arabian peninsula. do we have that same sort of granular information there? >> again, i think it varies depending on which al qaeda affiliate group you're talking about. and we can talk about specific cases involving specific known individuals in another setting. >> and then, can you describe in open session for the committee, what we know, what our intelligence has said about the relationship between isil and al qaeda. is it rivals? cooperative? what do we know at this point about their relationship? >> well, one of the things i think has been a -- a development that we've spent a great deal of time trying to understand and assess is the degree of conflict intention between isil and core al qaeda leadership, as i said resident.

in the effort to lead the global jihad. with isil increasingly posturing itself as the legitimate follow-on or heir to osama bin laden or al qaeda vision. and what that is also doing is causing intellectual ferment in the community around the world. we see this from other affiliates as they seek to decide for themselves, do we align with isil or maintain fidelity to our traditional bonds of loyalty to al qaeda core? one thing we can observe pretty obviously is that success breeds success. when isil has had success on the battlefield in taking over large swaths of territory in iraq, that has served as a draw not only to foreign fighters who might want to choose where to bring their capabilities but also to individuals who may be

affiliated with other al qaeda groups who decide i'd like to go where the jihad is the most hot and the -- where my ability to impact global jihad can be felt most acutely. and there's no doubt that they're at the level of individual al qaeda affiliated individuals that draw is out there. and it's something we'll see -- that will play out over time whether isil would supplant al qaeda core in terms of overall leadership of the global jihad, but it's clear if things trended in this direction for a long period of time, one could make that argument. >> thank you. >> all right. thank you, senator. senator portman, please. >> thank you, mr. chairman. and i appreciate the testimony today and the opportunity to ask you follow-up questions in another session. and there's so much to go over. but i'm going to talk a little bit about what you said today

and what some of my colleagues have asked about in terms of iraq and isil and how we got into the situation we're in. i think it's important not only to determine what we do know in iraq, but also to look to afghanistan. and what we were doing or not doing there to ensure that we don't have a similar situation. with regard to afghanistan, how do you assess the security forces there? the afghan security forces as compared to the iraqi security forces, mr. rassmussen? >> i'd want to come back -- >> specifically, their capability to conduct counterterrorism operations against the taliban and al qaeda partners. >> i believe we've made a substantial amount of progress

in bringing the afghan national security force up to the level where they can carry out counterterrorist operations against known terrorist targets inside afghanistan. what will be -- what we will not know until we see over time is whether the afghan government is able to sustain that capability, invest in resource and sustain that capability over time so they are able to do this as they encounter threats -- >> you think they have greater capabilities than the iraqi security forces assuming that as was the case over the last few years, there is no u.s. support? >> i'm reluctant to put it in comparative terms because i'm not sure i have the right expertise or knowledge through that. and i'd be happy to get you an answer from that. >> i think it'd be interesting. here's my feeling from some of your reports, which were made public and other assessments is that, in fact, the iraqi security forces were further

along at the time in which we chose to pull out. and if we decide to do the same thing in afghanistan and that the president has said he plans to have no more troops in afghanistan by the end of 2016 that we may have a similar, and i would say worse situation, given the assessment of their capability to be able to have an effective counterterrorism operation. i just make the obvious point that we need your help in terms of learning lessons from iraq. and hopefully taking those lessons to afghanistan. there's been a lot of attention recently to president obama's comments in last january about regional terrorist groups being like jv teams in relation to isil seasoning of fallujah, i'm sure you followed that back and forth. and mr. taylor, general taylor and mr. rassmussen, i'm not going to ask if you shared that

assessment at the time, because that was an assessment that he had. but i will say, given all the bloodshed and resources expended in the two attempts to take fallujah in 2004. and i was privileged to go there at one point in 2004-2005 time period. and those years of toil by our marines and soldiers in anbar that followed to make it a are particularly disconcerting. as you all know, we took serious losses. in one six-month period in 2005, lost 46 marines in one battalion, 22 killed from one rifle company in columbus. obviously this struggle affects a lot of our communities, including back home in ohio. i would ask you, mr. rassmussen, in 2013, did the intelligence community identify that al qaeda associated groups in syria had expressed interest in external operations?

>> yes, and we can talk about that more in closed session. >> yeah. in 2013, did the intelligence community assess the threat existed into western europe in the homeland from foreign flow fighters? >> absolutely. >> do you assess that the iraqi security forces who early this year have been operating without u.s. troops by their side for two years took any successful actions to the control of fallujah after they seized it in january of 2014, earlier this year? >> i'd like to get an answer for the record from you on that. i'm certainly aware of iraqi security force counterterrorism actions. but i want to be specifically -- >> let me ask a more general question, were they successful in resting control back? >> not in resting control back of the areas you describe as i understand it. >> okay. >> you know, i just think again, we should learn some lessons from this.

and finally i said do you assess -- in syria as well as inconsistent terrorism operations or pressures from the iraqi in iraq to escalate their operations? >> certainly true that they have escalated their operations and they've taken advantage of the lack of a real border between iraq and syria, which has allowed them to move resources back and forth to escape counterterrorism pressure whether it comes from the iraqi security forces or other elements inside syria who are fighting. >> well, i think your answers to these questions are helpful in terms of us understanding what we should be doing in iraq but also, again, looking forward to afghanistan being sure that we are prepared to take the steps to avoid a repeat of this. let me change topics, if i could. and this has to do with the ebola crisis. general tailor, i'm interested

to hear what work your office is doing to monitor the spread of ebola in africa. we now have over 2,300 people who have died. the world health organization tells us today they expect 20,000 people to die relatively soon. we had another u.s. citizen infected this week. what are you all doing? >> sir, my office works with our office of health affairs who is leading the effort of the department and the inner agency response to the ebola virus. and it's the consequences intently to the u.s. and as well as the africa region. their daily inner agency, trying to get aid to those countries to stem the spread of the virus. >> do you feel we have been effective inner agency and inner governmental coordination?

