There are going to go ahead and resume. Once introduced quickly our panel of speakers. This represents more of an institutional leadership and Innovation Panel where pariente have Anne Schuchat from the center for Disease Control and dr. Daniel salmon director of the institute for vaccination safety at Johns Hopkins university. We are very hard to have that there Maurizio Barbeschi health and security interface from the World Health Organization join us and hes gone above and beyond the call of duty as he came to los angeles and took the red eye to be here this afternoon so he has gone above and beyond the call of duty. Our final panelists is that your irene koek the administrator for Global HealthUnited States agency for international development. We are going to have a similar format for a last panel and i would also encourage the panelists if they feel the urge to ask one of their copanelists a question just interrupt me and do it and if i asked the wrong question as david said on the last panel just restate the question you would rather answering go for it. I think we are way behind so we can probably go to audience q a. There a lot of things we have talked about and i know they would like to Say Something so we want to make sure we give you an opportunity to ask questions of this esteemed panel. Dr. Schuchat and Everybody Knows you are our nations Public Health authority so we are pretty much familiar with the agency. If you want to we thank commission and the approach and talk about the great things that the cdc and colleagues are doing and many friends of mine thats great but maybe one way to do that is maybe you can tell us what we learned from past outbreaks and even a pandemic that i know you were in the middle of the 2009 and other outbreaks that we can apply as lessons observed for Lessons Learned for future outbreaks. Its a real pleasure to be here and appreciate folks who have stuck with us the whole afternoon. Its just been 10 years since the h1n1 influenza pandemic struck and we are, we have learned a lot from that and in some ways are a lot better off than in some ways theres a lot more to do. I think a key lesson there was the value of everyday systems. I think sometimes we want to have a the Fire Department for fires in a whole different Fire Department for bio terrorist events but i think the work that we do year in and year out the seasonal flu helped us with the h. One and went pandemic and their efforts has been to strengthen to prepare for seasonal flu. Whether the Laboratory Work the communication work the partnership the trusted relationships with public and private sector u. S. And global relationships exercising every day instead of waiting for the big one, i think thats a critical theme. In terms of learning from the west africa ebola epidemic as you heard its not enough to come in when theres an emergency. The countries that were affected in and the global Health Security agenda was really about taking sure every country could prevent epidemics and the world could search when needed. However that is we dont want to just come when they are in the middle of an ebola problem but we want to be working sidebyside with them to strengthen their systems. We are focused on the Public Health system and as with much of the primary care system. We use the Emergency Operation system to address trying to eliminate motherless child transmission of hiv are yellow fever or other conditions. We tried these Laboratory Networks and the workforce compassion for the problem of the day. I think we have activities and 57 countries right now. Very much focused on critical government priorities like pepfar or the Malaria Initiative but very much about the global Health Security and strengthening everybodys capacity to deal with the priorities they have. Thank you anne and actually id like to have dr. Koek from usaid jump in. I know the person who is sitting in your seat at usaid recently traveled maybe over a month now with dr. Read feld improperly came back for some interesting observations that have impact for both usaid cdc and other government agencies. Can you share some of the experiences and observations that you are think about both usaid and how that integrates and dr. Schuchat me jump back and let the great work you are doing in collaboration. Thanks. I would echo annes appreciation for being on this panel and being with you all here today. We are the Development Agency for the u. S. Government so please do work and health is one of the air areas working but certainly work in a number of other areas critical to building the capacity. To build countrys capacity to do all of the things whether it be and health or overnights etc. And help you work acrosstheboard closely with her our colleagues at cdc in a number of areas. We do have a number of programs and the congo. On the last panel for the big issues with this outbreak is it is in the middle of a war. War has been underway for a long time so it becomes extraordinarily difficult to do the kind of ongoing programs that you would be doing in that situation. Dr. Golden who was my predecessor in march with dr. Redfield and just last week tim ziemer who is the acting administrator for the assistance work we do was also there working with the current ambassador on communities affected. Whats really clear is the complex emergency that is underway in eastern congo is absolutely getting in the way of the kinds of interventions that we want to do that ultimately worked in west africa and worked very much in the last outbreak on the western side of the country. What is