elections that's going to affect our congress shall response to what should be done in afghanistan in order to strengthen that relationship. and it's not really responsive to your question but it's what i believe is so important not just today that i've spoken about the importance in terms of what the impact of its reporting is on the typical american's view of afghanistan. if that doesn't become more balanced somehow or another they can't see that grass half-full in afghanistan but getting fuller. they can to visit a university where girls or going to school or a health clinic providing health services or whatever it is. if they can't cover that and say look where we have helped,

obviously the afghan people have produced if we keep saying we want to open the door for people. we can't walk through that door. they've risked their lives and i don't know how many afghan soldiers have lost their lives, huge numbers have lost their lives in this fight and i think that on our side of the relationship could be the most important thing to happen because there would be a great willingness to be a true partner in afghanistan which is so important. >> i think we have seen today an example of this sound steady leadership showing.

he's been a supporter of the usaid and when you step down from the responsibilities he will be sorely missed on a range of issues. [applause] [inaudible conversations]

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[inaudible conversations] on a related program note we will be covering the discussion with the pakistani ambassador to the u.s. later on. look on c-span.org for coverage on broadcast information.

coming up later on c-span2 we will bring you live today's white house briefing. that is a 12:30 p.m. eastern. and campaign 2014 coverage continues with the delaware senate debate between democratid republican challenger kevin wade on the political report they listed that as a solid democratic. as of 8 p.m. eastern on c-span2. also at eight on the companion network c-span the third and final debate between kansas pat roberts and challenger greg orman. >> i am pat roberts and i approve this message. >> trillions of debt, obamacare and nearly 10 million unemployed. make no mistake these policies are on the ballot. every single one of them. >> of the senate in kansas to vote is a vote for the obama

agenda. >> make no mistake the policies are on the top. >> pat roberts is attacking me and that is what is wrong with washington today they would rather attack of the opponents than the problems we face. like many i've been disappointed with both. as an independent i won't answer to either party i answer only to the people of kansas. i stand up for the best idea regardless of who thought of it. i approve this message because while they attack and try to label me come our country's problems only get worse. >> hello, everyone. in case you've forgotten, i'm bob dole and i want to talk about my good friend, pat roberts. as a fourth-generation cans in who shares our values and fights for campus every day from protecting the national security to creating thousands of new jobs, pat roberts is a workhorse in the senate. the stakes are high, the choices

are clear. we need to keep pat roberts in the senate. >> when pat roberts first got to washington there were 1 million illegal immigrants in america. 47 years later the problem has only gotten worse. today there are 11 million illegal immigrants. instead of working on the solution, roberts came back to lying about greg orman. the truth, orman opposes amnesty, will build a secure plan that is practical and fair to taxpayers. >> i am greg orman and i approve this message because while they attack and try to label me come our country's problems only get worse. >> polls showing the kansas race as pretty tight. we will have that live at eight eastern on the companion network c-span and we welcome your thoughts to try to share some of your comments on the trigger at c-span and facebook.com/c-span.

up next, health experts discuss how to contain the ebola outbreak in west africa. this was part of a conference hosted by the johns hopkins school of public health in baltimore, and this portion is about two hours. >> good morning everybody. i have the privilege of being the dean of the bloomberg school of public health and i would like to welcome everybody to today's symposium. everybody in the room and

everybody that's watching on the internet. as you know, the title of the symposium is ebola the crisis, context and response. our school was founded 99 years ago. since then, we stood ready to confront the world's most pressing global health challenges, and ebola is no exception. currently, our school and the johns hopkins university school of medicine and school of nursing have faculty and staff in central and west africa who are working to reduce the transmission of ebola, prevent deaths and build trust with families and communities. the ebola viruses threatening the lives of people living in west africa and creating uncertainty and fear in our country and others around the world. this is a critical time for thought leaders and experts from the multiple sectors as well as the johns hopkins community to educate us about the virus.

today we will discuss the impact of the epidemic in africa by, current and future possible responses, the status of the vaccines and possible therapies and recommendations on the containment strategies to prevent the discredited disease. i would like to acknowledge the alumni network around the world but especially those that are working with authors without borders on the front line of this crisis. i'm especially pleased to welcome doctor marian who is with us today. the national coordinator at the school for the 23 union fifth three union of the 1988 class. welcome to doctor henkins and the 1988 class. [applause] i also welcome the speakers and i would like to thank them for being with us on such a short notice and i'm especially grateful to andy a faculty

member of the department of department of microbiology and immunology that organized the symposium and his team from external affairs who provided logistical and organizational support. thank you both for your leadership. it was just about a week ago that the director of the malaria research institute here at the bloomberg school contacted me to suggest that we invite a speaker to discuss the ebola epidemic. that idea and conversation grew into a symposium, but it was the university's president ron daniels but urged us to bring our insight to as large an audience as possible. ron is the 14th president of johns hopkins university. a former provost at the university of pennsylvania he was previously the dean professor of law at the university of toronto. since his arrival at johns hopkins in 2009, ron has brought an appreciation of the global impact to the universities that

have programs in 120 and 120 countries while emphasizing the importance of hopkins as an institution in baltimore. he has articulated strategic goals for the university and has led and pushed us to become one university. ron is a scholar at the intersection of law, governance and economic development. he's an elected fellow of the academy of arts and sciences and has received many awards and honors including an honorary doctorate from the university of toronto. it's my pleasure to welcome my friend and president, ron daniels to the podium. [applause] >> thanks so much, mike and you for your leadership at the bloomberg public school of health. i want to thank the exceptional faculty and staff of bloomberg who have worked so hard and expeditiously to bring together this remarkable assembly of

colleagues from across the university and the nation to share their experiences and expertise. the speed with which the symposium came together is the testimony to the capacity across the divisions from bloomberg school of nursing to the school of medicine to our affiliated partners to help understand the mounting a public health crisis and informed the fact of the response. this is simply put what people do and indeed have always done. as a member of the public health service, the founding professor of epidemiology compiled at the analyzed data on the epidemic of 1918 to 1919 providing the foundation for the food tracking still used today. the first step in controlling the epidemic is of course the accurate diagnosis. time and time again they've identified the various types

that wreak havoc on the vulnerable populations. the bloomberg school columnist led who campaign to rid the world of smallpox and return to the school. in the early years of the crisis the experts played pivotal roles identifying at-risk populations and stanching the spread of disease in hospitals and clinics from baltimore to uganda. as the numbers of rape reported and the death toll rises as the nations and the communities struggle to meet the basic healthcare needs of the populations come in addition to the managing acute care for the ebola patients, as we consider the daunting implications for the global populations is not met with an effective and sustainable international response we are acutely aware of the obligation to marshal our intellectual bounty as the world community brussels with its

unpredictable growing epidemic. an epidemic that who director general yesterday declared a crisis for international peace and security. with the communities across the african continent and their expertise in the basic science, clinical practice, public health and international public policy, we are well-positioned to unite ideas around the best practices and best practices and most importantly turn those ideas into action working in concert with our many partners. building on our past work, experts are as said well underway as the teams draw across the university to aid in the response and work with ministries of health. these collaborative efforts range from implementing programs that would put 1,000 health workers in liberia to assist with the epidemic management to developing the more robust

analytical model that will help those leading the fight to make better strategic decisions in the present. and in the communication strategies in harnessing the robust technology to educate and power front line workers and put the most current and reliable information in the hands of the affected populations. of course we play as it is evidenced today another essential role. we are a crucial convener of important and controversial conversations. in the conversations as today's featured speaker, michael has asked us to do we ask questions the world is most afraid to ask going on the diverse expertise in the room we can create a scaffold to discipline and informed the debate on those questions. and we reckon with the answers no matter how daunting, how complex or how unnerving.

