OK.
That was amazing, an incredible tour de force.
And really, as I said, nobody thinking
about how to protect our country and keep
it safe over the last 30 years than Tony Fauci--
so amazing way to begin.
What we're going to do next is I'm going
to bring the first panel up.
And we have a little video.
So let me line up the video while I ask
our first panelists to come up.
So if we could have Mike, Dennis, Hillary, and Mosoka
come on up, and join us.
And the first video--
so we had asked Larry Summers to come, and offer some remarks.
Larry is traveling.
For those of you who don't know, he's
the Eliot University Professor, a former president of Harvard,
former Treasury Secretary.
So then the question is, why Larry Summers?
He has been very deeply engaged in this,
and thinking about this, and cares a lot about this.
I was going say, I realize you guys
may not be able to see the video from sitting up there.
So it's up to you if you want to--
either way.
And so Larry was kind enough to record a video for us.
And it's about six minutes.
We're going to watch it.
And then I will introduce our panelists,
and we'll get started on our first panel.
[VIDEO PLAYBACK]
- I welcome the Harvard Global Health Initiative's review
of what happened a century ago with the flu pandemic
and its effort to look forward to mitigating the risks
and the consequences of future pandemics.
I am convinced that pandemic flu is the least focused on
of major global challenges.
Vast efforts and concern surround nuclear proliferation.
Vast efforts, appropriately, are directed to issues
around global climate change.
Taking the risks over time of pandemic,
I believe that the consequences are similar,
in terms of total economic impact,
in terms of lives lost, to the risks associated
with climate change and the risks associated
with nuclear proliferation.
And yet, pandemic risk is a obsession for specialists,
a preoccupation of those concerned with insurance
and reinsurance, but a much less-mainstream issue
than nuclear proliferation or global climate change.
And so, I believe that this initiative that reminds us
that more people died in the flu epidemic after World War I than
died as a consequence of World War I,
that reminds us of how profoundly society was changed
by a disease that took the strongest rather
than the weakest among us, those who
were young or of middle age, is something
that is very, very important.
We certainly have made immense progress
in the biomedical sciences over the last century.
And that is a positive development
with respect to pandemic risks.
On the other hand, we live in a much, much smaller and much,
much more interconnected world, which
means that disease vectors will be transmitted
that much more rapidly.
Full quarantines will be that much more difficult.
We live in a world that faces too much
superstition, propaganda--
dare I say it-- fake news, and confusion with respect
to vaccination, which has to be at the center of any effort
to control epidemics and pandemics.
And we live in a world where, too often, the preoccupation
is with the urgent rather than with the profoundly important.
And that diverts us, too, from preparing
for the next pandemic.
I believe that this is a central challenge
that deserves far more global attention than it is now
receiving.
And I am glad to see Harvard's Global Health Initiative do
its part to arouse concern, prompt study and reflection,
and drive preparation for the epidemics and pandemics that
are all too likely to come, albeit unpredictably,
at some point in the future.
[END PLAYBACK]
Great.
So as I said, most people in this room
have been thinking about and working on these issues.
But Larry Summers, who has thought broadly, has worked,
obviously, across a variety of sectors and is one
of the leading economists-- and I think, public intellectuals--
has glommed onto something that is really
a key issue, which is that this is not a specialized issue.
This is not a health care issue.
This is not an issue that specialists need to obsess on.
And the point he makes, that if you
think about the things that can cause catastrophic harm
to human society--
global climate change is more slow moving.
But if you think about things like a nuclear weapon going off
in a major city, terrorist threats,
we spend enormous amount of resources-- and rightly so--
on understanding those risks and mitigating those risks.
And then when we switch to something like pandemics,
it drops way down.
And we start thinking about, well,
do we really have the money to afford it?
Can we really make the investments?
So that's part of the challenge that we're dealing with.
And so our first panel for today is an extraordinary panel.
And I'm going to very quickly turn it over to them.
I'm going to do very quick introductions.
This is about understanding and mitigating risks.
And so the first panel--
for those of you who've been with us,
you've seen Mike Osterholm join us.
So thank you, again, for coming back, Mike.
He's the director of CIDRAP at the University of Minnesota.
And as I described him a couple of days
ago, when the country faces challenges
he's one on the shortlist of experts
we turn to, as he was after 2001.
Dennis Carroll, next to him, is the director of the USAID
Global Health Security and Development Unit
and has been deeply involved in these issues.
USAID-- when we talk about the importance of global health
security, we often talk about CDC,
and NIH, and the Global Health Security Agenda.
USAID has been a very central part of this.
And it's really been from Dennis' leadership.
Hillary Carter, next to him, is the director
for counterbiological threats at the National Security Council--
has been working on global issues--
not just global health issues, but global issues--
for quite a long time--
is a PhD from Georgetown.
And then next to her is Mosoka Fallah, whose official title
is deputy director of general and technical services
at the National Public Health Institute in Liberia.
What he really is--
he's been a close friend of the Institute for many years--
is one of the people who was central to turning around
the Ebola outbreak in Liberia.
And he did it through a combination
of both incredible intellect, but also personal integrity,
and trust, and working with the community quite directly
and has been a colleague, friend, and a hero of mine.
So I was thrilled to have Mosoka join us.
So why don't I turn it over to Mike.
I think everybody is just going to make some reflections--
up to you.
Do you want to come up here?
You tell me.
Why don't you come up?
I think people can see a little bit better if you're up there.
I'll sit.
And then we'll have a discussion.
Good morning, and thank you again for the invitation
to be here this week.
It has been really, truly a remarkable experience
over the course of the last four days.
And I just want to thank the organizers
for the vision to put this kind of a meeting on.
Let me begin by saying that I, as usual,
want to kind of send this meeting into a topsy-turvy
moment.
I would like to challenge the notion
of what we talk about when we talk
about pandemics and epidemics.
And there's a very real reason why.
It's not a semantic issue.
It's a actual response issue in a key way.
We often throw around the term pandemics and epidemics.
And we intermix them.
And I think that's at our own peril.
To my mind-- and I tried to discuss this in some length,
the justification and the background for it, in my book,
Deadliest Enemy, Our War Against Killer Germs, last year--
I believe that there really are only
two disease categories that rank in the category of pandemic.
Remember, a pandemic is a worldwide epidemic,
meaning every country, every region,
every continent has the chance to have the same problem happen
as does any other one.
Obviously, first and foremost is influenza.
Just to remind people-- and Tony showed a nice slide up here--
but our group went back and looked at this carefully.
And by the time that the first isolate of H1N1
was identified in California in April of 2009--
we now recognize that that virus was
in at least 27 countries for certain and maybe
as many as 43 countries.
It had moved that quickly around the world.
That's a pandemic.
The second category, I would say,
is an unusual one, in that it's not a disease in and of itself.
We are facing truly a pandemic of antimicrobial resistance,
which is a pan pandemic in the sense
that, on a worldwide basis, it's happening every day everywhere.
Some organisms may be more prominent in some areas
of the world.
But it's just a matter of time.
Beyond that, all these diseases we're talking about
are really what I call diseases of
critical regional importance.
Ebola is absolutely critical to Sub-Saharan Africa.
But will Ebola become a major disease problem
in the Americas?
No, not likely.
Now could we have cases--
as we talked about and I mentioned
in my previous presentation the other day--
that what kills us, versus what hurts us,
versus what concerns us, versus what scares
us can all be very different.
And we saw that with Ebola in the United States.
But from an impact statement that's very, very important
to distinguish.
Let me give you an example.
We live today in a global economy
that we are so dependent on others
out there to supply to us what we need every day.
As of this morning, pre-hospital drug shortages in this country,
meaning what's on the emergency room cart, what's
on the ambulance cart right now--
we have 189 drugs that are either absolutely not available
or in critical short supply.
Many of them are absolutely lifesaving drugs.
Why is that?
In part, because almost all of them are generic.
Almost all are made in China.
