>> tell that to somebody in a boat risking their neck. so thank you for your attention. thank you.

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you here and a pleasure to have sonia shah and her book "pandemic: tracking contagions, from cholera to ebola and beyond." she will read and talk for half an hour and take as many questions as we can fit into 20 minutes. we encourage questions but you have use this one microphone. it will help if after thuvent you fold up your chair and set it against a book shelf. sonia shah is a journalist, author and lecture. her work has been in the new york times, "wall street journal" and scientific evidence. crude, testing new drugs on the world's poorest patients, and in tonight's book, "pandemic," she

discusses pandemics from many ang angles including the outbreaks and the causes and going where pandemics affect people's lives and discussing what we know and how we can use this knowledge to p predict and contain the next outbreak. please welcome sonia shah. >> thank you for coming. this is my fourth book and third time at this bookstore. i think every time i have come i have a deep-seated understanding that i live closer than i do so i am always late. when i first started writing this book about six years ago, i certainly didn't expect we would be living through a pandemic of a novel passage of right when it came out. that is where we are with the

zika virus washing over the americas. 3-9 women who are infected with the zika virus have had abnormalities in their babies so it seem like it might have an affect on women. the zika virus is a good example of what is going on over the past decades and the reason i wrote the book. over the past 50 years we have had over 300 infectious pathogens emerge. we have had ebola in west africa where it had never been seen before. we have had avian in fluenza from asia that last spring caused the biggest outbreak in the animal industry. we had the middle east respiration syndrome, a corona

virus and the mosquito-borne stuff. what i wanted to look at as a journalist is how do the microbes that are tiny independent thing with no locomotion, how does it become this pandemic causing pathogen. first, i looked at the history of pandemics and picked one to focus on and that is one of the most successful pathogens and that is cholera. cholera has called seven pandemics. it kills half of the people infected and this can happen in a matter of hours unless they are rapidly treated. the latest one is going on right now.

just a couple hundred miles off the coast of florida in haiti. so i studied the history of cholera and went to places where new pathogens are emerging. south china, hong kong, port of prince, and elsewhere to look at how the story of cholera could shed light on what is going to happen to the history of the other pathogens. and the history of cholera is indicative of what is happening with the other pathogens. cholera came from the environment like a lot of new pathog pathogens today. 50% of new pathogens are coming out of animals and wildlife today. cholera did, too. it as a marine bacteria and lives in places like in

bangladesh where the major rivers drain. it is a huge wet land with water half salty, warm and alkaline and perfect to grow. it is a helpful inhabitant in its environment. people didn't live for a long time in areas like that were mangrove swamps. there is crocodiles, cyclones, tigers. but that changed when they chopped down the trees and90% have settled over the century. sudden people are in close intimate contact with cholera and the environment. that the allows the cholera in the environment to spillover

into the human bodies and adapt to us. of course what it does in our bodies is different than what it does in the environment. the first pandemic of cholera started in 1817 and spread into the russia, the industrialized cities of europe, and this is what is happening with our new pathogens. we are disrupting wildlife habitat or invading it and we are allowing animals and people to come into the novel contact and when that happens their microbes jump over into our bodies and become pathogenic. from bats we have a number of viruses. camels have probably giving us middle east respiration syndrome. monkeys we got zika virus.

we get the flu from the birds. we are allowing them to amplify in our cities and crowds. that started in the 19th century and cholera took advantage. people were flocking from the farms for the new factory jobs in the city. there wasn't a lot of urban sprawl. no metros to take you to the outlying areas so everybody riv lived near work. places like new york had a lot of people breathing on each other, touching each other, their waste was contaminating food and water. in new york, they had cesspools and out houses and there was no rule you had to empty any of