once again, this is a moment where hopkins must be present and accounted for. and this is more than a professional scholarly obligation. it demands that we continue to deploy the album of the inspiring courage that define us. for all these reasons i'm deeply grateful to each of you for being here today come in your presence and your engagement inspires optimism i know this will be a productive day and i think you each for being part of the omega session automator session that the important work that lies ahead. and here i hope and trust that we will be able to do more to bleed and lend our expertise and energy to be african continent. now i would like to turn the program over to andrea pekosz of biology and immunology at the public school of bloomberg health. andrea's research focuses on influenza but it's an emerging

viruses that have led to investigations of antivirus is, sars and most recently, enterovirus. the discoveries can be as important as making them and he's been involved in efforts to communicate effectively about the disease with the media and the broader public. in addition to his instrumental and valuable role in organizing this symposium, and he will be moderating the first part of today's program. andy, thank you for your extraordinary efforts to bring this together. over to you, and again, thank you all for being here today. [applause] >> good morning everybody. thank you to the speakers who agreed to come here and take part in a symposium on short notice. thank you to the audience and everybody that is streaming online as well. we put together a very broad ranging and informative symposium that we hope everybody

will be able to appreciate and interact with today. we split this up into two general sessions. the morning session will be presentations on a variety of topics related to the ebola parrot is in response to dealing with the epidemic. we will take a short break and then have the feature speaker from the university of minnesota against the keynote address and then we are going to convene a panel discussions and at that point in time we hope to engage the audience in terms of asking a range of questions they have regarding the challenges for the intervention and mitigation strategies for the outbreak. we want to focus our discussion here on the condition that is going on right now in west africa but obviously the concerns about ebola outside west africa are things that will catch on as well. without further ado let me introduce the first speaker. david peters is the professor and chair of the department of

international health at the johns hopkins school of public health. his seminar is titled be helpful, stay hopeful strategy to fight the ebola. [applause] >> i am pleased to be able to talk to you about the community-based strategy to fight ebola and it's an operation that we've been privileged to be involved in. i want to first put it in a bit of context. of course we see the disease at the center of this and this is a picture of the epidemic in terms

of the number of cases and deaths and as you can see although it started sometime in december there is now in the exponential part of the curve and so it's an increasing concern about this and i think others are going to talk more specifically about the patterns. but it's not just about a virus that started. there are a number of other types of epidemics went on in west africa. after the virus itself is a contagion of fear and distrust not only in the country internationally and this is led to a number of other types of patterns that i think important to recognize as we put into context what we are doing and why. so, one of them has to do with a series of self reinforcing types of feedback situations that lead to the epidemics and other epidemics of them dealing with

the health system itself that started off being an under resourced system intact they had four strikes before the ebola outbreak because of the inability to pay their workers and when the epidemic struck of course they had a tragedy with the loss of the health workers in liberia alone. huge problems with the motivation and the clinics have been closed and this is of course leading to the worsening of health conditions, collateral damage is not just for ebola but other health conditions and commenting is now being malaria, diarrhea and pneumonia. so this type of system but also in terms of the economy at the livelihood of people are no longer going to work the fields and are not being harvested. there is of course a loss of trade income and poor nutrition and the feedback cycle around this area and then another around about social capital

institutions as the government has been unable to deliver services to type there's been an increasing loss and trust of government institutions and the damage to the cohesiveness and the culture that is again reinforcing. part of the way of getting into breaking the cycles is to the leadership. i wanted to highlight the assistant minister of health in liberia who is the point was the point person for the ebola outbreak in liberia. he's also a he is also a graduate of the school of public health and a non- faculty associate and he has written how it is important to take international support in winning the public trust to stop the outbreak in his statement that i used for the title is we must be helpful and stay hopeful. he's saying this not only to me and the international audience but to his own staff and his own people. and the slogan is within liberia is something to the effect of

stay afe and keep serving part of the russian armored into the community-based strategy. this is actually written out by the regime, but it shows basically trends in the cases over the months where the capital is and what you see here is the one that is starting to tail off and this is one of the early counties they had problems with a lot of distrust and what's happened is that communities are mobilizing the communities are mobilizing different ways to organize themselves to try to address the epidemic. it has become the focus for how the community care center is being managed in liberia and it is really emerging out of these properties in the county itself.

there are some other rationales that these are pictures taken from doctor francis in charge of the community care center program and what he is showing here is in liberia there isn't a lot of running water and this is the kind of creativity that we are giving to create places where people can wash their hands in this place and this is another place. so trying to find ways to improve hygiene. these are things happening by the community themselves. a lot of innovation and there is some analysis also backs up the notion of the community approach that's needed. so the group that is collaborating with virginia tech took the models and updated them and tried to model some of the strategies here that basically the u.s. strategy of bringing in lots of beds in hospitals and you can know from here sort of the epidemic curve and the

projection in february. what was realized is that you need a lot of external mobilization and a few model adding on to the vet the massive soviet coat globalization strategy you can come up with a low projections that there is analytical modeling support to support this type of an approach but the other rationale comes from experience itself and this is another one of the big leaders that i think we should recognize in this outbreak. a minister of health from the congo they have experience with seven prior epidemics and they are currently managing eight. in the discussions that he was having with us and others in new york describing that the control depends on the community-based strategy into this during the

discussions that he actually offered to say that we have 120,000 doctors and nurses, we have the experience. he's offered to bring a thousand of them and their experience to west africa and that's where he specifically asked hopkins to get involved to work with unicef but also the other actors involved including the world bank. part of the task is to facilitate how this works and it's useful to show his perspective how the ebola outbreak is working. these are the ideas going back to the notions of the vicious vicious circle, the vicious cycle. what you see is the source of the community hospital level and these are where the transmissions occur when you have patients who are trying to identify them can identify sick people, ring surveillance in and try to transport them. at the hospital level you do the screening and sorting and then

you have the patient care said there is exposure to other family members as well as the hospital staff and then burial where again intensive context. it's worth saying a bit about funerals important in every society they take a special place in most african societies and practice not just because of what happens with inheriting the dignity for the bad but it's also the approach is involved often in very long funerals and they are expected to wash the body and many will touch the body many times and they have some that may last all day and all night and it's what brings the community together. so we are asking for some major behavior change. but he's noticed as there is a component around the identification context taking care of patients and again the contact during the burial and there is an important behavioral

component as he's called it. we are seeing here are the disempowerment and this evasive approach that is reinforcing the bad side of the epidemiological control and care at all three levels of the hospital care and burial. .. combining the human behavioral and epidemiologic aspects as all of the cool aspects where they try to reinforce ownership and integrate survivals and provide high quality of care and of course this is sort of the notion that is trying to be reinforce. what they have done with lots of experience with, one of this knowledge is passive knowledge and a lot of the roles that we

have laid is to formalize that in a way can be reinforced in a way that we can tuall get so part of this notion was around putting together what the ccc concept is, the community care center concept. this is a lot of text but the core is really this multidisciplinary team that able to act in a local area working with the wind carries the come on strategies all three levels, community, and hospital. it depends on the train paid workers and paid volunteers and then, of course, there's a whole series of standard operating procedures that we're working with them and trying to operationalize around ways of minimizing exposure to community never says will protect health, providing types of facilities to screen patients in separate areas as well as having its own

lab and outreach services and logistics. it's a package that has to come together and this is basically trying to codify the response that they have done in congo. a concept has been involving in liberia. originally they were having basically having the ccc as being a senate that would later transported to hospitals and they realize the congo experience will not have this is a place where they can take care of patients. it's also originally were plenty as community members and volunteers to be the transport and caregivers and we've transformed up with have transformed that into now having paid health workers and professionals managing. this is a schematic of what looks like in terms of how they coming. there's also facility for those come health care for those who don't have ebola if you set up at the site the basically this is sort of the scheme for what it looks like. just to give an idea, the drc,

but he will have about 33 people that have a coordination management side. we have a treatment center side with clinicians, biologist, lab. committee outreach site and they safe burial team. half of the clinicians are actually nurses. on the liberian team it's about 60 people. we will rely largely on their can be leaders and came into the local volunteers for care assistance, education and burial disinfection type of management. and, of course, we'll need some literally translation although we are trying to get as many english speakers as possible into the program. that's basically an idea of what the team looks like. i wanted to highlight some of our first responders, if we can call them that. literally within the same day of finding out about the congo offer, we had three people to come over to work in congo and developing protocols and putting the concept together. i want to note particularly

