held opinions based on that experience and everything that i have done over the last 35 years in medicine and research and public health on what i think is happening and what needs to happen to respond to the ebola crisis which is now in west africa but soon maybe elsewhere. this is a sign from sierra leone find everywhere, signs and symptoms of ebola virus. early clinical parts of illness are tied to symptoms that are nonspecific fever diary of and that means they are very much parts of the illness. the signs and symptoms are nonspecific. that means that they are very much imitative of common diseases, much more common diseases in west africa like malaria or typhoid or gastroenteritis so it's hard to know if someone has ebola or they have a much more common diseases such as malaria. you can see the signs and

perhaps you can't see that some of the symptoms are fever or and muscle pains. the bleeding comes very late. the red eyes and extreme weakness. it comes very late in the disease. early on its problem to differentiate ebola from other more common infectious and sometimes noninfectious diseases. this is also a sign you see everywhere not only in sierra leone but other parts of west africa where the viruses. the statement is ebola is real, it's not political. let's fight against ebola. this is the jewelers organization. you see them hospitals and clinics and buildings on the streets in airport so there's initially a perception that ebola is not real and sometimes it's not a virus that causes a contagious infectious disease and rapid death. from yesterday's w.h.o. world health organization update on

the number of people with common to think this is a minimum estimate people at ebola. what i want to emphasize is that the top liberia summer than 3000 in guinea this more than 1000. in seminole there's one patient who traveled from guinea. this is the map from yesterdays world health organization. as far as the location this is a map of the three countries in west africa where the outbreak is most intense so snow in the north is guinea with the capital of conakry and western sierra leone which is the capital of freetown where the capital freetown-ism in liberia. further down here is where monrovia is which is the most impacted, most devastating part of the epidemic right now. the outbreak started right at the confluence of the rural area of the three countries.

and then unfortunately it's spread through multiple rural areas. almost every district except for one. for example in sierra leon and i am skeptical of one not having any cases as well as most places in life. the majority in guinea and all three capitals of conakry, freetown and monrovia. in the 25 outbreaks of ebola in the past in africa it's always been an rural areas never in big cities and certainly not capital cities. this is different now. that is why i emphasize its urban ebola and its urban and rural but it's not the same ebola we have seen for 25 plus years seeing in sudan. do something different. its urban ebola. it's different in our way of controlling outbreaks in the past which were very effective.

contact tracing and isolates the people who are ill and cortina people who have been exposed. he went back into the animal area where it lives in bats and chimps and african antelopes. this time the control methods are not effective in my own opinion they are not going to be in effective in monrovia and freetown and perhaps other cities. yesterday's numbers from w.h.o., three and 48 health care workers in west africa have become infected with ebola ivers -- virus to more than half a type you want to emphasize that means almost half of survived and i think people who have survived and been cured of ebola or their own immune system and the help that they have received to preclude rehydration is important under besides. people who are survivors once they fully recover can provide care and personal protective equipment potentially donate antibodies against the virus from their own blood and most of

all they should be no longer stigmatizes having had ebola but they should be honored. in terms of personal protective equipment i'm going to have to wrap up in a couple of minutes. personal protective equipment. this is what you need to wear and perhaps even more. what you see on tv is doctors without borders on the frontier. ppe is i would say more complete, it is more complete than what we have here. this is a training exercise that i was privileged to be able to help participate in as a train trainer, training the trainers along with colleagues from sierra leone and the u.k.. we were trained each morning and each avenue -- afternoon for three hours each wearing this personal protective equipment. this is the largest ebola testi. in my 35 years as one of the three most precious and memorable hospitals i've ever worked in. this is the one large tertiary pediatric hospital in all of

sierra leone and a closed. everyone is discharged in the patients were discharged to home. children very sick with malaria and pneumonia and typhoid because there was one patient of borio that had ebola that was recognized in some people were exposed and the decision was made to close as so many other children and adults don't have access to medical care for diabetes, poor malaria, for complicated childbirth because of the ebola outbreak. this cascade of events is having a devastating effect across society. it's beyond the virus itself. and freetown airport i was screened as i was leaving. this gentleman is taking the temperature of people. i was tested twice when i came in to the airport and when i left. i had to fill out a a questionnaire had to have any symptoms? this is really just a few of many points that could be shown but it's very important regional campaign across all of west

africa where the viruses to stop it. we can't stop it only in one country. an expected to be stopped in the region. it won't happen. control methods as i mentioned isolation and quarantine are not working emerald and they are not working and freetown. there are enough health workers especially those that are well-trained and personal protective equipment and there's a lack of enough good high-quality protective equipment and that is why health workers become infected. it's very important, there's an op-ed document op-ed in the post two days ago with regard to the situation in sierra leone and the person they're emphasized he's not a health worker himself cumis and author, emphasizing the importance of survivors. many important aspects of survivors. they should be transformed from being stigmatized to being honored. they can provide care to people who are sick including young children of whom there are many.

they can offer antibodies in their blood for their immune system against the virus and they are living proof that ebola can be cured. my last life in my last minute, ebola crisis looking ahead near and far. in my opinion it will be a long time, more than a year before we have sufficiently large amounts of safe and effective ebola vaccines and drugs to develop antibodies against the virus. the epidemic is likely to last until or greater than 2017 will spread to more cities inside and outside of africa. that's my strongly held opinion. i hope i'm wrong but it's important to act now is that these are going to the facts in the near future. we need what i would call of ebola clinical trial units based on the 30 plus years of aids clinical trial experience for antibodies against the virus, vaccines against the virus injects its virus. if ebola becomes endemic in west africa and that's a real possibility in my opinion, then in my opinion we need what i would say is a campaign that the

global smallpox eradication program which dr. job berman who's who's sitting in a front row participated as well as the first ebola outbreak stopping it in 1976 in zaire for the drc. also i would ask as i have on multiple media interviews last week and i will continue to do for my own experience i think there's a huge gap that can and must be filled soon. in other words we need to have authoritative ebola expert and a global health crisis leader someone who's experienced in both over the health crisis outbreaks and ebola outbreaks. for rapid what i call command and control like the success of the world had against sars in 2003. a person to lead the global response against sars and who has extensive experience with ebola outbreaks in the 70s in the 90s in africa has worked in africa for more than 12 years who is now head of public health england was with the w.h.o. for many years and prior to that

