to people who said i am a decent right now must have accepted there is a degree of uncertainty. sometimes people to everyone who's undecided will go to no because if you're undecided you do with the status quo. that might be true if it's a quick decision but if you two years of thinking about it, i think most people for whom any uncertainty is a problem, they will have already decided by and large to go to know i think to a large group of them will be no. i think a lot of people who will say under no circumstances do i think i want scotland to just defend itself, i want the quite powerful uk as my defender. i think most of them are already on no. they might see their views now reaffirm. the current issue was a similar thing actually. most people said this makes me more likely to vote no or more likely to vote yes on majority of people who said that were people who already indicated that they would vote yes or no. what it might b do this for some

people to solidify their views on this but it doesn't seem to be shifting more people into this. that's as far as i would go with what we can say at the moment, i think. >> the gentlemen with a camera here in the back. >> i am a journalist with army television. the reason why we follow more closely -- [inaudible] the conflict has not evolved yet. so if people vote yes on september 18, to you think if scotland becomes member of the international independent, international commend into in memory, while they pursue policy more sympathetic toward these type of self-determination movements in the caucasus or elsewhere? i think i would an exception for

ukraine because western countries seem to be united against russia but how about other similar complex? my quick second question would be about edinburg agreement, independent from the results that we will have on september 18. do you think edinburg agreement will set up a precedent for other similar complex? because no they want to see it again and the caucasus or elsewhere, may appoint edinburg agreement and say you see in europe a lot more was negotiable so why should others do the same? thank you. >> i will not comment on any particular case because i don't have enough knowledge on other specific cases but talking about, i think it will be the difficult situation potentially for any independent scottish government because on the one

hand, they will not want to look hypocritical. unwanted i think they will want to say self-determination of people. and certain voice in support of the scottish national but at the same time they will want to join the european union, nato. polica lease that policy at the moment. and into, i mean, i sense of location people are quite pragmatic. i think scottish politicians are fairly pragmatic and some of the valuations. there might be some conflicts there. i have the distinct feeling that in general rhetoric on support up on contentious circumstances they might be for supportive but in things where it would be basically hindered their ability to integrate some of those things, but then that would partially depend on who the government of an independent scotland would be. the political landscape in scotland is going to change. it's very likely you will see a stronger conservative vote, whatever type of conservative

center-right party you have in scotland, they would probably get more votes because it wouldn't associate with westminster english conservatism. that's, the potential is there if you look at public attitude. if you get a different government in scotland you might have different -- that's what it's there for hard to predict and if you think and the edinburg agreement is a keeping. the use that as an argument because the key thing is that they say if everything works out as it looks at the moment in a case that scotland became independent it would look like a peaceful transition, hopefully, if that's the case. so there's a difference in the terms that is not seen a conflict the very few scots have said we are oppressed, our political will is oppressed at the moment. uk government agreed to the referendum. that's one of the key things that comes into it. i think that will be an argument in terms with you might want to

differentiate themselves. it would depend on time to, and didn't know which party would form the scottish government. i think that's quite a good point. >> thanks very much. imho info, i am with policy center international. i wanted to go back to your issue, jan, about the economy being of one. you mentioned yes vote is increasing and the most positive issue for people who thought that the economy would be better after independence, is there anything in particular that has convinced more people to think that way? i notice that businesses have weighed in on both sides of the debate. there seems to be more companies on the yes list.

was that a factor? or is there something else persuading people that yes, in fact, the economy could do better? >> this is really interesting when. there were two letters, first group of companies that supported the no side, and so the yes list has more compass but there are also smaller companies on that list. not surprising. not only small companies, maybe different types. what's really interesting actually, compared to 2013 overall in the scottish attitudes of it we have fewer people who thought scotland's economy would be better. but remember what i showed it. there was a much clear crystallization. i have to quote john courtesy. i didn't come up with the word crystallization, but

crystallizing really of those who think the economy would do better nearly almost yes. so it is within that group that nearly everyone is drawn on to the yes side. but the group overall has become slightly smaller compared to 2013. however, in august in the polls at least it seems of interest to be. it showed a big swing to guestco saw a quite substantial increase of people who thought the economy would be better. but over all actually not substantially more people than 2015 -- 2013, it might be a smaller group but that group has been convinced for the yes vote. it makes it all even more complicated kind of in that information. again it is a two year long process with a lot of specific debate, multiple actors coming into this debate. so people's attitude formation on this issue is quite complex, surprisingly.

[inaudible] >> thank you very much. as you know, as you know, the american government weighed in somewhat diplomatically on the no side. i wonder if that has had an impact one way or the other or what the attitude about that is. and also how, has been any discussion of what the sort of special relationship with the u.s. would be in the event of a yes outcome? >> really interesting when. i remember because it was the day when we just presented on new research results and cash, we're going to be out of immediate today.

when the statement was made by president obama and it didn't make the polls need a way. neither in january when commissioner barroso made his statement. a substantial thinking has shown the issues about kind of what happens in scotland dominates the decision-making. we have seen evidence from several people that did move the polls and i'll be slightly anecdotally. if you live in scotland, probably quite well if you've ever been to scotland, it's never very fruitful to try to tell scottish from the outside what to do. there's relatively little response to that. so it's not that they don't come it didn't matter that it's not something that people were basing their views on because the court issue of peoples seem to be what happens in scotland in the future.

so those issues were discussed but they are not the ones, you know, that are grabbed on. >> i'm an ex-brit who would vote no if i had a chance. but my question is, if the no vote succeeds, is it the end of the campaign for independence for scotland or will it happen again? >> that's a very good question. >> as of our city will be the end of the scottish national party as well. again, context is slightly different but i look at other referenda as well. they might be some intern re-org position in some way but the vote they would take this into campaign for the greatest level of further devolution. i me, the three-member before it

started the scottish government advocate for was a ballot for to two question. one of the independence and what about devolution to the uk government insisted on a simple yes no vote. silted because they didn't want -- i think the key thing is a people vote for maximum devolution which clearly very unlikely that wouldn't have worked because some of the other parties would advocate quite as welcome it would have been out of. now the we negotiations in event of a no vote. so s&p would be at the forefront i'm pretty convinced of advocating for further devolution. some of them it would be reached within the next few years. weetzie for the devolution of power to scotland and i think than it depends on the satisfaction. bbc with the next 10 years people become more satisfied with the settlement and the governments, what we have seen earlier, the way to still be fight with the relation between scotland and the uk depends on

the performance of their scottish government, of the people that represent them which makes sense. if they would be confident about that and the that like a, then another run for independence might not be very successful. if that levitt would be growing dissatisfaction, a feeling of being shortchanged, then, of course, there could be another. obviously, not within the next few years probably. the only thing that could be in the medium term and influence impact would be if it were a referendum on exiting the european union that were successful. and in that context i could imagine that at an earlier point in the future that issue would be brought back. but in a context of -- otherwise it would take quite a while maybe. although how long that is, i don't know. >> down at the end. this will be our final question.