And the business model has been set up to cover the mode,
cover the mean.
Don't try to cover shortages, et cetera.
It's too much money to have that much [? pan ?] capacity.
If you wanted, today, to go to war with China--
and for anyone who's in the room from China,
I hope that never happens.
They wouldn't need to fire one bullet
to put their drug supply hands around our neck
and strangle us.
Our military is totally dependent on these same drug
shortage drugs that we, as the public, are dependent on.
When the situation happened with the poor Hurricane Maria
in Puerto Rico, everybody seemed so surprised
that we had this big shortage of IV bags all of the sudden.
I gave a talk four years ago in which I predicted the next F4
or F5 hurricane to hit Puerto Rico was going to take down
our ability to supply IV bags because 80% of the world's
capacity to make them were all on that island.
Should we have been surprised?
The reason I bring this up is because,
from a pandemic standpoint, those diseases which impact
those kinds of critical supplies will
impact the rest of the world.
And from a health standpoint-- let me just say right now,
for the 690,000 Americans that have chronic renal problems
and are either on dialysis or drugs--
which are almost virtually all coming from China--
anything that shuts down certain parts of the world's ability
to move product, make product, distribute product
is going to have collateral damage second to none.
That's why we have to distinguish
between pandemics and epidemics of
critical regional importance.
And so I think, whether--
and last night, you heard me comment
on the issue around vaccines.
What we're talking about is a shortage
of epidemic vaccines, vaccines that
are going to handle those diseases
of critical regional importance, with the exception
of the issue of influenza.
Now let me just say one last thing for some
in the room sitting there saying, well, HIV and TB,
aren't they all pandemics?
Actually, by technical definition,
they're not anymore.
They were at one time, HIV in particular.
But now it's an endemic disease.
In some cases, it's hyper-endemic.
But it's not a new condition.
Suddenly, we're not going to see major social, political,
and economic implications because of HIV that
will disrupt that area of the world beyond what it's already
doing.
In some cases, it's a horrible situation
in parts of the world.
TB is a horrible situation.
But it's not going to change the political nature.
So I think today, as we talk about these,
it is important to distinguish about what really causes
a pandemic, a worldwide epidemic of a new disease,
versus those of critical original importance, which
can be very, very important.
But they have totally different implications.
We never worried about the impact on our US drug supply
or the European drug supply with Ebola in West Africa.
We worried about a lot of other things, but not that.
But a pandemic that shut down global trade and travel
would, in fact, be a very substantial problem.
Thank you.
[APPLAUSE]
Great, thank you.
[INAUDIBLE] And Mike, thanks for those opening comments.
I'm going to talk about one of the maps that Tony just showed,
which was the second map that showed the enormous diversity
of emerging infectious diseases that
have come up over the course of his career
over the last 30 years.
And what we need to understand is that, virtually
all of those agents that showed up on those maps,
they preexisted in wildlife on this planet
before they made it in to us.
We live in an ecosystem where the interface between wildlife,
livestock, and people is such an incredibly dynamic process
that a deep reservoir of an extraordinarily diverse pool
of viruses that have been resident in wildlife
forever are now-- the dynamics are changing.
And what I'd like to do is talk a little bit
about that relationship between zoonotic diseases,
those diseases that have their genesis in wildlife spilling
over into people.
And I would also like just to pick up on AMR--
that it is not a zoonotic a disease.
But what we also know about AMR is that the drivers behind AMR
are not simply the events that occur
within prescriber user practices within clinical settings--
that 90% of all antibiotics consumed
within the United States by weight
are done within livestock.
So as we think about how we protect and preserve
the well-being of our population,
we need to understand that it's not just
about humans or homosapiens.
It's about how we sit within the larger ecology on this planet.
So there are five points I'd like to make.
First off, even as we talk about zoonosis,
all of those diseases that we see spilling out
over the last 30 years is not a new dynamic.
In fact, many of the infectious diseases
that are part of the global burden today
had their genesis in wildlife-- malaria, tuberculosis,
and as Mike just pointed out, HIV.
And it's worth noting that, while we are here remembering
the 100th anniversary of the great pandemic of 1918,
in another two to four years, it'll
be the 100th anniversary of the spillover of the progenitor
virus from Simian populations from people that
unleashed HIV in the world.
And so we live in a place where zoonosis
is very much part of our normal landscape-- point 1
But point 2 is that it's not a steady state.
The dynamics of emergent spillover,
spread within human populations today,
is radically different in the 21st century
than any other point.
Someone mentioned earlier today that, if we were here in Boston
100 years ago, the world's population
was 1.5 billion people.
Think about it.
As a species, it took us 400,000 years-- plus or minus--
to get to that 1 billion mark.
In the space of 100 years, we've added another 6 billion people.
And by the time we get to the end of this century,
we'll add on another 5.
You can't have that kind of accelerated footprint
on this planet without having a hugely disruptive effect
on that ecosystem dynamic with wildlife, livestock,
and people.
So we live in a different space.
And as we think about the 21st century,
this is a period of great epidemiologic transition driven
by population pressures that will play themselves out
in ways both at the pandemic, but at the epidemic level,
as well.
That said, as we look to the 21st century
as a place of extraordinarily dynamic risk, it's safe to say,
we are not prepared.
We remain ill prepared.
Despite extraordinary efforts over the last decade
to build systems and capacities around the world
to deal with preventing, detecting, and responding,
the truth of the matter is, we're ultimately held hostage
to the fact that our toolbox of response
is an enormously inadequate one.
And Tony sort of touched upon it when he spoke to the challenges
we have in terms of developing countermeasures
in the midst of an event.
And while he talked about influenza in 2009,
it's worth noting that, by the end of 2009,
we may have had enough to provide maximum protection
for the American population.
But 12 months after the emergence of H1N1,
the total amount of vaccine that had been produced worldwide
would have protected 17% of the world's population.
2 billion people, by that time, had been infected.
There's a dis-link between what we're
capable of doing, in terms of developing countermeasures
after emergence, towards having maximum impact not just
on the people within the United States,
but the global community, those 7.6 billion people
that live on this planet.
Why are we still so ill prepared?
Why is that toolbox so fragile?
And I'd go to the last point on--
again-- Tony's slide, where he talked about vaccine strategy.
And he talked about the prototype strategy,
which is not to simply look within the flaviviruses
at developing a vaccine against Zika,
or yellow fever, or Dengue--
which we know do not cross-react with each other--
it's beginning to rethink what we
know about the relationships within those viral families,
and use raw data analysis across families
to be able to think about broad-spectrum countermeasures
for the first time.
But the weak link in that strategy
is that, for the six or so examples that he put up there
for the flavivirus, we know that there
is somewhere on the order of 6,000 other flaviviruses
circulating in wildlife--
same thing for filoviruses, Ebolas--
same thing for retroviruses.
We live in a world where the pool
of viruses which are circulating that we will become
increasingly more acquainted with in the 21st century--
we've only seen 0.1% of all of those viruses.
So I will turn you to my last point.
The opportunity we have is to be transformative,
move beyond what are the agent-specific interventions--
going after Ebola, going after yellow fever--
and begin turning the sciences for emerging viral diseases
from what are really low-data sciences, almost
mom-and-pop sciences, into big data.
What would it take for us to, in fact,
go out and characterize those other 6,000 flaviviruses
that are out there that are currently
circulating in wildlife?
What would it take for us to be able to go out and characterize
the 6,000 filoviruses?
The opportunity is extraordinary.
We are not limited by technology.
What we are limited by is political will.
And we know, from work that we've done in partnership
with many in this room over the last decade, the feasibility
of actually going out into wildlife,
collecting those samples, and beginning
that characterization, both in terms of their genetic
and their ecologic profiles, allow us to transform
the science of the emerging viral diseases
from a small, agent-specific science
into broad-spectrum, family-level, virome-level
sciences.
Final point-- Albert Einstein famously
observed that doing the same thing over and over
again is the definition of madness.