working for a decade was dr. david hammond. he would be my first vote but certainly there are other candidates. i would like to stop here and i'm out of time. thank you very much for your time. [applause] >> gonick speaker is dr. luciana borio. she is the system and director of counterterrorism emerging threats at the food and drug administration the fda. she also is the fda's medical countermeasures initiative. the key component of the broad government program to improve u.s. capacity to respond quickly and effectively to outbreaks such as this. lewis instrument on the fda's response to pandemic influenza in 2009 has also been very instrumental in more recent responses for example to the middle east respiratory syndrome murders in the middle east and the two year recent bird flu that has become a major concern

in east china and will be back sent in november or december as soon as the weather gets cold in china. please welcome dr. lou boria. [applause] >> thank you dan and thanks for inviting me today to discuss these actions to respond to the ebola epidemic in west africa. it really takes a special person to bear witness to all these devastating diseases as you do and try to make a big impact in its management. needless to say this outbreak is the most heartbreaking and tragic we have witnessed in recent history. and there are many challenges we are facing. specifically the minimal health care and public health infrastructure within the affected countries have made this very difficult. and as dan just mentioned the

primary approach for containing epidemics like this, the standard tried and true public health measures are not working. it's very difficult to implement in such a large-scale and the setting of this limited infrastructure. we are talking about identifying nations, confirming patients, taking care of patients, learning about their contacts, providing personal protective equipment to health care workers and burial teams, educating the population about transmission, being able to detect secondary infections in the timeframe that you can contain the outbreak. all of this has been extraordinarily challenging. in addition limited health care for structure has made it almost impossible to provide supportive care to the patients who need it and bet that i mean fluids, electrolyte replacement, things we take for granted in most of the world. like they say he ebola kills

twice. it kills people who are infected with ebola and it kills everybody else who has other diseases who cannot access medical care so women dying in childbirth, people dying of a broken bone. they die of malaria and a dive so many good things to give the complexity here is that we have no specific treatments or vaccines that have been shown to be safe and effective for ebola. and needless to say a safe and effective vaccine will be a total game-changer. we know from history that a vaccine can really change the way infectious diseases evolve. smallpox is an example. polio is another example and one of the struggles we have with malaria is the fact that we don't yet have a vaccine for widespread use. so i think i'll -- a lot of energy needs to be recognized to develop a vaccine to be able to roll it out to impact the

countries. i can't say enough how that would be it real game-changer. i'm here to tell you that oftentimes fda is perceived to be a barrier to responding to situations like this. people think, they talk about fda's regulatory hurdles which delays product development and causes unnecessary delays and public access to investigation of products. but in fact i would like to tell you that fda as a catalyst for product development. we work to facilitate the development, to facilitate manufacturing, to scale up manufacturing facilitate availability of investigational medical products. we have a very large professional staff. we have unique scientific expertise in all aspects of product development and we provide the expertise to all of our colleagues in our agencies

that are working to develop products with the private sector. so we support hhs agencies and the department of defense agencies and work very closely with them in tandem as they move these programs forward. we also work very interrogative way with the medical developers to advance their products including manufacturing scale up to make sure the products move as fast as possible. this is a resource intensive process and staffers are highly committed to doing that. we don't want to see any unnecessary delays in product development and availability. we also begin to review data in a situation like this as it becomes available so every time there's a new release of information the companies will submit it to the fda and reviewed in real time and again we don't want any unnecessary delays. product development is also seen as a very rigid and linear process because that is how it's

detected -- depicted in textbooks with many aspects can be done in parallel and that's where the fda plays a big role because we can guide the developers to do things in parallel and where can they expedite studies begin with the idea of moving things quickly come as quickly as we can. we also collaborate internationally with w.h.o. enter international regulatory counterparts, health canada, e. m. a., the german regulatory agencies as well as the u.k. and all of the west african regulatory counterparts. this is really crucial because fda is a leader in product development and regulatory authority so there's a lot of need to exchange information. we also have one of the most flexible regulatory frameworks in the world. we have a lot of authority to be able to make decisions based on the best available science and difficult to promote public health so oftentimes our framework is adopted by other regulatory agencies have to redo

some consultations. i like to stress that this investigation of products, we are talking about to vaccine candidates and a handful of investigational drug therapies. they are in the earliest stages of development and for most only small amounts are available and that's natural when products are in the early stages of the moment. there's no impetus to manufactured in large scale so this constrains options for doing large-scale trials right now and to widely distribute a product. it's investigational and not to mention there needs to be efficacy and to do that we normally would do critical terms. to do clinical trials and they affected countries right now seems like a daunting daunting endeavor. the announcement by the president last week that my colleague beth cameron is going to talk about is really very critical to not only taking care of the ability to improve patient care but also to be able

to begin to study these products and in the affected countries. so we do hope that it would be possible to conduct some trials for patients in the coming months. we have begun discussions with developers about how they can go about doing that. we have talked about simple trail designs that we believe can be implemented and can be extraordinarily informative to establish a safety and efficacy -- safety and efficacy for the products products they wants it the fastest on the coming months i think it'll be ready to go. the companies are already planning to do that and next week i will be in geneva to meet with representatives from the affected countries because critically their buy-in is essential and working with them to modify or plans tend to have a shared plan is to go forward is really essential. so ultimately the availability of these products in west africa will be dependent on multiple

parties working together, not only the companies who make these products, the health authorities, the regulatory authorities and the u.s. government's ability to establish this kind of infrastructure. this is all extremely challenging but i think failure is just not an option here. we do have to find ways to overcome the challenges. again failures failure is just not an option and i thank you again and fda is highly highly committed. we have more than 200 scientific staff involved in this response and we are committed to doing all we can to respond to this epidemic of ebola. i will answer any questions at the end. thank you. [applause] >> thank you dr. borio and thank you to your colleagues at the food and drug administration.