that stuff. people let it sit and try to decompose. but with 77,000 people per square kilometer that would not happen before the waste ran into the streets, overflowed into the people's wells and contaminated the ground water. so once cholera enters a way to spread like that spreading explodes. so the process of spreading is only reaching its peak. half of human kinds lives in cities and the majority of us living in cities by 2030. about not cities long washington. more like cities long mumbi with lots of infrastructure and slums. two billion people will live in

slums is the prediction. of the new pathogens taking advantage of the massive urban expansion in poor parts of the world. we have had ebola outbreaks since the 1970 but it never affected a place with more than a few hundred inhabitants. in 2013, in guinea it infected three cities with a combined population of three million. i think the zika virus is taking advantage of urbanization. we had zika virus probably since the 1940's and maybe before that but it was mostly in forest in asia and africa. it was carried by a forest

mosquito that mostly bit animals. it didn't bite people much. but now in the america's zika virus is being carried by a mosquito that specializes in living in human habitation. it be breed in a plastic water bottle cap. so all of the trash laying around is perfect environments for mosquitos to breathe in and they only bite humans. as soon as the zika virus got into this species of mosquito it grow rapidly. of course we car ry these things around. and that started the team engine where we started taking steam ships across the atlantic quickly and up and down the

rivers into the united states, and of course we connected waterways by building steam engines to build canals. the eerie canal opened just in time for cholera to come over from london to paris into canada into the waterways and into the entire interior of north america happening again and again. we are much better today with the flight network. we have not just a few capital cities with airports but hundreds of airports and tens of thousands of connections between all of our airports. in fact, this is a map i have in the book, you can make a map of all of the cities of the world connected by direct flies. if you run a stimulated flu pandemic on a map like that it looks like a petal dropped into a sea because you can predict

where and when an epidemic will strike by measuring the number of direct flights by infected and uninfected cities. that is how much of an influence our flight system has on the way epidemics spread today. these are some of the ways i talk about this and how modern life increases this. the other part of the book is what we do about it. we don't take them lying down. we have defenses. political and medical and all kinds of things we can do to fight back and contain these pathogens. it is interesting to look at what happened in 1832 in the book. i spend time trying to dissect that. in 1832, cholera came down to canada and the governor of new

york sent a top doctor into upstate new york and canada to see what was happening; if it was going to threaten the city of new york. he collected this data that has been mapped and the map is in the book. it showed a clear picture with clusters of pictures along the hudson river and eerie canal and you can see it coming down heading straight for new york city. very clear picture. but nobody in new york wanted to quarantine the canal. the canal is what had turned new york city into a backwater port into the premier port of the country. turned new york into the empire state. this is a hurj part of the economy and nobody wanted to close the waterway which would have been the obvious way to protect the city at the same. dr. beck said it might look like cholera is coming down the waterways but it is caused by a

theory that diseases like cholera and others are spread through essentially stinky air. they decided to blame the bad smells on the drunks, poor and immigrants especially the irish. they didn't just bad mouth them in the press but there was massacres of irish workers during the cholera epidemic in the 19th century. i lost my train of thought.

i am having a senior moment. >> they didn't want to quarantine the waterways, right. there were companies at the time that were distributing cholera-contaminated water and making money. the slum in the middle of manhattan called five points. gangs of new york was about five points. that is where all of the, you know, the worst parts of the cholera epidemic affected that slum. and that was the only source of flesh water on manhattan for a long time.

the pond was filled up with garbage and the slum was built on top of the garbage filled landfill. so the ground was low line, unstable, unlike the rest of manhattan that is underlined with bed rock. the ground water was easily contaminated because all of the material is sinking in the ground water. the state of new york chartered a company to deliver drinking water to the people of new york. that company, instead of tapping upstream sources of water, the brown river at the time was fresh and clean and knew it would taste better, they thought that would cost too much money so they made a decision like in flint michigan and decided not to tap the good water. they decided to sink their well in the middle of the slum.