these three. nancy glass of the school of nursing, whose leadership and expertise not only of congo and the technical ability but also to understand what the concept is and what the role of hopkins' which is around trying to standardize codify the knowledge and provide mentoring support to do this. trish perl was kindly able to jump across and work on developing both the clinical and the infection control -- control protocols. and anjalee kohl from recent graduate from school public health, words with nancy imbecile nursing and was able to help us on the committee mobilization aspects. we have an ongoing team and i just wanted, i guess this is an old set of slides. i wanted to shape of the 30 or so people that are currently involved across the school public health nursing. this is not the slide, but just in terms of who should pay

attention to in particular trish is the point person on the clinical particle and tom quinn is helping with that and we are relying on a number of people to provide assistance and support for there. derek cummings has taken the lead on the epidemiology and the data that will be needed for day-to-day management and assessment and trying to merge the protocols with the management. we have a large team with that. with about a dozen people who are already in the field volunteering either to go to congo or liberia initially in potential elsewhere. i won't be able to show them that there many people and we welcome more support on that site. what this is here is basically why we are involved and how we can work. this is not things i'm telling you. this is the things that were told to us why we need to be involved. one is we are an honest broker

and can negotiate between government and the chicken agencies, some of which have lots of experience. related to that is that we have alumni and professional networks across these agencies and that's important to be able to draw on. we initially got involved because of the need for analytics support and you have more about that from josh later and perhaps from derek. but is also notably it's a multidisciplinary type of support and their particularly interest in our experience of epidemics and implementation research. we're able to provide training, technical support and advice so it's a real challenge to match oour responsibilities here with clinical teaching and otherwise, but we are somehow managing. and, of course, a large area expertise that is needed, and we actually need to rely on our good name to be able to stand and protocols that are developing because a lot of these protocols, there won't be the evidence to support them and there's a lot of other agencies that will be able to stand

behind them. it's about making the most with what we have. and again it's also about convening and influencing to support the fund. so i want to end with statement from the front line. here's a picture of doctor francis. he had been given to his own staff and his own population. but i think it's just as important for us to up here. the message is we are neighbors, community leaders and global citizens uniting for the common good with you we can accomplish even more. thank you very much. [applause] >> thanks very much, david. and interest of time we're going to focus and move on to our next presentation. it's my great pleasure to introduce trish perl who is professor of medicine and senior epidemiologist, johns hopkins school of medicine and the johns hopkins health system. her presentation is entitled rethinking care, lessons from the current and previous ebola

outbreaks. [inaudible] >> thank you, and welcome everybody. and i want to thank the organizers of this as well as president daniels. and dean klag. i make chili charged with talking a little bit about some of the epidemiologic background and the medical aspects of this particular disease, and trying to tie it into what dr. peters just discussed, and making the argument that i improving care we can also improve engagements in the community. so just remind everybody, this is one of the viral hemorrhagic

fevers of which there are many. this is a final virus coming from the french word, or a string. and the art to viruses in this particular family, both ebola and marburg. ebola's name actually came from the ebola river which is in the democratic republic of congo, and it was first discovered in 1976. there are five species of this virus, all of which reside in africa except for ebola reston which has primarily been found in the philippines. that is the one of virus that i could does not infect humans as far as we know. zaire or the zaire strain is certainly one of the most feared of these an associate with very high mortality. the outbreaks primarily began in central africa, as identified by

the purpleish circles. this is where most of the experience of the 20 plus outbreaks that have been reported worldwide has been ordered. and it is actually relatively recently this has emerged in west africa. and, in fact, this actually started around the area of gueckedou, which is right at the corner of was sierra leone, guinea and liberia come together. the index case was thought to have been a two year old boy. if you look at this picture what you can see is a cartoon about transmission occurred moving from gueckedou throughout beginning as well as then -- dini, into sierra leone and liberia. so a nice chain of events if you will with transmission and moving from very remote areas

into urban sites. that is one of the most notable features of this particular outbreak. this is one of the few. there has been one other in an urban area. to date, the summers are changing all the time, there are thought to be over 8000 suspect cases. almost half a little bit moran have been confirmed, and about 4000 deaths. the country that's been most affected by this is liberia, but also significant cases in both sierra leone and guinea, as you all know. what's most important is most of these cases had really occurred in the last three to four weeks, and the burden of this particular outbreak is increasing. so in the democratic republic of congo, the outbreak is actually a separate outbreak and it began

in the equatorial province in the area very similar to were some of the original outbreaks occurred did you begin with a pregnant woman who butchered a bush animal that had been killed and given to her by her husband. since then the event 71 cases. it doesn't are the outbreak is slowing down. they have had 43 deaths with it. now, what i would like to talk about that is a little bit about the clinical presentation of this. this disease presents very acutely, usually six to 10 days after exposure but up to 21 days. very nonspecific symptoms with fever, weakness, diarrhea, vomiting, abdominal pain, severe headache. it sounds like the influence of an that's one of the big challenges is itself not only like influenza, it sounds like malaria, sounds like typhoid fever, sounds like a lot of things you see in this part of the world.

hemorrhage is most as a think about it's really not as dramatic as in the movie outbreak. what you see ptt, even a rash that looks -- but have french hemorrhages really rare and even in this outbreak it's less than 15% of the cases. and it's not what is leading to death in these patients. this is a cartoon really of how the disease progresses with these very nonspecific symptoms that occur early on. then you move to the more hemorrhagic phase just to emphasize that it can be very minimal, and then between six and 16 days is when people declare themselves, where they can either progress into a much more informative form of the disease with shock or they can move into a phase where they

have clinical improvement, which is really actually thought to be partly associate with an immune response. now, what i'd like to do is argue that we need to move away from just isolating patients. and i would like to show you some data about very basic medical care, and make the argument this isn't like hiv where we argued that we can take an hiv drug into africa and improve outcomes. i think we can take simple medical care into africa and improve outcomes. so this is david. there's an outbreak of marburg hemorrhagic fever with an extremely high case fatality rate of around 87, 88% in africa. when these cases came into more developed health care systems and people were given simple hydration, what we saw is a

dramatic decrease in the mortalities. and kikwit, one of the more famous of the ebola outbreaks, there's a case of fatality rate close to 80% with the first set of cases that occurred. the last 25 cases received intravenous fluid resuscitation, and the case of fatality rate dropped between 30-40%. so there's also no emerging data from these particular outbreaks that with iv fluid resuscitati resuscitation, even -- excuse me, the use of electrolytes, without being able to measure electrolytes. so we are just giving people electrolyte supplements. and therapy that the case of fatality rate and the camps

would have tried this or the ebola despicable treatment there is has dramatically increased. the investigational therapy also that up and talked about in the western world, i'm not going to dwell on these because somebody later in the symposium will be given a much more erudite discussion that i can give. but just to note that these have not really been used in africa. they have been primarily used here. not the second component of this is how do you keep transmission. and i fully believe, i mean, you will never get anybody who works in infection control not telling you that we must in infection control. and i absolutely believe that isolation is going to be part of what we have to do to break the chain of infection. this particular infection, this transmission to breaks of the skin, mucous membrane exposure and exposure with needles. you know, initially as i mentioned you can get infection from beating bush meet or an infected animal but the

transmission that is human to human is really the contact and direct contact with the secretions, whether it's sweat or blood, et cetera. there is no evidence really of airborne transmission with this particular virus. they can be aerosolized by some of our medical treatment, but at this point we don't think that at least the zaire strain is. so the risk of transmission, what do we know about this? so as i said there've been 26 part outbreaks. all of these have actually been terminated with pretty simple barrier precautions to a lot of what you are currently seeing has not been needed to determining these outbreaks. it requires a much, a there is said to us attention to making sure that your tpp is a