our next speaker will be dr dr. jesse bump who teaches at georgetown at the department of health. he has a ph.d. from johns hopkins and a masters in public health and global health or he served as a fellow in international health policy prior to coming to join the faculty here at georgetown. dr. bomb's research focuses on the political economy of current and historical systems in countries humanity directed health plans health system design health services delivery and social science thierry. please join me in welcoming dr. bump. [applause] >> thank you very much. thank you for inviting me. we have about 10 minutes and i

wanted to mention the historical and political dimensions. it's about how did we get here and where are we going to go? does anybody know if this is? this is the ebola virus. here is another pretty picture. this is the measles virus. some people talk about measles as a problem of low vaccine coverage and i'm going to give you a couple of pathogens more as a way of talking about the way people think about health problems around the world. these are tv bacilli so these are bacteria. this is a quote from w.h.o.'s stock tuberculosis program and i will highlight this part. it's conceptualized as an access

problem. it's an access problem to high-quality diagnosis and patients patient-centered treatment. these are malaria plasmodium. in the rollback malaria partnership, one threat to malaria was drug resistance and changing the policy. here's another malaria aspect. this is the mosquito. this is a gambia a bit transmit malaria and the global malaria action plan there are two approaches, long lasting insecticidal mess and residual spray. these are three diseases and therefore approaches. measles increased vaccine coverage, promote universal access to malaria, drug treatments come in this case a switch to a.c.t.'s or kill mosquitoes either witnessed or indoor residual spray. so here with a bowl of what are

the obstacles? here is a quote from one of w.h.o.'s fact sheet identifying very weak health systems. here is charles kennedy writing in "businessweek" identifies crumbling health systems. hear his voice of america in a story on the 20th of august noting the three most effective west african countries share weak health care systems. the world bank in a press release last week identified weaknesses in the health sector and suggested that limiting ebola and its economic impact could be done by investing in the health sector. so, why health systems and why don't we talk about it with other diseases? it's not that we don't talk about it with other diseases but we don't focus on it in one reason for that is that we are

at the limit of all we can do with ebola. there is no specific treatment or cure. there are no specific preventative technologies and there are no vertical solutions. the things that we are good at in global health tend to be things like disaster relief. they tend to be specific interventions that in ebola we don't have any of those options so we are left with this remainder bucket where what we are saying is to health systems. in fact the health system is necessary for all kinds of things but it engages some social, behavioral and cultural patterns that usual interventions and global health don't go near. these include death rituals. much has been made about that in the west african context where it bullock canon has been spread by the handling of deceased -- deceased ebola patients. includes burial practices. risk factors include consumption of -- made and general sanitary

practices. preventing and controlling ebola relies on state authority and citizen trust. in addition to these other factors. the ebola is not exceptional. health system have wide benefits so here is maternal mortality. roughly 300,000 women per year die of maternal causes. many of those can be prevented with a functioning health system. diarrheal diseases cost us 800,000 children per year. most of that can be prevented with a functioning health system. childhood pneumonia claims 1.2 million lives a year. most of that again can be saved with a functioning health system. malaria, 600,000 cases a year. hiv/aids, 1.6 million per year. we have done lots of things. we have made tremendous progress with narrow interventions for specific diseases. however we will always reach a

point where we need to have a health system. in hiv/aids for instance it's a continuum of care issues were patients need decades of treatments now that we are good at it. it's no longer just one thing we are worried about even in vertical programs because health systems are such a large limiting factor in our ability to promote health. so, why are west african health system so we? if they are so useful, if they are one of the most fundamental building blocks of a productive and safe society, well why don't we have functioning health system's? this is a historical view. in west africa rural health services all day to colonial sleeping sickness control programs. they were composed of mobile teams that went from village to village where they found signs of the disease. they did for spinal taps or lumbar punctures and then

mandatory treatments usually with a talk so. they have a single disease focus which is sleeping sickness. they didn't build any capacity. i would love to tell you that was a colonial pattern and we left it in the past but actually they have formed a template for much of what we have done for better and often for worse. after 1960 the countries themselves try to do better. in the 1960s and 70's the world health organization tried to improve systems among many other projects that pursued it. but in the 1970s commodity price collapses and the oil crisis hurt both countries and donors. in the 1980s to try to rebalance economies they were totally out of whack structural adjustment was promulgated by the washington institutions. one of the artifacts of that where the country stopped

investing in health systems. since the 1980s, donors have done very little in health systems involvement. the ebola outbreak is one way of talking about three decades of neglect and health systems. donors prefer things that are short-term as easily defining goals, that have simple links between input and outcome that can be somewhat easier to implement. they are wary of ongoing commitments and urgent tasks usually take precedent over others. so here is the calculus for it. think of how you would conceptualize malaria versus health system investments. annual death toll in a specific disease is clear. it can be measured and it can be estimated. the health system is diffuse. what is the intervention? that his drugs, spraying, but in health systems the intervention is diffuse. there are many possible courses

of action. infrastructure work for supply-chain logistics procurement funding education. think of credit claiming opportunities. with a specific disease there are a number of people treated but it's hard to measure the functioning of the health syst system. and costs. that's easy to specify but for health systems it's not. induration, well a particular program mike and health systems never do. donors are worried about these things. when it comes to advocacy, they look around the room and say well, who else is engaged? who is leading? what happens is that many many nations and entities pay some kind of lip service and i think some investment in health systems but if the answers to do much more of that. the ebola is a warning to us. it's a warning for a disease that is often fatal, that is relatively hard to transmit but as you can see in crumbled

states and nonfunctioning health systems it is gone viral. i mean it in a literal sense. diseases used to burnout. little epidemics of a epidemics of ebola would pop up here and there and it's so so deadly and they kill so fast that it wouldn't spread but now it has entered the general population in urban areas. so this is a call for us to take care of some long-lost business to invest in health systems in the health workforce and infrastructure, and to embrace the political economy for managing implementation. thank you. ..