>> my name is robert. i'm a doctoral student at georgetown. i'm kind of curious not in future production but perhaps a little more of the historical reasoning behind some of his did you mentioned a lot of these younger generations are feeling perhaps equally british and scottish or a less fully scottish, and i'm kind of curious, has there been policy changes from the english have influenced that? or what's going on in scotland perhaps that you think, you mentioned a generational thing with the internet but are there other factors getting them to feel that way? >> what we've seen, an increase also amongst the adults being slightly more likely to say equally scottish and british com, abit less like to say i'm scottish own. we've seen an increase in 2012, 2013, the thought the london olympics. if it had been something like this you would've seen a drop and we didn't see a truck.

it doesn't seem to be just something like the olympic gam games. then there's been much policy in recent years on the scottish government side to emphasize scottishness per se. schools are very, very careful. we've been involved with a lot of schools. we've done a lot of work in schools, mentor school student the schools are very, very cautious when it comes to political issues but based on our research that's what we are doing now, too cautious probably because a lot of young a lot of young people see schools as a place where they can discuss politics in a neutral setting. there were some council that said we prefer our schools not to discuss the reverend and even in a neutral way because they were afraid of parents would accuse them of biasing. if anything, they're quite stubborn and don't like be told what to do. they're getting very well informed from schools as their political confidence grows when they discuss the. scottish schools are doing, every time there's anything

about cricket, for example, there seems to be quite of emphasizing scottishness and there's a lot of critical commentary on this. there's now a bit more talk in the uk about emphasizing a british values and education. what that means in practice is to be seen and again, education is a fully devolved matter to scotland, so it will have little influence. i think those ships are not based, i was thinking that social by some political things, but more on experience. but i would say more research needs to be done. it's quite nice to the university of edinburgh for some people who have been researching national identity in scotland for the last 30 or 40 years, so it's a very stimulating place to discuss the issue. >> well, our website will have the slides act would make a couple of corrections to get in some likely votes.

on one slide, but they will be up in a day or so and you can consult vendor. meanwhile, join in thanking our speaker for a very stimulating presentation. [applause] [inaudible conversations] >> [inaudible conversations]

>> following the shooting of subsequent protest and ferguson, missouri, a senate panel holds an oversight hearing on how state and local law enforcement agencies are equipped using federal programs but officials from the pentagon and justice department will testify. you can join a conversation on facebook and twitter. watch live coverage from the senate homeland security committee this morning at 10:30 a.m. eastern on c-span3. >> with congress back in session here's a message to congress from on one of this years c-span studentcam competition winners. ♪ ♪ >> water, it makes up 75% of our

body. take water away and humanity would perish within a week. water is the most vital substance to the human body, yet it is because of us humans that nearly 50% of all streams, lakes, bays and estuaries are unsuitable for use due to pollution. in the u.s. we've learned to take water for granted. faucets, bottled water and flush toilets all have the same idea. water is an unlimited resource. but step outside to our local wetlands and their diminishing condition tells a different story. water pollution kills marine life, destroys ecosystems and disrupts an already fragile food chain. and animals are not the only ones that suffer the negative effects of water pollution. >> congress, in 2014, you must provide federal funding to wastewater treatment agencies across the countryewat. treatmes across the country. the lifeblood of our nation. it must stop here.

>> join us wednesday during "washington journal" for the scene of the 2015 c-span studentcam documentary competition. >> doctors and global health care officials met last week to talk about the ebola outbreak that has infected over 3000 people in five west african country. from georgetown university's institute for national and global health law, this is one hour 40 minutes. >> thank you very much, john, and larry, and for the convenience of this colloquium. it's an honor to be here. it was one of the greatest honors of my life to go to work in sierra leone for three weeks. i just returned about 48 hours ago. i'm in good health. i took my temperature three times a day. i have no fever, no diarrhea, vomiting. i didn't shake a single person's hand. kes hands.

no one has close contact either. i will try limiting this to three-minute. let me say there are three primary things that i try to focus on in sierra leone as many opportunities to do things, even as one person. so the first thing was a compassionate care and evaluation of patients as the ebola virus testing center. i the great coverage to work with the one and sometimes two doctors who work there, one from spain who work there straight through for two months and is still there now, and another 27 euros british physician from king's college, london. cited profound effect on me being able to help provide care and if i nts with ebola virus disease. secondly, closely debated activity was the training of

mostly nurses and doctors, approximate hundred 60 and have put on a personal protective equipment, and most importantly and more importantly is how to take it off safety because when you're taking it off that's when there's virus onto gowns and gloves and goggles or face shield under to take off in a very sequentially important manner washing your hands between each step. so i worked with the minister of health, chief nursing officer and the uk physician. and together trainers, frances and joseph in particular, training more people at will if in other hotspots. 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 18. 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. this at one eyed a small role to play in the article, which is an article i wrote and so i take full responsibility there's no one else who contributed to. it will 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 but it simply is how there 18 problems and needs in solution for how the ebola if i you wishing it could be made much better, much more efficient and provide better care for individual patients and for the

citywide response. the ebola. i would like to say that this able 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, it was announced probably a large outbreak will occur in the large oil said in nigeria linked to a physician who died and had many close contacts with patients and other people. in my opinion, and i would just say this, no one else has said it, and certainly its controversial but i could live after the three of being there in sierra leone, this is the first urban outbreak ever of ebola, series of urban outbreak. personally i don't leave our traditional methods of being able to control and stop, stop ebola outbreaks in rural africa, more than 20 of them since 1976,

isolation of people, corn king of people are ill will be effective perhaps in most of the cities. and, therefore, i think this outbreak will go on even longer than a year and that we are going to have to have vaccines, drugs, and the bodies against the virus and post exposure to stop it. we can do everything we can do no. we should do more to slow it down, to start it to decrease. i'm not cover the able stop it without what are still investigational therapies and vaccines. so again, this is much more -- much worse anything our member in aids incidence of 1982 or anthrax in 2001 or sars in china, hong kong, toronto, bird flu in asia and egypt, and murderers lest you but it's more severe than all of those come in my opinion. i'm very happy to go back later this month to monrovia, slavery to work for six weeks with

doctors without borders. thank you. >> dan, thank you for those remarks. 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 try to get a situation analysis of where things stand but i'm going to ask marty who has been tracking these issues across all the affected countries and populations, if you could give us an overview about where we stand. i mean, i think we know we are not at the end. i guess really what we want to know is are we at the beginning of the comptroller of the kinds of epidemics over individual epidemics, if you give us an overview that would be great to start the conversation. >> thanks to you and larry for the invitation but i really appreciate the opportunity. i do need to provide a disclaimer to larry's heating introduction.

i'm the one small part of this response in an agency that has mobilized several hundred, last count more than four or 500 people engaging, 70 deployed. i'm told more will be deployed internationally by the weekend. we will 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 on cdc, i think larry keeps 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 passed since its discovery in 1976? one of them is the location. so poverty as margaret chan said in her new england journal article, is pretty profound. we are 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. week 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 zeiger outbreak in 1976 in a very isolated, four state area that was unconnected, the tools of detecting an outbreak, case

identification, isolation, contact tracing a beginning to alter unsavory practices which really caused a huge amount of transmission happen in a very remote area, not reconnected or globalized a. and so the success and/or failure in some sense the trajectory of the outbreak, some cases 9% case that held and outbreak in some regards gets self-contained. and he we haven't outbreak that probably emerged at the intersection, at the boundary theories of three countries that are highly connected in some ways culturally and ethnically, with many improved roads and commerce and exchange, with kennedy 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 as 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 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 the legal outbreak in these urban settings with large population centers and connectedness, both regionally and to some extent through other places on the continent globally, it is a very, very unique circumstance. the health infrastructure was fragile at its start, that epidemics of disease like this, horrible diseases like this are often followed and improperly, understandably have epidemics of fears and epidemics of statement.

the fear and the statement in many ways combat's and complexity attempt to get an epidemic of disease under control. certain information, misperceptions, lack of understanding about the means of transmission, suspicion of lack of trust in government, suspicion of outside folks, not really understanding how the disease is spread over who was bringing it. ..

