died. And, you know, this happened again and again over the course of the 19th century. And these, and it wasnt just new york city, it was also london, paris, new orleans, a number of cities were plagued by cholera epidemics during the 19th century. So what i wanted to look at is how that happened and then, also, how we responded and how that could shed light on the challenges that we face today as we face our own era of new pandemics. So back in the 18, back in 1832 yeah, we can show that, thatll be good. Doctors collected this data. It shows a pretty clear picture. Choleras coming down the hudson river, coming down the eerie canal erie canal, headed straight for new york city. However, nobody in the city of new york wanted to quarantine the rivers or waterways because this was the time of the robberbarons, huge amounts of commerce coming down those waterways. So they refused to quarantine the rivers. Oh, my god. [laughter] yeah, just make it stay there. I dont know how to do that. [laughter] my powerpoint wants to give you the talk all by itself without me saying anything. [laughter] its very annoying. So they didnt want to quarantine any of the waterways. And they didnt. And doctors went along with this x they said, well, you know, they looked at this map and said, yeah, it looks like choleras contagious and coming down the waterways, but in fact, its not. In fact, cholera is caused by these stinky airs that rise up from decomposing vegetable matter, organic material. And this is based on a 2,000yearold hippocratic theory. And so they said, no, no, its not the waterways, its just these bad smells, and you know whos to blame for these bad smells . Well, its the poor, its the immigrants, its the drunks. So cholera came down the waterways and affected new york city again and again over the course of most of the 19th century. So theres actually companies that were making money selling choleracontaminated water to new yorkers in the 19th century. The epicenter of a lot of the epidemics at the time was in a slum called five points which is pictured here. And this is a slum, this is a slum that if anyones seen the Martin Scorsese film gangs of new york, that was about five points. Very crowded, very dirty, you know, very, very crowded place. About 77,000 people per square kilometer, six times more crowded than tokyo is today. But this slum had actually been built on what was once a pond. That pond had been filled up with garbage. And then the slum had been built on so much that. On top of that. Now, there wasnt a sewer system in 19th century new york. There werent even rules that you had to empty out your yes, sir pools and privies. It was cesspools. Now, of course, in this area the groundwater underneath this slum in particular would be extremely contaminated because the ground underneath it was lowlying, it was filled with garbage. It wasnt bedrock like the rest of manhattan. Now, the company that the state of new york charter ored to deliver chartered to deliver Drinking Water to the people of new york rather than tap upstream sources of water which they knew at the time would be cleaner, fresher and would taste better, they tapped a well right in the middle of that slum. And they delivered that water to onethird of the residents of new york city. And they did this over the course of centuries through repeated epidemics of cholera. And the company that did this, as an interesting aside, they did this because they wanted to save money. Sort of like what happened in flint, michigan. They wanted to save money. The reason they wanted to save money is because they wanted to start a bank. The companys called the manhattan company, the bank was called the bank of the manhattan company. Does anyone know what the bank of the manhattan companys called today . Jpmorgan chase. Yes, thank you. If i click the mouse, its terrible. Sorry. That one. [inaudible conversations] okay. So ill end the story just by telling you how cholera vanished from new york city, because i think its instruct i. Instructive. Eventually, new yorkers moved the well from there to up there. But they didnt do it because they wanted to uplift the Public Health. They didnt do it because the people of new york were screaming for better water. Which they knew would make them more healthy. They did it because the local brewers wanted better tasting water for their beers. They felt like this stinky water was putting their beers at a disadvantage, especially to all the brewers in philadelphia. So finally they moved the water intake, and cholera vanished from new york city after that. A century of cholera pandemics ended. And this spread throughout the country and throughout europe as well. So the question i have is, of course, we can do a lot better today in our era of emerging pathogens. But its really as this story to me says, its not necessarily about our technology. Its really a about whether we have the political will to do it. Thank you so much for listening. Ms. [applause] okay. So now were going to welcome Karen Masterson, the author of the malaria project, and i am going to switch with you, sonia, so i can imagine the pc. [laughter] [inaudible conversations] im a mac user as well. [inaudible conversations] okay. So i came to Global Health issues and microbes by accident. I was actually a political reporter. I was an environmental reporter before that for the philadelphia inquirer. But i was looking for something completely different, and i stumbled upon some records that talked about how our researchers during world war ii infected State Hospital patients with malaria so they could test new drugs on them. And i, this was shocking to me, and i couldnt find a whole lot of historical treatment of this. And as i kept pulling threads and searching through boxes in the archives, i realized i was in uncharted territory and that i had to tell this story. I didnt know much about world war ii or malaria, didnt know much about bioethics. But i got