>> i think we have effective coordination, but this is a global problem and it's going to take a global solution to solve it. and the nations in the region are less capable in certain cases of handling the kind of infection that they're seeing. so it will require a global effort to stem this particular issue. >> have you -- i understand health affairs is taking the lead here, but have you had the government did in relationship to malaria. in that inner agency process we've used? >> i've not personally looked at it, sir, i'm just aware of the efforts. my most recent experience has been with h1n1, which i think we had a very effectiveñr inner agency coordination on that. but not the malaria. >> i'm concerned that we are, again, not being as aggressive as we could be, and i would hope

that the agency would take a look at what we have done in the past and where we've been relatively successful and not just with foreign aides but also with the specific steps we were taking on the malarian issues. one final question, do you have any insights on how you see the spread of ebola developing. and what we should be doing here in this country. i noticed that you talked about the national preparedness month. and one of my concerns is based on some recent reports we're not prepared. we have, unfortunately, a situation where if a pandemic were to occur that there was some shortfalls, including explorations on some of the medical response that will be necessary. do you have thoughts about that? >> sir, i would prefer to respond in a more wholistic way in consultation with my

colleagues. so if i could take that. >> we appreciate you getting back to the commissioner. thank you, thank you, mr. chairman. >> thank you. thanks for those questions, especially the last ones. senator ayotte. and after you've spoken, i'm going to give mr. anderson an opportunity. i'll give you one opportunity to point that you want to make or share with us in the open session before we go to the closed session. you'll have that opportunity, okay. for now, senator ayotte. >> thank you, mr. chairman. i want to thank you for holding this important hearing, i want to thank our witnesses for what they do to keep the country safe. so secretary taylor, i wanted to follow up on some of the questions that senator baldwin had asked. and i would ask all of you to give me some insight on a comment that i heard from our fbi director. i think it's important that the american people understand what we're dealing with in terms of not only americans, but westerners who have potentially

traveled to syria or have interest in traveling to syria and joining with one of these extremist groups, including isil. so you had testified that more than 100 u.s. persons you're tracking and you've identified those as those who have intended to go and some of whom have been engaged and killed in this conflict. i note that the director said in august, when i give you the number of 100 americans, i can't tell you with high confidence that it's 100 or 200 that it's 100 or 500, that it's 100 or 1,000 more because it's so hard to track. here's a very important question that i think people need to know. and that is do we really know? and how many of these do we really have track of, and how many don't we have track of? >> senator, i would share the

director's comments in terms of we don't know what we don't know. and i think those -- that's the context with which he was making those comments. i think we have very high confidence on the number that we do know. and we have systems that help us identify more day in and day out. so i could sit here today and give you the number of over 100. and tomorrow, it may be based upon our intelligence investigation with the fbi, we'd have more identities that we didn't know about before. >> but is the reality that while we've had confidence in the hundred, that we really don't know how many more may be part of this? >> i think that's a fair statement. >> i mean, assume that's why the senator made that statement when he was specifically asked about how confident we are in the number of 100. >> well, given home grown

violent extremism, given the nature of how people radicalize, given the nature of the data in the, on the internet, it is very difficult to say with any degree of certainty that we know all that could be wanting to join this particular effort. >> so we know it may be more than the 100 that we're talking about. with respect to the 100 that we do know, do we have track of all of them? >> yes, ma'am. i would defer to my colleagues of the fbi who lead the joint task force looking at this issue for our government. >> senator, if i could address that. so i agree with general taylor whole heartedly. i could tell you any individual, and they definitely fit into the three categories mr. rassmussen had talked about.

whether they're abroad or in the united states. we also dedicate an immense amount of resources to covering individuals that we know about. i can't actually get into all those in this session, but we will in detail in the next session. >> let me ask you, the hundred that we know about, what authorities do we have to revoke their passports? in other words, your united states citizen, you're entitled to certain rights, but so what can we do to make sure that they can't get back in the community? if we believe they've joined, for example, an extremist group like isil who has brutally and horrifically murdered two american journalists? >> senator, that is a -- it's a very complicated question in terms of taking away an american's passport. there are judicial means to do that.