We're not mad.
But we are simply--
when we think about, what's our plan B to plan A,
we usually say, we'll do plan A better.
What we're arguing for is to transform
what we think about plan B, and open up the gauge.
Think about the role of this ecosystem we sit in--
wildlife, livestock, and people--
and use that understanding to begin
to transform the questions were asking
and the investments we're making.
Thank you.
That was terrific.
Thank you, Dennis.
And one quick correction before I go ask Hillary-- which is,
I got your alma mater wrong.
Your PhD is from Vanderbilt. And no offense meant.
But as soon as I said it, I said, I think that's wrong.
Yeah.
So, my apologies.
But I'm still completely thrilled
that you're here-- and your opening thoughts on where
you're sitting at the National Security Council
thinking about these issues.
Great.
Thank you very much.
And I was going to correct that, because I
can't discredit my alma mater Vanderbilt if there's
any donors in the room.
So thank you very much for the invitation and the opportunity
to be here.
It's a pleasure to be here with you all today.
And a big thanks to the Harvard Global Health Institute
for convening this Outbreak Week and convening
this symposium today.
This is an incredibly important opportunity
to come together and discuss options
that we have for the future to reduce these risks.
So today I've been asked to speak about the policy
and strategy development work that the US government has
done as it relates to biodefense and global health security.
So my comments will be mostly focused on that.
And I look forward to the discussion
if there's any further questions.
So first, let me start by saying that we believe that strategies
are important and that strategy should empower implementation.
Biological threats, whether they are deliberate, accidental,
or naturally occurring are among the most serious threats
to US national security.
And I don't need to tell this audience this.
This audience knows it very well.
Infectious disease threats do not respect borders
and in our interconnected world can spread rapidly independent
of origin.
Biological threats are a distinct aspect
of national security and require a focused and systematic
approach to reducing risks.
It's a vital interest of the United States government
to prevent, prepare for, respond to, and recover
from biological threats.
In December of 2017, the White House
released a National Security Strategy
which calls for combating biological threats
and pandemics.
There are three priority actions underneath this particular end
state.
And they are detecting and countering biological threats
at the source--
so global health security--
supporting biomedical innovation,
and improving emergency response,
which entails, domestically, understanding
and characterizing the outbreak to limit the spread of disease.
I highlight the National Security Strategy in this form
in particular for two reasons.
One, the National Security Strategy
articulates the US government view that health
security is national security.
And two, by including it in the National Security Strategy,
it indicates that protecting health security
is a national security priority.
I'll now turn to the most recently released strategy,
which is our National Biodefense Strategy.
On September 18, 2018-- so just last week--
the White House released the National Biodefense Strategy
and its implementation plan.
And the president signed a National Security Presidential
Memorandum-- which is a presidential directive--
on support for biodefense.
And biodefense in this context is defined very broadly--
that looks at actions to counter biological threats
and reduce risks and includes global health security
and domestic health security.
The Biodefense Strategy identifies five goals.
The first is to assess biological risks.
The second is to ensure capabilities to prevent
biological incidents.
The third is to prepare to reduce
the impacts of biological incidents,
and the fourth is to respond rapidly
to biological incidents.
And then the fifth and final goal
is recovering after biological incidents.
This strategy integrates the activities of more than 15
departments and agencies.
And it's comprehensive in four different ways.
The first is that, by threat, it, for the first time,
encompasses naturally-occurring, accidental, and deliberate
biological threats, bringing those into one
comprehensive strategy.
The second is by target.
It addresses threats to humans, to animals, to plants,
and to the environment.
The third is that, by geography, it
looks both here domestically in the United States
but also internationally.
As we know, biological threats are borderless threats.
Four, by discipline-- this strategy
takes a multi-sectoral approach and addresses
different sectors, including health, law enforcement,
defense and security, emergency response, science
and technology, and others.
Included in the annex of the National Biodefense Strategy
is its implementation plan, as I mentioned.
And the implementation plan provides granularity
for the objectives and the goals and describes in greater detail
the actions that the US government will take
to strengthen its biodefense.
And for this audience in particular,
I encourage you to look at the implementation plan
because that's where the meat of the descriptions
are on the different actions.
Also, I mentioned that the president
signed a National Security Presidential Memorandum.
And this presidential directive directs
the execution of the strategy and the execution
of the implementation plan.
And further, it lays out a framework
for coordinating the broader biodefense enterprise.
I'll go through the structure.
And I'll go through the annual process.
And then I'll get to the, so what?
What does it mean?
Because I think we are hoping to create something that's
responsive to some of the things that you heard Dennis raise,
that you heard Mike raise, and that you heard
Dr. Fauci raise this morning.
So the structure is as follows.
The Secretary of Health and Human Services, Secretary Azar,
is designated as the federal lead
for coordinating implementation of the strategy.
The Assistant to the President for National
Security Affairs, who is my boss, the National Security
Advisor, is the lead for coordination and integration
of policy for all biodefense efforts.
The presidential directive also creates a principal level--
so cabinet secretary level--
Biodefense Steering Committee, which includes eight cabinet
officials.
And then there's also a team created within the Department
of Health and Human Services to support those principals
and those cabinet officials.
The Biodefense Steering Committee and the Biodefense
Coordination Team have a mandate to reach
outside the federal government to non-governmental
stakeholders, including academia,
international organizations, international partners,
and to ensure their activities are
coordinated with the broader federal government activities.
There's also the annual process.
The annual process--
I won't describe it in detail, but it does a few things.
It's tailored to understand what the US government is doing
to counter biological risks, to assess if those activities are
meeting the goals as defined in the strategy,
and then to annually determine what our policy priorities are,
and link this policy prioritization
process to the annual budget.
And so, so what?
What's the significance of this strategy?
And why did we put this out and go to the trouble?
So first and foremost, I think what
you're seeing is an elevation of biodefense and priority.
You heard numerous panelists here today talk about,
why don't we give biological threats the same attention
that we give other actions?
I think what you're seeing here is an elevation
of this in priority.
Second, for the first time, we do have--
and we've established a federal lead-- which, again,
is the Secretary of Health and Human Services,
for a comprehensive strategy in coordinating these actions.
And then third, the strategy and the process
gets at, annually, analyzing the gaps in preparedness
across the US government and then developing policy
priorities to close those gaps.
And so you heard Dr. Fauci this morning
talk about biological threats or perpetual threats.
He said emerging infections, but I'll expand those
to all biological threats.
You heard Mike talk about distinguishing
between a pandemic and an epidemic.
You heard Dennis talk about our inadequate response toolbox.
What we're trying to do with this strategy
is create a structure to understand what we're doing,
understand what we're not doing, and then prioritize
our actions accordingly in the years to come.
Thank you.
Great.
Thank you so much, Hillary.
That's really helpful.
[APPLAUSE]
Are you going to go up there?
Yeah.
Great.
That was great.
Thank you.
And sorry about the PhD.
I don't know where I got that.
Thank you very much.
I'm going to be speaking briefly about some of the--
Can you speak into the microphone?
OK, sorry.
No, it's fine.
I'm going to be speaking briefly about the trace of epidemics
that we've had since Ebola ended.
Two things I want to say--
infectious disease anywhere is infectious disease everywhere.
And we have to be cognizant of the fact.
Yellow fever in Angola spread to Europe--
less than a week ago, monkeypox from Nigeria into the UK,
and people got infected.
We face this issue every day.
Neglected spots of today are the hotspots of tomorrow.
So I have this map attempt to show
you the level of preparedness in the West African region
towards epidemics preparedness.
You see predominantly most of the countries in the West
African region are in red.
That's low level of preparedness.
And if you establish a mediated premise
I have learned that infectious disease anywhere is everywhere,
that the neglected spot of today are the hotspot of tomorrow.
You can see a set of Liberia and other countries in yellow
are making some progress due to the lesson learned from Ebola
and also want to recognize the [INAUDIBLE] effort
on the [INAUDIBLE] grant that is trying
to do regional surveillance.