prohibited doesn't need to be super complicated. now, what do we know about these? well, and kikwit which is what the outbreaks were we have the best data, 16% household contacts developed ebola. 29% who had direct contact with cases and influence he came infected. but no household members who have no drug contact became infected. i think that's one of the messages that we can dispel is that if you have contacts are not going to become ineffective. interestingly in this outbreak, 80 of the cases, 80 out of 315 were health care workers, and the epidemic was interrupted by the institution, a very simple barrier precautions, and intend to turn. this is an epidemic curve from kikwit figures were to implement the barrier precautions. you can see that there were cases for about a week after the

implementation that would fit with the fact that this before incubating. there was one isolated case. by the way, the black bars are health care workers, where there was transmission. and this particular health care worker admitted to robbing her eyes. in terms of uganda, what if we learned? 26 laboratory confirmed cases, and the specimens were tested using rpc our. they actually found that you can find virus in many of the bodily secretion. cianci saliva skin, still. cemenseen it is important that y can actually continue for up to 90 days after you get better from the infection. but what i found most interesting about this study and the reason i present it is that among the environmental isolat

isolates, none of the isolates were positive from non-bloody specimens. it was truly the bloody specimens were you can isolate this in the environment. and then finally there is a very famous case from a johannesburg hospital, an unrecognized ebola case they came in and recovered. the patient had upper and lower endoscopy during the care and an anesthesia assistant put in a central line. the assistant remained undiagnosed for 12 days, and had many, many procedures that you would actually see commonly in the hospital. a puncture, was incubated, natural ultimately died. and despite this they had no secondary transmission. so what about spain and dallas? because of said trish, what happened there? what i can say is that there's a very dangerous moment when you

undress but and this is not a health care worker issue but this is really a systems issue. but when you get out of these isolation units, you are tired. take off your protective gear. you were sweaty. and remember, it's about 115 degrees in these suits, especially if you're in africa. and you take off your glasses or you just touch your face like that. i think i make me something as simple as that, that can be almost devastating and in this very unforgiving disease. so what do we do? well, what do we want? would want to identify cases, as david features mentioned. we want to triage these cases. resort want to put in place infection control i want to train people about doing it. i'm not going to dwell much on these. i think david covered this well, but just really wanted to point out that this outbreak has been complicated by a lot of human

factors and the distrust, not only of the government but of medical care providers. and by improving outcomes i think we can improve that distrust. the other human factor in terms of medical infrastructure, i mean, these are rudimentary overcrowded hospitals. i don't how many of you heard the piece on npr this point about the initial case in library and the challenges with isolation. it is a lack of protective equipment. sometimes it is reused and not appropriately cleaned. sometimes it's even makeshift. and just to give you a sense of this, here's from the mmwr last week with a talk about the challenges with supplies of nonsterile gloves, obstet gloves that were depleted or absent. there were not many handwashing

stations. the handwashing stations consist of water jugs and even sometimes those are scarce. their supplies of bleach and uncle joe are depleted, and has dashed if you have rudimentary isolation facilities. david really dealt with some of the challenges with the cultural habits that of complicated this. so let me just summarize by saying, this is an acute viral illness, but from my perspective what is remarkable about this is that this after sars, merz, h7n9, is one that really has impacted health care providers who are just doing their jobs. and i think that all of these are examples of failure of infection control. and this is something that it's not sexy. i mean, it's just about doing it right. it's like learning how to drive.

and we have to really start thinking about paying attention to how can we drive down this road a little bit better? to read honor the kind of respect -- not respect, but the kind of trust that we need in the medical care, i think we have to change that paradigm of care, look at these data about hydration and integrate those into the public health response, and start talking about not only decreasing transmission by isolation, and prevention -- but also by increasing mortality. so thank you. -- decreasing mortality. thank you. [applause] >> we are going to move on to our next speaker who is joshua michaud herzig associate director of global health policy at the kaiser family foundation

and also professorial lecture at the initial developer department of john's hopkins university school of advanced international studies. his talk is entitled financing and governing, the global response to ebola. are we where we need to be? >> i think we are ready to go. it's a pleasure to be here, thank you to the organizers for putting this wonderful program together. it's an honor for me to join the rest of the speakers here and talk about the very pressing issue. my talk today is going to be

focused on three main things. i wanted to cover the economic, social and some of the political impacts of ebola in west africa. i wanted to talk about the response, the u.s. government response to date and the international community response to date as well as the financing has been provided to support the ebola response in west africa. and then i would like to take a step back and look at the broader implications of this outbreak for the governance responses for public health events of international concern. so i think that the cases have been mentioned already. we are up to over 4000 deaths in west africa from this virus across the actual five countries that had cas cases by the threet affected countries. and what i want to focus on first was the sort of broader economic and social impacts. so the world bank put out a

study. initially in september and updated it last week, discussing what they saw as the economic impact of the able epidemic in the three most affected was african countries. this is just one of the charge from and. on many different ways that they have sliced and diced this data but they looked at several scenarios going forward. one where ebola is fairly well controlled which they call low ebola, and one where the epidemic is not controlled. and by the end of 2015, you have on the order of 200,000 cases, which is a very high estimate of course, but should that occur, the economic implications are very dire. in 2013, both sierra leone and liberia were among the countries that experienced highest rates of growth in the world. sierra leone was second, and

liberia was sixth actually. by the old ebola outbreak has already caused economies in these countries to shrink and that trend will only continue. wrapped up in this economic data is what's going on, is the major sectors that are drivers of the economy in these countries, the agriculture sector which makes up 50% of the economy in liberia, the mining sector which makes up a great portion of the economies in the countries are severely impacted by the controls on movements and the decisions made by individuals and firms and businesses do not engage in productive economic behavior. the fiscal implications, meaning the tax revenues for these governments just at a time when they need to be spending more on respond to the epidemic, has been shrinking.

tax and tariff revenues are down and will continue to do so. but most of the cost from the economic contraction is due to this aversion behavior, with the economists are calling aversion behavior, basically that there at the distrust that is demonstrated by the virus. while they don't have good data on the impact of that particular behavior in west africa right now, the world bank did a study on the sars epidemic and found that of the 30-$50 billion that were lost during that epidemic in 2002-2003, 80-90% of the economic losses could be explained by this aversion behavior, not the direct cost of patient care and not the interest cost of lost productivity. so this is obviously a very important for the government, has said this raises the specter of it becoming a failed state,

and that's not outside services thing. that's the government represented himsel themselves. they were meant to have a national election today, but were unable to hold a. they had to postpone it due to the emergency from ebola. so turning now to the u.s. government response, there are multiple u.s. government agencies that have responded to the outbreak in west africa. i won't talk about all of these. some of these are agencies are focused on vaccine development, and with other speakers to cover that topic, but i will talk about usaid, cdc and the department of defense. so usaid is the lead government agency that in charge of coordinating all of the different u.s. government agencies involved in the response in west africa. to have a disaster assistance response team which has been on the ground since early august. about 20-30 people, and they

coordinate all of the resources provided by the others but that includes the cdc which has on the order of 120, 130 people stations across west africa right now, the largest deployment of their staff for any international health response. it's the first time the u.s. government through the office of foreign disaster assistance has declared a disaster that is a public health disaster, so there are a lot of firsts involved in the response to this. as you likely have heard, the military is becoming involved in the ebola response. president obama made a statement about a month ago now saying that the department of defense would become increasingly involved. at the time he stated that, that would mean 3000 troops would be sent over to assist in the response. that's now been lumped up to 4000 troops. not all of those troops are

there. there in the process of scaling that up, somewhere in the order of 200, 300 troops are there right now but their responsibilities are to help build ebola treatment units in liberia. 17, 100 dead units is the goal. and to set up a training program for up to five and health care workers a week to staff those ebola treatment units. they also support logistics and transportation by crate and air bridge and moving personnel and equipment. and also are involved in laboratory testing. but there's been a bright line that has been drawn by the leaders in the department of defense in that no military medical personnel will be involved in direct patient care, at least that's the thinking right now. so the funding peace of this, this chart just shows you on the line as the cases have increased over time, the commitment by the u.s. government have also increased.