i'm not an expert in that, but we can get you the answer of what -- what are the authorities that would allow that to happen. >> well, i think that's really important. because we need to understand. we certainly don't want a situation where you all talk to someone you don't have the authority to detain them. we're in a position where they have to appear before a judicial authority, but in the interim, they're not detained and they have open access in america. so i would like a follow-up to know what those process are, what tools you have at your hands when there is obviously evidence that an american is involved with a group like isil so we can understand whether those authorities are sufficient. so i would appreciate a follow-up on that. i also wanted to ask, what i understand from hearing your testimony today is that you said that the threat of isil is really regionally focused, meaning the region of where they're operating in iraq and syria and this surrounding

regions. what kind of access do they have to financing? >> it's been one of our great concerns is that they've had the ability to draw on a wider array of sources for financing, including kidnap for ransom. simply occupying and taking over federal reserve holdings. >> i heard, an estimate of they're making at least $1 million a day. is that a fair statement. >> that's a fair estimate. >> okay. and as i understand, they have safe havens in syria, correct? >> yes. >> and they're obviously taking over more territory in iraq, correct? that is their design and one of the reasons, concerns we have with regard to what's happening in iraq right now. >> that is the ambition in iraq in recent weeks. security force action in combination with united states military action has stemmed the

ability of isil to gain more territory. >> but they have some territory right now. you would agree with me? >> yes. >> they have territory in syria, in iraq, they have a means to make money. and when we think about this threat on the passport issue, it's not just about americans, right? i know secretary taylor, in your testimony, there's about 2,000 westerners. but i've also seen estimates of 7,500 potential foreign fighters from all different countries that have joined this conflict starting in syria. i don't know how many of those have joined isil, but this threat goes beyond thinking about americans. how good, i know you talked about a good news story about more communication between those, our other countries with regard to these individuals who have joined this extremist groups. but we also have a waiver program with countries like the

united kingdom and france. and how good is our intelligence and ability to track those individuals? and we talked about the hundred, so we're worried about our people. but thinking about the individuals that don't need a visa to come travel to the united states of america. and as i understand it, there's actually thousands, the numbers that the united kingdom, great britain is facing is much greater than even the united states. can you give us a good assessment of how good a track we have on them and what ability we have to stop them from coming to the united states or to know exactly where they are so that we don't face a situation where someone is a -- the james foley video, that individual that committed that murder, he was clearly from great britain, you can tell from his accent. an individual like that coming

from the united states and then participating in an action here. so, can you give us a little more insight on that? because i think it's important for people to understand. >> yes, ma'am. i would defer to nick to talk about the intelligence cooperation that we had, which is significant with our european partners. and daily, we exchange information. more importantly, visa waiver does not mean people come to coming to the united states from outside the united states is screened through our terror screening system. and if there is derogatory data there, they're not allowed to come to the united states. >> but that assumes we have the data, correct? >> well, that assumes we have the data and that's what intelligence collaboration, cooperation is all about. is making sure that with our partners in europe and other places that we are getting that data and getting it in a

consistent fashion. >> so i think this is all, obviously, a very important issue, as well, is knowing and tracking who these individuals are who if we don't have the data, we may just allow them in our country without being able to stop them from coming. my time is up, but i just want to say one thing that concerns me. what concerns me is i know we've talked today about believing that really the focus on the threat of isil is a regional threat. but here we have a sophisticated terrorist organization, which our own secretary of defense has said is beyond anything we've seen. and, in fact, we have a situation where, you know, secretary dempsey described this group as an imminent threat. and we have combined with they have financial means to make money, they have territory and some safe havens. we know that in january, their

leader basically threatened the united states of america. we have seen through their actions with the brutal murders of these two journalists that obviously the threat that they face. the type of barbaric actions they're willing to take against americans. and then we know that if these people who joined this, if we're not quite sure how many there are and could return to the u.s., i'm concerned that it's an understatement this is a regional threat. in terms of what it might present to us in our homeland. >> can i respond to one -- >> yes. >> are you using the word regional in my remarks in the beginning, i by no means meant to imply not directed at u.s. citizens. because currently isil has the capability to threaten in surrounding regional states. our embassies, personnel, diplomats and nonofficial americans are certainly. >> what about here? >> as i said, if allowed over

time to utilize the safe haven they currently are enjoying. >> right now, you don't think they have that capacity? >> right now, we assess they do not have active ongoing plots aimed at the united states homeland. >> that's a different question of whether they have the capacity. we don't know of any active, ongoing threats, plots, but -- >> and we do not assess right now they have the capability to mount an effective, large scale plot inside the united states. >> large scale, correct? >> another piece of this you can't necessarily account for is grown violent extremists who may self-identify as acting in sympathy with or in support of isil. or perhaps never even touched leadership in any kind of command and control way. but in the aftermath of a potential attack, even here in the homeland might self-affiliate and describe. i don't mean by any means to minimize the threat to isil, that's not my intent.