>> 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 hard hit like liberia and in the capital. and i think that in those areas when you ask about the trajectory, we are -- 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 of equipment, the quantity of body bags, the people and the stuff that are needed to be able to get an outbreak 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 system, a health sector or public health response, but a full response. it represents a senate global health -- significant global health security threat. as new countries have a single introduction like nigeria on july 20th, and we're still trying to snuff out one chain of transmission from one introduced case. and you think about that possibility of an epidemic in lagos or an introduction into parts of, you know, we have -- one of the world's large 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 gatherings or mass communication are hard to fathom and other surrounding countries with also

fragile health care systems. so larry's comments are very point grant. 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 exponentially at least in some of the key areas. i'm going to ask steve, and i hope not to put him on the spot, but to give -- i mean, as you 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, 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 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, please. >> um, i think in the last six weeks this epidemic, 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, sierra leone, but also, i would say, guinea -- it's

triggered an existential moment for them. these states which were acutely weak beforehand, their functionality and their vulnerability to bosserrenning civil -- 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, and they've seen in the health sector, in 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 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. so it threatens another ten states where you have the likelihood of onward transmission. second point i'd make is that while this crisis has mushroomed in this last period, it has not

penetrated the level of world leadership and come to be recognized and acknowledged as a, as a global security problem. it has not been brought forward to theup security council -- to the u.n. security council. and why is that? why is that? if you have the kind of implosion that i've described and the implosion that now threatens the surrounding region and the human -- the magnitude of the human crisis on a skyrocketing 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's probably two to four times that level, so it could be 12 and 6,000, and we think it could hit 20. well, there's no confidence whatsoever that 20's a stop

point. so you're now in a world of great unknown, of trying to think about what the trajectory will be, and it's totally plausible to see this as going to 40, 50 or 100,000 or beyond because our confidence, our own confidence in calculating the numbers has eroded tremendously. this has been a very, very hard set of lessons for public health experts. so back to the question why have political leadership not grabbed onto this, i think there's a couple of answers. one is, this is the unknown. we did not know that there would be this cascade of catastrophes that would be triggered by this virus. we did not know that this perfect storm would appear and ignite. in this region. with the speed and ferocity that we've seen. i think that in the earlier days there was an overconfidence among public health officials

that the measures that had worked in earlier settings could be applied and would work in these settings. there was excess confidence in those tools, and when pleas were made to political leadership from that world for a higher level of attention, those went unheeded. so there was overconfidence, and there was an inability to pep trait to the higher -- penetrate to the higher levels. i think that in this 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 in syria and iraq, you have the israeli/palestine war, you have the russia/ukraine war. it's a pretty crowded, exceptionally crowded environment to push this through. the last thing i'd say is it's very hard to walk the sovereignty minefield here. and until the states in question are prepared to come forward and

plea for a higher level of commitment, how are you going to win consent to deploy peacekeepers into this 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 a deployment of protected authoritative forces into this setting. but to get to that point requires consent. it requires sovereignty be respected. and it requires political leadership. and there has not been political leadership on this matter, and i fear that what's going to happen is we're simply going to do what who is suggesting, which is draw up a list of 12 things and ask people to do more of those 12 things versus seeing the big picture and coming up with a response to address a -- we need to transform this exponential crisis, this escalating, runaway

epidemic, and we're not going to transform it by just doing more of the same. thank you. >> let me now, i think we've layered all three, the individual, the country level, the geopolitical. i would just -- before we turn to a couple of the issues that have emerged so far, i just want to invite anyone else on the panel who wants to come in, kevin or others, on steve's point. i want to emphasize a point that marty made in its relation to steve's. in the middle of a public health crisis, there's a lot of imperfect information. a lot of people may look back and wish you'd done things differently, faster or sooner. the really important point, in my judgment with, given where we are today what are the things we can do to attract the attention and the action of the players in the world who can make a difference in this dynamic? because it's, this is, i would argue this is a very, maybe not

unprecedented, but it is certainly a very rare place for us to be as a global community. anyone else? because i'd like to turn to a couple of the issues that have received considerable attention in the media, particularly around the issues of quarantine and around the issue of access to medicine. so let me -- let's start with because both larry and dan mentioned thish shies around treatment -- the issues of treatment and vaccine. i'm going to ask kevin to kick us off here. we had the well covered story of the two american health care workers who received the zmap medication, came back here, were treated at emory and now appear to be, to have recovered. we got yesterday hhs announced that they're going to accelerate their contract with the manufacturer to try to get more of that product available for clinical trials in the near run. as larry mentioned, dr. fauci at

nih has announced that we're going to move, we started yesterday going forward with the first trials of the ebola vaccine. but, you know, i think this stark situation has raised a couple really critical ethical issues, and one of them is, you know, the who convene a panel on this and do we all agree that it makes sense to provide medications that have not been tested in humans in a context like ebola as the who panel recommended? two, if the answer to that's yes, how do you allocate what will be invariably incredibly scarce resources in the context of the kind of catastrophe we're talking about here? and i guess i would ask kevin maybe to kick us off with a conversation. larry's written about this but, kevin, i know you've thought about this a lot as well. >> and, kevin, also if you will, differentiate between drugs that have not undergone safety or

efficacy trials with vaccines because you have a compassionate use of a drug when somebody's potentially dying. but vaccines are given to otherwise healthy volunteers which raise a whole other set of ethical questions. so if you could reflect on those things, that would be very helpful. >> absolutely. i mean, we've heard about the humanitarian crisis from the ground, from the doctors' point of view. as a beings, especially a physician who's spent much of his career treating chirp, it's devastating -- children, it's devastating just to hear about this. i can't imagine what it must be like to be living through that. we heard about the public health response, the inadequate public health response and how we're going to have to be able to do much more. that's certainly going to raise a bunch of ethical questions. but 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 can treat people even with experimental medications, you know, why aren't we doing that? i think that's one of the foremost ethical questions. i think that there are several that are worth thinking about, and we may be able to cover some of them today to. that would be number one on the list. the other one, i think, would also be that when we're considering the allocation of those 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 do have treatments available. and also i think that one of the questions that i would like to hear discussed before we're done is if the ebola virus has been known as a cause of disease since 1976, why is there no

preventive vaccine or effective therapy? i have some of my own opinions on that, but i'd like to hear everyone talk about that. now, first off, what about experimental treatments being offered? i think we have to consider the pros and cons of giving experimental drugs to people. these drugs have never been tested in humans before they were given to the sick patients, therefore, the dangerous and adverse effects can neither be known, nor safely protect predicted. -- safely predicted. it's entirely possible they may be ineffective or even harmful. in america all fda-approved studies have to go through a first stage where the likelihood of harm can first be assessed followed by subsequent phases to look for additional side effects and evidence of efficacy. so far, these have only been tested on a handful of monkeys and not even the first case. the monkeys, you'll be happy to know, are getting better.

but so far six people have received one candidate experimental therapy, zmap. two of them have died. this momentum prove that it's effective, and it doesn't prove that it's safe. we don't know what harms it may do long term or even short term, and the guiding rell to new medicine is, in the first place, to no harm. research is designed to answer questions about possible harms and possible effectiveness. but what has been done here is not research, but rather, it is scary, experimental treatment. it was done because ebola is a deadly, scary disease. but if we were to keep approaching it in this uncontrolled way, we may never know if these therapies are safe and effective, or at least not know until a great deal of harm may occur. the world, especially that part of the world now suffering most

from ebola, desperately needs to know if there can be an effective treatment as well as an effective prevention in the form of a vaccine. we owe it to all possible victims, current and potential, to get this right. there have been examples in the past of untested and undertested therapies being rushed into service and, ultimately, doing the patients a disservice. some of these misadventures occurred on the african continent leading to a pervasive distrust of western drug companies using africans as their experimental fellowshipny pigs -- guinea pigs. so i think that that is really an important issue. but definitely hook it to the issue of, you know, who should be treated. the simple answer is that all although the question's invariably important and complex, it'll remain moot until

therapies are made available. as we've already heard, you know, no tested or approved therapy exists, and we are at least months away before any therapeutic drugs could be each produced again for -- even produced again for testing, much less know that they're safe and effective. now, the happy news -- if there is any -- is as larry already pointed out, vaccine testing has begun. vaccines hay be able to be rushed into service sooner, we would hope, but advantage seeps will not -- vaccines will not save anybody who's infected and will only be effective if large numbers of the population can be vaccinated which preposes two things -- presupposes two things, first, that large a amounts can be produced and, secondly, that we can induce the threatened populations to accept