up to speed because this was a fascinating story that i wanted to tell. I actually wanted these slides to be deleted because i have 60 slides here for 15 minutes, but ill whip through them as fast as i can. These boxes look like this, the records, a lot of them were stamped top secret because this was a secret project. The world was at war, and nobody had a good malaria drug. And before normandy, most of the fighting happened in highly ma lair yous areas. If you had a weapon against this disease, you had a leg up on all the ballots. So our government battles. So our government, the Roosevelt Administration opened the spigot for this project, hired 400 scientists, 50 universities. Most of the American Drug companies came together to find a bomb. It was funded under the same Umbrella Organization of all the wartime science projects including the manhattan project. There were, the reports were in blackout, they couldnt be published, so they were written by the lead investigators and sent to a central clearinghouse at Johns Hopkins university, and there they met every month, the scientists, so that they could compare notes. I figured out how to not be totally judgmental of the scientists who did this work. I was taught that by this man, bill collins, whos at the cdc. I got a fellowship, and i got to go down and sit next to this man and listen to his stories and dissect mosquitoes. He had been around long enough so that he could study the disease and test drugs on their induced infections. The problem back then was that you couldnt grow malaria in a petri dish. You had to have live infections. And asth lair ya dried up in Northern Europe and the northern states of the united states, it was hard to come by. So if you infected people, you could just study it. And he called those the good old days. [laughter] and i said you know youre talking to a reporter, right . Im going to write this. [laughter] and he was sincere. Those were the good old days. Now at cdc you had to infect monkeys, and they were difficult and expensive, and they tried to bite him, and monkey malarias didnt extrapolate all that well to human malarias. They had to run all the i new vaccine studies off on these monkeys first, so he did lament the good old days. He had a room full of archives that no one had seen before from world war ii and the years immediately following world war ii, and he used the data that was collected from these infected patients to income todays inform todays vaccine researchers. The data that they had on live infections remains valuable to this day. He and one of his colleagues. So he actually got me thinking like a ma lairology, and i feel like i came to this story with a little bit more objectivity and not as much judgment. I tried to let the story speak for itself. I this is a, taking blood from an american soldier during world war ii. This is the blood stage of malaria. What the parasite does is it enters through the mosquito bite, kind of stickshaped. Sonya called them shape shifters. This is a shapeshifting parasite. It immediately gets into your liver, and there it incubates and hides from your immune system until its ready to launch an attack on your red cells. And when it does that, your red cells end up looking like this. And when you have trillions of these parasites in your body, you get sicker than youve ever been. It is a terrible, long, weekslong infection. At some point during the time when youre feeling the most sick, some of these parasites mature, and they become sexually distinct. They my grate to your surface cells, they emit a chemical that attracts mosquitoes. They fuse into an egg sac, and the mosquitos got about a week or two later, they burst with these sticklike microbes that get into the saliva, and then they infect again. I chose to tell the story about the world war ii project through this man for several reasons. One, i really liked him, and i didnt want to spend my whole time researching this book on one of the scientists who i felt had their biological thinking dialed up a little bit too much without really having enough empathy for their patients. Lowell coggeshall empathized with them. He was the dean of the university of chicago medical school, he was Vice President there, and he advised the Eisenhower Administration on medical education. He said we are teaching our medical students to specialize, to focus on body parts, and that is unsafe for us. We should be focusing on the whole body. We, as medical professionals and he was called a communist for it in the 1950s. Before the war he was a malaria expert. He started out as a graduate student be the Rockefeller Foundation as part of a Large Network of americans trying, american researchers trying to get a handle on the u. S. Souths terrible pandemic of malaria. This is lease burg, georgia. Lees burg, georgia. He worked in places like this where the cypress trees were being ripped up to keep up with the Development Going on in the northern states, and southerners were left with these gaping holes of larvaproducing swamps that filled the skies with mosquitoes that carried malaria. So throughout the course of the 1920s and 30s, he worked with these this is samuel darling who was the brains behind the effort to build the panama canal. Samuel darling was responsible for licking malaria there. Which had almost shut the american attempt to build the panama canal as it did for the french. And next to him is paul russell. Hes one of malarias most favorite sons. They, through the new deal, antipoverty programs, building dams in a way that eliminated mosquito larvae instead of producing mosquito larva, bringing electricity to places in the south and attracted industry which brought jobs so that people could get out of shacks and into homes with tight eves and screens eves and screens, eventually by 1940 most of americas malaria had completely dried up. While we were work on malaria in this way, this man, Julius Wagner be, won a nobel prize