i was simply trying to describe and in a sense concentric rings where the levels of concern we have at present versus what we see developing more over time. >> thank you. >> no doubt what you've described with the foreign fighters is what gives them the capability to threaten the homeland over the longer term. >> thank you. >> i'll just add one point. you know, you have to take the various members of isil to come across our southern border. it's out there, it's in the social media. so i know you all are looking at that, but the fact is, that's pretty scary. because we -- you talk about what we don't know, we don't know the people who are coming across our border, what their threat is to us. we don't know. >> i said, mr. anderson, we'd give you an opportunity to have a closing thought, please. >> thank you, mr. chairman. make a closing mark and turn

back to cyber for a second. when it comes to cyber, i've never seen more cooperation than i have in the last year or so. the people at this table, dhs, secret service, intelligence partners, we all get it. we get this is something that is going to go through from now to the next several years in our government to work together and work towards a fix. we talked about a little while ago a number of federal departments could be hacked and if they were, they just didn't know about it. i know one of the things we're all working on. but trying to figure out how we share realtime information with our private sector partners. i think that is absolutely imperative, mr. chairman. i think my colleagues here would echo that. one of the main reasons is, everyone knows a lot of our classified and very sensitive

technologies are developed, designed and then built out in the private sector way before they're ever classified. our adversaries know this. i've had the pleasure over the years to chairman feinstein, dr. coburn on many times regarding this kind of scare for us. and i would tell you that the one thing i see the whole of government coming together as one on this threat and really working towards a positive fix. thank you, mr. chairman. >> and i would just add to that the threat of isis and these other terrorist groups. are they a threat? sure they are. and we have to be eternally vigilant. it's not any time to pat ourselves on the back and become complacent or anything. it's time to be morez2ez vigila. we'll see what the president has to say and i hope he'll be very strong. i hope he'll lay out a game plan

an armata of other nations around the world. i'd also say one last word. i always come back to underlying causes, root causes. and we talked about underlying and root causes. and i would say a couple of them. one, underlying cause. you know, al qaeda in iraq was on their back. they were almost done. about seven years ago. and the policies of the iraqi government. often help them get off the mat and back in the game and be the threat they are today. and my hope is that the new prime minister, the new government that's being stood up in iraq will be part of the solution to help us accomplish what we did 7 years ago or to do it again. and even this time for good. all right. great to be here with us, i appreciate our colleagues being here, as well. we're going to move to a secure setting. and with that, this portion of the hearing is adjourned.

president obama tonight is set to talk about his plan. the a.p. writing the president plans to outline a broad expansion of the u.s. military role in combatting extremists in iraq and syria, including a call for arming syrian opposition forces and potentially launching

ire strikes in both countries. obama has told congressional lawmakers that he has the authority to proceed with much of his plan without their formal approval. however, he is seeking authorization from congress for the train and equip operation for syrian rebels, a request he first made earlier this summer. we'll have the president's address tonight live on the c-span networks, also on c-span radio and online at c-span.org. also tonight, a debate between south dakota candidates vying for the senate seat left vacant by tim johnson. and independents, former u.s. senator larry pressler and gordon howie. governor mike rounds, the republican candidate in the race has declined to participate. live coverage starting at 8:00 p.m. eastern on our companion network c-span 2.

last week, doctors and health experts came together to discuss the ebola outbreak. a cdc official taking part in the event said the virus is winning and that the resources available weren't enough. georgetown university's institute for national and global health law hosted the discussion. >> thank you very much, john, and larry, and for the conven s conveners. it's an honor to be here. it was one of the greatest honors of my life to be able to work there for three weeks. i have no fever, no vomiting. >> not shaking hands. >> i didn't shake a single person's hand. no one has any other close contact, either. so i'll try to limit this to three minutes to cover the three

weeks. let me say there are three primary things i tried to focus on. many opportunities to do many good things, as -- even as one person. so the first thing was the compassionate care and evaluation of patients at an ebola virus testing center, the largest one. i had the great privilege to work with the one and sometimes two doctors that worked there. one from spain who worked there straight through for two months and still there now. and another 27-year-old british physician from kings college. so it had a profound effect on me being able to help provide care and evaluation of patients we bith ebola virus disease. secondly, and closely related activity that i participated in was the training of mostly nurses, but also doctors approximately 160 in how to put on the personal protective equipment. p, pe.

more importantly, how to take it off safely. that's when there's virus on your gowns and gloves and your goggles your face shields and you have to take it off in a very sequentially important manner, washing your hands between each step. i worked with the minister of health chief nursing officer, and the uk physician, and sierra leone physician. and together, we trained trainers, francis and joseph in particular who went on to train more people after we left. both in free town and other hot spots. and the third was was to try to organizing children with ebola. the main pediatric has closed and hasn't reopened as of august

18th. many children with curable diseases like malaria and typhoid who are not able to get medical care as a result. just briefly, i did bring handouts. one on the pediatric situation in a publication called program for monitoring diseases. a small role to play in that article. this is an article i wrote and take full responsibility. there's no one else that contributed to it. it'll be controversial, but many people read it. and i distributed it to colleagues, more than 30 professional colleagues in free town. and it's not meant as a criticism to any one person or any organization, it's simply how there are 18 problems and 18 solutions for how the ebola virus could be made better, much more efficient and provide better care for individual patients and for the city wide response to ebola.

i would like to say that has a more profound impact on me personally, and i think it should on many of us because it's going to get much worse. just today, about an hour ago, w.h.o. announced a larger outbreak in the large oil city in nigeria linked to a physician who died, had many close contacts with patients and other people. in my opinion, and i'll say this, no one else has said it and certainly it's controversial, but i truly believe after the three weeks being there in sierra leone, this is the first urban outbreak ever of ebola. personally, i don't believe our traditional methods of being able to control and stop, stop ebola outbreaks in rural africa, more than 20 of them since 1976 that isolation of people sick, or people that are ill was going

to be effective in, perhaps in most of the cities. and therefore, i think, that this outbreak's going to go on even longer than a year and we're going to have vaccines, drugs, antibodies against the virus and post exposure to stop it. we can do everything we can do now, we should do more to slow it down, to start it to decrease. i'm not confident we'll be able to stop it without what are still investigational therapies and vaccines.&r>uv7hg> dan, thank you. for those remarks and thank you for your service.