this vaccine. and you have to understand in these areas we're having people still denying that ebola is real. and those who do get it or are at risk of getting it, are hiding from the medical establishment for a variety of reasons which is making the entire control of this epidemic much more problematic. >> [inaudible] >> oh, i was just going the follow up on that. but for the whole panel as well as you, kevin, i mean, i know this is a horrible thought, but it's occurring to me, and i wanted to ask the question. if you think about infew wednesday saw -- infliewns sa a, h1n1, which was a direct, potential threat to western europe, the united states, australia, we very rapidly got a vaccine. within months. here we're going back to,

essentially, a regional tragedy since 1976. i think public health experts at the cdc have said 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, the scale-up for well tested vaccines and drugs? >> i think the them to rate answer is, you know, there is an arduous process of developing therapies, developing vaccines. only one out of ten proves successful, which means 90 president of the candidate -- 90% of the candidate drugs and vaccines are not going to be usable for one reason or another. that's the 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. the first is as scary as this is and as tragic as the number of deaths are, this still represents a small market for pharmaceutical companies. >> and an unpredictable one. >> and an unpredictable one. and this is the other problem, it's a poor one. you know, i am convinced that if this epidemic were happening any place other than the poorest countries in west africa, you know, we would be seeing the attention that we have heard should have been given to this a long time ago. >> let me invite other people -- others on the -- because there's no question we're in a a different dynamic than a global flu pandemic. but, marty, do you want to say something?

>> >> just to give some context, i'm not saying i disagree with all of the issues at play, but to be fair be, you know, seasonal ininfliewns sa comes every year. there's hundreds of thousands of cases globally. this is something that's a familiar, recurring threat on the front line of everybody. everybody globally knows somebody who gets the flu and somebody who succumbs to the flu. and that level of prevalence and that level of frequency year in and year out as well as memories of pandemics past like 1918 and the devastation of an evolved, mutated strain to which the whole world is susceptible is a powerful driving influence. and we should not underestimate -- >> no, of course not. >> -- the difference in frequency of currents. i mean, it's easy to see, and there are many explanations behind this, but i don't want to -- >> right. no, but in a pushback, of

course, you're totally right, marty. but even with h1n1, and one can imagine this in so many areas, even though you might develop -- for good reasons -- a vaccine, the distribution of a scarce resource still resides. and even for seasonal ip flew went sa -- influenza, the low and middle income countries don't really have those supplies, don't use them. to is you see much greater -- so you see much greater death even for seasonal. >> yeah. but let's take neglected tropical diseases in sort of parallel and look at things like malaria, tuberculosis, etc. >> there has been scale up. >> there's been scale. i mean, it may have been later than we would have wished, but things that are more mono, that are more recognized -- that are more common, that are more recognized as daily routine every year in and out, killers have also been addressed.

there needs to be more done to combat neglected tropical diseases and so on. so i think, you know, you're still -- when we still look at ebola, we're still talking about in the scores of outbreaks not in the every year, you know, thousands, millions of cases like diarrhea, tropical diseases, etc. >> i think we are talking about two quite different markets here but, steve? >> couple points. one is it's important to remember that prior to the ebola outbreak in west africa, the total number of cases from the previous two to 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 disparate market numbers. and if you're going to apportion resources, scarce resources on

a, towards the development of treatments and possible vaccines, then where do you put your money? and i think that cruel, that cruel reality is with us today, and we're playing catch up. the other thing i would say is that this hasn't deterred in this context, this hasn't deterred gsk from stepping forward and partnering, right? i mean be, it has, there have been a willful, i mean, i think this has been a wake-up call across multiple sectors for folks, and there's now an urgent, there's now an urgent moment for trying to accelerate and with all of the provisions around preserving safety, safety and the like, but trying to change the market, the market conditions and move towards treatments and therapies and vaccines. but, and i think we will see

some results. whether we'll see some results in time to address the immediate urgent crisis is, of course, totally up in the air as a question which gets to my second point about ethics which is, it seems to me, the biggest ethical challenge in front of everyone with respect to the response today is how to go about providing low tech, low tech treatment to the large affected populations in west africa on a safe basis that is ethical because the more high-end treatment options are getting washed out. hospitals are closing, personnel are leaving, the personnel are not on the ground. so that, ultimately, leads you into inquiring about what are the options going to be for low tech palliative care that can be provided to people when are suffering from ebola and under

threat from ebola in this context which is going to to be wildly different from what we would do under a normal circumstance. it's going to raise ethical issues, issues of race, and that's the predicament, that's, i think, the biggest predicament we face on the ethical grounds right now. >> i think you're absolutely right. finish i think that what we really have to be focusing on are not the questions that made the headlines initially which were great because they made all pay attention to what was going on over there, but, in fact, if we're going to make a difference in the immediate future, it's with things as simple as gloves and gowns and antiseptics and public health measures. and those are the 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 that we're as far along as we are on the vaccine, and that is that it

was also realized that this might be a weaponnize bl infection. >> right. well, but that does present another -- i mean, it does, it's both a risk and an opportunity, right? it does speak, i'll just take a second from my previous life at hhs. two things i'll say is, yes, we did move quickly in h1n1 from identification of the virus to creating a vaccine, but that was not a given. it did work out in that sense. but i hope, as much as i think we're all incredibly hopeful about the prospects of an e bowl that vaccine, i don't think -- ebola vaccine, i don't think we can assume anything and, certainly, it's a very complicated situation that doesn't have the benefit of, for example, in the pandemic flu context, really an annual process of developing a -- >> and we're not even to effectiveness testing yet. we're literally just seeing if safe on healthy volunteers.

>> exactly. and the second thing i'd say is it does also make an argument for the kind of investment whether it's for both biosecurity and for to deal with manmade threats and natural threats, it is an argument, this 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 dan had mentioned this set of issues. is there nip who wants -- anyone else who wants to -- >> i do want to mention one thing. in 2011, again, we're coming back to h1n1, but in 2011, harvey feinberg who's just stepped down as the president of the institute of medicine, chaired -- as marty well knows -- the, a committee that was an independent examination of the response of the to international health regulations during the first declared public

health emergency of international concern. and one of recommendations that he made and his commission made, i think, was prescient which 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. but as marty said, you know, that should be there on the ground and quickly mobilized. so, i mean, i might just -- marty and others will know about the feinberg report. what could we do now to make that a reality? >> well, i was on that committee with harvey, and it was a yearlong process, and i think

there were many good recommendations. >> there were. >> it was a reflection of how the world responded to the pan dem cantic as well as -- pandemic as well as what can be done to strength the ihr, the international health regulations, and position the globe at the ready to deal with these what have become predictably unpredictable in timing, but predictable in to car insurance for emerging threats -- in occurrence for emerging threats. and i think you're right, the committee report and the committee unanimously felt very strongly about the need for such a global emergency fund that could be called in quickly. in addition, i would point out that over the last year there's been a tremendous effort to develop a global health security -- >> agenda. >> -- platform, an agenda that would really frame this up and that, you know, we can put a lot of, have a lot of conversation about the speed and fairness with which medical countermeasures are developed, but there's really nothing like

primary prevention because no matter what, there's a lead time for a newly emerging threat to come into the countermeasure be arena -- countermeasure arena. and really we need to invest in prevention up front where it's possible, primary prevention, the ability to detect rapidly and respond swiftly. and i think all three pieces of the global health security agenda are critical. and, sadly, this ebola epidemic is a very painful example of the true need for that type of an agenda with a serious investment and a global set of partnerships so that when these inevitable things emerge in our globalized, highly interconnected and interdependent world, we have the capacity to find them quickly, we have the infrastructures and the health systems to respond, and we have the ability -- even if we had a vaccine -- we have the ability to deliver preventive services

on a large scale in a quick time frame. and i think that those are key aspects. this is just one example. sadly, there will be more. and i hope we heed the call and the lesson and we invest, you know, with some look toward the future. >> steve, let me recognize you and then dan. do you want to -- >> thank you. marty raises, i think, a critical point for what can be done here in washington, and that's around the global health security agenda can. just to remind folks, this was launched by the white house in february of this year. tom frieden played a critical role from the director of cdc. the white house, laura hold gate and others, the president himself, it involved a consortium of 27 other countries and a number -- and margaret channing, a number of organizations. it was driven with an awareness around the antimicrobial existence, and around the

emerging infectious threats like we're seeing here today with ebola. it's resulted in the aspiration to create a network of emergency operations centers around the world. but it's being dope on a paltry -- done on a paltry budget, borrowed budget of 40, $45 million a year. there is no funding mechanism that is robust, reliable, durable, sustainable for global health security in the u.s. budget beyond our borders. and there is no institution that is the sole repository of expertise and isn't for lead -- and responsibility for leading on this. we're very fragmented, and to the extent that this crisis establishes a rethink within the administration, the global health security agenda provides a very, very good model or set of pilots which could be expanded, built upon quite aggressively. the summit for this is september 26th here in washington.