because he figured out how to give malaria to neurosafe littics and cure them of insanity. In 1927 he won the nobel prize because syphilis was rampant. The late stage of syphilis is an infection in the brain. It causes erratic behavior, insane behavior. Most people ended up in the asylums and State Hospitals, and a year or two later they would die. He figured out that you could save about 30 of them if you gave them malaria. Malaria fevers, if you could control them with quinine, would increase the bodys immune system to a point where it could actually fight off that difficult stage of syphilis which is getting into the brain. But because you cant grow parasites, these malarial parasites in the we try dish, he just kept his strains going by taking blood from infected patients and giving them to new patients. So this became the new way of treatment for neurosafe littic State Hospitals all over the world picked up this if they could afford it. You need lab work. But if you were lucky, you could be potentially be cured of it. This was a major breakthrough. Hes only one of two sigh chitists psychiatrists to win the nobel prize in medicine in history. The german Bayer Company who were trying to come up with a synthetic drug for malaria were very clever. They said, well, we dont need to go and do our studies in africa and in places where malarias endemic, well just run our studies on these patients who are undergoing therapy. Its a win win. We get to study the disease, test our drugs. Bayer came up with two potential drugs, which is made from a yellow dye. The dye attaches to the parasite, they add a side chain thats lethal to the parasite, carries the truck to the target and drug to the target and wipes out the infection. Pretty toxic drug, so they never broke into the market. Quinine was the only drug that was made from the tree, the bark of a tree that grew on plantations that the dutch had a monopoly on. So the world just kept using quinine. This is a german, one of the leading ma lairologists in germany ran some of these studies for bayer, and he said, you know, why top there . Why not run these studies on prisoners . The war coming and we have to find a drug. So he wrote a proposal to do studies on prisoners. Lets just give malaria to prisoners, and then we can test our drugs on them. And Heinrich Himmler thought that was a really good idea, and he gave him the dachau prison camp where he infected a thousand prisoners. Most of them were russians. His prisoners actually got an extra ration of food, and they slept on clean sheets, and they were, they were given their fever so that he could test his drugs. And then given quinine and cured and sent back into the barracks where they died, a lot of them, because of typhus and cholera. This is him trying to explain to american lawyers who liberated the camp that he was just doing malaria therapy. This was standard. He wasnt doing anything wrong, and they didnt really understand malaria therapy. And he hanged. Meanwhile, Lowell Coggeshall grew up, were back before the war now, and he knows leading doctors in germany, he knows that theyre working with bayer and testing their drugs on State Hospital patients x theyre actually making some progress in building drugs. And he comes up he masterminds a plan for the americans to do the same thing. Hes temporarily sidetracked to africa because an air route that we had created to supply the british and egypt and russians with guns and planes was completely shut down because of malaria in west africa. So that supplies started were flown out of miami down to the elbow of brazil, across to the hump of africa and then, boom, theyre stopped because the airfields there, the workers were all completely infected with malaria. And so the u. S. Air command asked if coggeshall would go over there and clean it up. He got there and found airfields being carved out of the jungles and creating massive mosquito production, massive mosquito breeding. And this was the reason why the pilots and the mechanics and the construction people were all getting malaria. He had quinine, but he realized under these conditions it doesnt work. He had the german drug under these conditions that doesnt work, so he tried screens. He said were going to screen up all the barracks, and you guys are going to roll down your pants, wear netting over your helmets, and to the best of your ability, youre going to wear bug spray. He had sessions every day. He made education the most important part of what he did. He told them if youre going to go the sex villages, you have to go during the day, not at night, because the malariacarrying mosquito bites at night. And in the course of six months, he the infection rates in liberia, which were about 100 , no, they were about 50 in the gold coast, now ghana, went were brought down to 1 . He was completely successful without the drugs, the quinine used as a backup just to save them from this african form of malaria which can kill you many a dayment in a day. He brought that back to the u. S. Military and said, the War Department and said its not just drugs, you need this multipronged approach. And they said we dont have time for you. Were training our troops in these pristine camps that we sanitized the mosquitoes, and well talk to you later. And then came baton. After the japanese attacked pearl harbor, they went and attacked the philippines. Macarthurs troops were forced down the peninsula, and within a month when their or quinine ran out, they started falling with malaria. 