i think we want to start with the human picture. because this is a particularly terrible virus and disease. but let's step back now and try to get a situation analysis of where things stand. i'm going to ask marty who has been tracking these issues across all the affected countries and populations. if you could give us an overview about where we stand. i think we know we're not at the end. i guess really what we want to know is are we at the beginning of a control here of the kinds of epidemics or individual epidemi epidemics. if you give us an overview, that would be great to start the conversation. >> thanks, john. and thanks to you and larry for the invitation i really appreciate the opportunity. i do need to provide a disclaimer to larry's heaping introduction there. you know, i'm one smart part of this response in an agency that has mobilized several hundred, last count, more than 400 or 500

people engaging, 70 deployed. i'm told more will be deployed internationally by the weekend will be well over 100. it's unprecedented in some regards, response for our agency, as well. and there are many, many brilliant minds and talents and dedicated and passionate people engaged, not just from cdc and i think larry heaped far too much credit on me individually and i certainly don't deserve that. in terms of context, i think i really appreciate dan's opening comments about perceptions on the ground. and what i'd like to say is why are, what are the characteristics of this epidemic and in some ways this epidemic that is very much out of control in some areas. what are the characteristics that make it unique in that regard as compared to, as dan pointed out, the many other ebola epidemics have passed since the discovery in 1976. one of them is the location.

so poverty as margaret chan said in her new england article is pretty profound. and we're seeing painfully the face of poverty and disparities in health systems and so on. and the impact of intersection of extreme poverty with a devastating and merciless virus is really staggering in that regard. weak and fragile health systems that have been suffering and in states that have only recently emerged from years of civil war and infrastructure challenges. another unique aspect. compared to the original outbreak in '76 in a very isolated forested area that was unconnected. the tools of detecting an outbreak, case identification, isolation, contact tracing and beginning to alter unsafe burial practices which really cause a huge amount of transmission.

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

in urban areas, which is, again, unprecedented, and the strategies and the thinking about how to control in dense, crowded urban slums like west point, you know, in the capital cities, in free town. the whole concept of how to deal with a lethal outbreak in these urban settings with large population centers and connectedness, both regionally and to some extent through other places on the continent globally is a very, very unique circumstance. the infrastructure, the health infrastructure was fragile at its start. but epidemics of disease like this, horrible diseases like this are often followed inappropriately understandably have epidemics of fear and stigma. and fear and the stigma in many ways combats and conflicts the attempts to get an epidemic of disease under control.

on certain information, misperceptions, lack of understanding about means of transmission, suspicion of lack of trust in governments, suspicion of outside folks not really understanding how the disease is spread or who is bringing it. these things contribute to a level, you know, have we seen resistant communities or anger, appropriate anger, which is often, you know, the mask of that fear and vulnerability. and the extent to which this is the first ebola epidemic in west africa, also places that in context. the lack of a long standing understanding of the disease and where it came from and how it spread, and the importance of burial practices. i think that context is important to understand how, perhaps, we got to where we were. you know, some people referred to it as being caught off guard. to me, it's more important thinking about where we're going and not sort of finger pointing

or blaming. this is a massive -- not only a public health energy of international concern, but a humanitarian crisis, which risks civil society, and we're seeing sort of the collapse of some of the key aspects of civil society to keep it functioning in areas hard hit like liberia and in the capital. and i think in those areas, when you asked about the trajectory, we are -- we have not turned the corner. the virus is winning this battle. it is outstripped the human resources as dan highlighted. the number of treatment centers that are needed, the number of health care workers that are needed, the degree of personal quantity -- quantity of personal protective equipment, the quantity of body bags. the -- the people and the stuff that are needed to be able to get an outbreak of this magnitude under control are just not there. and there really needs to be a wake-up call to the global community that this is going to require a coordinated,

international, all hands on deck, not just a health system, a health sector or public health response, but a full response. it represents a significant global health security threat as new countries become -- have a single introduction like nige a nigeria, a single introduction on july 20th. and still trying to snuff out one train of transmission from one introduced case. and you think about that possibility of an epidemic, or an introduction into parts of, you know, we have one of the world's largest mass gatherings coming up shortly. in saudi arabia. and the consequence and the concept of having introduced ebola virus into these other type of settings with mass gatherings or mass communication are just hard to fathom. and other surrounding countries with also fragile health care systems. so larry's comments are very poignant. i think it's a long road ahead. i think the w.h.o. road map is

very much welcome. 6 to 9 months, i hope we're there. in the best of circumstances, maybe. but right now, we haven't seen the bend in that epidemic curve. and i fear that it could be much longer as dan pointed out. and we really are going to need all of civil society to be fully engaged. >> so i think we've got a sobering picture on the human patient level, marty, thank you for that overview. and i think it's, you know, if we're in a situation where the epidemic is -- we have not turned the corner, it is growing exponentially, at least in some of the key areas. i'm going to ask steve and i hope not to put him on the spot. but to give -- there's -- as you think about. as we think about a crisis like ebola growing particularly in capital cities on a regional basis, you might want to reflect more generally, if you would, on sort of the impact on politics in africa, global politics, just a little bit of the larger