There is so much investment into regional surveillance,
training epidemiologists of tomorrow,
building laboratory capacity-- it's a very
good step in the way forward.
Because if you understand infectious disease--
like, I monitor what's going on in the DROC.
It worries me every day watching the trend.
And I hate to say this, but I'm so convinced that there's
a bigger threat, that it will spill over into our country
for a potential situation.
Because we saw all the arrows that
happened in Liberia repeating, except in the DROC.
The resistance, the military [INAUDIBLE] someday.
So we want to acknowledge the investment.
But this can tell you the situation in West Africa.
I will now narrow it down to Liberia.
If you compare 2017 to 2018, you begin
to see that there are increasing cases of outbreaks
that includes Lassa.
As I speak to this very moment, yellow fever
had been in the news in the southeastern part
of my country.
Lassa-- we have had consistent spread
of measles in the country.
We have our reemerging of new diseases.
Are we seeing the increase in outbreaks because of Ebola,
and we have enhanced our surveillance capacity?
Richard Cash used to say to us, "When you look for it,
you will find it."
Are we finding it because you are looking for it?
Well, he showed you are increasing outbreak in Liberia.
I want you to watch carefully what's happening.
Over three years period, we see increasing cases of Lassa.
In Liberia we have, like Dr. Fauci said, Lassa [INAUDIBLE]
of the year.
And certain area, we call the Lassa belt.
But for the last couple of years,
there is [INAUDIBLE] for the Lassa belt to move countries.
Not only that, but we are also beginning to see
that it is lasting more longer.
And because it is lasting longer,
we are having more cases of Lassa.
I share this slide.
If you look across three years, you
watch the number of cases we've had,
the number of confirmed cases.
You'll will see that, in 2018, the case fatality rate
has increase as a function of the number of cases
the severity of the disease.
[INAUDIBLE] to tell you that we're
going to face greater threat every day.
Not only have we seen that epidemiology and the biology
of diseases that we knew are changing, and posing
more threats, and killing more people,
but we begin to see a re-emergence of new disease.
Yes, we begin to see monkeypox.
Since the '70s, monkeypox was essentially eliminated
from Liberia and West Africa.
Last year, we begin to see new cases of monkeypox spread
across the country.
Monkeypox is no more restricted to Liberia.
But we see cases in Sierra Leone.
We see cases in Liberia, Central African Republic,
and as I said to you, Nigeria, where two
cases got imported to the UK.
And someone in the UK got infected.
So the chances of--
I always say to people, I can have breakfast here today,
and I can have my dinner in Liberia with the global travel.
I can be incubating a disease this very moment from the US.
And I will be in Liberia, and spread it.
We saw that happening with Ebola.
OK, another care here--
for a long time, we're blessed.
Liberia was outside of the meningitis belt.
All of a sudden, we're in a conference with the US
Administer of Health.
We had a cluster of death.
A person died.
From symptom onset, to severity, to death--
24 hours.
We're very confused.
All of a sudden, we thought it was Ebola.
We went around through metagenomic sequencing
at the CDC.
We realized that it was [INAUDIBLE] meningitis
serotype C.
This was now-- it's spreading in Liberia.
Liberia was not in the epidemic belt, the meningitis belt.
All of a sudden, it went back.
And the most important one that is
so critical from a global health perspective
was the one in the northwest.
This is the boundary between Liberia, Guinea and Sierra
Leone, the red circle where Ebola started from.
This is where we had a big outbreak.
And to make it more interesting, the outbreak
was ongoing during the inauguration
of our new president when international guests
were flying in.
Airplanes were coming into Liberia.
We had to do the issue of information management,
keeping the outbreak contained.
We had to move in massively with ciprofloxacin.
And we were able to treat over 1,000 people
to prevent a spillover into Sierra Leone and into Guinea
and to ensure that we kept the outbreak contained
so it wouldn't come to Monrovia, where
we had thousand of guest, presidents, and ministers
where they have a meeting.
So outbreak anywhere is everywhere.
What are some of the threats?
So I gave you the fact that we still have a threat.
The biology of the disease is changing.
The epidemiology is changing.
Global travel facilitate the disease.
But they are traced.
I tend to show this slide.
Ebola has helped us a lot.
We've built a resilient system.
We have a huge support where we have surveillance
system in the country.
But the two dips, I show you, was a point in time
where some of support we get from international donor
stopped coming.
And the workers went on strike.
So there's still a fragile system, the system that
is so heavily donor dependent.
That system gets so fragile that, whatever
happens to Monrovia in the midst of donor support, it drops.
How do we transition to develop sustainable
financing for health care is a critical issue.
The second threat is that we've done
an assessment of our emergency stock, PPEs and glove.
It we were to have an outbreak tomorrow,
you would be surprised to note, PPEs and glove
are now zero in country.
These are all fragile system that tell us,
in the midst of increasing outbreaks,
you begin to see the little logistics are
absent or at a stop.
What that simply means-- tomorrow,
if we had an outbreak of Ebola, say, in northwestern Liberia--
that it's impossible because of [INAUDIBLE]..
We don't even have PPE.
It's that we have to re-shape the model.
And so much has been invested in this country.
Liberia alone from Ebola got $1.5 billion investment.
How [INAUDIBLE] sustaining an investment in the country?
So I will shift gear.
One of the way we've done investment
now is to create these National Public Health Institutes.
I was one of those who have to form the Public Health
Institute of Liberia.
I went to Thailand.
I went to Norway to study that system.
And we build a public health institute from the lesson we
learn from Ebola, that a minister of health cannot be
focused on health care delivery and preventing threats.
So we developed this institute to narrowly focus on threats,
on surveillance, and diagnostics,
and building capacity.
This concept has now spread across Africa.
There is a African CDC and the [INAUDIBLE] CDCs
with a goal of building core public health capacity
for surveillance and response.
With funding from the World Bank and other institution,
we begin to make substantial progress.
And that's the only way we can save
infectious disease in these neglected spots
from coming into the developed spots.
Now to mitigate the risks is an investment in laboratory
system, diagnostic system.
I was involved in Ebola.
I was in Liberia at the time, having completed school in US.
When Ebola struck Liberia, we literally
had to take the samples to the border with Guinea,
cross them in a canoe, drive them to [INAUDIBLE],,
and bring the result back to Liberia on five to seven days.
There was absolutely no capacity to diagnose.
So those are the factor that spiral.
With support from [INAUDIBLE] and the CDC,
you see, now we are able to diagnose priority diseases--
Microphone.
--like Lassa.
Mic.
Priority disease like Lassa.
And so that gave us a complete speed in the management
of [INAUDIBLE].
I tell people every day, speed, speed, speed, and communication
are the two critical factors.
With the ability for diagnostic capacity in-country,
we can now diagnose and respond to outbreak immediately.
The second most important investment
is an investment in the civilian system, the public health
capacity.
If you look at the time, most of our outbreak now
we are responding with less than two days, which
is the standard set by the VHU.
You see, all in red, we have zero now.
Because we have built a human capacity.
There have been investment.
That's the way we need to get the [INAUDIBLE],,
finding the core human capacity, training them, and supporting
them to be in-country before you expect them flying.
[INAUDIBLE] that our turnaround time are quicker.
So we are able to continue outbreaks from spilling over.
Finally, I just have this point.
The international community have learned their lesson
from Ebola, I have to admit.
And some efforts have been made.
One has been the Joint External Evaluation,
where they expanded the panel evaluation of where we stand.
As a result of JEE, we now have the National Action Plan
for Health.
For Liberia alone, the Action Plan of Health
has been cost-checked.
It will take $150 million investment
to prepare Liberia for sustainable
financing for outbreaks, for preventing,
for vaccine over 5 years.
Of course, we've been part of the Global Health Security
Agenda [INAUDIBLE] to USAID in Liberia.
We've invested in the One Health approach.