80 of them had malaria at the time of surrender. Commander said we had rifles, we had bullets, we had plenty of ammunition, but nobody could lift their heads. Everybody was sick with malaria. We had no quinine. That woke up the War Department. And they opened the spigot for this big plan that coggeshall and a will a lot of other sciens came together to argue for. While 10,000 marines were landing on guadalcanal, the first meetings of this malaria project took place. They were recruiting top scientists in their fields from many of these men had never learned about malaria, but they were needed for this project. This was the number one medical priority of the War Department. And they started working on drugs as the marines on guadalcanal ripped up the landscape. The waters pooled, the mosquitoes bred, the camps turned into mud hoels. At one mud holes. At one point a a medical corpsman said we have got to do something about all the mosquitoes that are breeding because were going to have terrible malaria, and the commander said were here to kill jalapenos, and to hell with jafs and to japs and to hell with mosquitoes. It was actually recorded and sent back to headquarters that that week the first cases of malaria landed in the field hospitals. By january of 1943, the infection rate on guadalcanal and on new guinea and some of the other islands was 3,000 infections per 1,000 men per annum. So they were going to get it three times in a year. So the War Department said, well, we dont have a drug yet. The malaria project, the scientists are screening drugs using bird malaria which definitely doesnt extrapolate. Theyre doing toxicity tests on dogs which didnt translate very well for humans. Theyre fighting a lot with each other. Ask and the War Department and the War Department said stop and make this drug work, this yellow drug. So they did, and the American Drug companies started making it. They didnt really know how to do it very well. We ended up overdosing our troops on the pacific and the atlantic side. They were soiling their pants in the middle of battles because of uncontrolled die saw. Diarrhea. They were vomiting up their rations. Some of them had psychological episodes because this is a neurotropic drug, and it affects certain people that way. And so the men refused to take it. So the War Department turned on its Propaganda Machine which happened to have theodore geisel, dr. Seuss. [laughter] so he drew cartoons, he made posters. The guys, the troops these poster were so ubiquitous that the troops started calling the mosquito ann. They understood. They started to get it that if they listened to their commanders and rolled down their pants and wore their mosquito repellant and protected themself from these mosquitoes that they wouldnt get this disease, malaria. The War Department was encouraging the men to take this drug. They had lowered the dose, and they learned that they actually could use it as a prophylactic. It wasnt great and still made you sick. Clearly, they thought sex would help get the message out. [laughter] they trained about 10,000 men in new orleans to form malaria units that attached to combat units. Instead of using how to use rifles, they learned how to use dipsticks so they could catch the larva. You look for the certain kind of mosquito. Once they were attached to their combat units, they hired thousands of local men to clear the waterways. Running water kills larva. Stagnant water produces mosquitoes. They sprayed tire tracks and dumps with kerosene to kill the larva. They studied the problem in their tents. They would take blood from local people and figure out what how seeded the locals were and how large the malaria problem they were going to have. The doctors had to go to malaria school. They had to learn the difference between the kind that Julius Wagner used in his malaria therapy. Its the one that you can control quite easily with quinine, and its not deadly versus the other which is the kind that you get in africa which is quite deadly. They had to know the difference between dengue and malaria. This is macarthur, you can see him, he even had to go to school. Everyone up the chain was educated on what malaria was and how it worked. The army air command had to spray the flooded areas in italy after the germans retreated and destroyed all the pumps so that they could flood the landscape and produce maas quito larva and slow the fifth army down with malaria. It was about this time when italy looked like this that the malaria project at home had a major breakthrough. Again, they had made almost 7,000 compounds. Nothing had been produced that was worth anything. They were fighting, and they ended up with a report on their desks that had been captured in tunisia. It was a report that showed some results from studies that were done in the adobe villages of tunisia using this drug which was from bayer. Bayer was the most advanced in coming up with these potential synthetic quinines, and this, the study showed it not only worked as a prophylactic but that it was a cure, and it was nearly 100 . So the malaria project finally had something to work with, but they had used up all of their State Hospital patients because there werent that many State Hospitals or patients. So they didnt have clinical material. Many of them just referred to their patients as clinical material including James Shannon who would, in the 1950s, become the head of the nih. So they decided that they should go into prisons. That they could have plenty of men to do their research on in the prisons. So in goldwater Memorial Hospital where they had been running malaria studies, they just this was on what was then welfare island, today Roosevelt Island they grew the parasites that were captured in the men who were coming home from the war. They grew them in manhattan hospital, millageville state hasnt in georgia, the South Carolina State Hospital, and the blood from these different kinds of parasites that we needed to build bombs against were sent to this man. He ran the most successful project in figuring out how to use this drug in im going to go past this one in stateville prison. He said i dont need to go into the State Hospitals. I dont need to use those people at all. I have plenty of prisoners here who will volunteer to be part of my project. He grew his malaria in prisoners, and he tested his drugs on the prisoners that he infected with his