it was an early response back when the first cases, the cluster of cases were reported out of guinea. cdc was involved in the early response, but that skill level but in august as the first dart team members were sent up and, of course, last month they were dramatically scaled a. the pledge for the use government force of timber was that $750 million would be provided for the ebola response to this has not increased in october to $1.25 billion. 1 billion of which is made up of the department of defense budget, which has been freed up to be reprogrammed from war funds, the funds meant for supplemental funding for the war effort in iraq and afghanistan is now provided for this humanitarian effort. and clearly the largest expenditure on humanitarian effort in dod's history.

but that money is not free and clear, it's not ready to go. that congress has asked the administration and the leaders of the department of defense to provide a more detailed plan about how that money will be spent, and exactly, in which ways they plan on doing that, by the end of this week as a matter fact. so turning to the international response, what has been the international donors support for the ebola response? this data comes from the u.n., the office of the coordinator for geometric affairs, and they have a financial tracking service which tries to keep tabs on all of the money being provided by all of the different is not just documents but private actors as well. that are being funneled towards the support for the west african response. i just pulled out some of this information. you can see at the top there are

two categories of financing. there are contributions and commitments which they considered to be firm either money in the bank or commitments made on a legal basis of the contract signed so there's a fairly solid commitment of financing bigger additional pledges of support those import to keep in mind what the commitment and the the pledge and you can see together they total $818 million. and i pulled out from that data the commitments in this bar chart by various donors and actors. you can see the trend as provided the most in terms of financing to date but to our very important supporters such as the world bank, african development bank and even the gates foundation is on the. they pledged $50 million have provided 14th of that as far as the data showed yesterday.

and other governments have provided much less of course and there's been some pressure on other wealthy countries to provide more and support. so this is what's been provided to what is the estimate for what's needed? the u.n. also done investment of that and released the report in the middle of september. basically outlining what they see as all the financing needs that would be required to mount a full and complete response to ebola in west africa. i won't go through all of these categories here, but you can see they are fairly cover it up in that they not only consider the cost for treatment of individuals in the ebola treatment unit and contact tracing from a public health standpoint, but also food security, providing nutrition, making sure that there are

transport and fuel for cars and vehicles, and also community engagement. so you add up the assessment of all of the things that are needed, we get to basically a billion dollars for the next six months for the ebola response. so we think back to the previous slide in terms of firm commitments, we have about half a billion dollars, or 50% of the state that's estimated by the u.n. but if you add in the pledged amount, we are about 83% of this total. so that's the financing peace but, of course, if you're going to build a 17 ebola treatment units in just liberia come you're going to need the staffing. one of the most striking figures, at least to me from a recent world health organization situation report from last week, was this chart showing the bed capacity and requirements for patients for a bullet in the three countries most affected. you can see it in the case of liberia and sierra leone that

only 20-26% of the cases that need to be isolated in beds are currently in those beds. so the demand is much higher than the current capacity as far as estimated by the w.h.o. these data come from the ministries of health of the relevant country. so another bottleneck here is not just the financing of course but where will all of the health care workers, the staff, all of these beds and clinics come from? there's work being done to train those health care workers but there is a lot more to be done. the president of sierra leone says he believes up to 3000 people are going to be required in his country just alone. so just to close i'd like to step back a bit and talk about the governance and the financing of response to emerging

infectious diseases in jeddah. the theme that has been emerging over the past several months in relations to ebola has been that the international kindred has done too little, too late and it's been poorly quartet at it has approached this. it might seem ironic that it's just less than 10 years ago that the international kindred came together to basically reinvent the framework by which they come together and mobilize against emerging infectious diseases. that framework is the international health regulations which were revised in 2005 and came into effect in 2007. now that framework when it wasn't revised expanded w.h.o.'s mandate in the context of the public health events of international concern, and it set minimum requirements for country to build the capacities

to prepare for, detect and respond to emerging events of international concern within their borders. and so in theory the framework was there, but clearly in reality the investments have not been made over the seven or eight years since that document was signed. and the weakness has been all along that these countries that are very poor are unable to invest in their core capacity. and there is no mechanism or no requirement for international assistance to help in this regard to build the basic health capacity. everyone was on their own. even though it was in the best interest of all to make sure that those capacities did exist. so right now, and even earlier this year there've been efforts to try to bolster that effort.

the u.s.-led effort to make the international health regulations vision of reality is called a global health security agenda and this was launched in february. you may not have heard about it then that you might have heard about it now. because of the time it was announced on a day when u.s. government was actually closed due to a snowstorm. it didn't have the kind of attention that it is now because of the ebola crisis represents the exact thing that this agenda is trying to address. so just a few weeks ago they had a meeting in d.c. bringing together leaders of the u.s. government, and they were very high level representation, including president obama, as well as the organization and 30 other part of countries which may pledges toward building the capacity in their own countries with assistance from the united states. as of now there's no additional money associate with this

agenda. it truly meant to be a mobilizing force to get the different actors to work toward a common goal of building public health capacity. another idea has been floated just last week by the president of the world bank, jim kim, saying he thinks there needs be a global pandemic emergency facility. basically pre-positioned money and assets including personnel who are expert in responding to emerging diseases. that can be rapidly mobilized in the case of an epidemic. this is just an idea at this point. it's unclear how it would work out but it's clear from these efforts that the framework encapsulated by the international health regulations hasn't done the job it was intended to. and so either by working on bolstering those things are actually kind of going around the global health organization and the international health regulations and another set for this global pandemic emergency

facility. there are attempts to try and tweak the system and make it work better for the next time. so in closing i would just say that the lessons that i can see from this epidemic so far for the body landscape of governance in this case the public health emergencies, or that there is a substitute for making sure that every country has the basic capacity to detect and respond to emerging infectious diseases. because they can and do arrive and spread without warning. therefore, any country without that capacity becomes the weak link for its neighbors and perhaps even for the entire globe. and, finally, underfunding global institutions leads to underwhelming results in a time of need. thank you. [applause] >> all right. thank you for the. so we've incorporated some time

for questions in the supposed because we fill its import not just that people speak to the audits but also set up a conversation between the audience and experts. there are two microphones on the side here. right now this is a very natural breakpoint. i encourage anybody who has a question walk right up, and we will call and you. if i can ask the three speakers from this morning's simplicity, and maybe field some of these questions. it's sort of a natural breakpoint in a presentation. we've heard about the ebola outbreak in some othe of the responses. or we can stand with your idea microphone -- not microscope. sorry, thinking about my laboratory again. hopefully we can a field some questions about this part of the presentation before we move onto the second part of our symposium. if my facts are active we can sit down. >> we hear different numbers.

some of them are over 1 million in 2015. some of them are a couple hundred thousand, and i saw a slight today that was projected 15,000 what assumptions go into those numbers to say how many cases or how many deaths we will have by 2015? which one do you think is closer to reality? >> i'm happy to answer them. and actually josh epstein will be talking a bit about this more because it's part of, part of what his talk is. i don't think any of the numbers can be believed in terms of what the actual projections are. some of the high-end projections actually are over 4 million. the problem is the assumptions that go into it are very unclear and the types of models we have a rather outdated. so, for example, the model we show from cdc assumes there's about two and half times as many people who have the disease the actual identified.