My colleague, [INAUDIBLE],, will tell us,
we know One Health approach, you have a coordinating mechanism
with the highest political support with the vice
president of my country serving as a head of the One Health.
We are getting involved into integrated disease
surveillance and response.
Lack of time--
I can't go into that.
But it's this framework developed for the AFRO region
to support IHRO.
And the last point I want to speak to
is the fact that we now have documented
that clinical research can be used as a response.
[INAUDIBLE] as example that clinical research
can be a component part of a response.
And we see these very same thing is
going be happening in the DROC, where they're trying to do
this three-arm therapeutics.
The work of [INAUDIBLE] NIH in Liberia
is a [INAUDIBLE] example that there
can be connection between developing
and developed country to build sustainable capacity.
We are running over nine clinical trials in Liberia.
I'm the PR on three of those trials.
We are published.
We are in [INAUDIBLE] journal.
It can be done.
And to close, I will say that infectious disease anywhere is
infectious disease everywhere.
And in the neglected spot of today
are the hotspot of tomorrow.
Thank you very much.
[APPLAUSE]
Thank you.
Thank you, Mosoka.
And a reminder of just how much progress Liberia
has made just in a couple of very short years--
but as you said, still remains a very fragile system that
can be quickly put at risk.
So I'm going ask a couple quick questions.
Then we'll open it up to the audience.
And my first question is a point that several of you
hit on but we have spent very little time talking
about this week, which is antimicrobial resistance.
It, as an issue, comes right up to the issues
that we have been talking about around outbreaks.
I would argue that it sort of belongs inside the tent
of this conversation.
But reasonable people can disagree.
Given the focus on pandemic influenza that we've had--
but really just as a model for threats
that can quickly harm human health--
I'd love it if we could all just comment
on antimicrobial resistance, how big a threat it is,
and how big of a challenge it is, and whether the tools
that we are thinking about from surveillance systems,
building better vaccines, all of the stuff we've
been talking about--
to what extent is that helpful in this conversation?
Or does AMR need a different set of strategies?
And I know several of you touched on it.
And Hillary, as you've thought about the national global
health security strategy, biosecurity strategy,
to what extent has AMR played into that conversation?
And then, Mosoka, when we get to you, as you guys have thought
about your surveillance systems for these very classic
diseases, what about AMR as a threat
to the population of Liberia?
So I won't ask any more.
I think I've laid out the question.
I'll start with Mike-- and then if we can just go down the row.
Well, first of all, I think we have to just really come
to grips with reality that, like earthquakes, hurricanes,
and tsunamis, antimicrobial resistance occurs.
A very fascinating study that was done a few years ago when
a group of researchers went back into one of the most
distant areas of Carlsbad Caverns, an area that
had not ever seen human contact before--
400 million years back in time.
And when they sampled the walls aseptically,
they not only recovered a whole number of bacteria,
but they found that the bacteria are
resistant to 14 of our current leading
antibiotics we have today.
And you say, well, how did that happen?
Well, they were, all along, competing for space and food
as bacteria.
And they had their own evolutionary pressure
that brought them to develop similar resistance
issues to what we, today, capture
relative to our modern antibiotics.
So this has been happening.
What we've done is we've put it on steroids
in a sense by the dumping of the amount of antibiotic
into the environment that we have,
whether it's through humans, or whether it's
through animals, whatever.
And so what we have to understand is,
from an evolutionary standpoint, this is going to happen.
It is happening.
And it's only going to get worse.
It's accelerating.
And I think that, to the extent that we, for a long time,
have predicted severe challenges around antimicrobial
resistance, we're now just really beginning to realize,
in depth, the extent to which it's impacting treatment
of disease, clinical outcome, how it's being used to cover
for poor sanitation, et cetera-- which then
just accelerates the problem--
and the role that the food supply plays.
I just would add one last piece.
I think one of the areas that's going
to come back and be a real challenge for us, also, is--
and I think this clearly has been well-described recently
in the microbiome studies, antimicrobials
have a lot of downsides to humans
that we never appreciated.
Clearly, they've had a lot of upsides.
They have been lifesaving in so many ways.
But the relationship between those gut bacteria
or those skin bacteria that we've
evolved with over the last hundreds of thousands of years
were very critical in terms of the human physiologic response
and the signaling that goes on between them.
And when we came in and started altering that
with antimicrobials, we've actually
created a whole other set of health problems.
And I think that we are going to learn one day that how
we use antimicrobials to reduce the risk of infectious diseases
is going to be critical.
To just very briefly say to your question-- yes,
we need whole new strategies.
And when I say we, it's the world.
If we don't take this on globally-- and to follow-up
on the point just made-- if there's a disease anywhere it
will be everywhere-- we're seeing it
without antimicrobial resistance.
The Chinese introduced colistin to the hog
population four years ago.
And before we knew it, overnight,
colistin-resistant bacteria were around the world.
And so I think that, to the extent
that we also deal with this, it can't
be a coalition of the willing.
It has to be a complete, worldwide effort.
Because otherwise, we'll just continue to accelerate it.
Great.
And Dennis, as you answer this, I'm
going to put one more little spin on,
which is-- so as a practicing physician,
I feel like I get bombarded with antibiotics stewardship.
And yet, I hear 90% of antibiotics by weight
is in the farming sector.
And so whose fault is it?
Is it mine, or is theirs?
How do we apportion blame between me
versus our food supply, and our food industry,
and our farming industry?
And I'm not really trying to apportion blame.
But I'm trying to get a sense of, from your perspective,
as you think about zoonoses, as you think about AMR, where
are the major sources of that evolutionary stress that
are creating these problems?
Well, it's unfortunately in both categories.
And they do accelerate different kinds of problems.
The animal husbandry industry clearly
has contributed a substantial amount.
And there has been a defensive posture
there that has made it very difficult for us
to try to deal with that issue.
But humans have contributed their own.
I would also add, though, that what we don't understand
is on the global level, whether it's animals or humans,
antibiotics are like candy.
They are basically the first, second,
and third line of medical care-- is
to go to your local, quote unquote, "store."
Because frankly, they don't have access to health care.
And because of the diseases, particularly
of low- and middle-income countries,
this becomes, by default, what you do.
So that has to also be added.
Let me just add one last piece, because I
was involved with this, and some of the people know about this.
Just last week, we made an announcement.
There turns out that there is a very major trade
in dogs being sold in pet stores throughout the United States.
And as result of the exchange that
goes on between these animal breeders and so forth,
we now have bred a strain of campylobacter
that we have no antibiotics for.
If you get infected with this thing, good luck.
And we have seen numerous infections, particularly
in young children, that have been
very severe and acute that we don't
have anything to treat it with.
And it's now part of the dog breeding
industry in the United States.
So there's an example where it wasn't even livestock.
It was pets-- and the concern that we have with it.
Let me first bring the discussion back to 1918.
Because what's the difference between 1918
and if a similar virus were to emerge in 2018
or this upcoming spring of 2019?
And in 1918, what didn't we have?
We didn't have antibiotics.
We didn't have antivirals.
We didn't have vaccines.
If we were to have a similar event, for as long as it takes
to get the vaccine, we would still have
antivirals and antibiotics.
And that's significant.
Because when you look at retrospectively at 1918,
half or so of the deaths were due to the virus.
Half were secondary bacterial infections.
So antivirals and antibiotics will be a very fast
front-line response.
It's important.
If we move into a post-antibiotic world,
we're moving back to 1918.
And so just to tie the circle back,
the vulnerabilities are extraordinary.
The other about what's the relative balance of influence
at livestock, aquaculture, human, environmental,
we don't know--
and largely because we've spent a lot of our effort
over the last two decades really zeroing
in on clinical practice, prescriber users.
There's a big black hole out there
in terms of, what's the contributing
factors around animal husbandry, aquaculture,
and environmental contamination in an environment where,
as Mike said, you already have just a natural dynamic
of evolution within bacteria?