malaria, and he even used prisoners aztec in additions. Among the most famous was nathan leopold, and i dont know if anyone remembers the leopold and loeb murder case. In the foreground is clarence darrow. These two boys were brilliant. They were from wealthy families x they picked up a neighbor off of their mansionlined streets and killed him just to see if they could get away with it, because they thought they were so smart that they could. And they didnt. Loeb was killed in a shower stall, but leopold went on to be a ringleader in the prison, and he was brilliant. And he worked in the lab and helped turn this drug into im going to skip that too into one after the war was used like aspirin in the tropics. When, before the war the approach to eliminating malaria was multipronged, it was long term, it was hard, it cost money, it meant creating jobs and putting screens on homes. After the war because we had this drug and ddt which is another privilege that came out of the war product that came out of the war, suddenly they said weve got these magic bullets. And the World Health Organization used them in this global effort to eradicate malaria. In 1957 reus dance developed resistance developed against, in the malarial parasites, so it stopped working, and by 1978 it had spread throughout africa. You could change the dates and replace the drugs, and the same, the same route would hold true. Every drug thats been made since the first to fight malaria has suffered the same fight, and the last remaining drugs that we have in fact, the only drug that we used that wasnt created during or at least the parent molecule wasnt created during this wartime project, that is also going down in this same route. Resistance has developed in asia, and its spreading. The reason why i find this story so important and why ianted tell it is because it is instructive. I think we have these Global Health programs that focus on drugs. We need drugs, we need vaccines, but we need to do the harder work too. And thank you. [applause] i think ive gone over. [applause] thank you both so much for fantastic presentations. Ill just ask one question, and then we will open up for questions. So be ready with your questions. So your final words there and that pink and green map that shows the development of resistance almost as soon as the magic bullet is developed and, sonia, in your book you talk about the development of resistance to multiple different kinds of pathogens. That is the pattern. These pathogens evolve with us and around us. And im wondering, its a political year. What would you recommend in terms of the paradigm shift necessary to move between this dominant paradigm of searching for a magic bullet in the context of the germ theory to wading into the complex intersections of commerce and politics and war and the environment that actually lead to the e emergence of these pathogens, to their spread and to their success . So how should we be talking about that . Well, i think thats a great question, and i think theres a big sort of elephant in the room that we never get to when we talk about this problem which is that if we aim our Public Health goals towards furthering biomedical interventions, that really dovetails with economic interests, right . And theres powerful private interests that benefit from that. Drug companies and others. When were talking about Public Health interventions that are about social and political changes, they often are going to be in conflict with those same private interests, right . And weve already seen and this is something ive been writing about now, is how a lot of our Public Health agencies have become really beholden to some of these private interests. And its partially because theyve been underfinanced for so long. And now we have this whole movement to Public Private partnerships which i think is a generally good idea. Yes, we should have it be part of Public Health. But when we have, you know, companies telling the cdc how they should, you know, earmarking money for the cdc and saying, well, look into this and look into that, and this is how we will sell more of our products or divert things away from our economic interest, and this is whats been happening. Who gets twothirds or more of its budget from private donors. These are agencies that are getting their money from people who can buy control at our premier Public Health institutions. So i think we really need to address that before we can even, you know, of course were going to always do the more industryfriendly Public Health interventions so long as private interests are such a huge influence on our Public Health actors. If you look at the 19th century Sanitary Movement which they didnt know that clean water would make us that much healthier. They had these ideas, and none of it was actually true. Their theories were all wrong, but they fought for clean water and better housing and sanitation, you know, in the face of a lot of scientific uncertainty. And they said this is what we need. And it doesnt matter the if it disrupts commerce. We as a public are going to demand that. There was a social movement that did that. And i feel like thats the big, missing factor now, you know . As a public were very sanguine to say, well, a new disease . Okay, lets throw some money at the Drug Companies and get some scientists to come up with a magic pill or drug that will fix the problem for us. And i think what were finding is thats not going to be enough. Right. And think its a matter of perception. We have a certain perception about how to handle anything that has to do with disease, right . So i have, im a swimmer, and i have a shoulder thing going on. And its bugging me. So i went to the doctor, and doctor said you have bursitis and tendonitis, and you should go get a cortisone shot. And i said this is my first time coming to see you, this is my first problem in my arm, and you want to give me a cortisone shot. So then i went to see my act