in chief of staff for the honorable andy would have heard. earlier in her career, she worked from 2003 to 2010 at the department of state, where she did again extensive work in national scale with biological, chemical and nuclear weapons redemption. prior to working in the executive branch, she was a fellow with the american association for the advancement of science and at that time she worked for senator edward kennedy. dr. cameron holds a bachelors

degree in biology at the university of virginia and a phd genetics genetics and biology from john hawkins. please join me in welcoming dr. beth cameron. [applause] >> thank you to tm and thank you to everyone for inviting us here today in putting together this whole symposium continue mac for your personal, what i would pay her with him for going to the effect that countries them for helping. it is definitely an untapped resource of people like you who want to help and one of the things we are trying very hard to do is put in place the mechanisms so people will be able to do that or because there will be the training emplace needed to gap for people they are. so we have a pretty somber occasion today with the ebola

epidemic. we've heard people talk about the possibility of it becoming endemic and we've certainly seen the numbers continue to rise in the news reports. today the modeling coming off of who and cdc certainly show what could happen if we don't have an international assistance, which is something that many of you probably saw last week, president obama is very dedicated to doing. so i had the pleasure today of talking actually not as much about the immediate response, but building on what dr. bob talked about, which is very difficult to develop a crisis, but how do we get ahead of day not only in west africa, but all over the world. your last site i think was a reminder that health systems are at the root of this situation

and they are often one of the most difficult aims to measure and find an bad is one of the reasons we launched the global health security agenda is not only a substantive agenda, but a political one as well. so i'm going to focus most of my remarks on mac, and starting in 2011, president obama said we must come together. it is coming he meant not just other nations. events across the government. bringing together my great colleague, dr. vittorio, collects across the u.s. government and now all over the world from departments of defense, from foreign affairs, from usaid and other agencies to public health ministries, this is a nation that can't be done by one country or one agency allowed. it has to be a group and it has to be synergistic and organized in all those things that global

health security incredibly difficult but incredibly important. so we launched the global health security agenda with 29 other countries and i will talk a little more about that in a minute. nobody launched in february of this year before the first case is reported as ebola and we've been speaking about this not just within the u.s. government, it who, fao, and colleagues around the world for quite some time. how do you make this issue something that is politically palatable and vice president obama has now said recently about the ebola epidemic, this is a national security priority. it's a public health priority, so what is the proper vision? our vision is pretty ambitious, but it's the right vision and that is ultimately attain a road severe from infectious diseases. so we're not going to an

outbreak, but i would like to do is prevent them from becoming epidemic. so we need to put in place the mechanisms that are needed to do that around the world. when we launched the agenda in february, secretary sebelius of health and human services, secretary kerry and the president for homeland security and counter terrorism, lisa monaco also put out the administration's vision for this agenda. i'm going to read it because it's operational and i both and i will value we release date and when i was talking about this with people in february, dare was definitely quite a bit of that is aspirational. if you look at what is happening now, and it needs a little bit differently than it did then. new diseases are inevitable, but the 21st century we have the tools to quickly reduce threats posed by global epidemics. we can put in place a safe,

secure, globally linked interoperable system to prevent disease drive, detect outbreaks in real-time and share information and expertise to respond effectively. this is the vision. we would not be seeing what is happening right now west africa and this is the vision that we need to get to. i don't actually have to answer the question anymore. this fiber facsimiles made many months ago. i think that global health security is no longer a question that needs to be answered, that's unfortunate because it took an epidemic of this magnitude to get to that point. obviously, we are interconnected and not me say this is no one nation's responsibility. the international health regulations hearken back to the sars epidemic, which we talked about earlier today on this panel briefly. dan mentioned flowers and i think it is important to talk about the devastation and lies,

but the economic consequences of 30 billion in four months. if we look at the investments flowing and for ebola and the need for significantly more investment because of that gap is enormous and what we need to do. you look again at what the value of prevention, detection and response on the front end is versus about will be paying for the backend demise last and economic peace and security consequences as well. the ihr, i am preaching to the choir on this, but the ihr were put in after the sars epidemic in 2005 to really push together the core capacities to effectively prevent and respond to outbreaks before they become epidemic. the isr's are wonderful because every country on the planet that

is a member of who has the responsibility of implementing that, but it's difficult to have resources for all core capacities across the board. as mentioned, actually synergize in a non-disease by disease manner and to seek funding is also a difficult challenge. so the isr's have been successful, but in 2012, only 20% of countries were able to report to the who they had met them, but 80% of countries in 2012 were not prepared and i think i was a huge wake-up call for us then for many other countries around the world and it is directly linked to the global health security agenda. before i show a side of what the agenda is, i will say what it's meant to do. it is meant to discuss and identify three basic risks. risk by drug resistance and the intentional creation of

organisms in bioterrorism. it is supposed to address pre-opportunities. right now we have enormous commitment. i think that it's grown tremendously since this slide was conceived of back in february. this is tom friedman slide tiered i stole from him and it's the best slide. we have a lot of models out there for how to build good global health security capacities. one of the challenges is replicating those models and replicating those in an organized way that's not piecemeal so the countries end up with the capability at the end that is attainable and exercisable unmeasurable has been very difficult for the ihr. and to capitalize on three priorities, printing or possible, detecting rapidly responding effectively. the agenda itself is much nicer looking online and very difficult to fit into a slide and be able to read it. i made a rather ugly slides that you could read the words. in a sense, capitalizes on

everything that is part of the ihr that relates to infectious disease recognizing ihr has chemical and radiological threats in the agenda does not. related to infectious disease threats, the agenda does include all the implementing the ihr, but the performance of veterinary services of the world organization for health. it also includes areas that have been a huge priority for who, but not included in the ihr prominently such as countering bacteria. another issue that is of huge importance to the administrations in which we also announce a large effort on earlier this month. so we also plan out the agenda in february, we put forward this plan as a way to not only say exactly what we want to achieve in layman's terms, but to elevate this issue with other

countries. if you look at foreign ministers are national security advisers, this thread is currently at the top of their list because there is an epidemic going on here than is usually not the case if you look over the past decade, it is hard to keep this on the front burner generally speaking. one of the reasons is because it is very hard to feel the impact or the economic consequences of months you are in the middle. we are currently in the middle of bad in everyone feels the consequence, not the least of which every effective country was dealing with untold lives and economic consequences. they keep the myth of the security priority in sars has been incredibly difficult. how can we capitalize by using language leaders understand and target an effective measure that can actually be utilized by countries to show they are achieving success and potentially measured externally by others, which is another