they distributed that water to one third of the people of new york. and this is through repeated cholera epidemics. the person who maneuvered this was burr. alexander's nemesis and murdered. the company that did this was called the manhattan company. the reason they wanted to save money and they wanted to start a bank. the bank of the manhattan company. and that exist today. jp morgan chase. the biggest bank in america and that is their earliest history.

we got rid of a lot of malaria before we had solid biomedical solutions by changing our land use policy. we started building dams but the h people on the board of the dams to make sure we didn't extend the mosquito habitat. people started putting screens on doors and windows. we lifted people from poverty in the rural areas giving them electricity and mechanisms on their farm. we built it out. this is before we had specific drugs to deal with malaria.

this created an establish that was potent at curing disease very effectively. we gave over public health to a biomedical establish. what happens when we have outbreaks of disease, we don't look for the social and political roots. we wait for the epidemics to erupt, people get sick, and we hope we can throw sufficient vaccines and drugs at it to make it go away. that works for some cases but it is not sufficient for new diseases because when new pathogens come up we don't have the vaccines made or the drugs

and these things can spread exponentially. one example of this, of not looking at the social and political roots, is the ganghi outbreak in florida in 2009. it was centered in key west in 2009. it was immediately attacked as this biomedical program. attack the insect. but the mosquitos that carry this fever has been present in florida for a long time. florida has been surrounded by countries where this is around. that is not new. so there wasn't been any innovation -- invasion. we had the foreclosure crisis in

2008 and that meant a lot of abandoned homes. and in florida that means a lot of empty swimming pools. when the rains came, the empty swimming pools filled up with water and became giant mosquito hatcheries. and low and behold a year later we have this unprecedented outbreak of this mosquito borne virus in florida. so i don't know if addressing the housing crisis would have helped contain the gangi outbreak because nobody tried that. what i do know is the biomedical model failed. we are continuing to have the outbreak there in florida and it is considered a permanent part of the city there.

if we can prevent pandemics and engage with the root causes of them which are more often political and social and it is not a question of waiting for the perfect cure but a question of our own political will. thank you j listening. i will take questions. >> if you have questions, please go to the microphone. >> hi, i am natalie perue. i am enjoying your book. i have a question about the zika virus because i think it came right after with your thoughts about political, economic and every kind of treatment in terms of the olympics and given your theories in the book what would you suggest? >> well, i think it is a difficult situation. the argument they are putting forward in brazil of why they should have the olympics and why people should come anyway is because it is winter there.

it is true when it is dry and cold the mosquitos will not hatch as ready because you need standing water tr a for a week or if they do hatch that will not live along enough to spread the virus because they have to live seven days and it is cool. that is true there is a possibility there might be less virus around. but at the same time, we have living in a time of unstable weather patterns. all we would need is a good rain storm a week and a half before people started coming for the olympics and some of that water to remain standing. those eggs of the mosquito that carry zika virus can decimate and last for months. you just need a little water and they will come alive again. it is a risky endeavor. but at the same time, there is

no stopping the zika virus. it is going to come and it is here probably in far larger numbers. 80% of people that get it don't have symptoms. we are counting the tiniest tip of the iceberg. a lot of people who have symptoms think it is a rash, fever, and get better. it is probably already here in a more widespread way. if you consider the fact of 15 suspected sexual transmission cases in the united states. if there is a hundred introductions supposedly a hundred or so introductions and 15 of those have transmitted sexually those don't match up because sexual transmission is a rare form so there is likely many more cases. olympics or not, it is coming, it is going to be here.