so that moment will arrive, and my guess is ebola will figure very prominently in the discussions around why it is that you can have such an igniting, ignited crisis in a place that really has not built up any of the capacities outlined under the international health regulations. >> i definitely want to move to large -- but, dan, no, why don't you -- please. >> just briefly, i want to turn to the science about the vaccine. so nature doesn't really owe humans anything, and one example of that is vaccine development. so we can put a lot of money and effort and resources and brilliant minds towards developing a safe and effective vaccine, but there's no guarantee that that'll work, that that's good enough. and the most glaring examples, i would say, are ones we're always familiar with, hiv, hepatitis c. there are no vaccines against any parasitic disease. so those are some examples.

and a lot of brilliant minds and effort and research has been put forward, for example, to developing a noro vaccine, an hiv vaccine. but we're not there. i only say that because there's no guarantee that we'll have a safe and effective ebola advantage seep. hopefully, it's going to be safe, hopefully it'll do some immune response. so the last thing i want to say is that using the model, trying to learn from the past, past is prologue to now and the future, one thing we've tried to do for almost 30 years is to look for a protective immune response that occurs naturally. with ebola, it seems that it does. so in this outbreak approximately 50% -- it depends on how accurate those numbers are and only time will tell, but approximately 50% of people have survived. they're not, they're not feeling really good -- they're feeling really bad when they've survived, but some are feeling

better than others sooner than others, etc. so so one of the point 16 out of 18 is persons who are cured of ebola are underappreciated, and i'd say from multiple points of view, one of which is the scientific point of view. so is i'd argue it would be potentially of value if we were able to better understand the immune response that's been induced be i the natural ebola virus infection itself. is it neutralizing, is it not, and what kind of t-cell responses are ip deuced by the natural infection and then try and mimic our vaccines to reproduce the natural protective immunity against ebola. >> and hope that the virus doesn't mutate. >> right. which it already has. this is almost a different species. it's a different strain of the entire species. >> and that is another question about whether a vaccine for this species would be effective across the range. but let me -- >> could i just add one comment

to that? even before figuring out the immune issues around the survives, now engaging the survivors in their control and the response, having survivors be part of the social mobilization and telling the story of ebola, having the survivors potentially play an important role in safely providing care at areas where there's limitations and ppe until ppe can be scaled up. i think that's an underappreciated and immediate public health goal. >> and just scientifically for the audience, once you recover, is there complete immunity to reexposure? >> it's not that recovered persons are -- >> completely. >> certainly in the short run. the duration of that, you know, and the species variation on that may be different, but there's no reason to believe that people will be repeatedly infected in the same outbreak or epidemic. >> well, you know, thus far what

we've talked about in terms of response to the outbreak, we've talked about the importance of a therapeutic response both in terms of vaccine development and drug development. we've talked about the sanitary and public health response in terms of trying to make sure that we have adequate personal protective equipment, safe and secure and hygienic isolation rooms, a public health infrastructure to do the contact tracing which is massive and the like. and we've also talked about the idea of just lower tech caring; nursing care, hydration, things like -- those are all, and then we've to back that up, i think the panel's been almost unanimous in that we would like

to see a surge capacity that's a standing surge capacity in relation to emergencies. but what we haven't discussed yet is the, if you will, it's a more ancient response, but one that we've seen here which is -- [inaudible] it's basically a guarded area where people can't come in or go out of. in many cases it's been enforced through the military, and there have been discussions about food security short shortages and clean water, viable employment, travel, commerce, all of that. but let's, i'd love the hear the panel's view about what role there is not just for --

[speaking in native tongue] as a it has been used, and it was just lifted i think today or yesterday for -- >> from west point. >> from west point. >> [inaudible] >> yeah. but what a smart one might look like, would it be effective, could it be effective, what role would it play in registration to all these finish relation to all these other therapeutic interventions? >> and i guess i'd just ask marty maybe in particular to just share with us the current public health recommendations in this space in your expeemps. because i think that's also -- >> sure. well, this is an area that there's been a lot of thinking about in preparation both in terms of preparation for a devastating ip fliewns sa pandemic in particular and many other things. i think the tool, the public

health measures are based on the principle of isolating the sick, warp teening those who are exposed but not -- quarantining those who are exposed but not yet ill and fully separating the well. and creating that space around the principle of breaking transmission. and, clearly, the the two huge, primary goals in this epidemic is to stop transmission inside the epidemic zone and prevent spread, prevent seeding of new locations. >> and also prevent spread within the -- >> yeah. and prevent reinfections and reseeding. but to really stop transmission inside. and so we've 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 4th century leaving -- 14th century leaving, you know, a ship off the shore of venice for 40 days where the idea comes from and letting it burn out.

both in terms of the speed and volume of mobility, that part of the modern challenge as well as the ethical challenge. thankfully, we don't live in a world where we sacrifice the victims, you know, for the bicep benefit of everybody else. what are the ethical principles behind using that tool in an effective way, and i think that some of them that have been written about by others as well as papers that i've published on this involve proportionality, making sure that the measure is proportionate to the threat, involve using the least restrictive means necessary to create that goal and dialing them back and minimizing the duration as the need for that no longer exists. a process that inside the ring, and this is probably the most important thing, the incentives need to be alined between the victims -- alined between the victims and the communities that are being protected. they have to have a common set

of incentives. and there's nothing that could propel an instinct to flee more quickly than armed guards and barbed wire locking, you know, someone into a space. that just goes against your primal instinct that it's so bad that i've got to be locked in here, i better get out, and i better get out quickly. and so we can't confuse those incentives. and i think that part of what is essential in a modern context is delivering effective goods and services inside, not choking an area off from food and nutrition and medical care. the treatment centers have to be adequate and sufficient. the work services, the compensation, the permissions, all of what would need to happen to align a community to voluntarily in some ways if the incentives are designed right, you don't need a perimeter guard. what you really need is a compelling argument, public

trust and community engagement to voluntarily participate. and it's not m possible to create that. we saw, actually, the vast majority of quarantines globally that were applied during sars were voluntary quarantines under recommendations with good advice. again, we didn't have a direct medical countermeasure, we didn't have a vaccine to the rescue, we didn't have a specific treatment, but there was a compelling argument and alignment. it was a different circumstance? absolutely. but i think the principles of that obligation. and then in addition you don't want to create a hypertransition zone. so you still have to identify the sick, pulled out and separated. so you need safe spaces, say within a commitment or a village, where the sick can be isolated, where food and wart and nutrition and other -- water and nutrition and other incentives can be in place. and those are the cop sents. now, those are not easy to do, and the risks of doing it wrong,

i think, are exactly what we saw in west point, that a simple military cordon enforced with guns and barbed wire in communities that already have a tremendous amount of distrust in government and authority, that has the potential for real disaster. >> i wanted to just ask a follow up and maybe have steve come in with this because i've heard -- one of the things that perplexed me as i, most of the things that we've said today there seems to be great unanimity among the public health community. but i have heard some discorps dancy about the role of the military. some have said that the military is the only group that has the operational capacity to deal with something this big. others have talked about the need for security, securing e bowl rah treatment -- ebola treatment centers, scaring doctors -- securing doctors and

