this round table at georgetown, and it demonstrates how georgetown university as a university can work together to convene legal, ethical and scientific experts on timely and topical issues in global health and also seek to inform the debate among not only students and faculty, but within the broader washington community and the global community. i'd like to thank some of the people who made this round table possible. first, oscar cabrera and susan kim who did so much to make this happen. so thank you very much. some of the people in the audience, keith martin who heads up the consortium of universities for global health, jeff crowley who's a form toker white house chief on aides who's now at the o'neill institute, miked the ard of -- stoddard of georgetown's institute of health

studies, john monahan who's been involved with the o'neill institute and is now the special assistant to president dejoy ya on a range of issues, including health issues. tim and linda o'neill who made the o'neill institute possible through their vision and generosity and, of course, to the faculty director of the to kneel institute, larry godsden, who really is just a visionary in global health law and who has done so much to focus us on this crisis and to bring us here today. so we brought together the most influential speakers in the country from the cdc,. doctors working on the ground in west africa, as well as global security experts. this is the convening power at its finest. thank you all for being here, and let me turn things over now to dr. godsden. >> thank you very much, bill. we really appreciate you taking the time to come.

what i'm going to do is, first of all, you can see we're sitting could be on easy chairs -- down on easy chairs, and we're planning to do that because we want to have a highly engaging conversation among each other ask and then with you. this, believe it or not, is actually a class, and it's the o'neill institute's colloquium on national and global health law. and by tradition in the class, the students get the first shot at asking questions. and they always ask good, incisive, highly respectful questions -- [laughter] as we have only the best here at georgetown law. what i'm going to do is, first, give you a very brief update on the ebola epidemic in west

africa and then introduce speakers and then turn it over to john monahan, and we will begin our, what i hope to be a very, very engaging conversation. as dean treynor said and as we've been talking at lunch and elsewhere, this is one of the great humanitarian tragedies of our time. i don't think people outside the region really understand the nature of this humanitarian disaster. marty citron has been working at the cdc on these kinds of epidemics and humanitarian crises for over 20 years, said to me that it was the worst he'd ever seen. and it was in many ways highly preventable. as i will explain just in a

moment. this is the first ebola outbreak in west africa, and it's the first one that has engulfed major capital cities. in the most affected countries -- givenny, sierra leone and -- >> [inaudible] >> and liberia, and it's also now jumped most recently to senegal. the international spread of this disease goes back more than five months. that is, between the time that the who put out its epidemic road map which just came out a few days ago was five months

late, five months after the first international spread. the international mobilization has been highly humanitarian but highly incommensurate with the vast needs. we're on a panel at csis yesterday, and the panelists -- tim evans from the world bank and tony fauci and, of course, steve morrison was there -- talked about this epidemic now being out of control. while there was a rise in cases, now it's exponential, going straight up. it will take us many, many months, probably six months to get it under control, and and if we're lucky, we won't then have an endemic situation in west africa.

so we're talking about a really horrible crisis. now, why do i say that it should be averted? there's, i have an article in the lancet coming out tomorrow morning, it's embargoed for the morning, but essentially what it talks about is the fact that this has been a perfect storm because ebola which is a horrible, horrible way to be sick and to die, has engulfed the region which has two post-conflict states, very, very fragile health systems. the doctors and nurses to begin with were just a minuscule number of what was needed to have even a basic, bare minimum. and now well over a hundred health care workers have been

taken by this disease, and more have been sickened, and some are frightened and don't faithfully report to work. so you can see we're in a devastating situation. so what the lancet article calls for is an international health systems fund that would be involved with two components. one would be a crisis response fund that would be mobilized when who declared a public health emergency of international concern, and the other is a longer-term, much-needed course correction in global health which is to build strong health systems. and strong health systems will help us not only control the next ebola outbreak -- and we know there will be, there have been more than 20 in the past, and yet we've been caught by

surprise with this one -- but much more than that, it will help with the wide range of health threats that engulf the region; aids, tuberculosis, malaria, noncommunicable diseases like heart disease, diabetes, injuries, all devastating. and with a collapsed health system for the long term that is problematic. and so what we want to try to avoid is leaving when the crisis is over, but leafing these -- leaving these countries in the same kind of fragile health condition that they exist now and is being worsened. and so it's very opportune that we bring together this really august panel, and i'm going to introduce each one in turn.

dan lucy is an adjunct professor in the medical school. he's been one of our university leaders in global health in many aspects of it, but i think most admirably he's just come back from sierra leone, he's been working on the ground. he's kind of human being that really provides service as well as rigorous academic examination of problems. i mentioned marty citron. marty is the director of global high gration and quarantine at the centers for disease control and prevention. he is the u.s. representative of the world health organization's ebola emergency committee. he's been highly involved at the

cdc with tom frieden who just came back there the region -- from the region and was visibly shaken, i think, if you saw him on the press conference yesterday, you could see that. and, but marty has been one of the masterminds of the response, and he's going to be talking about, you know, what we can do now to bring this under control. kevin donovan, we're extremely fortunate to have here at georgetown. he's the director of the center for clinical bioethics, and he's been here since september of 2012. he came to us from a magnificent career and work in clinical ethics, and he's been really at the forefront in this particular epidemic trying to think through

the ethical dilemmas of the compassionate use of untested drugs. and, of course, now we have vaccine trials, and we were with tony fauci yesterday at nih, and he told us that the very first safety trials for an ebola vaccine were -- began on yesterday. and so kevin will help guide us through that ethical thicket. steve morrison is the senior vice president and director of the global health policy center for, at the center for strategic and international studies. for those of you who work in the global health space, we know him to be one of our great global health heroes. he's been working in this field and advising governments and

communities for many, many years, and it literally has been -- and literally has been great leader for global health in the united states and beyond. so you can see we have a remarkable panel, and the panel will be moderated by my dear friend john monahan, the very first director of the o'neill institute, then as a hiatus worked with the secretary ott at the department of health and human services, kathleen sebelius, and then went to the state department where he was one of the state department's representatives at the who. john is now back here at georgetown as a special adviser on global health, and he's going

to begin by kicking off with some questions. so thank you, john. >> larry, thank you, and just as larry noted, this is a terrific panel, so thank you to the panelists. and everybody should know also that larry himself, as you may know, is really the premier scholar in this space and has devoted so much time and energy, so thank you, larry, for everything you've dope in this space. you've done in this space. let us -- my goal for today, one, you have terrific people to listen to, so my job, hopefully, is to get them to say as much as they can to help educate both our students that are here and those that are watching on tv and elsewhere. most of today is going to be about policy issues and about how government works, but i want to -- but before we do that, well, just one more housekeeping matter is, larry's right, this is a class. so when we finish the conversation up here on the dais, then we're going to turn first to a set of questions from the students that are enrolled

in this class, and then open it up to questions from the larger audience. but before we start to focus on the policy issues, i just, i think i'd like to ask dan lucy to take just a couple minutes to tell us from a firsthand perspective what he saw in sierra leone. i know from e-mails and communications with him over the last several weeks it has been moving and challenging x if you could take a -- and if you could take a few minutes to share with us what you've seen, i think it would be powerful, to thank you. >> thank you very much, john and harry, and for the conveners of this colloquium, it's an honor to be here. it was one of greatest honors of my life to be able to work in sierra leone, in freetown, for three weeks. i'm in good health, i took my temperatures three times a day, i have no fever -- >> but not shaking hands. >> i didn't want shake a single -- i didn't shake a single person's hands in sierra

