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 k