thing the ihr has not typically included overtime. so we launched a target for ourselves that we also publish and these are available online, 12 targets for our own efforts to improve global health security capacity and at least 30 countries over the next five years. the targets i am not going to go through because it's an incredibly long list. but they were put in place with a lot of consultation of experts across the u.s. government scientific literature and isr implementation studies done over time. feel so wanted to choose things that were measurable by countries. i encourage you interested to take a look. next step. so is dan mentioned earlier, i think john also mentioned this in his opening remarks. on friday we are bringing together countries that the white house. we've had seven months of work that has gone on since february with an incredible amount of

work and leadership around the world. had to development meanings, one hosted in finland, one in indonesia that is at 200 participants of a free 44 countries to the white house on friday with international organizations from who, fao, owyhee. enter perl, world bank and the european union, african union and the united nations. the world is to highlight a tremendous number of new commitments in every country invited disaster bring one for the event. president obama will participate in that event and local is to do for action to prevent this from happening again. we'll be looking forward and sustainable mechanisms to keep this going over the next several years and without taking away from the leaders who most certainly be making statements about this in the coming days, i

would watch this space because we are very much interested in how we will take the model forward and most importantly for this group have been nongovernmental academic sector in the young leaders that the united states and the planet can take part. the ebola epidemic has garnered a tremendous amount in the academic cheerleaders community and that's another thing georgetown has really taken a leadership role on. we are looking forward to how that can be capitalized on to build this agenda and also provide great assets to the immediate response. just in closing, the last thing i would say it is difficult to focus both on the short-term immediate response, which is so overwhelming and paramount, while also looking at what we need to do for the future. i think it is critically important to note that to close by using a quote from our president from last week, where he talked about the immediate response. but if you read what he said on

this site and if you actually read a little bit further in that speech, the president himself is focused on the future and i think we have to be because the message here is we can't do this. we have the tools for this national security threat. any other threats are less track the brokenness on, but we have to mobilize together and organize systematic way to do it. thanks. [applause] >> thank you very much, dr. cameron. we have just about four minutes left for questions, some of which you submitted to me now. dr. cameron i think is going to have to return to her place of work. however, i was wondering if dr.

dr. bob would join me up here for just one or two questions. after this we'll go ahead and transition to our first pm all -- panel. >> again, briefly in the interest of time, i was wondering if dr. creely would ask not what she or it intentioned, but more detailed to the food and drug administration been a catalyst for helping to bring new vaccine, dedications, devices that are safe and effective to the market for people who need them, particularly in this context of a bullet in west africa and international communities. you're going to geneva. in terms of clinical trials for

candidate ebola vaccines or treatments with drugs or antibodies, can you just in general terms without referring to anything proprietary of course, talk about his very precedent for this type of international response during the public health emergency and if not, how d.c. working within working with international partners, regulatory and otherwise further response to a bowl of? >> is this on? so clearly there is precedent, that the scale of the response -- >> i'm sorry, is it on in the back? sorry. >> so there is a precedence for this scale and vapidity from which the response is somewhat different of course because of the unique characteristics of this outbreak. and also because of where we are

today as are today is an fda. five years ago the president launched an initiative, which provided additional resources to the fda to be able to more effectively engage out of resources and staff of the scientific program, specifically to address these types of issues. so as a result, diagnostics we have a long-standing collaboration with the department of defense and we have been engaged with them and the diagnostics for pathogens such as ebola, which are very difficult to validate in the absence of disease gives these are the validation to require actual disease. but because we had all of this work, we are able to in a matter azoff erased the use of their test for emergency use. and this diagnostic test

developed by the dod is used not only overseas, but in our own u.s.-based laboratory response now work to when patients come back from affected countries and insufficient ebola, this is authorized for use in this emergency is being used. so that is just one example. it is not just the emergency response. there's a lot of activity that happens even before the emergency. the same thing with the developers for products. in addition to the regulatory review and helping them with ready applications, we have incentives we can make use of to speed the development as well as some financial incentives. recently we designated one of the products for oregon drug designation which provides incentives and resources for clinical testing as well as if

they get the credit approved they will have exclusivity, which again is an incentive for these countries to engage in there appear to ask. so it is a multifaceted response and again, we lived in every possible way to engage the developers, the product development and market access to progress for the view. >> thank you for a much, dr. borio. we have about two more minutes. one question for dr. bob to spend time of the year he talked about. if i understood you correctly come you mention in the past in west africa refocus a single disease 10 amaya says. another is a focus primarily on one disease, ebola virus disease. could you comment on how the response to the ebola epidemic going on now in terms of health

care systems might be approached in a more optimal manner in terms of not only responding to the ebola crisis that we have now, but going forward in terms of strengthening the health care system across the countries impacted by a bullet in west africa and i hope this will lead into the next two panels at the morning as well. >> thank you. of course that is a great question. it is one that is very hard to actually operationalize. it is easy to imagine what a single intervention should look like an easy to feel the heat and a crisis. so in this case, to make a clinical example, this is like someone in the midst of a heart attack they could about they should really exercise and stop smoking. well, those things will kill you. even though it is challenging to conceptualize what is going to look like, are obstacles here certainly begin restraints but at this fire.

a bullet is deadly. in this case, maybe 50% mortality. so we need to step up here but every setback, when he could think about the underlying systems. where is the health workforce? are they being trained? are the numerous enough? then you have to ask where the patients get health information? what is there in the face of the government? do they trust the government? the underpinnings of a health system include the technical and the moral as well as the political. so the most promising of the most attractive approaches in a first world setting usually to think about the technical. we certainly need to do that and that is the basis of our response. and we need to think about the political decisions in the decision-making processes we can use to set priorities, manage implementation of what are the moral things, what are the choices? were the trade-offs of one disease versus another? those are things that should be done in washington. the should be done in the

people. thanks. >> thank you, dr. bob. dr. borio. >> thank you for joining us this morning. this is the first panel of the ebola symposium this morning. this one is giving us some historical, social call troll political economic context for the reasons behind the devastating ebola crisis in west africa. we have a little bit different this morning. we have a political scientist, health economist and a cultural anthropologist. so let me first introduce the panelists and then we will begin. first, welcome to dr. sharon abramowitz, assistant professor of anthropology and african studies at the university of florida. cultural and apologist abramowitz has studied the labor studied the labor and health factor in west africa and humanitarian response for the last decade.