We don't know.
And that's one of the really important One Health agendas--
which is to bring a much deeper evidence base to understanding,
what are the relative contributions?
Because it talks about risk mitigation.
And you really need to be smart about that
because Mother Nature is doing her own--
independent of us-- evolution, as well.
Great.
Hillary, how have you guys thought about this
in the national strategies?
Yeah, so I will add just a few things
to the comments my colleagues made.
And that is, from my perspective,
we think of things in terms of policy.
How do we put in place policies?
How do we mobilize either the US government
or the global community toward specific actions?
And AMR will certainly continue to be
a critically important issue.
And so from the vantage point of organizing actions,
one of the effective ones has been the Global Health Security
Agenda, which you heard Mosoka mention
in terms of a group of over 60 countries
working together towards specific technical actions
as defined in the Joint External Evaluation.
And AMR is one of the action packages under GHSA.
There is a working group that is--
it's a global working group--
that is very active.
And they're trying to identify new solutions
and trying to put in place actions
to counter this problem.
But it certainly will continue to be a critical issue.
And I'll just take a moment-- since you
asked about the Global Health Security Strategy,
which I didn't have time to mention in my previous remarks.
The National Security Council, in particular,
has been tasked with coordinating
the development of a global health security strategy.
This was an FY18 omnibus.
And so we are working on that.
There are specific things that it
asks the US government to do.
But we're taking a comprehensive approach--
similar to what we did with biodefense--
to look at, how do we define global health security?
What does it include?
And does it go beyond some of the things
that we've traditionally thought of?
So that's all I can say at this point.
But it's a really great opportunity
to think through these issues and specific
to global health security.
Great.
Thank you.
With respect to surveillance for antimicrobial resistance,
we did a rough analysis of the total number
of acute fever illnesses in Liberia for one year.
We found out there were about 2.5 million cases of fever.
Of the 2.5 million cases, 1 million of those cases
were confirmed to be malaria and were treated accordingly.
The rest of the 1.5 million were treated with antibiotics
presumptuously.
So basically, there were no causative agent discover.
But they were giving antibiotics.
So that's tell you the level of the lack of stewardship
for antibiotics in the country.
The second challenge is that there is a lack of data.
And so because we lack data, it's
hard to convince the stakeholders.
I think just about a week ago, I sent an email back,
because I'm trying to commission a research
to look at antibiotics susceptibilities
and [INAUDIBLE] with diarrheal diseases.
It hasn't even gained traction.
We have advanced some initial discussion with GLASS in Sweden
to begin traction.
So basically, this is Liberia going
many of the African country's antibiotic stewardship.
And the treatment presumptously by doctors--
our teaching hospital does not have
a microbiology lab for now.
But we are all trained doctors.
So it's not taken as serious as it should be taken.
And so that's a big threat that is going all across Africa.
If I'll add lastly is the issue of [INAUDIBLE]
with lack of active substance that comes into this country
and needs to be control and regulated.
And so we're just starting.
We know the drugs are there.
We know that there is abuse of antibiotics
and no prescription.
Anyone can walk to any drug store
and just pick up antibiotics of your own choice.
And so the last one is that we have
a test in Liberia that is a water test, a test for typhoid.
I think the sensitivity should be around 40% or 30%.
But that's not what you're seeing right now in Liberia.
And everybody gets typhoid.
And everybody is put on IV ciprofloxacin.
Until we can deal with the issue of viral-sensitive diagnostics,
we are going to be abusing antibiotics in Liberia
or the rest of Africa.
Mike, were you going to--
Yeah, I just had a question-- a point you had asked us.
And none of us really addressed it head on-- is the tools
for dealing with the AMR.
Let me just say right now that I think
that the future for antimicrobial research,
and development, and bringing products to the market
is going to be very challenging.
And the reason is, again, the business model.
We keep talking about that.
Think about the car salesman who has the best damn car
that anyone could ever want.
But you've got to tell the people who
buy it they can only drive it from 10:00 to 11:00
on Sunday mornings.
That's it.
Who's going to buy that car?
Well, part of the problem is we're
trying to get new antimicrobial agents for very serious issues
around drug-resistant infections.
We want you to hardly ever use it.
And so trying to incorporate that into the business model
is a challenge to get people to want to get into that business.
So it's going to happen, but it's going to be challenging.
But the second piece of this is--
I, last night, laid out categories of vaccines we have.
I'm predicting that, in the next five years,
we're going to see a new category of vaccines.
It's called vaccines for preventing
antimicrobial-resistant infections,
meaning that we're going to actually start targeting
diseases for which we don't have any other really good
antimicrobial treatment options--
or at least they're very limited.
And we are going to make these high priority.
Staph aureus is one, as an example.
The second thing is we're going to see
unconventional treatments.
I predict that, within five to 10 years,
we will see major emphasis on phage treatment
for antibiotic-resistant infections,
which is going to be a whole new area that--
the Russians are way ahead of us on this one
and have been working on it for some time.
But I think we're also going to see that as a new--
Do want to give a one-liner on the phage treatment stuff?
Because I think it's really interesting.
Because I'm assuming most people don't know.
Phage, as I think you know, is viruses that infect bacteria.
And we've already had some wonderful clinical successes
with very, very serious resistant infections,
where we can match up a virus.
And actually, you treat the patient
with the virus that is very specific
to that infectious agent.
And the Russians did it for a long time
before we had heard about it or got into it.
And there's been several really highly-noted treatment
successes, where people literally
were on their last leg with a total resistant infection.
And the phages actually-- and the work that was being done
saved them.
It's really a arms race between us and the bacteria.
And we're actually playing on both sides
of the battlefield, which makes it a bit more challenging.
If people have questions, please come on up.
I'm going to ask one more question of the panel--
and then, again, there is a microphone up there.
So please come on up, and ask questions.
The last question I want to ask before we open it up
is something Mosoka just mentioned at the end.
So we spend-- and when we think about our response tools,
we talk about vaccines, antimicrobials, antibiotics,
antivirals, surveillance.
One of things we talk a little less about is diagnostics.
And diagnostics become a really critical part of this.
And I remember thinking in the early days of the Ebola
outbreak--
people got fever.
Well, we knew most of them did not have Ebola.
They often came into centers where they then
sat next to somebody else who probably did have Ebola
or might have had Ebola until the test became
positive or negative 48 hours later.
This is the wrong way to do this.
But we didn't have any alternative.
And so are we prioritizing and investing
enough in diagnostics as part of our strategy
for keeping the population safe-- really
front-line diagnostics?
Well, you guys know the story.
So anybody-- if somebody wants to take on--
how do we think about diagnostics
as part of this conversation?
And you're not allowed to have nobody take this on.
Well, I'll [INAUDIBLE].
Because, again, having just done the R&D roadmaps for Ebola,
Lassa, and Nipah, where we did vaccines,
diagnostics, and therapeutics-- so diagnostics
was a very key piece.
In the middle to high-income countries,
the private sector is doing very fine with this.
And in fact, it's exciting as hell
to see some of these graphing-based procedures,
where we can delineate a number of agents right down
to genetic sequencing within minutes.
And it's going to get more cost effective.
The challenge is bringing highly-usable diagnostics--
because of the standpoint of whether electricity based,
or not, et cetera, sensitivity, specificity, ease of use--
to the low- and middle-income countries overall for this.
But as you'll see with Ebola, that's happening.
There's been some major advances made in the last several years
on just the Ebola.
So I think, actually, the diagnostic area--
surely, the low-income countries need assistance and support.
But it's actually pretty healthy.
And we found that within our work with these diseases
that there is a lot of good new technology coming forward.
Great.
Anybody else want to take this on?
Mosoka and then Dennis.
I want to speak.
Because we publish a paper called "Free Blood Draw."
And anyone can read it.
Basically, in the subsequent resurgence,
with the deployment of the GeneXpert diagnostic
that could run for two hours, basically if someone
got infected or had a fever, we would isolate the person
at home, draw blood, take it to the center that
determined the results, and got back to the person within three
hours.