leone. no one shakes hands or has any other close contact. i'll try to him this to three minutes, and let me say there are three primary things i tried to focus on although many opportunities to do many good things even as one perp. so the first thing was the compassionate care and evaluation of patients at an ebola virus testing center, the largest one in freetown, a hospital. i had the great privilege to work with the one and sometimes two doctors who work there, one from spain who worked there straight through for two months and is still there now, and another 27-year-old british physician named johnson from king college, london. so that had a profound effect on me, being able to help provide care and evaluation of patients with ebola virus disease. secondly, and closely related, activity i participated in was the training of mostly nurses,

but also doctors, approximately 160, in how to put on the personal protective equipment, so-called ppe, and most importantly and more importantly is how to take it off safely, because when you're taking it off, that's when there's virus on your gown and gloves and goggles or face shield, and you have to the take it off in a sequentially important hander, washing your hands between each step. so i worked with the minister of health, the chief nursing officer and the u.k. physician, dr.er rends, and a colleague physician, dr. navo, and together we trained trainers, francis and joseph in particular, who then went on to train more people after we left both in freetown and other parts where there are hot spots. and the third thing was to try to organize what do you call it, perhaps a working group on children and ebola. unfortunately, the major

pediatric hospital closed while i was there and hasn't reopened. as of august 18th. so there are many children with curable diseases like malaria and pneumonia and typhoid who are not able to get medical care as a result. so just briefly, i did bring handouts, one on the pediatric situation in a publication called the program for monitoring diseases, there are two articles, i had a small role to play. and this is an article i wrote and so i take full responsibility, there's no one else who contributed to it. it'll be controversial, but many people read it, and i distributed it to colleagues, more than 30 professional colleagues in freetown, and it's not meant as a criticism to any one person or organization, it's simply how there are 18 problems and 18 solutions for how the ebola evaluation unit where i worked could be made much better, much more efficient and provide better care for individual patients and for the

the citywide response. to ebola. i would like to say that this ebola outbreak has a more profound impact on me personally, and i think it should on many of us because it's going to get much worse. just today, about an hour ago, who announced probably a larger outbreak's going to occur in the large oil the city in nigeria linked to a physician who died, had many close contacts with patients and other people. in my opinion, and i'll just say this, no one else has said it and, certainly, it's controversial. i truly believe after the three weeks of being there in sierra leone, this is the first urban outbreak ever of ebola, series of urban outbreaks. personally, i don't believe our traditional methods of being able to control and stop, stop ebola outbreaks in rural africa -- more than 20 of them

since 1996 -- quarantine people who are ill is going to be effective perhaps in most of the cities. and, therefore, i think that this outbreak's going to go on even longer than a year and that we're going to have to have vaccines, drugs, antibiotics against the virus and postexposure to stop it. we can do everything we can do now, we should do more to slow it down, to start it to decrease. i'm not confident we'll be able to stop it without what are still investigational therapies and vaccines. so, again, this is much worse than anything i remember from aids in san francisco working there in 1982 or anthrax here in 2001 or sars in china, hong kong, toronto, bird flu in indonesia and egypt and mers last year. it's more severe than all of those, in my opinion. i'm very happy to go back later this month to work for six weeks with doctor thes without borders. so thank you.

>> dan, thank you for those remarks. and there -- and thank you for your service. it's extraordinary. i think we want to start with the human picture because this is a particularly terrible virus and disease. but let's step back now and try to get a situation analysis of where things stand. i'm going ask marty, who's been tracking these issues across all the affected countries and populations, if you could give us an overview about where we stand. i think we know we're not at the end. i guess really what we want to know is are we at the beginning of a control here of the kinds of epidemics or individual epidemics. if you can give us an overview, that would be great to start the conversation. >> sure, thanks, john. and thanks to larry for the invitation, i really appreciate the opportunity. i do need to provide a disclaimer to larry's heaping introduction.

i'm one small part of this response in an agency that has mobilized several hundred, last count more than four or five hundred engaging, 70 deployed, i'm told more will be deployed internationally by the weekend. we'll be well over 100. so it's an unprecedented, in some regards, response for our agency as well, and there are many, many brilliant minds and talents and dedicated and passionate people engaged not just from cdc, but i think larry heaps far too much credit on me individually, and i certainly don't deserve that. in terms of context, i think -- i really appreciate dan's opening comments about perceptions on the ground and what i'd like to say is why is, what are the characteristics of this epidemic and in some ways this epidemic that is very much out of control in some areas. what are the characteristics that make it unique in that regard compared to, as dan pointed out, the many other

ebola epidemics of past since its discovery this 1976. one of them is the location. so poverty, as margaret chan said in our new england journal article, is pretty profound. and we're seeing, painfully, the face of poverty and disparities in health systems and so on and the impact, the intersection of extreme poverty with a devastating and merciless virus is really staggering in that regard. weak and fragile health systems that have been suffering and in states that have only recently emerged from years of civil war and infrastructure challenges. another unique aspect. compared to the original zaire outbreak in '76 in a very isolated, forested area that was unconnected, the tools of detecting an outbreak, case identification, isolation, contact tracing and beginning to

alter unsafe burial practices which really cause a huge amount of transmission, it happened in a very remote area, not very connected or globalized area. and so the success and/or failure, in some sense the trajectory of the outbreak would be steep, in some cases, 90% case fatality, and the outbreak in some regards gets self-contained. and here we have an outbreak that probably emerges at the intersection, at the boundary areas of three countries that are highly connected in some ways culturally and ethnically with many improved roads and commerce and exchange, with community practices that involve marriages across boundaries and burial practices that are often distant from the original village and so on. so the degree of human mobility, i think, is a factor that plays into the spread. because this outbreak is unprecedented both in geographic

spread, its scope as well as its magnitude in terms of cases. this outbreak is also occurring in urban areas which is, again, unprecedented, and the strategies and the thinking about how to control in dense, crowded urban slums like west point, you know, in the capital cities of monrovia and the capitals of freetown, the whole concept of how to deal with a lethal outbreak in these urban settings with large population centers and connectedness, both regionally and to some extent through other places on the con innocent global -- continent globally, is a very, very unique circumstance. the health infrastructure was fragile at its start, but epidemics of disease like this, horrible diseases like this are often followed -- and appropriately, understandably -- have end dem cantics of fear and epidemics of stick that. and the -- stigma.