he is the author of the reason i published book entitled searching for normal in the wake of the liberia more. many of you know dr. scott taylor, associate professor at school foreign service and director of african study programs. dr. taylor research centers on politics and political economy but reticular and essays on business state relations, private sector development, governance and political and economic reforms. finally, we have dr. james haman who joins us from a poor school of public policy here at georgetown university. his research interests are in development economics and political economy, with particular interest in constraints to help as well as health policy. he also brings insider knowledge to the panel in uganda during the ebola outbreak in 2007. before we begin the discussion amongst the panelists, i'm going to pose a question to each of

the panelists to give us some context into their particular perspective, beginning with dr. abramowitz. dr. abramowitz, you've been sending the liberian health factor in west africa and humanitarian response for over a decade. this means you have connected years and the fieldwork region, including gaffin now reaching of new guinea, the first area of the outbreak. can you provide us with some context for what is it about the situation in liberia, specifically that is made this crisis? >> sure. thank you for having me. it's really another to be your and i really applaud the efforts of everybody in this idea to put together an academic and governmental response as quickly as possible. as a cultural anthropologist, mike to start off with the story. this is coming from a friends of

liberia dispatch released in late july 2014. during the visit to a family of ebola orphans, three little boys come a health care worker tracking cases is just way by the orphans uncle. before she was chased away, the uncle explained to the health care worker their mother had contract of ebola from aunt who had died. their mother then showed signs of the bola, the family called the widely advertised ebola hotline at the ministry for health for several days, but no one took her to retrieve a unit. they called and called. she died in the called and called and then finally after two days of peril they can to take her away. soon after the father became symptomatic. the family called the hotline for days but no one came. the father died in a few days later. all team came and took away the body. the uncle noted the early signs of the bola much of the children

and such of the health care worker, your minister for health cures more for the dead and the living. this isn't true, right? it happens to be a fact that in the early days of the epidemic the senior leadership of social health and welfare in library work with the telecommunications companies in liberia to set up a phone bank of landmines of the administrative health and social buffer could respond to phone calls related to the epidemic. on friday as having a conversation with a senior official and he said the problem in liberia right now is the phones are ringing that nobody is answering the phone. why not? why is there this juncture between people calling in people not answering the phone. this is a very different kind of the story than the one we hear the media. in order to understand the story come you have to have an understanding of the liberian health factor and a little bit of history. it's important to understand the liberian health chapter was

largely decimated late 1980s not just as a result of capitalist job at a government, but as a result of political violence. between 1985 and 1990, there was a third lit up a violence against the intellectual elites in liberia and many medical professionals. soon in the 1990s, the civil war broke out in the entire liberian health sector fell into a state of collapse. during the 1990s and well into the early 2000, most of the health care provided almost entirely by the international community. in 2003 when civil war came to them came to anand, the liberian population was widely accustomed to slowly receiving health care from ngos like doctors without borders. between the period of 2003 and 2005 communitarian organizations continue to provide health care to the entire liberian population of the same time a massive repopulation after --

resettlement effort was underway for refugee camps in guinea, donna, s-sierra lau -- sierra leone. .. >>

>> from the humanitarian isn't -- humanitarian development. put in place was a set of structures to establish the liberian health sector to be more robust. i will give a little bit of perspective. said country of liberia is $500 million. $200 million is being spent on health care. of that roughly 80% is spent by the international community so liberians social welfare is all but 20% that goes to civil

service. so when ways talk about the liberian sector it is true for a certain extent to sierra leone is the sector we have no international community with our contributions or tax dollars. these are the health sectors. so what we will do with the system put into place is to gain that international lovell of commitment while debating the minister the ability to bring these organizations under the authority. the plan did that very well. with us this day and system with primary health care workers at the bottom of the system. trading went into reverse is a.m. doctors at the bottom level. but what was not established

was a robust middle with bio surveillance is the middle where it response happens the middle where it entered regional interstate coordination happens with emergencies like ebola arrived. those are not put into place. so during that period. there are a few canaries in the coal mine. the international community worked closer with the ministry of social welfare although not in the advisory capacity because of that contribution to the health sector but during this time on an annual basis in a country like liberia epidemics are endemic. on an annual basis

cholera, malaria, it pops up over and over and over. with the system put into place it was not ideal but acceptable for pop up epidemics to be identified by organizations that we provide primary health care. as long as the response was quick in response coordinated it was the except will step -- acceptable step. nobody anticipated the epidemic would pop up. what caused this is we were depending upon the pop-up and then when it did it was recognized for what it was

intel was too late then also floor where it was. when a first popped up it was in a rural area it is not as much as where the media would lead us believe in it branches off then leads to sierra leone them proceeds down to the north of liberia taking directly of the urban road in to the liberian capital of monrovia -- monrovia. right now in my area there is 4.3 million people. of that approximately 2.1 million live in the urban areas and almost all of them are on that road.

it is highly trafficked cover the central commercial artery that link together sierra leone guinea and others. so what we look at is a missed opportunity to stop the academic. why did we miss it? because of that health structure all three of these were dependent to do this kind of work it was doing this on a state-by-state basis when it had a problem solved they shut down operations and they failed to recognize that i enter regional network to spread the epidemic to turn into a

the plague that it is becoming. >> that is a good transition but under a the international community they have reconstituted so to talk about government and a capacity to intervene with the already strong international support and why do they not effectively responded to the border crisis? >> then tried to keep my chair from collapsing under the weight. lewis is doing the blaming? seeing increased numbers of reports of people in various areas for the government for

the lack of response but looking into their own government there was an interesting piece in the "washington post" of the total shutdown of the facilities in liberia and a couple jumped out at me. so why not just ebola so traditionally should be addressed from the issues we talked about earlier. so with the blame at the government level is partly a result of the ears of

democratic rule from liberia and sierra leone where we have seen some improvement from service delivery but not enough. with considerable growth not significant poverty reduction. with the rising expectation with that participatory culture. with social tension leftover from a the liberian cases that contracted the outbreak. in with any political situation in that country.

and to stand of to these challenges. but at the same time essentially it is the political equivalent. the democratic regime inherited a broken economy and build from scratch of many years of civil war. of course, in sierra leone you're talking about 5,000 in each country.