also coming clear and there is a lot of consensus about the need to do a much more holistic approach. Not just medical interventions of people coming in but what are the needs of the community and what does the Community Need and what do they want in order to bring the interventions we need around the ebola response. We talked about it in last panel its not just ebola is the issues being faced there. People are dying of malaria and dying of tuberculosis. Women are dying in childbirth. There a lot of issues on the ground and lots of fear with everyone coming and so trying to engage very actively with local communities and local ngos that faithbased, church and other annotations to try to reach the community on a much broader scale than simply around inspection prevention control and as well as the vaccine really does make you feel much more holistic and thats certainly the impression might colleagues have come away with. Dr. Maurizio barbeschi id like to turn to you if i could. You are heading up the interface at the World Health Organization i suspect many in this room may be or not familiar with the health and security interface so first if you could gives us an overview of the Health Security interface and impact how that supports pandemic Public HealthEmergency Preparedness and your work with cdc and usaid. Thank you and thank you all. Its the result of the failure of the International System to have the definition on Health Security. Global Health Security for the u. S. May not be the same definition or understanding of the security treatment for health in another part of the world. Most of your Intelligence Surveillance interview investigator may mean certain things from Law Enforcement and civilians may not the sensitive. Health was central where this understanding was put on the front page. For instance in thailand that contributed to the investigations here and it killed 1500 people in the 1920s. That wouldnt apply to political possibilities with the u. N. Making the case and which kind of patients to sample. A similar thing when the world uses chemical weapons. Not only the concept and epidemiology at how to get people the proper care but how to preserve, how to maintain this year the event. Also the colic asked the question in nigeria without involving the day when i landed in nigeria but david we asked for help from the police but otherwise we would have never gone out. Its basically impossible to move and have one contact trained that they without a police escort. The now of course you have to ask which neighborhood to go with the police in which neighborhood not to go with the police. We elucidated in essence we are facilitating across all the systems. To exploit all those opportunities for w. H. O. Into the security sector. If you have a normal response for the pandemic you cannot do Public Health without the roadblocks, people bringing the food to the quarantine. Really its a multifactorial and we should start recognizing that we are just a really complicated pandemic when you cross the border in three countries like in 2013. Read it on line with is three different Health Systems, the same tribe. The same tribe which wasnt very friendly with each government so going back to the dialogue what w. H. O. Contributes us to have those messages across many countries. If there is an event which is deliberate or suspected which country are going to be listened to . And reflection point that could offer the answer. He dr. Salmon i want to inject a new but very related topic into the conversation and would like to ask you how you see the role of vaccines with very specifically Vaccine Hesitancy and how that may impact preparedness or response when a vaccine will be absolutely essential. Thank you for the opportunity to speak to everyone today. Its been an interesting day. Its a great question because my experience with h1n1, and speaking as an academic. The time i was responsible for overseeing and coordinating the vaccine Safety Monitoring Program at the International Vaccine office. The point about the value of 14 influenza control efforts are really important because what we had to work with was what we had at the time and i remind you what the secretary of defense Donald Rumsfeld said about when you go to war you use the army you have a army you you want and thats the reality on the ground. When you look at things like vaccine safety for example. Vexing to use routinely are very safe and thats very fortunate. Flu vaccines are very safe. Theres always the possibility of something you dont expect as was the case in 1976 with the swine flu. You have to always look for that and if youre talking about a vaccine where you have experience the potential for real safety problem to occur may be greater but you also they have the problem which is if you vaccinate everyone today every bad thing that happens tomorrow happens within a day of vaccination and thats the problem domestically but especially a problem in parts of the world where more bad things happen every day. People naturally assume the temporal relationship is a coppola relationship and you will say look at all these people that got the vaccine and then something happened. We need science to separate the coincidental from the true adverse reactions. Science takes time but the more of the structure you have the better and the faster you can respond with good science. That infrastructure needs to largely exist before theres an emergency because they dont have time to go oh now we can put this thing together. One aspect thats really important which is in the report has