frame. because this is a -- this has moved, as marty said, beyond a public health sector issue. broader, potentially set of issues around security. >> and steve, i would also love for you to talk about the security implications and the role of the united nations and the security council, please. >> i think in the last six we s weeks, this epidemic, the surge of this epidemic has forced us to recognize that it's moved beyond being a public health crisis. it's become a security, fundamentally a security crisis. it's triggered for the states in question, particularly liberia, sierra leone. but i would also say it's triggered a moment for them. these states acutely weak beforehand, their functionality

and their vulnerability to worsening civil conflict is now magnified tremendously. they have seen their already marginal health systems eviscerated and overwhelmed. they've seen food insecurity now touch well over 1.5 million people. they've seen their markets, their production, their economic integration disrupted. they've seen their integration into global airline systems disru disrupted. pretty much halted. they've seen the sudden exodus of talent out of these states across multiple sectors. and they've seen in the health sector in the emergency response sector they've seen a worsening of the risk environment, a deterioration of the risk environment reaching such a point that medical personnel

simply cannot be effectively protected in many of these situations. whether they are at work in these protective clothing or they're outside of work in a -- in a -- what's supposed to be a more normal situation. so what you're seeing is the insertion of teams that get exposed and they get suddenly and immediately pulled back. so my first point is this is not a health crisis, this is a security, a multidimensional security crisis within this region that now threatens neighboring and nearby states. so it threatens another ten states where you have the likelihood of onward transmission. second point i'd make is that while this crisis has mushroomed in this last period, it has not penetrated the level of world leadership and come to be recognized and acknowledged as a a -- as a global security

problem. it has not been brought forward to the u.n. security council. and why is that? why is that? if you have a -- the kind of implosion that i've described and the implosion that now threatens the surrounding region, and the human magnitude of the human crisis on a skyrocketing trajectory where we were told last week, yes, 3,000 dead, 1,500 -- i mean, 3,000 cases, 1,500 dead, but we thi think -- this is the w.h.o. -- we think it's two to four times that level. it could be 12,000 to 6,000. there's no confidence 20's a stop point. so you're now in a world of great unknown of trying to think about what the trajectory will beei and it's totally plausible

to see this asúg!a'g to 40, 50, or 100,000 or beyond. our own c in calculating the numbers has eroded. this has been a hard set of lessons for public health experts. so why has political leadership not grabbed on to this? there's a couple answers. one is this is the unknown. we did not know that there would be this cascade of catastrophes that would be triggered by this virus. we did not know that this perfect storm would appear and ignite in this region with the speed and ferocity that we have seen. i think that in the earlier days there was an overconfidence among public health officials that the measures that have worked in earlier settings would be applied and work in these

settings. there was access confidence in those tools and when pleas were made to political leadership from that world for higher level of attention, those went unheated. so there was overconfidence and there was an inability to penetrate to the higher levels. i think last summer regrettably it's been a terrible environment to get a virus-driven security security council when you have the islamic state in syria and iraq. you have the islamic/palestine war. you have the russia/ukraine war. it's a pretty crowded, exceptionally crowded environment to push this through. the last thing i would say is it's very hard to walk the sovereignty mine field here. until the states in question are prepared to come forward and plea for a higher level of

commitment, how are you going to win consent to deploy peace keepers into this setting. the model of response has failed. there needs to be another model of response that treats this as an emergency humanitarian catastrophe that requires a deployment of protected authority tative forces into this setting. but to get to that point requires consent. it requires sovereignty be respected. and it requires political leadership. there has not been political leadership on this matter. and i fear that what's going to happen is we're just simply going to do what the w.h.o. is suggesting which is draw up a list of 12 things and ask people to do more than of those 12 things versus seeing the big picture and coming up with a response to -- ?elereneed to transform this exponential crisis and we're not going to transform it by doing more of

the same. thank you. >> we have all three, the individual country level, the geopolitical. i would just i want to invite anyone=a else on the panel on steve's point. i would say this. i want to emphasize a a point in its relation to steve's. in the middle of a public health crisis there's a lot of people may look back and wish you'd done things faster or sooner. my summit, given where we are today, when are the things that we can do to attract the attention and the action of the players in the world who can make a difference in this dynamic because this is -- i would argue this is a very maybe not unprecedented but a rare place for us to be as a global

community. i would like to turn to a couple issues that received attention in the media particularly around the use of quarantine and access to medicines. so let's start with because both larry and dan mentioned the issues on treatment and vaccine. i'm going to ask kevin to kick us off here. we had the well-covered story of the two american health workers who received the medication. came back here and were treated at emory and have appeared to be recovered. yesterday they announced they are going to accelerate their contract to get more of the product available for clinical trials in the near run. as larry mentioned, the doctors announce announced that we're going to