it is just a matter of time before we see it manifest in a more detectable way. >> we are in washington, d.c. so it is hard not to talk about what the government is doing on the positions. for 12 years i was a leader dealing with infectious disease and bioterrorism. with your comment under clinton and bush there were large staffs at the national security council focus on biosecurity. there were 25 agencies and you have to have white house control or nothing. obama comes in and wipes it out. gone. it is not one of the 11 top priorities for the administration in terms of security. it is not even mentioned. under bush, tens of billions

went to figure out to get development of vaccines and therapeutics. all of that has been dismantled by obama. do you have any -- actually the explanation that we heard was widely quoted and it was cheney thought it was important and therefore we don't. that is what was widely quoted. what is your take of how it is possible, given these are existential threats where a billion people could die from a flu epidemic if it is the same lethality as 1818. you could lose a million people. you could have quarantines and pard

panic. how is it possible this administration has essentially zero interest in this issue? >> i think you said it all. i am not sure you had a question as much as a comment and fair enough absolutely. i do think we need to do even more than that really. what i am trying to talk about in the book is not just let's stockpile vaccines and have experts -- we need that but to look at health care infrastructure in poor parts of the world. are there enough primary services to those most vul nerable? how are we regulating the way we use land? we are breaking up pristine tracks of land and there is a lot of reason not at a -- not to do that and this is another one. these are reservoirs of microbes that can spill into your bodies.

we need the expertise you are talking about but i would like it to be a more multi faceted defense strategy. >> as you know, washington, d.c. has the highest rate of hiv in the united states as you probably know. from a global perspective, what lessons do you think can be learned in a pproaching these outbreaks. what can you learn from the global spread of disease as it relates to a smaller population. >> we have seen this in the history of lots of diseases and that is it is marginal communities that suffer the outbreak. this the like the epidemics of

cholera and that is we had slums in the middle of new york city. that was new at the time. usually the poor people were out on the outer areas of the units but with urbanization the slums were starting in the middle of the city and that was epicenter that sparked out to the rest of the city again and again. and there are a lot of parallels right now. ebola is a great example where simple interventions could have controlled that but there was nothing on the ground. even soap and water could have helped control the spread of a virus like that. but we don't have those services for those remote communities and that puts everyone at risk. that is something, you know, i think is a big lesson of the history of contagants.

>> hi, sonia, i am scott and work for a global health organization mainly lobbying the government to focus on health and strengthen the global world. i don't think it is ridiculously hard when you take a country and know what is killing people line in kenya where hiv and malaria are big killers. it is not hard to figure out what investments you can make that will make the biggest difference saving lives and having the biggest impact. but that is harder when you are looking at pandemics and don't know what the disease is or where it will emerge. priority setting is important. should we invest in health and strengthening verus vaccines and investing in labs. there is a ton of things we can do to prevent pandemics but i don't have a lot of ability to

say which things are going to have the biggest bang for our buck and i would love to hear your thoughts. >> i don't have all of the answers either. you are right we need all of it. the most glaring is health care in poor people. the cholera epidemic has been going on for six years in haiti but i was there a few years ago. we traveled maybe 50 miles from the capitol and that took eight hours because the place is so cut off. the thing that was so ironic is they were not so cut off they could not get cholera. cholera had come into this vil lage but they were cut off enough to not get any resources. they had one pipe of water coming down from the hills that the belgiums had built like 20 years ago as an aid project and

never gave them any support for maintaining it. no sources or know how for how to maintain this. when i came this pipe that brought the sole drinking water to the community was supposed to be on a cliff but because of the erosion in haiti it has fallen down to sea level and the storms are coming in and hitting had pipe. they had 32 holes in it and nothing to patch it up. they were using cloth and wrach wrapping it around. everyone was getting buckets and leaving it out. and when you only have a bucket of water you don't give up eating and cooking. you give up washing as much. so those really simple things like clean water and aid that is

sustainable over time, empowering local communities, those are all vague things. i am looking at how these things spread and what approaches we can take to empower communities to come up with their own solutions is the hugest lesson. when we go into the those communities do we ask them what they would like and they say i would like insecticide treated bed nets. no, they don't. they say we would like better treated water. >> i am from a part of the world myself where this problem is starting to develop for us. although i am from a different part of but none the less i am talking about the caribbean where haiti has a huge problem because of the tremendous poverty there.