and the fear and the stigma in many ways combats and conflicts the attempts to get an epidemic of disease under control. certain information, misperceptions, lack of understanding about means of transmission, suspicion of lack of trust in government, suspicion of outside folks, not really understanding how the disease is spread or who's bringing it. these things contribute to a level, you know, we've seen resistant communities or anger, appropriate anger which is off, you know, the mask of that fear and vulnerability. and the extent to which this is the first ebola epidemic in west africaal places that in context -- also places that in context. the lack of a longstanding understanding of the disease and where it came from and how it's spread and the importance of affecting burial practices. so i think that context is really important to understand how perhaps we got to where we were. some people refer to it by being

caught off guard. to me, it's more important in thinking about where we're going and not sort of finger pointing or blaming, because this is a massive -- not only a public health emergency of international concern, but a humanitarian crisis which risks civil society. and we're seeing sort of the collapse of some of the key aspects of civil society to keep it functioning in areas devastated, hard hit like liberia and in the capital. and i think that in those areas when you asked about the trajectory, we have not turned the corner. the virus is winning this battle. it has outstripped the human resources, as dan highlighted. the number of treatment centers that are needed, the number of health care workers that are needed, the degree of personal, the quantity of personal protective equipment, the quantity of body bags, the people and the stuff that are needed to be able to get an yacht break of this magnitude under control are just not

there, and there really needs to be a wake-up call to the global community that this is going to require a coordinated, international, all-hands-on deck, not just a health sector, a public health response, but a full response. it represents a significant global health security threat as new countries become -- have a single introduction like nigeria, a single introduction on july 20th, and we're still trying to snuff out one chain of transmission. and you think about that possibility of an epidemic in leg goes or an introduction into -- we have one of the world's largest mass gatherings coming up shortly, the hajj in saudi arabia, and the consequence and the concept of having introduced ebola virus into these other type of settings with mass be gathers organize -- gatherings are hard

the gather. so larry's comments are very poignant. i think it's a long road ahead. i think the who road map is very much welcome. six to nine months, i hope we're there. in the best of circumstances, maybe, but right now we haven't seen the bend in that epidemic curve. and i fear that it could be much longer, as dan pointed out, and we really are going to need all of civil society to be fully engaged. >> so i think we've got a sobering picture on the human/patient level. marty, thank you for that overview. and i think it's, you know, if we're in a situation where the epidemic is, we have not turned the corner, it is growing exto poe 9/11 cially in at least some of the key areas. i'm going to ask steve, and i hope not to put him on the spot, but to give the -- i mean, as we think about a crisis like ebola growing particularly in capital cities on a regional basis, you

might want to reflect more generally, if you would, on sort of the impact on politics in africa, globalling politics -- global politics, just a little bit of the larger frame because this is, this has moved, as marty said, beyond a public health sector issue to a much broader potentially set of issues around security. >> and, steve, i would also love for you to talk about the security implications and the role of the united nations and the security council. i -- >> i think in the last six weeks, the surge of this epidemic has forced us to recognize that it's moved beyond being a public health crisis, it's become a security, fundamentally a security crisis. it's triggered for the states in question, particularly liberia, syria leone, but also i would say guinea, it's triggered

antics ten cial moment for them. these states that are acutely weak before happened, their functionality and their vulnerability to worsening civil conflict is now magnified tremendously. they have seen their already-marginal health systems eviscerated and overwhelmed, they've seen food insecurity now touch well over a million and a half people, they've seen their markets, their production, their economic integration disrupted, they've seen their integration into global airline systems disrupted, pretty much halted. they've seen the sudden exodus of talent out of these states across multiple sectors, ask they've seen in the health sector and the emergency response sector, they've seen a

worsening of the risk environment, a deterioration of the risk environment reaching such a point that medical personnel is simply cannot be effectively protected in many of these situations. whether they are at work in these protective clothing, or they're outside of work in a what's supposed to be a more normal situation. so what you're seeing is the insertion of teams that get exposed, and they get suddenly and immediately pulled back. so my first point is this is not a health crisis, this is a security, a multidimensional security crisis within this region that now threatens neighboring and nearby states. ..

on a sky rocketing trajectory where we were told last week yes, 3,000 dead, 1500 -- i mean, 3,000 cases, 1500 dead but we think this is the who we think it is two to four times that levels of it could be 12 and 6,000. there is no confidence whatsoever that 20 is a stop

point so we are now in a world of the great unknown of trying to think about what the trajectory will be and it's totally plausible to see this as going to 4050 or 100,000 or beyond. so, our confidence, our own confidence in calculating the earth has eroded tremendously. this is a very, very hard hard to set of lessons for public health experts. subject to the so back to the question why have political leadership not watched onto this big answer is this is the unknown it could be a cascade of tester fees that could be triggered by the progress. at the perfect storm would appear and ignite in this region

the members that worked in the early settings could be applied and work in these settings. there was over excess confidence in those tools. and the political leadership in that world for the higher level of attention those went unheeded. so there's overconfidence and and an ability to penetrate to the higher levels. i think that in the last summer regrettably it's been a terrible environment to get a virus driven security crisis onto the agenda of the security council when you have the islamic state and theory in iraq and of the israeli palestine war and the russian and ukraine war. it is a pretty crowded, exceptionally crowded environment to push this through. the last thing that i would say is that it's hard to walk the sovereignty minefield and until

the state in question are prepared to come forward and plea for a higher level of commitment how are you going to win the consent to deploy peacekeepers into the setting? the model of response has failed. there needs to be another model of response that treats this as an emergency humanitarian catastrophe that requires deployment of protected authoritative forces into this. but to get to that point requires consent and requires the sovereignty to be respected and requires political leadership. they would've dropped the list of things and ask people to do more of the 12 things seeing the big picture and coming up with response to address and we need to transform this exponential

crisis, this escalating runaway epidemic and we will not transform it by doing more of the same. thank you now we've learned all three of the individual country level geopolitical. i want to emphasize the plaintiff marty made and that is in the middle of a public health crisis there is a lot of imperfect information. a lot of people may look look back and issue things faster and sooner. the really important point is the one that steve left us with in my judgment. given where we are today, what are the things we can do to attract the attention into the action of the players in the world can make a difference in this dynamic because i would

argue this is a very maybe not unprecedented but certainly a very rare place to be in the global community. anyone else? because i would like to turn to a couple of the issues that receive considerable attention in the media particularly around the use of quarantines and access to medicines. so, let's start because both larry and dan mentioned the issues are at the treatment of vaccine and i would ask kevin to kick us off. we have a well covered the story of the american health workers who receive the map medication and were treated at emory and it's now appeared to be recovered. we got yesterday the hhs announced they are going to accelerate the contract with the manufacturer to try to get more of that product available for the clinical trials. as larry mentioned, doctor kochi

at nih started yesterday going forward with the first trials in the ebola vaccine. but this situation has raised a couple of ethical issues. one of them that who convened a panel on this and do we all agree that it makes sense to provide medications that have not been tested in the context of likable but the panel recommended. if the answer to that is yes, how do you allocate what allocate what would be invariably and incredibly scarce resources in the context of the kind of catastrophe that we are talking about here. i would ask you to take us over the conversation. i know you've thought a lot about this as well. >> if you will differentiate

between drugs that haven't gone underground safety or efficacy trials because you have a compassionate use of the drone when somebody is potentially die in dying that vaccines are given to the vice healthy volunteers which raise a whole other set of ethical questions. so, if you could reflect on those things that would be very helpful. we heard about the humanitarian crisis from the ground from the doctors point out the. it's devastating to hear about this. i can't imagine what it would be like living through that. we heard about the public health refund.