doctors without borders, other ngos working in the field. and yet from a public health point of view, having the military involved is jarring. >> i want to qualify, my comments were about military, armed military enforced -- >> no, i wasn't referring, no, no, i wasn't referring to you, i just wanted to get a wider discussion about that. >> yeah. i think those are different roles. and so -- >> well, what is the appropriate role? >> what's the appropriate role of the military, and steve and others -- [inaudible] [inaudible conversations] >> that's the question. >> particularly, i think particularly in the context of postconflict states where we know there's continuing -- >> i mean, but also what the international -- okay. well, yeah. >> so there's several questions or dimensions to this. keep in the mind in high beer ya and syria leone, these are countries that went through decades of internal war that

involved particularly heinous abuses of civilians at the hands of armed entities, some of them official armed entities, others militias or optional -- oppositional ones. and it's hardly surprising, it's hardly surprising that creating a -- [inaudible] in the parrots peak area where supposedly 70% of transmission, that that has failed, that it's permeable and people don't trust it, and they flee. so i think the idea that the militaries can win the trust and confidence of their populations is a pretty dubious proposition, and we've seen it in west point where what looks like, what looks like basically creating a death zone or a tomb and saying those inside, good luck and

those outside, thank your stars. i mean, that's sort of the mill militarized thing. what i meant about military was the fact that there needs to be some kind of mobilization that can bring into this, that can create the lift capacity -- because the lift capacity has disappeared on the civilian side in terms of air, and it's highly disrupted, and we know from countless natural disasters and postwar situations that blue helmet deployments are critical to are restoring security and making it possible for all of the civilian-based things to go forward. and this is a situation that says, okay, its genesis is a virus, but it's morphed into a multisectoral crisis, and there has to be security restored, and it would make sense to turn to that model in the first instance

providing you have the will to put troops into that. a request was put out to, we heard yesterday -- >> yeah, we did. >> -- 53 countries, a quiet request through the u.n. channels as to who might be willing to entertain donating troops, and one country of 53 said possibly they would consider it. keep in mind also you have today 4600 blue helmet troops deployed in liberia that are part of the original peacekeeping force that was at its peak 15,000. and that is in a phase down. it's supposed to be down to zero in 2016. the filipinos have said they want to get out for the safety and protection of their forces. you have a force there that if you could hold that force and build upon it within liberia and rethink its mission and give them confidence that they will be protected, you could begin to move in the direction that i'm talking about. but it's going to be hard. it's going to take an enormous

political investment to make this work. >> so you're thinking of international peacekeeping forces. >> yes, they could be white helmets, they would have to have a different look. but why is it that the president of msf is out saying that this has to happen? >> right. >> the reason that joanne lieu is saying that is because msf is shouldering two-thirds of the burden today of delivery of service in three countries. one ngo. this is a gritty, determined, disciplined and remarkable institution that does not shy away from brutal, violent, broken places. they're in eastern syria, they're in myanmar, and they're in west africa in the center of ebola, but they've reached the outside limit. they have a thousand employees. some other force has to step in to take things to the next stage. >> steve, would you say, if you

could, just two sentences for the audience of distinguishing the types of roles that international peacekeepers can play, blue hats, white hats, different roles the international troops can -- >> well, i was making up the white hat thing. [laughter] >> it'll be quoted. [laughter] >> but the blue helmets, i mean, blue is the color of the u.n. it's troops that are on a volunteer basis placed under a u.n. flag and a u.n. command in order to play under the geneva protocols to play different functions. and the precise functions are negotiated with the countries in question. and the duration and the rules of engagement and the deployments and the command structure and all of that gets negotiated out carefully. it's not easy. but at any one time over the last two decades, theup has deployed upwards of 20 peacekeeping missions with over 120,000 blue helmet troops into conflicted sites. i see no reason why this

situation should not, we should not be looking at that option and asking the leadership of liberia, sierra leone and guinea why this would not be acceptable. >> and the reason i asked you, every one of those steps has a history and a process that we have to go through with the cups, countries that are in crisis by all of the things we've talked about here. i'm just going to take a little liberty here. we've got about a half an hour left. one of the things -- well, this panel has been amazing, and we've identified multiple issues and just to kind of, you know, we've talked about quarantine and issues relating to that. we've talked about various kinds of medical treatments and advantage seeps and other -- vaccines, and we've talked about public health interventions. we've got a crisis of really extraordinary proportion. it's not clear the trajectory, though as marty's laid out, there are things we can do can, but we are at the tough part of

beginning the control at a minimum, and as steve notes, we don't know that. we have, there are a lot of unknowns here. so my question to the panel before we turn to questions is a number of you have cited sort of things from the very specific, the lessons we've learned in the first five or six months of this. one, what could we apply in the countries right now? and i think marty and dan have alluded of things we can -- let's not make the same mistakes twice. what have we learned, what can we do differently. and then second, looking maybe on a global stage, and steve's identified several ideas that use of u.n. peacekeepers, the taking advantage of the global health security agenda meeting that's coming up. i can ask people to think both on the near term and longer term, what can we do? and i guess maybe with the kickoff to that being who's put its road map out. it's costed it at $490 million -- >> that's an underestimation.

>> that's at least a first guess. does anyone have anything to say about the prospects of that happening? i guess i'd offer anybody on the panel who wants to say something in the next few minutes before we turn to the audience. steve? >> on the who road map, it was released on the 28th, 489 million. it was hastily concocted. it didn't answer a bunch of questions. it's now up to 600 million according to margaret chan's statement this morning. it's not clear where the world bank 200 million might fit, it's not clear where the african development banks, 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? you know, the big question is what do you do from here? who in the midst of this crisis has been enfeebled by staff and

budgetary crises, and this has been a terrible, terrible episode for, in the history of the who. so it has put forward this plan. the question it begs is who's going to, who's going to make this happen, who's going to put the operational details together and authoritative in directing this and raising the money and getting this forward? i don't feel that many people are confident who can do that. so what does that lead you to? and i would suggest the u.n. security council needs to to take this up and create a mechanism, a body charged with doing this. and, of course, who would be part of that. but as i said earlier, what has failed is not going to get us out of this mess up to now. and it was a good step to lay out in that 489 million plan the number of personnel needed by country, the number of treatment sites and isolation centers and all of the other technical

pieces and the personnel gaps that exist. and they were staggering. but to actually operationalize that, there is not yet clearly defined. and that, i think, is what we need to focus on. >> and, kevin, marty, anyone else wallet to add finish. >> marty. >> marty? >> well, i think that, you know, i'm going the stay away from that specific topic -- [laughter] and suggest that, you know, right now in the studying of a crisis there'll be plenty of time to look back and to an after action, and there'll be numerous dope. but i think right now in the setting of what's needed to move ahead and get things under control is a coordinated international effort with a lot of partners. and i think one of the areas that's been perhaps underutilized is the importance of communities, ground-up, community-level engagement, social mobilization, messaging

and communication, the use of survivors, even community mitigation and community control strategies that are better aligned with the cultural acceptability in the areas where the control has to go on. and i think that, you know, an increasing role for medical anthropologists, we really need to to define very clearly the major driverses of the epidemic. and this is not just, you know, one homogeneous epidemic. it's multiple p demicks -- epidemics that probably will require multiple, tailored strategies to appreciate. it's one strategy that's applied when you have a single introduction into nigeria or senegal or another country, and you can stamp it out in a chain where you have the numbers and the capability to recognize, detect and try to snuff it. it's probably a different strategy when you're on the accelerating exponential growth

phase in an urban area like monrovia. and i think that 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, you know, break the chains of transmission. ..