i am happy you talked about the fact thatpublic health issue and sanitation issues are more important than medical issues to stopping a lot of stuff happening. two questions. the first question is because i can talk about it but i know i am from the united states of america and other developed countries that tend to place people in the tropics, africa is example, to try to figure out potentially coming epidemics and how to track them. that is the first thing i want you to talk about. and the spread of the zika virus starting to happening in the caribbean. not on my island yet but only a matter of time before it is there also. there is a complexity coming out of brazil about the issue of the

consequences of it for kids that people are saying, yes, potentially for certainly people with genetic profiles this can lead to catastrophic consequences but you said 80% don't show a thing. there is a problem no one is talking about. in a lot of neighborhoods where this is happening, especially with the kids, and these neighborhoods were bombed with a lot of pesticides and stuff. if is zika virus plus the other elements that led to that. have you thought about that and i would like to hear from you. >> there has been alternate theories about why we had the rash of encephletisis in brazil.

the pesticide theory is probably not the best scientist. there has been used in other parts of the world and no spike we have noticed elsewhere. could it have been used differently in these places? because of cultural reasons or other could they have gotten a higher dose? i don't think. i think it is a mistake to just dismiss them as conspiracy theories. that is the initial response from the global health administration. but there is a reason why these alternate theories come about and i think it is useful to look at that. they come about because of a lack of trust in our biomedical establishment.

if you trace it back and this is something i do in the book, i look at why were health workers during the ebola crisis attacked and slaughtered? doctors were stoned in the streets, there was mobs, you know, burned down quarantine hospitals. we see this again and again. and if you walk it back, you know, there are transgressions that have occurred between the biomedical establishment and local people and maybe through the best of intentions but it is still there and needs to be addressed. that lack of trust is deal and needs to be addressed. when we dismiss alternate feelings we are dismissing the fact they don't trust us. it is the same thing with the anti vaccine argument where

people say those people are so stupid and ignorant. of course it doesn't cause autism but where does the distrust come from? people are concerned about corporate control of medicine and secrecy and they are real issues worth addressing and worth addressing why people feel they can't trust these issues. when a big pandemic comes we need to trust our authorities so we need to work on this. we need to be on the same page. we are not there yet. we have a lot of pockets of mistrust and conspiracy theories that come up almost immediately. with zika virus there was the gm mosquito and the monsanto and all kinds of theories about why this is happening. >> hi, i am studying public

health at george washington university. i am taking a class called the social deterrents of health. and my question is how would we work toward creating policy that is affecting environmental issues but perhaps getting at the root cause of social issues. >> how people experience disease and what interventions make since is a huge thing. this is a huge issue of malaria where we were hatching plans in countries that didn't match up with priorities. bed nets were a good example. we created insecticide-treated bed nets. it was cheap, easy, don't need refrigeration or roads or anything.

they can be in the most poor, deprescri deprescrid deprived settings and we can give them this and save them. we did that, spread the nets around, and it was a huge effort with a lot of good intepgntion d money and resources. and only 20% were being used. they sent people in to look at what is happening and people don't consider malaria a killer disease but a normal problem of their lives. the nets are hot, they are square and they live in a hut, they are the nicest material so they are saving them. all things not considered. people on the ground with the most malaria think of it differently.

they have immunity to it. if you survive the gauntlet of the first two years of life you have immunity to it. and malaria comes and goes. it is like you and i think of the flu. if we had african scientist coming to the united states saying all you need to do is wear this mask for six weeks. it is simple. we don't need anything fancy. we will give you these for free. would we do it? we don't even wash our hands during flu season. >> i have sort of a question about the contrast and ted copal's book about massive power outages. what are your personal akction

you have done to prepare for pandemic or what do you do in daily life to avoid the emdepics? .up and i am the daughter of tw daughters. i grew up with that feeling of who cares, i will take them antibiotics like