i think that we have to remember that this is ultimately about people about the people involved and there is a tremendous urge to say if we see if we can treat people with experimental medications, why aren't we doing that? that is one of the foremost ethical questions. there are several that are worth thinking about and we may be able to cover some of them today. that would be number one on the list. the other one i think would also be that when we are considering the the allocation of scarce resources, the most pressing question then would become who should be treated? because we have a whole lot more people who might be candidates for treatment than we have treatment available. and also i think that one of the questions i would like to hear discussed before we are done in his dot e. bola virus has been

known as the cause of disease since 1976, why is there no preventative vaccine court effective therapy clicks i have my own opinions on that but i would like to hear everyone talk about that. now, first off without experimental treatments being offered they are giving drugs to people and these drugs have never been tested in humans before they were given to the sick patients and before the dangerous adverse effects can neither be no more safely predicted. it's entirely possible they may be ineffective or even harmful. in america all fda studies have to go through the first stage for the likelihood to first be affected for if i would buy the subsequent bases to look for side effects and evidence of efficacy. so for these therapies have been tested only on a handful of monkeys and not even the first that occurred for human beings. the monkeys you will be happy to

know are getting better. but so far six people have received one candidate and experimental therapy. two of them have died. this doesn't prove that it's effective or that it's safe. we don't know harm it may be long-term or even short-term and the guiding principle to any use of medicine is in the first place to do no harm its answer questions about possible harms and effectiveness but what has been done here is not research but rather it is scary, experimental treatment. it was done because he bola is a deadly scary disease. if we were able to keep approaching it in this way we may never know whether therapies are safe and effective or at least not know until a great deal of harm they occur.

the world especially that part of the world suffering most from ebola need to know if there can be an effective treatment as well as a prevention in the form of the vaccine. we we always go to all possible victims current and potential there've been examples in the past of untested and under tested therapies being rushed into service and ultimately doing the patient a disservice. some of the misadventures occurred on the african continent leading to a pervasive distrust of western drug companies using africans as their experimental guinea pigs. so i think that that is really an important issue but then when we look at the issue of who should be treated, the simple answer is that all of the questions are very important and

complex. it will remain moot until the therapies are available. and so we have already heard, you know, the tested or approved their key exist p. exist and we are at least months away before any therapeutic drugs could be even produced against testing much less know that they are safe and effective. the happy news if there is any is as was already pointed out that seem testing has begun. then they would be rushed into service sooner but the vaccines will not save anybody that is infected and will only be effective if large numbers of the population can be vaccinated first the sufficient amounts are safe and effective vaccines that can be produced and secondly that we can induce the

populations to accept the vaccine. you have to understand in these areas we are having people still deny that he ebola israel and those that are hiding from the medical establishment for a variety of reasons which is making the entire control of the to make much more problematic. >> i know this is a horrible thought, but i wanted to ask the question if you think about what will influence as a direct potential threats to western europe and the united states or australia we very rapidly got a vaccine within months.

we are going back to a regional tragedy since 1976. public health experts say one day it will come to the united states but we will quickly contain it so it doesn't represent the same kind of threat to us. what's the reason why we haven't seen the investment and the scale up for the well tested vaccines and drugs? >> the answer is that there is an arduous process of developing therapies, developing vaccines only one out of ten prove successful between 90% of the candidates and the drugs and vaccines aren't going to be usable for one reason or another that is a nice answer.

i think there's more to it than that. i think that the stark reality is that pharmaceutical companies are a business and the business has to have a market and there are twofold problems there and at the first part is as scary as it is and as tragic as the number of deaths are. >> and it's an unpredictable one. >> and an unpredictable one. >> and this is the other problem. it is a poor one. you know, i am convinced that if this epidemic happening any place other than the poorest countries in west africa, you know, we would be seeing the attention that we've heard that should have been given to us a long time ago. >> there is no question we are in a different dynamic --.

>> of the seasonal influenza comes every year there's hundreds of thousands of cases. >> it is a reoccurring threat on the front line of everybody, anybody globally knows somebody that gets the flu and is somebody that has succumbed to the flu. that level of prevalence and about level of frequency year in and year out as well as memories of pandemics past like 1918 and the devastation of the evil strain to which the whole world is susceptible is a powerful driving influence and we should not underestimate the difference of frequency of occurrence. it's easy to see and there are

many explanations behind this, but i don't want to -- >> of course you are totally right. but in a pushback to death. even with h. one and -- h1n1 you might develop for good reasons a vaccine vaccine distribution of the scarce resource here reside and even with seasonal influenza, low and middle income countries don't really have those supplies were to use them so you see much greater death. >> let's take the neglected tropical diseases and disorders look at things like malaria, turkey ... etc.. it may have been later than we would have wished that things that are more common and recognized as daily routine every year in and out, killers

have also been addressed and there needs to be more combat on the tropical disease. we are still talking about in the scores of outbreaks and not the thousands and millions of cases like bees etc.. >> on the different markets here a couple of points. one, it's important to remember that prior to the outbreak in west africa the total number of cases from the previous two dozen outbreaks was 5,000. the total number of deaths was under 3,000. you contrast that to the 39 million estimated deaths from hiv aids and the current population of 34 million living with hiv those are rather desperate market numbers and if

you are going to apportion scarce resources, towards the development of treatments and possible vaccines then where do you put your money? and i think that's cool reality is with us today and we are playing catch-up. this hasn't determined them from stepping forward and partnering. there has been a wake up call across multiple sectors for folks. and there is now an urgent moment for trying to accelerate with all of the provisions around preserving safety, safety and the like but trying to change the market conditions and move towards treatments and

therapies and vaccines. and i think that we will see some results. whether we will see the results in time to address the immediate urgent crisis is of course totally up in the air as a question that gets to my second point about the ethics seems to be the biggest ethical challenge in front of everyone with respect to the response today is how to go about providing the low-tech treatments to the large affected populations in west africa on a safe basis that is ethical because the high-end treatment options are getting washed out. hospitals are closing. the personnel are leaving and i'm on the ground. so that ultimately leads you into inquiring about what are the options going to be for the palliative care that can be provided to people that are

suffering from ebola and are under the threat of ebola that is going to be different from what we did under the normal circumstances it's going to raise ethical issues and issues of race and that is the predicament on the ethical grounds right now. >> i think what we have to be focusing are not questions that made the headlines initially which were great because they made all of the attention to what is going on over there. but in fact, if we are going to make a difference in the immediate future it is with things as simple as guns and downs and measures and those are things we do need to focus on. soon we will have, i hope, a vaccine and maybe there will be an adequate market for it. the sad truth is there's

probably another reason we are far as we are in the vaccine and that is that it was also realized this might be a weaponize double. >> it is both a risk and an opportunity because it does speak out and take a second from my previous life to things i would say is yes, we did move quite quickly from identification of the virus but that isn't a given. it did work out but i hope as much as we are all incredibly hopeful about the prospects of the ebola vaccine i don't think that we can't assume anything and certainly it is a very consultative situation that does not have the benefit for example the flu context of an annual process of developing a vaccine.