they have assumptions about full mixing of the populations, and assumptions that basically look at what happens at the hospital in the community and that burial, and they have these sort of contained, contained areas where different transmission rates. but they don't account for changes in behavior and changes in implementation. so they are really kind of rigid in terms of what they can do. i would look at the model not so much in terms of the exact numbers of what projections, because none of them have a way of actually changing the exponential curve until it's saturated. that's clear that the case in reality. i think you can use the model sort of as an indicator of relative impact of different strategies at this time and that's how i tried to use it. but i think that this is an area of importance of actually developing a different class of model that can be more responsive and put in place in

the future. but i don't want to anticipate -- i think josh will talk more about this specifically. >> good morning, and thank you. i'm from library you. i've been here three months. i was at cdc last week attending a training course to return in liberia and three weeks. my concern here is we figured out at the time most of the international organizations, the ngos which are nongovernmental organizations, are now sending people to cdc to get trained. it's a very intense course for three days. before they can volunteer to go to anyone at a west african countries. just a simple calculation, they were training, like 50 but some of them were just researchers or people who would not be working in the clinical aspects. if the cdc is the only site -- well, my question is, is johns

hopkins thinking of also developing a site for training volunteers or others who want to go to these countries? we ask the question at cdc because they had many library and nurses and health care workers in minnesota. we asked them, is there training there? their problem is they do not have enough instructors. so i'm just wondering, would it be better if these training centers are set up at different institutions? >> i don't know the answer. >> i think that's a good question in terms of what we can do here at the hospital. i think that's one of the reasons why we got involved in congo, is because it was actually with being able to do the training there. and partly it's also question being able to adapt to the kind of resources that you actually have. so the kind of protective

equipment we have here at the hospital is going to be very different from what we're going to be able to get in liberia, sierra leone and guinea. but i think that's a good point whether they can be more here in the u.s. i think that's important to if we found opportunity to do something until these 1000 health workers in these coherent units together, i think, hopefully we can build from that experience. >> we have gave was to also who can comment on that. >> w.h.o. is actually also doing training. so there are multiple groups that are doing training, but one of the challenges with this is that the efforts have not been well integrated or catalogue. and so it's hard for a lot of people to really get their hands around all of the activities that are ongoing. i think your point is absolutely valid in that we do need to make

sure that we provide these resources. this is something that we are good at, but really to do this effectively, we probably are going to have to really encourage a lot more international leadership and we've seen to date. >> thank you for the comment. i think it really helps concentrate the will of the institution to step forward and do this type of training. there's a fairly major effort afoot involving the head of the armstrong institute. mr. armstrong himself was one of the members of our board of trustees to put a fairly major program together related to training, training the trainers and training individuals. and this is actually going to get in a major way tonight, has already senior level institutional support. the real question is how quickly

can we act? because your question raises we need these people now, and there are people i want to be trained. and everybody going to the cdc is just a little bit of a trickle. so your comment helps is to concentrate the urgency to put these kind of programs together. >> another question. >> good morning. item from sierra leone, and ebola has created a lot of -- in sierra leone. [inaudible] in sierra leone over 15,000. the are no systems in place for of options and whatever one needs to do. are there any plans in place to take care of orphans who have lost their family members to

ebola? >> well, i don't know of any large plans, but it was certainly something that was highlighted in congo by the competition and by unicef. and so it is part of what they've asked us to do actual as well in the community mobilization team is to look at what did you do with orphans. actually there's a lot of stigmatization around survivors as well. as well as a lot of i guess which michael psychosocial trauma among the caregivers. so there is a need to have a kind of program to address those kinds of concerns for orphans, as well as for survivors and caregivers. and i think that's something that's going to emerge. it's something we're working on but again i think we are a small part of what has to be a larger effort. >> i know save the children is

working with unicef in these countries on the thread topic to try to bring awareness. so those are two organization. i know save the children with a good place to look for those efforts and where they are right now. >> let's take one last question then hold your question until later. i would appreciate that. >> my name is catherine and my question is in relation to a slide from trish perl showing the three stages of signs and symptoms. and it looked like from the slide that it was really on the latter stage where your immune system is going to kick him or not to defeat the disease. and so my question is, is there -- what we know about cases where maybe they immune system kicks in during sort of the earlier stages? or if there are cases where there are mild symptoms that

present where your immunity system kicks in. >> so i think it is going to be a little bit of a discussion later on in the next session about some of this, but if you notice what you're hearing in the press is that people are getting given serum from kent brantly early on and it was and this is an attempt to neutralize antibody early on. sojourner, i think there's a sense that this acts like a lot of ordinary viruses and that you can modulate the immune system in a way to impact this, not only the severity but even perhaps the development of infection. the other types of interventions that are going on is there's actually vaccine and people early on after exposure to see if they can prevent also the severity of illness.

so i would say there is not a lot known about this and a lot of the things the research community is trying to do is to better understand the mechanisms of illness given that this is really the first time that the developed world in a large way is involved in the care and having access. so i think there's a lot to come, but i know that doctor charlie will be speak muslim these issues in the next session. >> okay. they given much for those. [applause] >> so the second of course the bosom of our featured talk and then morph into a panel discussion. a panel discussion is going to focus on issues of challenges and implement an medication intervention strategies of the current outbreak. to introduce our featured speaker, i would like to

introduce a colleague of mine, a nobel laureate, director of the mueller research institute and professor of molecular michael biles you in a noted at the johns hopkins bloomberg school -- bloomberg school of public health. peter? [applause] >> thank you and good morning. our nation's leading public -- is my privilege to introduce michael osha home. mike is the potential -- public health director of the center for infectious diseases at the university of minnesota. a native of iowa, mike attended luther college in the core and went on to university of minnesota where he studied public health and lead a very distinguished a long and distinct career in public health. the activities following the 2001 september 2001 attack might

stepped up in the national and international arena. he was appointed special invite you to secretary of human health and human services to advise on bioterrorism and public health awareness. is a point to the world economic forum working group on pandemics. and for this work my kids receive multiple honors including election to his fish of medicine of the national academies, and owner of additional duties at mike's of the multiple task force for the institute of medicine including microbial threats, food safety and antibiotic resistance. raising public awareness without producing -- porton and difficult task. requires bravery. on the one hand, the risk drawing rebuke from the public officials who don't like to be criticized and at the same time that the risk of causing panic amongst the public. mike has done a very wonderful and eloquent job communicating with the public.

in 2000 he published the book, living tears, what america needs to know about iowa terrorism, which made "the new york times" bestsellers list. in response to the current epidemic of ebola mike has published a series of articles, articulating what is happening and what we need to know. the "washington post" august 1 he published an op-ed entitled what we need to fight ebola. in this he makes the case the ball has not changed. africa has changed. large population shifts. in september 11 in new times he published an op-ed entitled what we are afraid to say about ebola. in which he raises the possible of shift to respite or transmissions. it calls for leadership by the united nations. september 30, a lyrical featured an article by mike and i were able epidemic is about to get worse, much worse. the real discrepancies and the predictions by leading organizations such as the cdc

and the world health organization come 100 fold or in terms of predictions. and, finally, an article published in the "jama" this past weekend, he raises the issue of the black swan, an unprecedented event with a huge impact for which we're most certainly back right to actively i regret how we proceeded. mike will present a lecture entitled a perspective on the west africa able epidemic, leaned forward with one step back. p2n and will coming dr. michael osha home. [applause] >> first of all, thank you, peter, for the very kind introduction. peter is a dear friend and colleague and i very much appreciate the invitation from you and michael to come. in addition i have to say it's very humbling to be or because two of the mentors in my career have been your two preceding

themes through today is in london and could not be with us. as i told you earlier a day for spots with all the things i say wrong. ..

and it was just heart wrenching to hear a man that has spent all this time in the treatment center watching people go after the street and watch the children. we can never forget that the heart of all of this is that. let me just start out by saying that i have no disclosure to make a financial standpoint but i do have one major disclosure to make. i know a lot less about ebola today than i did six months ago. so, you can take whatever i have to say in that light because as i've learned more and have made a real effort to understand ebola come our group right now is giving a major piece in the transmission of the ebola virus we have now reviewed over 900 papers published, 700 of them in great detail. and i can't argue the more i learn the less i know. but so, let me used to set the tone for what my comments will be today.