And that changed the dynamic of the transmission.
Because then we kept people at home.
They trusted us.
We do the test.
And it made such a very big difference
when the GeneXpert was introduced,
the speed, the turnaround time.
Now we face a challenge.
The company that making the GeneXpert
has increased the price of the cartridges
and reduced the shelf life of the cartridges.
So essentially, the GeneXpert were made and deployed.
But we can no more use it because of cost.
Yeah.
Dennis?
And I think it's also important to realize that we're
in the midst of a technological revolution-- and to the extent
that we're not necessarily exploiting
that for field applications.
And I'll give you an example.
We have been supporting, up on the China-Vietnam border,
the use of what are called pocket PCRs.
They're a little larger than an iPhone.
But the big question about-- and a virus coming--
H7N9 coming across in the markets into, say, Vietnam--
how do you pick that up?
The current protocols are you collect samples.
You send them back down to Hanoi.
They run them through a PCR.
They then make a determination, and send the information
back up-- maybe.
You're talking about a week.
Whatever it is that trafficked across that border
has been consumed in Hanoi already.
It's gone.
The pocket PCR is this extraordinary tool,
which is rapidly evolving.
But it's basically-- you can collect samples in a market.
And as long as you have a primer,
you can do it against anything.
You can do influenzas.
You can do coronaviruses.
It doesn't matter.
And in two hours, in that market,
you can have a positive or negative.
You can know exactly what's there.
And you can link it to action.
So the Vietnamese government has revised their protocols now.
It does not need to go back to Hanoi.
They are able to stop, and quarantine, and take actions
on the basis of this protocol.
And their ability now-- the next generation of these
is that they immediately move the information into the cloud
so that it's immediately available for access.
So how can the global community, working
with the national authorities, really move these technologies
into the field-- point-of-capture diagnosis?
And that's against the known.
I'll come back to the fact that we were flummoxed.
As Tony was talking about SARS--
there was a period of time they did you not know what it is.
The issue was when something new comes out,
we're even more challenged.
And I would go back to this issue
about developing a deep, rich database about all
of the virome to be able to have a diagnostic platform that
allows you to rapidly--
and so for those that would be interested, I am part--
along with a larger community-- around the Global Virome
Project, which is about a 10-year effort to document 70%
of the virome within mammal and waterfall populations--
big implications for diagnostics,
big amplification for countermeasures
across the board.
But it's moving from small to big data, technology
into the field.
That's amazing.
All right, let's open it up.
We have about 10 to 15 minutes.
So if we could do two things, which is--
I'll take two questions at a time,
have whoever on the panel who wants to respond.
Then we'll do the next two.
Please quickly introduce yourself,
and ask your question.
Thank you.
[INAUDIBLE] my corporation was privileged to lead
a team at HHS in 2006 that wrote the requirements for an Ebola
vaccine, put it in priority document
for our medical countermeasure strategy and implementation
plan with Dr. Parker.
I'm a scientist and a big fan of transformative science--
but also, realistic expectations.
So the de-prioritization of one bug one drug solutions arguably
led to the consequence of us not have an Ebola vaccine when
we needed one, despite the fact that it was a priority in 2006.
So I want to talk about realistic expectations
about transformative science and broad-spectrum solutions, one.
Two is the business model.
And Hillary, thank you to you and your team
for getting the National Biodefense Strategy--
long awaited--
out.
I wonder if you have the sense for where we're starting?
You talk about-- one of the important deliverables
from the federal group is the assessment.
Do you have any sense, walking into this now
with the first National Biodefense Strategy,
are we at 5%, 10%, 50%, 90%?
How do you approach this first assessment of the National
Biodefense Strategy?
And where are we after billions of dollars
and arguably at least 17 years of effort?
OK.
And let's-- next question.
Thank you for both of those.
Yeah?
Sure, thank you.
My name's [INAUDIBLE].
I'm a doctoral student in the School
of Public Health in Infectious Disease Epidemiology.
And there's been a lot of talk this week about vaccines,
other medical countermeasures, some talk
about contact tracing.
But one topic that has rarely, if at all, come up
is questions and controversies about general restrictions
on movement, on closing borders either at a sub-national scale,
like between different districts or counties
in an Ebola-type situation, or between countries, potentially.
We see, often in various kinds of public health emergencies,
political and other public leaders
suggesting that keeping people who
might have a disease from traveling is an intervention.
And I think, in the public health community,
there's a fairly strong consensus
that, for most diseases, that's not a good idea.
So my question is sort of twofold.
First of all, it is, how do you communicate
in those situations where that's probably not a good idea
why something that--
there might be some intuition to why
people think it's a good idea.
How do you communicate that that's not generally the case?
And then the second part of the question,
are there situations where the potential for other control
measures is so low and the risks are so large
that movement restrictions actually would make sense,
even acknowledging that they have
severe economic consequences?
Great.
So a series of questions across both of those--
one bug one drug, being more realistic
about these transformative technologies,
one question very specifically to you, Hillary, about--
is this a great strategy?
Where are we on this, 1% or 99%?
And then this issue of restricting movement-- it does
feel very intuitive to people.
I cringe when I hear that, because I
think it's a bad idea.
It won't work.
It will make people turn away from the system,
all the things that we lay out.
And so the question for the panel is,
are there times when we may actually
need to resort to that?
So whoever wants to start us off.
Well, let me start with realistic expectations.
Because realistic expectations have embedded in it a time
frame.
And what is it we expect today?
And what is it that we're trying to build for tomorrow?
And the older I get, the more I realize
tomorrow isn't that far away.
Because yesterday seems just like a moment ago.
And part of what we need to be thinking about
is where are we going to be in 2028?
2008 is literally not that far in the back.
And what are the steps that we need to take?
Either we begin to ask a different set of questions,
and figure out what a different paradigm for problem solving
might be--
and take those investments.
And there's risk embedded in that.
Like, when I began my career, I was a researcher at one point.
And I was at Cold Spring Harbor at the moment
when the Human Genome Project was first
being put on the table.
And Jim Watson, who was my boss, he was the first lead on that.
And it was an enormously controversial discussion.
Go after the entirety of the human genome.
What are you going to get from that, as opposed
to focusing on very specific domains
within the human genome?
There were wild expectations, lots of promises.
The world we got is very different
after we've sequenced the human genome.
We wouldn't have CRISPR-Cas today
if it wasn't for the Human Genome
Project having been done.
Now I think part of this is that, when you try and make
a different way of thinking about problems and using data--
we live in a data-rich world now.
But the computing power to analyze data
allows us to think fundamentally differently.
Emerging viral diseases has not kept up.
And the transformative issue is, in
that massive data set are new insights, new opportunities.
We're not quite sure what they are.
So expectations-- be realistic.
But the world is a far more complex environment
than Ebola or Marburg.
It is a hugely complex issue.
And how do we open up the entirety
of that window for filoviruses, flaviviruses, et cetera,
and then see what the power of big data
allows us to understand.
So this is not a trade off between making decisions today
at the expense of something today.
It's about making new decisions to open up
new doors for tomorrow.
In some ways, I'm reminded of an old line that
has been attributed to Bill Gates, which is,
"We overestimate what technology can do in the short run
and underestimate what it can do in the long run."
Hillary, on the biosecurity, where are we on the pathway?
What is your sense?
Yeah, so I think where we are is we'll
know a lot more in 120 days.
If you look at the NSPM, it has some very specific tasks,
what I'm calling the 120-day sprint, where
we have to define roles, responsibilities, milestones,
metrics, and end states for the implementation plan.
So there's analysis that's associated with defining
those specific things.
And I think that will give us a really good sense of where
we are relative to the goals, the objectives,
and the sub-objectives.
I also want to highlight that there is a mandate to release
a public report in one year.