>> the second thing i would say is it makes an argument for the kind of investment whether it is for both security and to deal with man-made threats and natural threats. it is an argument for thinking about why you need to invest now for what may be something coming down the road. but let me ask others on the panel i know that dan had mentioned this issue. is there anyone else that wants to jump in? >> in 2011, again, we are coming back to the h1n1, harvey feinberg just stepped down as the president of the institute of medicine and as marty knows, the committee. the response on the health

regulations are in the first declared public health emergency of international concern. one of the recommendations that he made in the condition i think was pressing was to have an ongoing health contingency emergency response fund. something that provides surge capacity early on that you don't have to now five months later be asking for funding that should be there on the ground and quickly mobilized. so, i mean, i might just -- you will know about the report. what can we do now to make that a reality? >> i was on that committee and

it was a year-long process into their were many good recommendations. it was a reflection of how the well responded pandemic as well as how what can be done to strengthen the international health regulations and position the globe at the ready to deal with what has become unpredictable and timing but predictable in the current or the emerging threat and i think you are right to the committee report and the committee unanimously felt very strongly about the need for such a global emergency fund that could be called and quickly. there's been an effort to develop a global health security that would really frame this up and we can put a box of -- had a lot of conversation about the

speed and the fairness with which the countermeasures are developed. but there is nothing like primary prevention because no matter what, there is a beat prime for the newly emerging threat to come into the countermeasure arena and really, we need to invest in prevention upfront where it's possible primary prevention. the ability to detect rapidly and respond swiftly and i think all three pillars of the global health security agenda are critical and sadly this epidemic is a very painful example of the true need for this type of an agenda with a serious investment and a global set of partnerships so that when bees and affordable things emerge in our globalized highly interconnected interdependent world we have the capacity to find them quickly. we have the ability to begin

develop preventive services on a large scale in a quick timeframe. and i think that those are the key aspects. this is one example. sadly, there will be more. and i hope that we heed the call and the lesson and that we invest with a look towards the future. >> let me recognize you and dan. >> marty raises a critical point for what can be done here in washington and that's around the global health security agenda. just to remind folks, this was launched by the white house in february of this year. tom friedman played a critical role from the director of the cpc. the white cdc. the white house and others. the president himself. if involved in the consortium of 27 other countries and a member -- margaret and a number of other organizations. it was driven with an awareness around the antimicrobial

resistance, and the bio security threats and the emerging threats ike we are seeing today with ebola. it's resulted in the aspiration to create a network of emergency operation centers around the world. but it's being done on a paltry budget of 40, $45 million a year there is a funding mechanism that is robust, reliable, durable, sustainable for the global health security in the u.s. budget beyond our borders. and there is no institution that is the sole repository of expertise and responsibility for leading on this. we are very fragmented. and to the extent of this crisis rethinks on the hill and the administration, the global health security agenda provides a very, very good model or set of pilots which could be expanded and built upon quite aggressively.

the summit for this is september september 26 here in washington. so that moment will arrive and my guess is that it will figure very prominently in the discussions around why it is that you can have such an ignited crisis in a place that really hasn't built of any of the capacity to outline under the international health regulations. >> i guess i will move to the large -- why don't you, please. >> so, you know, nature doesn't really owe humans anything and one example of that is the vaccine developments. we can put a lot of money and effort and resources towards developing the safe and effective vaccine and the pathogen. it's just no guarantee that that will work. so that is good enough. in the examples i would say for hiv.

there are none against the pacific disease. those are the examples that forward for example to developing another vaccine to develop an hiv vaccine that we are not there. and i say that because there's no there is no guarantee that we will have a safe and effective vaccine. hopefully it is going to be safe and will do some response in the cells that are going to be protected. the last thing i'm going to see is using the model from now to the future one thing we've tried to do in developing the vaccine is to look for the protected response that occurs naturally. unfortunately as we all know that never occurs with hiv. but with ebola, it seems like it does. so in this outbreak approximately 50%, depends on depend on how the numbers are coming and only time will tell, but 50% of people have survived. they are not feeling really

good. they are feeling bad when they survived, but some of them are feeling better than others. so, one of the planes for 16 out of 18, for persons that are not cured under appreciated and i would say for the multiple points of view one of which is a scientific point of view so i read about it could be a value if we were able to better understand the response by the national virus infection itself in terms of antibody and is it mutual life of mutual life income is it not and what kind of responses are induced by the natural infection and trying to mimic the vaccines to reproduce the natural protective? >> only if the virus doesn't mutate. >> this is almost a different species. it's a different strain of the species.

>> it would be effective across the range. >> even before figuring out these issues around about survivors now engaging the survivors in their control and response, having the survivors be a part of the social mobilization and telling the story, having the survivors potentially play an important role in safely providing care in areas where there's limitations until they can be scaled up i think that is an underappreciated -- >> once you recover justified into just fine into victory for the audience, once you recover, is there a complete immunity to the re- exposure? >> in the short run the duration of that and the species may be different but there is no reason to believe people would be repeatedly infected in the same outbreak or epidemic.

>> this far what we've talked about in terms of response to the outbreak, we talked about the importance of a therapeutic response both in terms of the vaccine development and drug development. we talked about the sanitary and the public health response in terms of trying to make sure we have adequate protective equipment, safe and secure and hygienic isolation rooms. a public health infrastructure to do the contact tracing which is massive. we also talk about the idea of the world lower caring.

the panel has been almost unanimous with that and we would like to see the surge capacity that is expanding the search capacity in relation to the emergency is that what we have not discussed yet is if you go is a more ancient response but one that might be seen here which is the quote on the sanitary ware people can't come in or go out of. in many cases, it's been enforced through the military and there've been discussions of the food security shortages and clean water, viable employment, travel, commerce, all of that. i want to see the view about

what cool there is not just for the sanitary as it has been used and it was just lifted i think today or yesterday. what a smart sanitary items look like, would it be effective, could it be effective and what kind of fool would play in relation to all of these other therapeutic and health interventions? >> i would ask you to share with us the current public health recommendations in the space that we are experiencing because i think that is also. >> there's been a lot in terms of the pandemic and many other

things. the tool of the public health measures are based on the principle of isolating, quarantine those that are exposed but not yet ill and fully separating the exposed and creating that space around the principle that the transmission is clearly a huge primary goals in this epidemic is to stop the transmission in spite of the epidemic zone and prevent the spread of the new locations. >> we have highlighted how much we are a globalized world and how much mobility and interdependency there is so that is a formidable challenge in contrast to the 14th century leaving a ship off the shore of dennis for 40 days where the

idea comes from and letting it burn out. both in terms of the speed and mobility in that part of the modern challenge as well as the ethical challenge we don't live in the world where we sacrifice the victims for the benefit of everybody else. so, the question of you asked now is what are the principles behind using that tool in an effective way into some of the better written about as well as the papers that i published on this involved proportionality making sure that the measure is proportionate to the threat involved using the least destructive means necessary to create that goal and dialing them back and minimizing the duration as the need for that no longer exists the process inside the ring and this is probably the most important thing we need to be aligned between the victims and the communities that

are being protected. they have to have a common set of incentives and there is nothing that could propel an instinct to flee more quickly than the armed guards and barbed wire locking someone in space. that goes against the primal instinct that it's so bad i've got to be locked in here i've got to get out and i better get out quickly. we cannot confuse those incentives. the part of what is essential in the modern context is delivering effective goods and services inside, not choking an area off of the food into patrician and medical care and treatment centers have to be adequate and sufficient and the work services and the compensation and permissions and to align the community to voluntarily in some ways the incentives are designed right you don't need the guard

what you really need is a compelling argument, public trust and community engagement to voluntarily participate. and it's not impossible to create that. we saw the vast majority of the quarantines globally that would apply under the recommendations with good advice again we didn't have a direct medical treatment but there was a compelling argument in alignment and a different circumstance. but the principles of that obligation and then in addition inside of the area, you have to -- you don't want to create a hyper transmission zone so you have to identify this at the need to be pulled out and separated so you need a safe spaces the safe spaces in the community or village where they can be food and water and nutrition and other structures can be in place.