daniel bornstein the former library congresswoman said the greatest obstacle discovering the shape of the earth and was not ignorant of the illusion of knowledge. we will talk about that today. the second thing is that the technology must take presence on the relations where nature cannot be fooled. i would add a slight addition to that and say in this case the successful public health response we must take place for the nature. today that sets the tone for my comments in which i want to share with you. as peter laid out effort in a series of articles that over time even watch my own evolution where i was back in july when i worked with the first piece where i am today and i will try to share that with you. i don't consider having been wrong before, but i also am willing to understand that as we learn more, we we mailed them if they have a change in how we look at and they understand what

happened in the world around us. i use often the event as you know as an economist actually described very nicely this metaphor of the black swan a bird that was threatened ... is a very well-publicized "he is said and ears up and actually took that beyond financing suggested they would come at us at a great surprise. it are typically catastrophic events and they are the ones that when we look at the often tend to happen quickly, which may be the first slight alteration from this event but in retrospect often times we should have known about it and we if we could have dealt with it. i would also like to challenge that notion today because i think that we are about to see a whole blackout associated at this event and i hope we can prevent a number of them by

participating as opposed to waiting until they happen and then understand what happened and what we could have done about it. imagine the storyline of the west indies in this country and individual that had come from west africa to dallas county texas had been rapidly identified, had a very effective and comprehensive response to the context into the community and the healthcare worker evaluation situation is one where we did it right. we could have kept an extra ten days on where this has to be. in retrospect we can figure out and figure out all the things we should have and could have and might have gone right if we had done something different. i hope in the presentation to share with you the sense of how to be leaned forward and think about where tomorrow is and change tomorrow by doing something today. but only by actually taking the step back and asking ourselves where we are at. i think that is going to be a critical issue.

so, today let me just say that i am of the notion that we have a lot of unexpected things ahead of us. come to expect the unexpected. do not expect anything carved in stone today will not be blown up by some scientific or intellectual piece of dynamite. it might be. that is different than saying we can do nothing, we know nothing, we are afraid that we can't respond. that is a very different statement but it's also what i believe will sustain the credibility of who we are in a public health world. let's take a step back. one of the things i find humorous today is the amount of hubris that we know about ebola from the standpoint of our history has done in the ebola virus. to date, there have been 24 outbreaks of the virus infection in humans and i use outbreaks loosely 19 of those were community outbreaks. five of them were one or two

cases were a laboratory situation. in those outbreaks have been roughly 2400 cases of illness. that is in 40 years. if you look more specifically the longest set of generations we can find a strong together in the outbreak had five generations. five. it's hardly pinged us yet we have this sense that we know so much about it. we know the virus and what it does to people. and maybe we do. maybe when we get done we are going to find out those first 19 cases were just like the next one. something is different today. the virus hasn't changed from africa changed talking with the organization that we had long anticipated was just a gas can waiting for a match to hit.

maybe it's not just completely that and i will come back to that. is this outbreak of the past? though it's not. is it in a different setting? it could be a viable share more with you on what i think about that. let's acknowledge one thing. we are making this up as we go but that isn't new to public health. we've done that in the past. it's not a bad thing we just have to be mindful that we are making it up as we go. and in doing that, we have to become more comfortable with uncertainty. i categorically reject the idea that you can't tell people you don't know because you are afraid that people scared them. there is a can leave a literate -- if you tell them this is what i'm doing to learn or what they say something and it might be very scary the literature shows over and over again there are two things that will turn them to be very concerned if not

scared if you tell them with certainty a and then you told uncertainty be or amd don't happen in the way that you tell them, then they wonder about your credibility. the second thing is if you get dueling banjos one person saying you're going to scare people, don't say that because it's not true that when people get concerned. so with an idea let me just say that one of the worst enemies that we can have today is dogma. it should be at the first instance the thing that we jettison immediately. that's different than staying behind the science and knowing what we know and how we articulate it. but do not fall into the trap of dogma and i see too many people doing that for the fact that they want to reassure the public about a b. or c.. that is a dangerous path. in the piece i wrote on politico week and a half ago i actually laid out what i said were three

plans. a, b. and c.. i started out by saying we are failing miserably on plan a.. in the countries using the techniques that we had so well used for so many years used effectively. and there were reasons for that. first of all i want to point out that we did have one miraculous save. it really was remarkable that happened in nigeria with one individual of the minnesota resident who traveled from liberia and was inducted when he got off the plane. but if you look at the intensity of that effort over a thousand people followed up and someone who is part of a high socioeconomic status group virtually was in the healthcare setting with exposures occurred and the fact that they extinguished that was remarkable. that is a testament to the nigerians and the cdc. but if they had gone undetected for a couple of generations that wouldn't have been the same situation at all i am convinced

today. we know these things can work but when you get into the setting can they work? imagine you have this hour after hour but you put them in the river the current is going 6 miles an hour to upstream and every hour they are down the stream them further before yet they are going like the devil. the question is do our methods work when you have such a situation that you have with no infrastructure, no healthcare etc.. so we have to accept first of all the unpredictability. we don't know what will work. we don't. somebody is going to ask us did what you said you were going to do work?

i still got a the mandate and i still say the treatment is the key and you want to try everything that you can even in the home and infection control kits anything you can do but let's not make promises that we know right now we cannot answer because then we are just contributing to the problem. the presentations are simply outstanding but i want to point out the presentation. it was really very good. one of the areas we are giving a lot of criticism right now is wait a minute. we have the cdc saying the case is in the middle of january for the two countries but the who says 20,000 cases by the middle of november for three countries. how can you be so far off? this is another one of those areas where the hubris and i say huber is not not hubris not in an unkind way to get us in trouble. my answer which is really simple is there is going to be lots and lots of cases and lots and lots of deaths we don't have that

number is going to be and we have to accept the fact that nobody is right or wrong. we don't know the procession around the estimates are in fact big enough to drive an entire convoy through. we also have to understand that the progress is painfully slow. i talk about the fact that the virus is operating on virus time and the bureaucracy program time and the virus is winning hands down and it still is. i commend the u.s. government response. no other country in the world has put forth the same response to u.s. patents. the response has been woefully inadequate. when the president is a five weeks ago that he's going to send 3,000 troops and until last weekend there were only 200 on the ground and gather her 300 on the ground for the logistical support, that isn't 3,000. these beautiful slide show over the nations that have been made and that isn't fair.

it isn't happening. and nobody is to blame. everybody is to blame because the world was not prepared to respond to a crisis like this. isn't it rather ironic that the only nation in the world that actually has an operating medical center right now center right now staffed with experts in the medical area is cuba, the only country in the world that has been on reading medical facility in the three affected countries as cuba and they are actually getting a lot doing a lot more work. where are the rest of us? i know that we are coming and that is important in the sense that it's down the road. but this is something that's operated in a very different situation. imagine the city of minneapolis having a large fire in minneapolis had to call the new york city fire department to come as background. there would be helicopters going down interstate 80 and it would be wonderful. that's what we have to understand as the new world order when it comes to infectious diseases. we have to understand the health

system and the countries has collapsed completely. by my best calculation, we still have many more deaths in those three affected countries today for an hiv, tb, the nature measles outbreak right now from pregnant women delivering their children and the in the most terrible condition etc., etc.. for the humanitarian standpoint of it is a tragedy that isn't even reported right now and that is as desperate as we could imagine because there is no other healthcare of any kind. and that, to me, is also another storyline that talks about what happens when you have the scale of state situations and we have what is going on. the health system collapse has been incredible so don't talk about just going over to build a ebola treatment center beds. we have to talk about an entire system if we are going to impact even ebola. it's going to be very important. again i come back to the fact i want to leave no lack of parity.