chew puncturist, he said i just need to loosen your muscle and im going to stick some needles in your arm for a couple of weeks, and youre not going to have to get that cortisone shot. It was that medicalized, immediate solution to a problem that, yeah, needles are going to take longer to get me back in the pool swimming, its going to be more permanent, and im not going to have sidefects. I feel like side effects. I feel like this is what we as consumers are fed in our personal lives. So when we take our per especially to Global Health and to, you know, these matters of pandemics like ebola, we think, oh, my god, the only thing we can do is come up with a drug or a vaccine when what we really need to do is think about poverty, we need to think about surveillance, we need to think about health systems. They all need to be in countries where theyre nonexistent, they need to be built. If were going to be protected from things coming across our borders, we need to care about how well the Surveillance Systems are in other countries. If we took a percentage of the money that we spend on Global Health, much of it comes back to western labs and to scientists salaries and just decided that we should spend this on different ways of creating a better surveillance system, the products that we actually produce in those labs will last longer. And theyll work better. So our perception is off. The solution is always a medicalized one, and its exactly the germ theory led us there. The germ theory, we came to understand germs as the, you know, the devices that caused illness, and our First Response was to come up with ways to prevent those illnesses using, first, vaccines and then chemistry labs. But its more than that. We need to take a broader view. Thank you very much. Id like to open up. Does someone have a microphone for questions . Okay. And im going to repeat the question in case anyone doesnt hear it. Hi. Thank you for the presentation. I have a question. I have noticed that every time there is an outbreak whether its ebola or zika virus there are, there seems to be a fringe group where theres conspiracy theorists. As somebody whos not even seeking out those, i was a amazed by the number that just pond up on my social media feed, people saying, oh, zika virus is caused by gmo crops or something else. So you have a public who is, one, not even taking the threat seriously in claiming that its a big conspiracy and saying, you know, any vaccine that might be prevented is out of the question for them and even any preventative measures. Is so my question is what are Public Health organizations, ngos and governments doing to try to combat that even though this is a very fringe group with the power of the internet and everything like that . These theories are spreading quite well, almost like a virus. [laughter] yeah, yeah. I think youre absolutely right. And i think and this is something i go into in a chapter of the book,s which is why is it that theres no little trust of our Public Health authorities that when we even have good evidence that zikas being carried by mosquitoes, its actually a virus, we have good evidence for all of these things. Why is it then that there are these, there are groups of people who fervently believe otherwise and come up with these alternative theories in and i think, i think our traditional response is to say, well, theyre ignorant, theyre not literate scientifically, lets dismiss it. Its the same thing we do with people who dont want to take vaccines. Their dumb, theyre backward, its selfish, whatever. So what i look at in the book is what if we trace that back . Where does that mistrust come from, you know . Is and what and frequently it does come from something real, you know . That people are mistrustful of the corporate influence on medicine, theyre mistrustful of transgressions in western medical science thats happened all over the world. I mean, karen just told us about a great example. You know, theyre mistrustful of chemical contaminants in the environment and a syringe coming into your body that inserts those in there. Those are all, in my opinion, real concerns. That need to be addressed in an honest way. So we cant just say dismiss these theories, these alternate theories as conspiracies coming from, you know, muddled minds. I think they come from somewhere real, and i think they need to be addressed in a real way, and i dont think weve done that yet. Yeah, i agree. I think its the other side of the coin where probably a majority of people would assume that a medical response to, you know, a Health Problem is the most appropriate when perhaps its not. Theres a pushback on that. Because the pharmaceutical industries have so much influence on how we perceive things, theres a pushback. Why should i trust you when your commercial interests arent my personal, arent in line with my personal interests . So its exactly what sonia said. I view it as the, you know, the extremes that are coming from, you know, a public thats too trusting of the medicalized approach to our own health. You were talking about basically, i guess, between the public and private interests getting all mixed in. Im wondering if you find that i know ag gag laws are usually based on the way animals are treated, but do you find that those same laws are hindering getting Accurate Information about how much waste is on these factory farms and how much like how big those i think you called them lagoons manure lagoons. Yeah, the manure lagoons are . From looking at that side of things from an Animal Rights perspective, ive never put it together with perhaps learning where these pathogens are coming from. Yeah. Im not that familiar with the laws around, you know, disclosures about these things. So these are, these are estimates that other people have put together that im synthesizing in the book and in my research. So i really dont know. But, of course, in all of these areas this is a great deal of proprietary