those are not easy to do and the risks of doing it wrong are exactly what we saw in west point but the simple military enforced with guns and barbed wire and communities that already have a tremendous amount of distrust of the government and authority has the potential. >> one of the things that perplexes me today there seems to be great unanimity among the public health community. what i had heard some discord have heard some discord and see about the role of the military. some have said they have the operational capacity to deal with something this big and others have talked about the need for security, securing the treatment centers and doctors

and doctors without borders and others working in the field. yet from the public health point of view having the military involved is drawing. >> how do you want to qualify my comments about the armed military and forced for the logistics -- >> i just wanted to get a discussion about that. >> i think those are different roles. >> what is the appropriate role of the military? >> i think particularly in the post-conflict states where there's continuing challenges. his back but also in the international. >> so there are several questions or dimensions to this. keep in mind in liberia and sierra leone, these are countries that went through decades of internal war that

involved particularly heinous abuses of civilians at the hands of armed entities into some of the unofficial armed entities and others militia for the oppositional ones. it's hardly surprising that creating into remote area where supposedly 70% of the transmission. but that had failed. it is permeable and people do not trust it. so, i think the idea that military can win the trust and confidence of the population is a pretty dubious population and we've seen it in west point where what looks like creating a

death zone the saying those inside could look into those outside think your stars. there needs to be some kind of mobilization that can create the lift capacity because the lift capacity was disappeared on the civilian side in terms of air. we know in the postwar situations at the blue helmet of deployments are critical to restoring security and making it possible for all of the civilian-based things to go forward. it's morphed into a multi-sectoral crisis and there has to be security restored and it would make sense to return to

that model in the first instance providing that you have the will to put the troops into that. a request was put up to 53 that we heard yesterday 53 countries on the quiet request through un channels as to who might be willing to entertain the donating troops and one country said to possibly they would consider it. keep in mind you have 4600 deployed in liberia that are a part of the original peacekeeping force. they said they want to get out wanted out for the safety protection of the forces. you have a force that if you could hold the force and build upon it in liberia and rethink its mission and give them confidence that they will be protected you can begin to move in the direction that i'm talking about.

but it's going to be hard. it's when to take an enormous political investment to make this work. why is it that the president of the sf is out there saying that this has to have been? the reason that joanne is saying that is because nsf is shouldering two thirds of the delivery of service in three countries. this doesn't shy away from brutal violent broken places. they are in eastern serious, myanmar and west africa in the center but they've reached the outside of limits. they had a thousand employees and some other force has to step

in to take things to the next stage. >> if you could say to sentences for the audience in distinguishing the types of roles in the initial peacekeepers can play and the different roles the international troops. >> blue is the color of the un. it's the troops that are on a voluntary basis placed on the flag and the un command in order to play under the geneva protocol to play different functions and at that precise functions are negotiated in the countries in question and the duration and the rules of engagement and the deployment and command structure and all that gets negotiated out. but at any one time over the last two decades the un has deployed 20 peacekeeping missions with over 120,000 new helmet troops into the conflict

of sites. i see no reason why the situation should not, we shouldn't be looking at that option asking the leadership of siberia, sierra leone why he this would not be acceptable. the process we had to go through with the countries that are in the crisis by all the things we talked about here i'm going to take a little liberty we have about a half an hour left. we've identified the multiple issues and we've talked about the quarantine issues relating to them and we talked about various kinds of medical treatments and vaccines in public health interventions. we have a crisis of extraordinary proportions.

we don't know that. we had a lot of unknowns. what we learned we've learned in the last five or six months number one, what could we apply in the countries right now. let's not make the same mistakes twice. what have we learned and what can we do differently. then second, looking at the global stage that taking advantage of the global health security agenda meeting that is coming out i would ask people to think in the near term and the longer-term what can we do and i guess maybe the kickoff to that. it is the $490 million.

and that is an underestimate. is there a prospect of that happening? how does that fit in? >> near-term and long-term i would offer anybody on the panel that funds to see something for a few minutes before we turn it over to the audience. >> on the who roadmap it was released on the 28th, 489 million. it was conduct it. it didn't answer questions and it was up to 600 million according to the statement this morning. it isn't clear where the world bank 200 million might fit and it's not clear where the african development bank's 60 billion plus might fit. it's not clear who's in charge and it's not clear how to raise the money. so how are you going to fix that? the question is what do you do from here?

in the midst of this crisis we have been enfeebled by staff and budgetary crises and this has been a terrible, terrible episode in the history of the who surveys put forward this plan but the question that it begs is who is going to make this happen? who is going to put the operational details together and be authoritative in directing us and raising the money and getting this forward? i don't feel that many people are confident that the who can do that. what does that lead you to? i would suggest to the un security council needs to take this up and create a mechanism charged with doing this in the first who would be charged with doing that. but as i said earlier it has failed us and going to get us out of this mess up until now.

the number of the treatment site and isolation centers and all of the other technical personnel gaps that exist but to actually operationalize that is not yet clearly defined and that i think is what we need to focus on. >> anybody else want to add? >> i am going to stay away from that specific topic and to suggest right now in the setting of the crisis there will be plenty of time to look back and do an after action. but i think right now in the setting of what is needed to move ahead to get things under control is a coordinated international effort with a lot of partners, and i think one of the areas that has been perhaps underutilized is the importance of communities, ground-up

community level engagement, social mobilization, the messaging and communication, the use of survivors, even community mitigation and community strategies that are better aligned with the cultural acceptability in the areas where the control has to go on. and i think that the increasing role for the medical anthropologists we really need to define very clearly the major drivers of the epidemic and this is not just one homogenous academic. it's multiple epidemics that would require multiple strategies to appreciate. it's one strategy that's applying when you have a single introduction into the synagogue or another country and you can stamp it out in the chain where you have the numbers and could be recognizing to try to snuff it. it's probably a different

strategy when you were on the accelerating exponential growth in the urban area like monrovia. i think we need to be able to look at this as a multifaceted epidemic and identify the major drivers and engage the understanding, the public trust, the community support to help break the transmission because as doctor friedman and many others have said repeatedly, it's not that we don't know how to control the disease like ebola. we know how it spreads and we know that if you can reduce the contact and you can use personal protective equipment in the safe means of interacting with one another at those who care in the setting, we know that that will work that we but we need to scale it and we need to engage in some community level involvement in building that support. >> did you have one have wanted -- >> i was going to say one thing that you were talking about the drivers and you are absolutely

right. one of the things that we have not emphasized very much as the fact that one of the drivers is a population's response to that ebola epidemic. you know, survivors don't want to be identified. those who are potential victims don't want to stay put. the reason it's spreading in fact in some of these areas is because people who were affected flood the treatment centers in the infection elsewhere. that will make it extremely difficult for us above and beyond the usual. it is a challenge. but the antidote to the anger and recalcitrance which is a mask of fear and vulnerability is education and empowerment and that is the vaccine that can help turn around behaviors that are clearly the behaviors that are clearly not only individually counterproductive. not understanding where the epidemic is spreading and then

engage in solutions to imagine how to impose that. >> the panel has given a number of questions, so we've got about 25 minutes. the way we do this is first take questions from students enrolled you're not self identify it, so i guess i am trusting everybody. i know couple people in the front rows are not students but beyond that i don't know who is. but me see if we have a question -- >> i think that we should take several questions. >> why don't we try three. we have one here and one in the back and won over here. i don't have any on this side of the room so let's do one, two, three.