been shared his trust and trust specifically in Public Health authorities. This is very complicated. What makes people trust Public Health and is probably a whole bunch of things from transparency and equity and a lot of different pieces that have trust. We understand it and we dont measure very well. We need to do that. For health is important you measured in the improve it and we need Peoples Trust and their confidence. We need their confidence in our Public Health measures that the benefits upgrade the risks and we are doing the right thing. The end of the day we need their compliance. He you brought up the relationship with seeing a vaccine and something bad happens even though there is not a causeandeffect and the trust issue. We seem to be in a state right now where the public distrust of public figures. How do we rebuild that . We need to address legitimate concerns. We all his appearance have legitimate concerns. How do we rebuild that trust and develop effective education and Communication System . Those are Great Questions and we are at a point where trusting government is well. We are in a world of alternative facts were somehow something can be said within a short amount of time have the population questions the birthplace of our president. So i think the problems are complex and the solutions are also going to be complex. I think we need to make sure we have the rigorous effective science. Think it needs to be rapid. The tape the autism example it took longer than it should have for us to have it. We had really good data. We had 15 wellconducted studies the founder of the world showing vaccines are not associated with autism but in a time for when that paper was published when science became available you have a very charismatic wellcredentialed person traveling the world creating fiction. I think we need a spokesperson who is really really trustful and we need to address it that way. Even if in the United States certain countries or certain areas you possibly listen to tom brady more than local health there are countries where if you start they will go directly in the other direction. The issue which has been researched but not that well because by the time the Research Gets done social media really changes the opinion and becomes much more of the phenomenon. Its an iteration of the complication. I have a lot of thoughts. [laughter] i need to calm myself. One thing i want to say we are at a record right now with more ebola cases this year than we have had in 25 years and larger and longer outbreaks in a couple of areas of the country which are really quite difficult to control to. Think its really important for people to know that here in the United States most parents make sure their kids get vaccinated against all the things that are recommended and in fact if you look at 2yearolds its 1. 1 of them to have gotten no at all. We are not in crisis mode across the country everywhere with everybody opting out of the system but i think we are really delicate period in terms of trust which i think building up panel is really local parties to be the people trusted their family physician. They often trusted their mom or the grandmother right now a lot of parents and grandparents have different opinions that we are in a New Territory with that. I think there are many other influences and some of them are pacifists and some of them are active. The current outbreaks appear having some of the influencer at this targeting vulnerable candidates with very targeted misinformation. Thats quite challenging but its not as problem. You look worldwide there are a lot of different factors including confidence of vaccination confidence in the Health System and this is where we cant put all of our eggs in one basket of the perfect spokesperson are the perfect role. You need to look locally at the Public Health systems. We need to make sure we get the best information so partners would be more trusted than we are. It is really about who is the most trusted voice in a given setting and getting that good quality scientific information in a way that is understandable and observable to the people you are trying to reach. Complicated studies for. Understanding the lancet is not something necessarily my sisterinlaws going to just dandy want to get that information in a way thats understandable but really understanding who are these folks in a given area. There is a lot of evidence from the behavior change colleagues who have really looked at this. How do he get that information out in a way thats going to change that behavior and can be understood and trusted and look back at some of those approaches as a way to try to get on top of these kinds of misinformation and misunderstandings. I think we need to be careful not to respond. There are two places that im worried about in particular. One is there is a push to eliminate nonmedical exemptions and i understand the desire. My concern is that it doesnt get at the larger issues. The impact on california which did so in response to a Measles Outbreak in 2015 is that the impact was really small. It reduces the economy and disproportionally for lowincome people that might not be able to afford their shop doctors. My concern is that of trust in the herens feel like we are being more draconian they are maybe a backlash and also the question of social media. That the letter itself is misinformation is coming from government leaders. I think working with social media is great, and much rather see it done between individuals. In the Companies Taking social responsibility. I think we have to be care