i believe the only thing we can do today is to try to treat that approach to do as much as we can to isolate infected individuals and quarantine and so forth but i am ready to acknowledge i'm swimming for miles an hour in the current 6 miles an hour. it's not going to be enough and let's not fool ourselves. don't tell the world it's going to. it's time to reconsider the response. federal agencies are willing to now consider the response. you know what we should be able to do that and it feels like we screwed up we should be able to do that and not feel like we are to blame yet we expect you to accept the accusation that we screwed up and i have to tell you a lot of the public thinks we have a cause we are not willing to get our message out to see that uncertainty is reality. i am not afraid to say i don't know. i'm not afraid to speculate what

might happen but i always come back to what are the data. we need to do more of that. plan b. this was the pardon my article when i said wakeup world, we don't get it. when it's over there in west africa is kind of easy just to call on west africa. now when you live in a place like bloomberg school of health where it is a prominent important part of that, that's not true and i commend you for all all that's come about a love of the world west africa is there created they can't quite tell you isis is in east africa were west. and we however have to understand what is very likely to have been. this is very troubling when i did this. i published in the political piece a very well known part and i know we have individuals from the affected countries here today who i welcomed them to

speak to this. but every summer in august, september and october, the number of young men and boys basically come home to help harvest the crops well established like the married like them or it could be for migrant workers in the country and in early to mid-october they leave to go back east to work in the plantations and the goal lines and the operations in some cases fishing. i wrote about this in the political piece and several media sources questioned me about it and went to find out on their own and sure enough the sources us was happening. these people moved by basically the back places nobody knows. they ask where i got this information. i just got it from talking to the to the people the anthropologist of sociologists have spent a lot of time trying to understand the whole issue

and have years and years. they've been the anthropologist and sociologist. it's been a crash course and a very valuable one. but what does that mean. they are burning away and the sparks flying occasionally into dallas imagine what that wind is drifting to the east right now. i don't know how it won't in those other countries. and i can show you the route that we know that these people moved to or just jobs. literally it is a one and a half day trip for these people. even ken chaucer isn't that far. do you know they live in all of the slums of the countries combined they wait for the match to edit and the rest of central

effort to his waiting for the match to have it and we don't quite get it yet and there is no plan b.. how would we fight this if in fact this were to suddenly flare up. we can't fight it it into one front front and all i'm asking for is not to divert from west africa but somebody got ought to be thinking about plan b.. i will come back to it in a minute it's not just about ebola. i've done several briefings on the hill for the house leadership and the people that had the most interest beyond the immediate health group was the intelligence committees because we see if we destabilize this part of africa the whole terrorist issue is remarkable. we are already concerned about the ground right through to eastern africa. so you know as much of this is the humanitarian effort, and it

is common is, but make no mistake about that this is an interest. if we were ever going to invest in a timely major way we would invest for that reason alone we do not want to give the world another place where the states are so filled that you can go without impunity in terms of issues around her was him, planning, location, etc.. it's huge. i also talked briefly about another plan b. that i will do in a moment that some were concerned about because i did mention about other modes of transmission. i don't want us to it to be a focus, but important one. plan c. is one that is the only hope to really have. i worked very closely over the last few months and again and organization if anybody could win a second nobel prize, they

should. they have seen themselves this flash of cases shut down the clinic move bring it back, shut it down, bring it back. we don't really understand what's going on. that is a huge piece. so to me at this .1 of the things we have to understand here we don't understand what is going on in all of that and that's why i understand this will be an endemic situation. having said that i have great concerns about the situation right now. some might say i was brain-dead to talk about something i talked about with ebola. i got in the trouble back in the 1980s when others made the comment they would have a vaccine and i was quoted in "the new york times" that same week

saying i didn't understand how that could happen happen and i didn't delete that we could have an effective vaccine. i couldn't get my arms around how it was going to work. it's like the beam me up scotty sheen and i was welcoming the chance to be wrong. i sit here today and say show me the aids vaccine and i still have that issue. i do the lead we can have an effective ebola vaccine. ie really be legally can. but there is a big disconnect between the work to get us there , the time it takes to get us there and then getting it to somebody in africa. what we are not doing right now we are not basically gaining this all the time all the way through. when we are talking about a 57 million-dollar investment sounds like a lot of money and i think the united states for that. that's a drop in the bucket if we are interested in moving the vaccines. and in this regard actually, we need to be dealing with everything at the same time.

the r. and d., the potential for measuring how it is going to work or its vaccine effectiveness, how are we going to make it, how are we going to finish, how are we actually going to get into africa, how will that be sustained, i want to know that now. i don't want to do it sequentially and wait and then work on b. and c.. we need to imagine that it could be on fire. that means now they would be sponsored by my organization as well which we are bringing together the experts in those areas and we will be coming out in 30 to 60 days laying out the challenges that must be mapped to get to the effective vaccine. it cannot be business as usual. it doesn't mean that you take shortcuts that will impact negatively on people's lives but

you don't wait for program time to catch up to virus time because it never will happen. to me that's a very important part of it. the other part is we need the research agenda. we have none. i understand in the time of dire humanitarian straits, it's hard to do research but we are not doing it for research sake we are doing it for prevention because we have some major questions we have to get answered and we don't know. i think it is a travesty we are now in this outbreak this far and we have a single set of isolated genomic data from one location and we have people making pronouncements about what the virus is doing but they don't know what the hell they are talking about. we don't know what's going on. we need to have that kind of agenda right now and understand better what is happening there. why is this different?

isn't just the population or are there other things going on? i don't know that there is and i don't want people to walk away saying that scary -- i see evolutionary biologists commenting all the time about what is happening there and we do not have a clue. we are working through a set of foggy binoculars. i think today you saw some very good information. what makes a the difference? is this a classic storm have seen with other conditions and what can we do about that? right now there is one approach they've taken in liberia because of the dire conditions of delivering care, helping to understand how well that works versus the more intensive care method is true. finally the issue of the risk

communication i just have to say right now we have to do a better job. i think we have had a number of people who've tried very hard to do a good job and i think they have but we have a problem in the fact we think we are going to scare people into the certainty does not exist. we have to start being honest about that. that's different than being scary. we already understand the issues. you saw sunday's la times. you saw the piece. the who report, 7% of cases had a fever there was a problem with that because you have to have a fever to be part of the case definition or to be found positive in addition so there was a certain self-selection. i'm not saying how big it was. maybe it was minimal. i personally heard from

clinicians to cases where people did not ever present the entire time from the mission to the treatment until they died they ever had a document on hundred five were 101.5. they never did. now we have focused so heavily in the clinics and so forth but if somebody present and doesn't have a fever what happens when the media gets all over and says you told us there would be a fever and now you didn't know what you were talking about now is the time to anticipate that an essay we saw that but we don't know about this group and we are trying to learn more about it. tell them what you might have happened and that is how you will learn about it and feel like you can't talk about it and number two, when it happens if it it happens and i believe it will, you don't have to feel like somehow you didn't tell them the complete truth.

i just want to cover this one briefly and say to comments about this. please understand we are talking about two different issues. there's been a series of things written about this recently where i've got to tell you that we would have never been into position to judge whether it could have been because it's always been overwhelmed by the transmissions. but by the work that's too many in sections where somebody needed podium and nailed the first something over the next 48 hours even though no one ever touched the ball you. we have seen far too many things like that. we don't completely understand. i'm not here to speculate. i don't know what happened but do we know that there was an issue because the focus is now on the incubation so there may be in that space a very limited kind of thing but to say that it doesn't happen that's the question that we should try to

understand that. it was never something that we could do before in the epidemiological and we could but we never could quite study it. i raised the issue about the potential for the airborne transmission being more of a transmit agent and i think i'm bringing up today as more of a classic example of what we should do. i raised that's because i've been talking to a number who were very concerned about it and they were concerned about it so that made me concerned about it. they decided they'd were recently talking about it and it's not as great evolutionary we are going to have what's going to happen. but me tell you how some people take this. in "the new york times" carl zimmer zimmer and some people would say is a very noted science writer variant of this science writer he said the chance of an american getting ebola are tiny to be a ebola itself is very unlikely to change so much it could go from being fluid poured airborne. that's just fear. that's like saying you are

afraid that wolves are going to be born with wings and fly around and attack people and fly from montana to new york. that's not realistic it doesn't work that way. i was one of those people early on explaining why hiv was never going to be a respiratory pathogen because we never understood which sells the virus was in and we understood that wasn't going to be an issue. that's different than this. number one, we have had examples of subhuman primates. we had one where the pigs transmitted to the subhuman primates and it was interesting to the people that counted a lot on this said that's not a problem because it's just from cleaning up the floor which is even worse if they fought through it it was deposited in the air slides that is worse. but the plaintiffs some people are concerned because we don't