>> i noticed for the last few months and read on the top of the list there are personal protective implements. what is the logistical breakdown of getting this to the health system? is its budgetary? and if it is budgetary what is the cost? >> let's take a couple. i can't see your face. yes, please. >> one of the questions i have i think the theme that has been eluded to a lot is in the countries that have the resources to deploy and help there is not a sense of urgency either with the public or with our elected officials. so how do we go about trying to change the tone in the public discourse? >> in the back?

the question is why does it appear that despite the nature of how we've dealt with these it is like the hiv epidemic and stuff like that and reinvent the wheel [inaudible] >> those are all good questions. let me suggest if i could maybe you could help us address this particular question. steve with a sense of urgency anyone can jump into answer. i'm just thinking in terms of starting and then the last question i think really for anybody from your experience do you want to talk a little about that? >> it's about the logistics and the scale and in the areas where

it is most needed and most urgent the supplies are desperately short and that is being scaled up and i think that getting back data in and providing the logistics, some of the response is being hampered and choked by the reduction of the commercial movement and it may take the un support list to continue to move the goods and services into people into the area to make sure that there's adequate supply. the other quite frankly is figuring out how much of it you need and based on what strategy and i think a lot of that has gone into that by a number of agencies including the who and the cdc coming together. that should be an achievable result. having this stuff is one is one thing and distributing it is another thing. but actually training it in its proper use and most importantly

how to take them off in a way that you do not contaminate yourself scaling up the training around the practices is an ongoing high-priority effort and that is something that is going to take more time than buying goods. >> it is logistical but beyond that, it is just in the capital here in sierra leone it didn't get to where we needed it. more workers have been infected with the virus as mentioned. more than 120 have died. so the largest testing of the facility where i work in the hospital did not have growth. it broke easily.

we didn't didn't have these shields until a few days ago. they had been washed so many times and watched through bleach you couldn't see them plus you sweat like crazy. i cannot over emphasize this. use with so much because it is hot. there is no air conditioning. you are sweating like crazy before you step in to get dressed so it's hard to see. i will be honest it's very hard to see. so you walk in and you can't see. why is that? so i talked to everyone i could and the ministry advising colleagues that are helpful and one of them took me to his hotel room and he says you can have anything you want. it was a very kind gesture. [laughter] >> i took them back and you

could see through them. now there are some face shields. then you reach back there and if you have your gloves on there's no shower, etc.. something below needs to be a clinical command center that makes sure that people that need the equipment and the training and it needs to be done with a cascade of training so people are confident and protected otherwise they are not going to put their lives at risk. >> does anyone want to comment on the particular steve and maybe kevin to offer some thoughts on the sense of how to create a sense of urgency given where we are now? >> that is a great question. the first thing that i would say is americans and others outside

of west africa have been certainly bombarded with the news accounts around this in the media every day the media coverage has focused on this in great detail and considerable depth. we've seen a lot of important voices. the secretary-general's pe steve of them. tom friedman has been kind of loosened allotment and powerful way, david from the un and the president constantly so there is no shortage of people trying to break the barrier and bring us to peoples attention. people's attention. and i did that for a lot of

americans, the polling data shows that people are scared. they are scared by this and alarmed by this. they are less clear about what they should do and about what it about what are the strategic choices that powerful governments face in despair -- this period. bringing forward the next layer of communication from the president and from samantha power at the un security council and from other like minded personalities including the president of johnson and including the nigerian head of state and minister of health and including many others would be very valuable as making clear what needs to happen and why does this tie into the u.s. national interest at this moment? the are having obviously when you look at isis and the other

crisis and with ukraine there is a debate going on in the u.s. foreign-policy projection of power, risk about what we are willing to take, the risk of the military and all these things. that has not happened in this case we haven't had that debate about what is in stake so what are the assets and what can we do and what should happen in this next period. >> i think that you are right and i think it's difficult to have a query and call when we are still blowing an uncertain trumpet. i think in fact it is happening now is we are realizing the scope of the problem and getting an idea of how the world needs to respond and not just a country that you've also pointed out i think that an important issue and that is we have to believe that it is in our

self-interest. we are a wonderful and a generous country that if we are going to mobilize and where we are threatened by think that the unfortunate infection to the american missionary healthcare workers was what brought this to the front page. there have been hundreds of people infected. hundreds and hundreds of deaths including among the health care workers who are taking care of these patients from the beginning some of them took a couple americans to bring it to our attention. that is the way the world works. that may be the worst-case scenario but it would bring it to everybody's attention.

>> the point is well taken. why does it take so long? i don't know the answer but i do think that it is an important next step when there is widespread transmission that is coming coming in at the base and hyper endemic and educating and empowering kids thinking about how that strategy meshes. you played it off as either or. we need a creative community engagement and hyper and then it areas where some of those other things are just too hard or cannot be accomplished quickly enough so it is and all of the above. and i think that we are playing

an important role in the effort that has been amplified. there is an encouraging things going on. the ebola that some of you may have read about that was brought on by somebody that didn't believe it was real and engaging in the community and the social networks. but he wrote to the scope that he wrote stories that appeared and the nurses on the front line, these are glimmers of hope and inspiration of many crises actually have within them and we need to be able to tell the stories and tell the story of the survivors and of the courageous people in all of that because that is also part of the social fabric of the response and elevating those people rather than the stigmatizing them come elevating them as heroes that they are rightfully so can't help change the community dialogue about how we engage and what we bb and i

think that it is really important. >> should we be thinking of the community in that location in the same sense that we think of it here? i mean, there may be people in this room who might not react well if there was a knock on the door and someone said i'm from the government and i'm here to help you. but it seems like that even much less likely. >> that's true but i'm not an expert. >> i don't know that it's a the government that needs to do the knocking on the door. [laughter] >> know i think that it is a grass roots evolution inside out rather than top down but it is also desperately needed and that is working on controlling the epidemics for decades as it has been pointed out.

if there isn't a public trust and community participation and engagement with the epidemics are hard to control in particular because there needs to be education around the very secret things. in some belief systems properly honoring the dead could bring on the scourge and we need to understand that from the medical perspective figuring out how to meet those deep-seated needs in a way that is safe and i think it can be done. and controlling the epidemics and understanding and altering these kind of practices to improve the safety area with. if this is happening in a new area where that level of community education has occurred i think in in a crisis listening is one of the hardest things to do especially in the communities that are right in front of you so i think that is true for political leaders at all levels.

we have about ten minutes left. i don't see any other hands from students in the class. let's try to do a couple of the open group and then bring this to a close. >> i know that many of you have mentioned if i were president of taiwan or even just to the regional house in taiwan and i do want to contribute something either money or material to join the battles what would you

suggest that we would do to get started to the individual label? >> your question? >> i'm a student at georgetown law -- >> my question is about the region where this epidemic is happening and the nature of the mobility and the human traffic and i know that some are in this country but many people cross the borders and places that are not. how do you think that is being treated after considering that the epidemic is spreading to places like nigeria which is hard on the continent. >> i'm going to take to questions from the audience and then invite the panel to apply

because then we will be at the end of our time. this is not fair at all but i'm just going to try to take one from the left side. the lady in the middle. we have to on the left side. that is all that we will be able to do. let's go ahead with the question i'm over here. ..