So there is transparency built into this process
so that, in one year, we'll be able to comprehensively answer
that question of where we are relative to the strategy.
I think, right now, if you ask individual departments
or agencies, they can tell you for their line of effort.
But there has not been a comprehensive assessment
across the US government.
And that is what we are attempting to do.
Anybody want to take on the movement question?
Yeah, so we did restriction.
Like Tony said, it's a message and a messenger.
The first time that we attempted restricting a whole population,
it resulted in the riot, the military moving, and two person
were shot, and one died.
We learned an important lesson from it.
The lesson was that a restriction cannot be external.
It has to be negotiated.
It has to be discussed.
And so we developed a concept called
precautionary observation.
We did not go call it quarantine.
So whenever there was an outbreak,
we approached the group and discussed with them
that, for the good of the public,
are you willing to stay home?
We made the agreements.
And on our part, we'll supply you food.
We'll give you water.
There were a time we provide television for people.
They said, we want to watch movies.
We will give them movies.
And we ensured that their jobs get protected.
And through what we call negotiator quarantine,
we succeeded in doing that.
The last [INAUDIBLE] I can tell [INAUDIBLE]
a lot of American institution was involved
was the time we talked to the two drug
addicts who were exposed and moved
into a center for quarantine.
And literally, to keep them happy,
we supplied them drug for 21 day.
We supplied them cocaine for 21 days.
Because they were homeless.
They were drug addicts.
They couldn't live outside.
We weighed the risk of spreading the disease.
And so we negotiate that.
And they said to us, we are drug addicts.
If you guys are going to keep us quarantined,
will you provide the drug?
And it's an ethical dilemma that I still struggle with.
But I literally went and bought drugs
and brought it for them-- so the message and the messenger.
The way you do, it's possible it can be done.
OK.
So Richard, Mark, let's go ahead--
Richard.
And then we'll take final comments.
And then we'll wrap up, please.
I'm Richard Cash from the Harvard
School of Public Health.
I think Mosoka's comments were absolutely critical.
Because what he was demonstrating
is that the actual epidemiology and the value
was coming from the country itself
from somebody who's from that country.
And what concerns me is we're talking about global.
But the fact is that money that goes
into training of people locally and in this country is really--
compared to the rest-- in really short supply.
I believe very strongly that you develop local institutions.
And the number in West Africa and throughout the world
is pathetically small.
I was in Liberia 50 years ago for a cholera outbreak.
And the amount of capacity building
since that time, until the Ebola epidemic,
was not what it should be.
So what I'm interested in is, what of all of this money
spent and so on should we put into the development
of local capacity building?
I'm not sure we can trust the United States much more.
We almost zeroed out the Fogarty.
CDC people can't go out into the field
because of travel restrictions.
So what are we doing?
What should we be doing in terms of national security
in developing local capacity to really deal with these issues?
Because that's where the answer's going to come from.
Great.
So we're a little short on time--
if everybody can just make a comment.
And if you don't mind working--
not everybody has to deal with this--
but on the issue of trust.
Because one of things that Mosoka did brilliantly
in the outbreak in Liberia--
but even brings up his latest example--
is that trust becomes such an incredible force--
glue for being effective in these things.
But really, I'll leave it open to you.
Mike, your thoughts?
Thank you.
Quickly, let me just say we're schizophrenic.
We talk all the time about the threat
that infectious diseases play to global security,
our economic security, et cetera.
This year, we'll spend about $750 billion in defense.
And we'll spend maybe $14 billion
on all areas of infectious disease and public health
control of infectious diseases.
I don't know enough about battleships.
So I can't say what we need or don't need.
But I have a relative sense that, if it really it's
that big of a risk, we have to rethink the actual magnitude of
how we respond, and why, and what we invest in.
The second thing-- I just have to add this piece.
My dear friend, Dennis Carroll, I
would love to believe in what you're suggesting
with all this additional data.
But I think that the Virome Project is one of the most
misspent monies we spend today.
I think that it's really--
provides us really nothing that will
prepare us for public health.
If we can't get vaccines for what
we know now, Ebola, [INAUDIBLE],, MERS, et cetera,
knowing about 5,000 new viruses is
like identifying 1,000 new stars and think
we're going to have a lower risk of an asteroid hitting
the Earth.
It just isn't going to happen.
And I think that we can't sell that any longer
as pandemic preparedness.
It's not.
I'd love to know the information.
I'm curious, too.
But until we can get a system to making the current vaccines
that we already know we have a risk for,
I don't need to know about 1,000 new filoviruses.
We can't have a panel without a little bit of tension.
Dennis, any thoughts?
Is this just a pie in the sky, wonderful thing
that we'd all love to know, but we have to make priorities?
Look, this is not much of a different discussion
than, again, when I was in Cold Spring Harbor in 1986, '87.
And the point is well taken.
But it's also-- look, vaccines may inherently not
ultimately allow themselves to be broad spectrum
in a consistent way.
It may be that vaccines are inherently
a 19th-century technology that will always
be somewhat limited.
But the issue fundamentally is, by opening
up this insight into the data-- also
allows you to think about what might be new ways of even
asking the question.
So the whole world of gene editing coming out
of CRISPR-Cas allows us to think fundamentally differently
about different countermeasures.
How do we think about application
of those technologies, those approaches
once you begin enrichening the data field?
So I'm not putting everything on the back of vaccines.
I'm not personally convinced vaccines
do have that big potential in a consistent way.
But Mother Nature is an extraordinarily intricate
thing.
And getting insight into that requires opening up the data,
getting insight.
And I think that's what we're going to learn.
Your viruses-- we know about a handful of viruses.
You're saying the Russians are showing--
can be enormously impactful on bacterial infections.
What other viruses out there might
be able to provide an even more robust--
that we don't know about?
So it's not just about one approach or another approach.
It's really just trying to rethink the entirety.
And smart people can get smarter.
Hillary, any closing remarks on any of this?
Sure.
I'll just briefly respond to the last question
that was addressed.
And thank you for that.
I think there is certainly agreement within the US
government that responding at the local level
and working with our partners to build local capacity
is critically important.
Right now, the US government has 17 partner countries.
We're proud to say Liberia is one of our partner countries
under the Global Health Security Agenda,
where we have CDC field offices that work closely
with our partners to build that local capacity
and have a mutually-learning relationship.
And so I think when it comes down to it--
and again, coming back to the strategy
and what we're trying to do is, broadly speaking,
stepping back.
What are the risks?
What risk can you accept, and what risk
can you not accept-- and then prioritizing your actions
accordingly.
Great.
Mosoka, any final thoughts on the--
Yes, I'll speak to what Dr. Cash have said.
And the timing in Liberia for me was I
had opportunity to have a US education.
And so I knew what to do.
And it made such a substantial difference.
But we need to produce many other young people [INAUDIBLE]..
And education is going to be very critical.
Unfortunately, sometimes, some of our donors
don't see that as a long-term investment
because it does not have quick returns.
After Ebola ended, I sat down with a group of guys.
And we wrote a curriculum for an MPH program
for the next generation of leaders, applied epidemiology,
health system management, environmental health,
and laboratory science.
We have taken this proposal to multiple international donors
and say to them, this is the way you prevent less outbreak.
Nobody is paying attention.
We have this proposal.
We took it to the university.
The faculty [INAUDIBLE] as a program.
We couldn't start this year.
We're trying to see 2019 if we can start it.
Because we cannot have a single donor saying,
I will put money here, because this is the way I'm going
to protect the world by treating people locally.
So sometimes, there's a big challenge with us.
They will come in all the money.
But the long-term sustainability is sometimes
[INAUDIBLE] but I would tell anyone
that the human capacity is the most critical investment.
Because at the end of day, we'll still
come back to fundamental public health intervention, isolation,
contact tracing, the cases.
Human capacity is the most important area for investment.
That's a very good line to end it on.
This has been an extraordinary panel.
Let's give them a big round of applause.
Thank you, everybody.
[APPLAUSE]