secrecy. So its really about, like, my Research Method is all about looking into the gray literature and digging around in kind of unlikely places to find some of this data and then putting it together into a larger story. I new you had a question . I think you had a question . On the issue of [inaudible] we often say that doctors are casually overprescribing, and im sure theres validity to that. But theres also the case, i lived in the middle east for a long time, and you can buy antibiotics. You can just go to the drugstore and get them many places. Public Health Official in oman which has an advanced medical system told me the problem sometimes is not what the doctors doing. The doctor may do the right prescription, the patient maybe a bedouin whos come 800 miles to get there, gets the prescription, goes home and after three days feels better, so throws away the rest even though it was a tenday rebelling member or rebelling member and doesnt feel better, throws them away. So no matter what happens, it advances the bacterial resistance. Well, i guess ill take that one a as the physician up here. [laughter] no, i think its a good observation. I think that questions about monitoring of prescription practices for human beings and i think actually more importantly for animals, tons and tons of antibiotics that are actually used in animals, i think, are an even greater threat potentially to us. And weve seen strong data in some European Countries which have banned the prescription of antibiotics as a growth enhancer for animallings. So i think that access to and appropriate use of antibiotics is incredibly important in order to try to preserve those that we do have that still function against our most dangerous pathogens. First off, thank you for coming, and this is a very interesting topic. Kind of to get at that original that last talk, that last question. Its interesting, that specific issue of patient compliance or adherences has directly informed our approach to tuberculosis, for example. Directly observed therapy is now a world standard regarding that specific disease, combating drug resistance. What i wanted to is ask you about is something i find interesting in mosquitoborne illness. This new use of geneticallymodified mosquitoes or bacteriallyinfected positive mosquitoes which is something i hadnt heard of until just recently. If you could talk about that as a new Disease Control approach. We both really want to answer that question. [laughter] we were just talking about it before we came on, because weve both talked to enough entomologists. They come up with a wonderful technology, and its Exciting Technology on how you can geneticallymodify a mosquito, a male mosquito, to prevent, you know, pregnancy in female mosquitoes. But they stop there, and then everyone else extrapolates and starts talking about using these geneticallymodified mosquitoes to displace natural mosquitoes excuse me, natural habitat. And the entomologists all raise their hand and say we didnt say you could do that. Thats actually shirt pretty hard, and were pretty sure that you cant, but we have this technology, and were still working with it. Yeah. And i think its interesting, too, that, you know, theres been so much press into these gm mosquitoes, especially with zika coming now. And yet its a very, its actually a very delicate thing to do, to disrupt transmission of these mosquitoborne diseases. Look at malaria or zika. Youre looking at only femaleinfected mosquitoes who carry, you know, who are the problem. Right in thats a subset of the population. On top of which a mosquito has to bite one person, get infected, wait 57 days before theyre infective to another person. So were really talking about the grandmother mosquitoes. Those are the only ones you actually need to kill. Geriatric mosquitoes. [laughter] yeah. The old ladies, thats all you need to get. And we dont, you know, the whole way were approaching Mosquito Control is a very blunt tool for a very delicate task, you know . We dont need to kill all the mosquitoes and, in fact, we dont even know how many how much Mosquito Control you would have to do. Like, would you have to get down to 99 control in order to actually reduce transmission . Be because who knows . Maybe those female grandmother mosquitoes are really recig cent. We dont know their habits. And because were not studying it in an ecological way at all. So i think theres this big push to use the latest technology, but really huge questions as to whether itll work. I mean, all the Mosquito Control that theyve been doing for dengue for years has not worked to key minish dengue, you know . Mosquitoes are adaptable. In zambia there was an effort to make sure that a set number of villages were using bed nets properly. So there were a lot of Public Health, a lot of american Public Health experts living in these villages, working with the villagers. It was an intense effort to make sure that these villages all used their bed nets properly. Theyre not used properly in many parts of africa, and all kinds of bad outcomes have developed because of that. Especially jeffrey gettingman wrote an excellent story in the New York Times if you want to look it up. In these villages what the entomologists found was when there was almost 100 bed net coverage, the mosquitoes changed their biting habits, and they bit earlier. They find a way. Theyre adaptable. Theyre small, and they can change their habits pretty quickly. There are so africas main malaria carrier a rural mosquito. But and as africa urbanizes, there are projections that suggest malaria will not be as large a problem because its a rural mosquito. Well, indias malaria carrier is an urban mosquito. These mosquitoes will adapt. As africa urbanizes, theres no reason they wont adapt and become an urban mosquito. So the frustrating part of reading the news is seeing a simplistic representation of how these insects operate in nature. Knowing and, you know, i know just enough