>> you can see the patient didn't understand why they had to be inside the facility and if people don't understand it they don't realize how much of a danger they are to the community. if being in the camp means that they are serving their love and

protecting everybody. and we cannot win the war. going from experiences with hiv this is what i am basing it on. it made me think about the human rights aspect. the peasants feel it was their right to decide whether to be subjected to treatment or because of the problems and then the government -- >> to engage the human recognize rights dimension of the

intermentiinte intervention. last question? >> how do you measure the risk of controlling this epidemic in countries asking for assistance and not undermining the work that has been done. everybody is talking about the fragile states but they have had gains in the last five years. they have setup financial mechanisms and there is concern that international ngo's for their response that is in nine or 12 months and there is going to be a shell of ministry left. how do you control balancing the epidemic but maintaining the gains that have been made? >> we have four questions and i am not sure we will be able to touch them all. but one thing i would ask is if marty can talk about the poorest borders and the travel

restriction and larry and kevin can talk about the human rights dimension. on the history of capacity, steve can maybe speak to that. the end goal is strong functioning state and that is where we need to be sure we end up. we have about 3-4 minutes. i think if people could just take a couple here. i think we can do this pretty quickly. marty, tell us a little bit about the borders. >> the point is well taken. air connectivity from the three epidemic prone area is relatively speaking limited. it is a different story if there is an epidemic in the big hub areas. i think the reduction in capacity of commercial airline for a bunch of reasons: dollars, logpistics and other

things and it is down 50-80 percent in those country. i think your point about the land borders is an important one and understanding the poorest nature and potential reduction in the inner section of the three counties needs to be addressed but i think it needs to be addressed through more creative approaches. >> do you want to speak about human rights? >> i wanted to hear what larry had to say. >> i am sure you can do a better job, kevin. but i think human rights are critical here. they are critical because i think when you have significant human rights violations it is really the antipithis of a

health response. it has been violent. and those are two of the things. the other thing is human rights include social and economic rights. the right to health. the right to food security. to clean water. to all of those things that really all part of a good public health community. we cannot forget about those in the midst of a disease crisis. in fact we need to reinforce all of these crisis during those chris times because as we know from so many hundreds of years back our worst instincts as human being come forward when we feel threatened by an epidemic and we have to overcome that. >> i think what larry was saying

is going to link nicely because one of the remaining questions is how do we help without creating reacsidual harm for th structures in place but rather stregthen them. >> i would like to talk about p protecting and balancing off the accomplishments and programs and achievements that have been made. we have seen of the 3,000 cases and over 15,000 deaths we have seen 240 health workers infected. we have seen the disruption of services have huge implications for child birth and any other health needs where there have been these gains. so how do you take action in

order to staunch the further erosion? and that has to do, i believe, with protection. the risk environment for exposure and the fear environment has become persuasive in many of these areas in particular liberia and sierra leon and how do you push back in order to preserve gains? i think the protection has to be met. on the border and air link issues, we are moving toward a de facto of the region. as air links put up bans on land, sea and air traffic into senegal, ghana and other countries that are more remote.

we are moving into that. and the question is how do you push back on that in a const constructive way to maintain the flow of goods that are essential to the response. simply appealing not to do this has failed. so what are the measures that are going to do that. >> i think it has been an amazing two hours. i believe we in some ways are are we were at the beginning that this is a crisis that has a real human personal dimension. we have seen this epidemic out of control in many places and certainly in parts of the three countries in west africa that are most impacted. but as steve outlined the regional and global dynamics here are extraordinary.

i would ask everybody to thank our panelist for joining us. [applause] >> we at georgetown want to thank all of you who came here and are watching on the internet or tv. this is an issue that we can't take off the screen. this is one that our country plays an important role and all of you do, too. thank you for coming.

[inaudible discussion] >> join us later today for a debate between senators for the north carolina race. you can see them live at seven eastern on c-span. here is a look at some of the political ads running in north carolina. >> tired of being disgusted by the news? the federal government has lost the american public interest. i came up in the real world. i was a paper boy, short order cook, a warehouse clerk and then

a partner at ibm. i am tom tillis. i approve this message. let's make it right. >> i am kay hagan. one thing i love about north carolina is unless you are talking basketball you don't have to pick a team. that is how i get results at home. republican or democrat -- if an idea works for middle class families i am all for it. i approve this message because i was proud when the non-partisan journal ranked me a moderate senator. not too far left or and not too right. >> we will have live coverage between the democratic incumbent and her republican challenger starting at 7 eastern on c-span. here are highlights for this

coming weekend: friday live at 10 a.m. eastern the nebraska supreme court will hear argument on the keystone xl pipeline. saturday on the communicators watch the debates on c-span. sunday at noon, kay hagan and tom tillis and from the california's governor race jerry brown and republican nominee neal. and friday at 8, john yu shares his potential on international law and what little affect he believes it has an powerful nations skwchlt mike gun owners on how he thinks republicans will make gains. our three hour conversation with the chair on civil rights. friday night at 8 eastern

authors and historians talk about the burning of washington during the war of 1812. saturday on real america the building of the hoover dam saturday night at 8. find our schedule at c-span's website and let us know what you think about the program. 202-636-3400 202-636-3400. like us on facebook and follow us on twitter. the environmental protection agency held a first in a series of hearing on clean power plants that is proposing cutting the largest source of pollution in the united states. they will be held around the united states to give the public the chance to comment before it

takes place in 2030. the comment period is open until october 16th. up next the second portion of the day long hearing. this is just over three and a half hours. >> power plants are the largest source of pollution in the united states occurring for 1/3 of all greenhouse gases. the first rule for existing power plants consist of two parts. >> this proposal gives the state's flexibility on how they will meet their goals by 2030. the second rule is epa's

proposal rule sets rules for two groups. those making physical and oprationale changes that income the plants hourly rate and those that exceed 50% of the capital cost of a new facility. if you would like more details on either proposed rules there are fact sheets available near the registration desk. today's hear is one of four public hearing we are holding across the country this week. we have had a lot of interest in the hearing and i would like to thank you for taking the time from your day to join us and share your comments. we have a lot of people signed up to speak today and want to hear from all of them. i would like to go through a few house keeping rules that will make the hearing run smoothly. be sure you have checked in at the registration desk even ifia are not planning to speak. if you planned up to speak online or on the phone but haven't told us you were here,