the fact one of the drivers is a populations response to an ebola epidemic. survivors don't want to be identified. those who are potential victims don't want to stay put. the reason it's pretty effective some of these areas is because people who suspected they were infected lead to treatment centers and brought the infection elsewhere. and that will make it extra me difficult for us, you know, above and beyond the usual public health, it is a challenge. >> but the anecdote to the danger and recalcitrance with his a map of fear and vulnerability is education and empowerment, and that is the vaccine that could help turn around behaviors that including not only individual counterproductive, but socially counterproductive. and we will have to do a lot more in understanding the cultural context in which this epidemic is spreading and engage solutions rather than trying to

imagine that we understand from outside exactly how to impose that. >> i think that's a point well taken. so i think the panel has given us a rich number of questions, so let's, we've got about 25 minutes. to the way we typically do this is we first take questions from students who are enrolled in the colloquial. so i guess, you are not self-identified, so i guess i -- >> there's no stigma of. >> i'm trusting everybody to raise -- i know a couple of people in the front rows are not students but beyond that i don't know. let me see if we have questions from -- >> take several questions before we get the answer. >> why don't we try three? we have one year and i have 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. let's start in the front. >> i've noticed for the last few months and i read on the top of

your list the our personal protective equipment. what's the logistical breakdown of getting this to the system? isn't monetary, budgetary? if it is budgetary, what is the cost? >> larry, let's take a couple. i can't see your face. yes, please. >> one of the questions i have, i think a tea theme that has ben alluded to a lot here is in countries that have the resources to deploy and help you with these crises, there's not a sense of urgency, even with the public or with our elected officials. and so how do we go about trying to change that down in the public discourse? >> that's one question. in the back. >> the question would be, why does it appear that despite the

nature of how we have dealt with hiv and stuff like that, why are we seem to have to reinvent the wheel when it comes to using -- [inaudible] now we are having this conversation again. >> good questions. let me suggest if i could that maybe, marty, you could help us address the ppe question. steve, on the sense of urgency in terms of, and everyone, everyone can jump on the edge. just in terms of starting and then allows question i think really, invite everybody but dan in particular from your experience, so why don't, marty, to want to talk a little bit about that? >> i think the ppe issue is in the back about logistics and scale and supply. in the areas were most needed

almost virtually the supplies are desperate in short, and that can and is being scaled up. and i think that getting that stuff in, providing the logistics, some of the responses being hampered and choked by the reduction of commercial movement. and it may take u.n.-based support to continue to have goods and services and people into the area to make sure there's adequate supplies. the other quite frankly is figure out how much is it that you really need, and they somewhat strategy. a lot of thinking has gone into that by a number of agencies, including the w.h.o. and cdc, and that's coming together. that should be an achievable result. that's not what stops the because it's not just about, i think dan said in his opening, having this set is one thing and distributing it is another thing. but actually training and its proper use and most important and training and had to take off

the ppe in a way that you don't contaminate yourself, and scaling up the training around infectious control practices is an ongoing hybrid an important effort. and that is something that's going to take more time than simply buying. >> i can't at the sites enough don't think it's a money problem. it's logistical but be on that there's ppe in freetown, the capital city of lyon, but it didn't get to where we needed it. more than 240 health care workers, 120 have died. more census figures came out that i know. in sierra leone. so the largest testing an isolation facility for ebola in freetown where i worked in that hospital, we did not have gloves that i felt safe with. we didn't have surgical gloves. they broke easily, they toured

easily. just came up to your wrist. we didn't have taste shields until a few days ago. you have these goggles that been washed so many times, washed through bleach you couldn't see through them, plus you sweat like crazy. i can't over emphasize this. you sweat so much because it is so hot. there's no air-conditioning. you're sweating like crazy before you even step foot into a war to get dressed. it's very hard to see out of your goggles. he walked into a room and you can't see. you have gloves you're not getting that confident in. why is that? so i talked to one i could in sierra leone hierarchy, ministry, two colleagues were very helpful. one of them took me to his hotel room, opened up his foot locker and said you can have anything you want. a very kind gesture. i did take some facemasks. [laughter] but he didn't have surgical gauze. i took those back and you could see through them. you could see through them.

so you can draw blood safely. now the are some pictures but they're still not ideal because that these ties that tie back into reach back and maybe you'll get a virus on your scalp. there's no shower, et cetera. personally i think there needs to be something below the emergency operations center, some kind of clinical public health command center that make sure that people that need the personal protective equipment and the appropriate training, a cascade of training the people are confident and to protect but otherwise they are not going to put their lives at risk. >> visiting bills want to comment on the personal protective equipment? i will ask steve and maybe kevin on the creative sense of urgency given where we are now. >> that's a great question. the first thing i would say that americans and others outside of

west africa have been certainly bombarded with news accounts around this, right? our media every day, our media coverage has focused on this in great detail, and considerable depth. we've seen a lot of very important voices, secretary-general ban ki-moon speaking, margaret chan has made some dramatic and very powerful and eloquent statements. tom frieden has been, in his usual kind of lucid powerful way. david frum the u.n., and others constantly. so there's no shortage of people trying to break the barrier and brings the people's attention. and i think for a lot of americans the polling data show

that people are scared. they're scared. they are alarmed by this. are less clear i think in the minds of what we should do. they are less clear about what are the strategic choices that powerful governments face in this come in disputed. and in that sense i think bringing forward the next layer of communicate and from the president, from samantha power at the u.n. security council, and from other like minded personalities, including president johnson sterling, including the nigerian head of state and minister of health, including many others would be very valuable at making clear what would be the level of urgency, needs happen and why does that tie to u.s. national interest. at this moment. were having obviously when we look at isis, when you look at the other crises areas with

crimea, with ukraine, putin, there is a deep debate going on the run u.s. foreign policy projection of power, risk, what we're willing to take, use of u.s. military and all of these things. that debate hasn't happened in this case. we haven't had that debate around what is at stake in terms of u.s. nationals, what are our assets, what can we do, and what should happen in this next period. >> i think you're right and i think it's difficult to have a clarion call when we are still blowing an uncertain trumpet. i think in fact what is happening now is that we are realizing the scope of the problem and getting a clear idea of how the world needs to respond, not just our country, but you also pointed out i think an important issue, and that is we have to believe it's in our self interest. we are a wonderful and generous

country, but if we're going to mobilize when we think we are threatened, and i think the unfortunate infection of the two american missionary health care workers was really the thing that brought this to the front page. you know, there have been hundreds and hundreds of people infected. hundreds and hundreds of deaths, including among the health care workers who are african and have been taking care of these patients from the beginning. that it took a couple of americans to bring it to our attention. that's understandable. that's the way the world works. i hope we don't see more people getting infected and bringing it back to this country. that would be, human, the worst case scenario. but it would bring it to everybody's attention. >> let me, there was a third question about immunity based education. does anybody want to wrestle with it? dan on marty? >> well, the point is well taken.

why does it take so long? you know, i don't know the answer but i do think that it is an important next step when there's widespread transmission that's immunity based and hyper endemic, and educating and empowering and providing kids and thinking about how that strategy meshes. it's not a substitute. you played off as an either or, at a don't think it is an either/or. i think these are both and. we need to scale up in terms of quantity or all the traditional approaches fighting evil and we need a level of preparedness in neighboring areas of high risk, and we need creative community engagement and hyperendemic areas where some of those other things are just really too hard or can't be a cobblers quickly enough. so it's an all of the above. and i think, you know, unicef is playing an important role in the

social mobilization effort, and that has been amplified. there's encouraging things going on your the ebola raft for some of you may have read about, you know, brought on by someone who didn't really believe it was real and engaging the music community and the social networks. the hero stories, i believe i peered in the near times and on the frontlines. these are inspirations that minicrisis actually have buried within them come and we need to be able to tell those stories and tell the stories of the survivors and tell the stories of the courageous people and all of that because that is also part of the social fabric of this response, and elevating those people rather than stigmatizing them, elevating them as heroes that they are rightfully so can help change the kennedy dialogue around how we engage in what we believe but i think it's important.