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

have a compassionate use of a drug when somebody is potentially dying. but vaccines are given to otherwise healthy volunteers, which raises a whole other set of ethical questions. so if you could reflect on those things, that would be very helpful. >> absolutely. i mean, we have heard about the humanitarian crisis from the ground, from the doctors point of view. as a physician who spent much of his career treating children, it's devastating just to hear about this. i can't imagine what it would be like to live through that. we heard about the public health response. the inadequate public health response and how we're going to have to be able to do much more. that's certainly going to raise a bunch of ethical questions. but i think we have to remember that this is about the people

involved. and there's a tremendous urge to say if we can treat people, even with experimental medications, why aren't we doing that? i think that's one of the most ethical questions. i think there are several that are worth thinking about and we may be able to cover some of them today. that would be number one on the list. the other would be that when we're considering the allocation of those scarce resources, the most pressing question then would become, who should be treated because we have a whole lot more people who might be candidates for treatment and we do have treatments available. and also i think that one of the questions that i would like to hear discussed before we're done is if the ebola virus has been known as the cause of disease since 1976, why is there no preventive vaccine or effective

therapy? i have my own opinions on that, but i'd like to hear everyone talk about that. now first off what about experimental treatments being offered? i think we have to consider the pros and cons of giving experimental drugs to people. they have never been tested in hum humans before they were given to the sick patients. therefore the effects can neither be known or safely predicted. it's entirely possible they may be ineffective or even harmful. in america all fda approved studies have to go through a first stage before the harm can be assessed. followed by looking for side effectings and evidence of efficae effica efficacy. they have only been tested on mo monkeys and not even the first stage for human beings. the monkeys are getting better.

two of them have died. this doesn't prove that it's effective and doesn't prove that it's safe. we don't know what harm it is may do long-term or even short-term and the guiding principle of any new medicine is in the first place do no harm. research -- it's scary, experimental treatment. it was done because ebola is a deadly, scary disease. but if we were to keep approaching it in this uncontrolled way, we may never know if the therapies are safe and effective or at least not know until a great deal of harm may occur. the world, especially that part of the world now suffering most from ebola, desperately needs to know if there can be an

effective treatment as well as an effective prevention in a form of a vaccine. we owe it to all possible victims current and potential to get this right. there have been examples in the past of untested and undertested therapies being rushed into service and ultimately doing the patients a disservice. some of these misadventures occurred on the african continent leading to a pervasive distrust of western drug companies using africans as their experimental guinni pigs. when we look at the issue of who should be treated, the simple answer is all the questions ethically very important and complex it will remain moot until therapies are made available.

as we have already heard, noest itted or approved therapies exist and we are months away before any therapeutic drugs could be produced again for testing much less know they are safe and effective. the happy news, if there is in, is as larry already pointed out, vaccine testing has begun. vaccines may be able to be rushed into service sooner, we would hope, but vaccines will not save anybody who is infected and will only be effective if large numbers of the population can be vaccinated, which presupposes two things. first, that sufficient amounts of a safe and effective vaccine can be produce d. and secondly, that we can induce the threatened populations to accept this vaccine. and you have to understand in

these areas, we're having people still denying that ebola is real. and those who do get it are hiding from the medical establishment for a variety of reasons, which is making the entire control of this epidemic much more problematic. >> i was just going to follow up on this. i know this is a horrible thought, but it's occurring to me and i wanted to ask the question. if you think about influenza a and h1n1, which was a direct potential threat to western europe, the united states, australia, we very rapidly got a vaccine within months. here we're going back to essentially a regional tragedy

since 1976. i think public health experts at the cdc have said one day it will come to the united states but it will quickly contain it, so it doesn't represent the same kind of threat to us. what's the reason why we haven't seen the investment, the scale-up for well tested vaccines and drugs. >> i think the temperate answer is there's an arduous process of developing therapies, developing vaccines, only 1 out of 10 prove successful which means 90% of the candidate drugs and vaccines are not going to be usable for one reason or another. that's the nice answer. i think there's more to it than that. i think the stark reality is that pharmaceutical companies

are a business and the business has to have a market. and there are two-fold problems there. the first is as scary as this is and as tragic as the number of deaths are, this still represents a small market for pharmaceutical companies. >> and it's an unpredictable one. and this is the other problem. it's a poor one. i am convinced that if this epidemic were happening any place other than the poorest countries in west africa, you know, we would be seeing the attention that we have heard should have been given through this a long time ago. >> there's no question we're in a different dynamic than a global flu pandemic. >> just to give some context. i'm not saying i disagree with

all the issues at play, but to be fair, seasonal influenza comes every year. there's hundreds of thousands of cases globally. there's -- this is something that's a familiar recurring threat on the front line of everybody, everybody globally knows somebody who gets the flu and somebody who has succumb to the flu. . and that level of prevalence and frequency year in and year out as well as memories of pandemics past like 1918 and the devastation of an evolved mutated strain to which the whole world is susceptible is a power driving influence. . we should not underestimate the difference in frequency of occurren occurrence. there are many explanations behind this, but i don't want to -- >> but in a pushback, you're totally right. but in a pushback, even with

h1n1 and one can imagine this in so many areas, even though you might develop for good reasons a vaccine the distribution of a scarce resource still resides and even for seasonal influenza, the low and middle income countries don't really have those supplies, don't use them. 3:wz even for seasonal. >> let's take neglected tropical diseases and look at malaria, et cetera. there's been scale. it may have been later than we would have wished, but things that are more common that are more recognized as daily routine every year in and out killers have also been addressed. there needs to be more done to combat neglected tropical diseases.