250,000 in liberia. that took up much of the 1990's when africa was going through the transition. that was substantially delayed. 2002 and 2003. but with a authoritarian from 2,008 was to struggle so as to talk about unsettled political context with a rebuilding effort. you have the odd juxtaposition with it at the

same time it is still an incredibly limited. the 2008 article notes that it is in reverse that the national level to be induced by civil war but the cost of the war keeps accumulating. it estimates 14 years to reach the counterfactual narrative. so you can see this scenario with these protracted conflicts although resolved

through the gdp basis was 14% last year. that was pretty impressive of nine or 10%. over five or six% over the last decade but some was incredibly low. we are broadly familiar with the conflict and the aftermath that these are devastating political economy is./a so like mozambique is taylor as the fastest growing country and the world but it has taken in a generation to begin to rebuild that country and similar here. we're still looking among

the lowest gdp per capita and the socio-economic indicators they all fall very low with areas of great concern. the challenges of rebuilding we were just talking about the spread of ebola from the confluence of three countries down to monrovia. but most of that infrastructure is not that good. it is terribly degraded so a situation where services are

very difficult and reconstructionists very difficult. i will end their but to reconstitute policies from the ground up in only a decade is enormous. so for the of for agile economies the evans is clearóz is this something that the word blame the national community.

so basically we should not have expected to be able to respond given the legacy they have inherited. the international community response is something we've talked aboutfm in that you see a muscular response it is late in this day but it goes without saying the enormous amount of attention that is not politically or a the health care of complete development. >> talking about the framework of the structure,

doctor, would do speak about what challenges around a the ebola epidemic? is it one way have observed? but what's this - - but they don't fully understand it comes from every which way. but,because he was in uganda during the outbreak. and with no other in engagement with the

population of ebola. >> i am not the anthropologist but as indicated. [inaudible] and we had the six months old boy. my wife's brother was getting married. this was the day that we arrived.

end of the ground the parents ever betty once to hold the baby.l but the president made his statement to say no handshake. when people running into each other for the first time they hug and people are respectful to not told the baby. but maybe what was different with uganda which did have the ebola epidemic so in

some ways the 50% to some regions of the country. so then there are frequent outbreaks. there is something that is more challenging to learn about what it is. and with that response. going to what sharon said earlier if you think of the hiv epidemic in africa it was the challenge the government did not help itself to take a position but people had doubts if it

was of relief. and people thinking this is not really what people think it is. but to learn from the household level but also in general. and then in the same conditions. but they have lots of problems to deal with the issues.n but with the hot line it

reminds me of the challenges. but the brain drain cannot explain the fact. it is not high tech the managing. and there is some research. it is a big challenge to get people to show up to do their work is quite a challenge. with 30 or 40%. the where they are supposed to be. that isn't even if they have the facility or treatments. i don't know liberia or zero leone very well but it makes

it really hard to respond to something like this.; they cannot get what they need and it makes it very hard. so talking about learning or to learn about a disease but for me and more than happy. you don't need a lot of dollars to get people to show up. >> to recently emphasized

the need that is a good talk about what is that the heart to provide care for people. of a blade to open in the question to all of you to be in response to the crisis? >> i can start with one proposition treating health care workers says if they are the front line to the international response and what we provide to international staff. health care workers are the most affected by the ebola virus in mortality rates are much higher. they are heroically showing up to clinics every day with

insufficient materials and support to provide care to people who braved their way through and they get sick and die is the notorious embarrassment when a doctor requested evacuation and he was denied permission and he died. he is not the only one that is in that situation. the weather are not local health care workers and other experimental therapies but we have not had a strong2 perception is if we claimed them as ever own with therapeutic support they might need. that is one step.

>> but just to repeat what we have talked about these countries cannot do this although we start to see that now. with eight months after the first case and more than two months later i think they coordinate the international response to get to the goal. >> so from the outsetr so it is part of prevention.

one of the challenges that meets the of global health and to offer to generate but then in some ways have the technology to deal with malaria. so this is an opportunity to focus of the way of resources if there is a

silver lining and but to focus to that area. >> it is important to recognize. is the parade of palms so you tend to see that caretakers.vq and then my first response is to not put on protective gear with ebola. but there is an issue other

people are willing to evacuate the we're proposing to recognize that the families and loved was -- was will come first people's first response is a family members do separate myselfgú to send myself to a therapeutic center i may never see you began. -- again. >> if we have thus similar social conflict have is that messaging? and those complex years ago.

>> but the one big difference with the outbreak and where they have happenedp because of the 20 years ago. but in some ways the outbreak happened but now it just goes up the coast. and in some ways and in the condo there is a little outbreak to generate the same level.