>> let me ask you a question for me because you've been over there. should be thinking of community in that location in the same sense that we think of it your? 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, i'm here to help you. but it seems like there, that's even much less likely. >> i think in general that's true but i can't say i'm an expert for the culture in sierra leone, unless the. >> i don't know that it's the government that needs to do the knocking on the door. >> that's not what i'm talking about. >> no, i think it's a grassroots evolution inside out rather than top down, that is also desperate to needed. you been working on controlling ebola epidemics for decades as has been pointed out. it's always a spouse if is not a

public community but suspicion and engagement, those epidemics are really hard to control. in particular because there needs to be education around very sick with things like practices which are sacrosanct. in some belief systems, and properly honoring an appropriate honoring the dead could bring on the scourge. and so we need to understand that from a medical ethical logic perspective and figuring out how to meet those deep-seated intro needs in a way that is say. i think it can be done. it's been done effectively in uganda in terms of controlling ebola epidemics and understand and altering these kind of practices to improve safe burial but this is happening in a new area where the level of community education has occurr occurred. >> i would only add i think any crisis listening is often one of the hardest things to do, special in communities that are not quite in front of you. i think that's true for political leaders at all levels. let me suggest, we have about 10

minutes left, i didn't see any other hands in the earlier round from students in the class so i'm happy -- oh, i see more. let's try to do a couple more, to more students and then we tried to do two more to the open group, and then will have to bring this to a close. are you a student in the class? and then this lady back here. >> i am from taiwan. i notice many of you mentioned global involvement effort. if i were president of taiwan or even just superintendent of regional house in taiwan, and ur do want to consider something, either money or material, manpower to join these battles, what would you suggest we do to

get started? >> your question? >> my name is vicky. i'm a student at georgetown law. >> can't do. speak up a bit. >> my question is about the borders were this epidemic is happening and the nature of mogadishu and human traffic. i know that some airlines fly into these countries but many people also -- sumter county think that is being treated? also consider the epidemic is spreading to places like nigeria which is the heart on the continent. >> i'm going to take two more questions from the audience, and then invite the panel to apply a cousin think then will be at the

end of our time. so this is not that at all but i'm just going to try to take one from the left side because no one -- i don't have anyone on that site. the lady in the middle, and i have one, how about at the end. we have two on the left side. i think that's all we will be a good enough between now and 3:20. let's go ahead with a question from over here. >> you can hear me? i'm a student and global health law. i'd like to associate myself for inside out approach to the treatment of this epidemic. i'm just wondering why if we are not already doing this, we are

not drawing from the already existing activities we have with hiv and other, that we have had in africa. i watched a clip yesterday on bbc, circulating in the social media about how the medical stuff will we are capturing the patient, and it says to me that the approach, it needs to be already implemented. because you could see that 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. and is being in the camp means that they are sharing the love,

protecting everybody, it's a lot especially because we cannot win the war. so drawing from experience as we've had with hiv, for instance, yeah, so, so it made me think about the human life aspect. the peasants feel it was their right to decide whether to be, you know, such and such a treatment. they have a right to be subjugated or because of the problems, then governments -- >> engage the human rights of the intervention. i think that's exactly right. and our final question? >> i guess my question gets to the sovereignty issue a little bit and you've spoken about this, but how do you measure the

risk of really control this epidemic in countries like liberia asking for assistance and being so grateful? also not undermining the really hard work that's been done. everyone has eluded, spoken about the fragile nature of liberia and sierra leone but these countries have had tremendous games the last five years. liberia met their goals for maternal health and that set up financial mechanisms and suddenly there's concern that international donors will find international ngos for the response in nine months or 12 months they would be a shell of the ministry of health left. so how do you balance we controlled the epidemic with maintaining a small but important gains that have been made since the end of the conflict in these countries? >> so we've got four questions. i'm not sure we will be able to touch them all but i guess one thing i would ask is that maybe marty to toggle a bit about the borders and travel restriction.

larry, maybe you and kevin could say a word about the human rights of dimensions. on the issue of capacity in the nation's, maybe you could speak to that because the in goal here is to have functioning states and we need to make sure that's where we end up. we've got about three or four minutes but that may be -- i think if people could just take a couple points i think we can do this pretty quickly. marty, you want to tells a little bit about the board of? >> the point is well taken. the connectivity, yeah, fortunately from the three academic prone areas is relatively speaking more limited. it's a whole different story if you have an epidemic in legos, odyssey and other big areas. i think the reduction in capacity is commercial airlines for whole bunch of reasons, dollars, which is six take place for crew, many things we been trying to actively combat.

it's down about 50% in some of those countries and more in others, 80% in others. it is choking the response and we are going to need an alternative way to respond i think your point about the lab orders is a really important one. and understanding the porous nature of potential reintroduction, especially in that hyperendemic zone, the intersection of the three counties needs be addressed by think it needs to be addressed again through more creative approaches. >> do you want to say a word about the human rights and also the understandings because actually i wanted to hear what larry had to say about that. [laughter] >> actually you could do a good job, kevin but i think human rights are really critical here. they are critical because one, because i think that when you have significant human rights violations, it really is the antithesis of the public health response.

it's our instinct of people to fight or flee. there has been violence. those other two exact opposite things we want. the other thing is that human rights includes social and economic rights, the right to health, the right to food security, thing water. all of those things that really are part of a good public health community, we cannot forget about those in the next of the disease crisis. in fact we need to reinforce all of these rights during those crisis times. because as we know from so many hundreds of years back, our worst instincts as human beings come forward when we feel threatened why an epidemic. and we have to overcome that. >> i think what larry was the same as going to link very

nicely to steve's, because one of the remaining questions is how do we help without creating any residual harm to the structures that are in place. >> i'd like to address the point around protecting and balancing off those accomplishments, those programs and achievements have been made against this urgent requirement. we've seen of the 3000 cases and over 1500 deaths, we've seen 240 health workers infected and 120 killed, right? we've seen the destruction of services have huge obligation for childbirth, for treatment of any number of other, of other health needs where there have been these games. so how do you take action in

order to staunch the further erosion? and that has to do i believe with protection. i mean, the risk environment for exposure and the fear environment has become pervasive in many of these areas, particularly and liberia and sierra leone now, and how do you push back on the end of to preserve these gains? i think the protection has to be met. on the border issues and the airlink issues, we are moving toward a de facto of the region, right? that is what is happening here. de facto, as airlink and as governments put up as many other regional governments under threat have put up bands on land, sea and air traffic into senegal, ghana, other countries, more remote country.

so we are moving into the. and the question is how do you push back on that in a constructive way in order to preserve and maintain the flow of goods and people that are so essential to the response? simply appealing as has been the case up to now not it is has failed. so what are the measures that are going to do that? >> well, i think it's been an amazing two hours and i think, i believe we in some ways where we were at the beginning, that this is a crisis that has a very real human personal dimension. we have seen this epidemic out of control in many places, certainly in parts of the three countries in west africa that are most impacted, but as steve outlined just in the last comment, the regional and global dynamics are extraordinary. i just would ask everybody here to first thank our panelists for

joining us. [applause] >> we at georgetown want to thank all of you who came here and you are watching either on the internet or on 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. so thank you for coming. >> c-span2 providing live coverage of this senate floor proceedings, and key public policy events. and every weekend of tv, now for 15 years the only television network devoted to nonfiction books and authors. c-span2 greeted by the cable tv industry and brought to you as a public service by your local cable or satellite provider. watch us in hd, likes of facebook and follow was on twitter. >> and it's almost 10 p.m. eastern time. we'll have live to the floor of

the u.s. senate about the gavel in for morning business, continued consideration of the resolution proposing an intimate to the constitution that would grant congress the ability to limit campaign contributions. no votes scheduled today in the senate, and this it will be recessing from 12:30-2:15 eastern for senate party lunches. now live to the senate floor here on c-span2. the president pro tempore: the senate will come to order. the chaplain, dr. barry black, will lead the senate in prayer. the chaplain: let us pray. eternal spirit, the fountain of our joy, you see our thoughts from a distance, comprehending the nuances of our motives. lord,