to be dangerous, you know . But i know that this is a lot harder said than done, because if it were easy, we would have done it, right . There are plenty of other diseases that came before zika that screamed for mosquito elimination, and its not really doable. What we can do is work on, work on the conditions that people live in so that theyre not exposed to mosquitoes. We know that works, but thats too politically difficult, so we dont do it. So we try to eliminate mosquitoes as a species. Last question. To mosquito transmission, how many of these emerging viruses are microphone. Sexually transmitted. So the question was how many of these emerging viruses are sexually transmitted in addition to transmission through vectors. I think zikas a really interesting example of that. As far as i know, its the only mosquitoborne virus that is also transmitted sexually. And is so that allows it to spread beyond where the mosquitoes are climactically present. Thats going to be a really Interesting Development in how that disease flows. As far as i know, thats the only one than able to do that that we know of. Well, with reference to mosquitoborn, of course, ebola also is and theres an interesting project going on in south africa right now looking at the viral population of the prostate, actually. And so ill be very interested to see because its a clever place for a virus to the hide. Finish so we may learn more. I think all right. I had a question. Thank you. Thank you, this has really been fascinating. Really, really fascinating, thank you. But my question is so we keep on running from one part of the world to another, you know . Like, oh, ebola, and then everybodys running to work on ebola and, oh, my god, zika. Everybodys in brazil. When you look at the world and you look at just where you think were doing next with our next run to the barn after the barn door is left open, where do you think what do you think is coming up . Well, thats what the books about. [laughter] so maybe i should just end it there. [laughter] but, yeah, i think youre right. Thats the Million Dollar question is like, you know, can we track this back so that we can look at the drivers of where these pathogens are coming rather than waiting until they erupt, waiting til we have exponentially growing outbreaks of untreatable disease and then scurrying to come up with drugs and vaccines to try to throw at it. And i think thats been our model. And maybe that would work okay if we didnt have so many new pathogens emerging, but the way we live today we do. And so i think were going to have to go backward, and were going to have to look at, you know, access to health care in poor communities, restoring wildlife habitat, addressing the intensification of agriculture and livestock waste and all these things that we know are drivers. So we dont know which pathogens going to cause the next pandemic, but we do know how it happens which means we can also predict where its most likely to happen, and emerging disease experts have come up with maps of hot spots of where pathogens are most likely to emerge. And in those places at least, we cant track every single microbe, but we can do active surveillance to see where are the microbes changing . Lets analyze them and try to detect these things before they start to cause disease. And i think thats, you know, that is a technological approach, but by doing that, we will learn so much more about the underlying conditions that lead to these. Then we get this huge opportunity to address those. Thank you so much. Thank you all. [applause] id like to thank all of you for your attention. Please remember to fill out the evaluationings. I hope you with enjoy the rest of the festival, and sonia and karen will be here until 3 30 to answer additional questions and sign books. Thank you. [inaudible conversations] when i tune into it on the weekends, usually its authors sharing their new releases. Watching the nonfiction authors on booktv is the best television for serious readers. On cspan they can have a long or conversation and delve into their subjects. Booktv weekends, they bring you author after author after author that spotlight the work of fascinating people. I love booktv and im a cspan fan. I think thats a question that people have, is why, right . So why did dylan do this . And i know you talk in the book about lots of folks theories about that, media and others, but im interested in what are your thoughts on that question. Well, first of all, the likelihood that someone you love, that a child that you have will take part in a school shooting, the chances of that happening are one in millions. So this is not an everyday occurrence. This is not something that every parent should be concerned about, that his or her child will become a school shooter. The far more dangerous thing for our children is how many of them have thoughts of suicide and selfharm. And if we look at a murder suicide such as the columbine tragedy, murder suicide is a small subset of suicidality. Perhaps 12 of suicides will result in the killing of someone else. So my recommendation is that we focus very much on trying to understand suicide and trying to prevent suicide so that these things dont erupt boo a terrible into a terrible tragedy. You did ask why this happened, and in the book i talk about i think the more e educate if give effective question to ask is how does this happen. What is the mechanism through which ones thinking deteriorates. And the way i have come to explain this to myself is really a medical model. If we look at suicide and consider it to be a health risk as we would Heart Disease or diabetes, we know that there are many factors involved. What happened was the very rare set of circumstances that overlap perfectly if you look bad day then diagram of interlocking circles that a friend who was possibly very disturbed and controlling an angry with his own wish to die from the pain he was in psychologically, bullying