>> to make the point about families and caring for one another. in the context could the message be delivered to families to put on the protective suit? >> the methods that i experienced directly, i don't think it strikes directly or is conditional. i think ed is a very challenging the fed. -- ned said. it is very challenging.

and those are very difficult i don't thank you can read it -- uganda did anything special. >> there are some reports i have been hearing that these are coming from the ground up in remote areas of liberia where people don't have access. the like when you go to a5h the market there are tons of plastics. so family members when they handle their loved ones they put that back but it is coming from their ground up.

so then they turn to the problems in collaboration. about nigeria. and how is this different? >> but to make much of what had been in nigeria can be credited to a political response and the fact the first infection occurred there is another way around.r

there is the outbreak there. the efficiency of the government's with a the governor but they have managed to institute the infrastructure by leaps and bounds in liberia and sierra leone. the nigerians and all of us have forced the outbreak that started there and apparently has been able to be contained. but look at nigerian development and infrastructure and the criticism that nigeria's against and in this case

they think they have a right. >> it is quite the word for efficiency. with that outbreak becoming out of control. and the government in some ways and to be more efficient but with the timing and the nature. coming up with a revelation oft" what is going on is just the right response.

and it is of big scandal. so they should take them in far more proportions. said they have had a couple cases. >> good to show what it is like. when we think about what the strong state is this is not enough with the understanding and to have

the inordinate amount of the social welfare clinic to be concerned about the response but what you see is the difference between political will and political leadership. it takes that middle bubble of collaboration and responds to be the response below the top level support or the bottom level response >> marissa mayer really good questions. with some long-term investment to identify with that enter regional

coordination. >> is that for me? [laughter] i think one of the of conversations about the lead period health sector going sovereignty and self governance. there is a crisis to restore health sovereignty as part of the move to restore general sovereignty to the state.z

>>

with those states actors with $17,000 in cash last month and with the sierra leone community. [laughter] >> can i turn that question on its head but for that response to the epidemic one that has been met coming in out of the ebolayoz

>> and i think they say they

have never done that immediately but some health networks of today. >> let me take a crack at this. with the urgent issue the training, it is the way to have the capacity to do with future issues. so the first issue that must be dealt with is how vague allocate resources between the hospitals in the capital

city and other areas 34qñ from the facilities and this is real community. 10 years ago the world bank brought seven countries looking at the,$1ç absenteeism and also what existed if it was the random sample of facilities and unannounced visits and one of the strong correlations was the of quality of the facility.'z

is my facility well-stocked? so stocking up with these facilities shows accountability in the government's with that facility actually get there and don't end up in the market. i disagree a little bit because we have political and help sovereignty it is clearly the big things international community has to play but some of these get stuff the way it has to be, that is no local accountability problem. in some ways those parliamentarians should lead

the charge. so the first pep is the health facilities very close to these and the tools and the training because dealing with ebolúrqnx very different so people need training for that they need the confidence to ring gaugec0uv. -- engage. it is certainly more than it helps. >> in order to leverage the participation of the communities with those partnerships to reestablish

the trust and various authorities the problem is context where services are declining but distressed levels are rising. but in order to engage the communities the very first thing that needs to be done is to reestablish trust. >> al will ask a theory. then i will look give each some time to give your concluding thoughts. we have little bit of extra time so i will take advantage. there are a lot of questions

that lead me to understand what does this mean to have that responds? so could you speak to the liberian situation how does boots on the ground work together? >> one narrative and that came out was last week. and he wrote a note to a past friday that had traveled to every treatment center in monrovia and he was turned away for lack of a bet then use public transportation to go to the ministry of health and social welfare where he waited three hours for someone to help him but nobody said find a bet for

him. finally he left. but if he went off alone to prevent the spread of infection of his loved ones nobody knows where he went. so we were asking questions to the health workers were. does it have been within the home? is a the nurses and doctors to provide clinical treatment of those that are in treatment centers? the answer is we ask them to be more responsive but what way? if you have people coming to use seeking support live there is no beds and they are turned away and nobody

has anything to offer until day of the then what is it we're asking them to do? there are no more beds. united states said we will go and train 500 health care workers per way to provide services. what does that mean? we will provide to people in local communities? we will also announce we will be building 15 or 17 therapy treatment facilities and that means support will be provided there but this is not just a problem of human resources but many

people are willing and eager to provide treatment. >> what does that look like? description? >> it is rehydration so people can allow the system to develop. for example, in those rural areas where a makeshift clinic that care for people. the services they're providedççrn is rehydration and treatments. >> but with those responses

who runs the clinic? >> the local ngos? >> says the question because people are involved. >> but i also want to ask the absence of additional answers we heard last week emerging black market with survivors blood people are distributing?ç, that also raises public health issues as well and we should be mindful that the people are generating.

>> let me just say quickly quickly, most of my research falls let people describeel) as the rising narrative and focuses on the disasters of economic development over the last 16 years. general. but my fear of ebola is now the narrative for all of africa and we see this every day from the trivial cancellations to the of closing of borders with that

african response to research of colleagues and canceled trips because they are afraid of ebola. this just borders on hysteria and that type of response is negative but also not realistic. that danger as we talk about this very important disease with the debilitating crisis have when not lost sight of the fact that this is not all of africa? not preaching to the choir so much but i was shocked on my colleague that was avoiding because of ebola that shows the forums that

could come to grips with the scope to combat but not to lose sight of the fact that thankfully the user of a particular region at the moment that hopefully will be contained. and that this is not an africa problem the rather a global problem with the global response and also to have a realistic view of what is happening to the rest. >> i will point your direction into place at the same time but swallow whole crisis is unfolding be mindful of the populations

that have the extraordinary resilience under extraordinary circumstances. but that is not done doable and where we see a real risk to do break that down with food security as a result of the ebola crisis people are hoarding food and there is some price gouging taking place and those areas that have not been taken advantage it has doubled. areas under quarantine will requirexe#6x supply for a long period of time. you may not see of large 9/11 response to ebola but you will to hunker.

that stands the risk to have that have been. also to highlight the fact i am very hopeful that integrating a social bow cultural aspect into public health and medical responses could have a powerful effect on the epidemic outbreak. there is not dead days significant of reach in order to understand those factors with response to public health and medicalgç aspect. that is taken up much more quickly as soon as possible with robust integration.

it will have, counting dividends to hopefully bring it to the and=+ñiñ -- and. >> and finishing up on communications with road safety we realize that simple imperative and in some ways that would make sense about these different methods and if we get that right to it is much cheaper. but to add on what was what we were talking about earlier but it is hard to figure out the benefits.

to manage and provide the materials of the systems is just the history but if there is any good thing to come out of this crisis is not just that coalition to provide relief0 xt for the crisis that is great. but what we need for the future is to increase the effectivenessshys. it doesn't matter how good generate for people that have these problems. in some ways that call to

action is the high long-term investment..wxñ . .