and so i think where when we still look at ebola we're talking about in the scores of outbreaks, not in the every year thousands, millions of cases like neglected tropical disease. >> i think we are in different markets here. >> it's important to remember that prior to the ebola outbreak in west africa the total number of cases from the previous two dozen outbreaks was 5,000. the total number of deaths was under 3,000. you contrast that to the 39 million estimated deaths from hiv aids and the current population of 34 million living with hiv, those are rather desperate market numbers. if you're going to scarce resources on towards the development of treatments and

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

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

it's going to raise ethical issues, issues of race and that's the predicament we face on the ethical grounds right now. >> i think you're absolutely right. i think that what we really have to be focusing on are not the questions that made the headlines initially, they were great because they made us pay attention. but if we're going to make a difference in the immediate future, it's with things as simple as gloves and gowns and public health measures and those are the things we do need to focus on. soon we will have, i hope, a vaccine and maybe there will be an adequate market for it. the sad truth is there's probably another reason that we're far along as we are on the vaccine. and that is that it was also realized that this might be a

weaponizable infection. >> right. >> that does present another -- it's both a risk and an opportunity, right? because it does speak -- and i'll just take a second from my previous life at hhs. two things i would say is, yes, we did move quickly from h1n1 from identification of the virus to creating a vaccine, but that was not a given. it did work out in that sense, but i hope as much as i think we're all incredibly hopeful about the prospects of an ebola vaccine, i don't think we can assume anything and certainly it's a very complicated situation that doesn't have the benefit of the flu context of really an annual plrocess of developing a vaccine. >> we're not even to effectiveness testing yet. we're seeing whether it's safe on healthy volunteers. >> the second thing is it does make an argument for the kind of

investment whether it's for both biosecurity and for to deal with manmade threats and natural threats, it's an argument that it's about why you need to invest now for what maybe something coming down the road. let me ask others on the panel who i know dan had mentioned this set of issue. anyone else that wants to jump in. >> i want to mention one thing. in 2011, again, we were coming back to h1n1. but in 2011 harvey fineburg who just stepped down as the president of the institute of medicine, chaired, as marti well knows, a committee that was an independent examination of the response of the international health regulations during the first declared public health

emergency of international concern. one of the recommendations that he made and his commission made was precedent, which was to have an ongoing emergency response fund. something that provides surge capacity early on that you don't have to now five months later be asking for funding, but as marti said, that it should be there on the ground and quickly mobilized. so i mean i might just marti and others will know about the fineburg report. what could we do now to make that a reality? >> i was on that committee with harvey, and it was a year-long process. i think there were many good recommendations. it was both a reflection of how

the world responded to the pandemic as well as how the -- what can be done to strengthen the international health regulations and position the globe at the ready to deal with these what have become predictable in occurrence for emerging threats. and i u think your right. the committee report and the committee analysisly felt very strongly about the need for such a global emergency fund that could be called in quickly. in addition, i would point out that over the last year there's been a tremendous effort to develop a global health security platform, an agenda that would really frame this up. we can put a lot of -- have a lot of conversation about the speed and fairness of which they are dropped, but there's nothing like primary prevention because no matter what there's a lead

time for an emerging threat to come into the arena and really e we need to invest in prevention up front where it's possible, primary prevention. the ability to respond swiftly. i think all three pieces, all three pillars of the global health security agenda are critical. sadly, this ebola epidemic is a very painful example of the true need for that type of an agenda with the serious investment and the global set of partnerships so that when these inevitable things emerge in our globalized, highly connected world, we have the capacity to find them quickly. we have the infrastructures and health systems to respond, and we have the ability, even if we had a vaccine, we have the ability to deliver preventive services on a large scale in a quick timeframe. i think that those are key

aspects. this is just one example. sadly, there will be more. i hope we heed the call and the lesson and we invest with some look toward the future. >> steve, let me recognize you and then dan. >> thank you. mar marti raises, i think, a critical point for what can be done here in washington and that's around the global health security agenda. just to remind folks, this was launched by the white house in february of this year. tom played a critical roam, the white house and others. the president himself it involved a consortium of a number of other countries and organizations. it was driven with an awareness around the antimicrobial resistance and threats like we're seeing here today with

ebola. it's resulted in the aspiration to create a network of emergency operation centers around the world. but it's being done on a paltry borrowed budget of $40, $45 million a year. there is no funding mechanism that is robust, reliable, durable, sustainable for global health security in the u.s. budget beyond our borders. and there's no institution that is the sole repository of expertise and responsibility for leading on this. we're very fragmented. to the extent that this crisis stimulates a rethink on the hill and within the administration, the global health security agenda provides a very, very good model or set of pilots, which could be built upon quite aggressively, the summit for this is september 26th here in washington. so that moment will arrive and my guess is ebola will figure

very prominently in the discussions around why it is you can have such an ignited crisis in a place that really has not built up any of the capacities outlined under the international health regulations. >> i definitely want to move on. >> briefly, i want to turn to the science issue about the vaccine. so nature doesn't really owe humans anything. one example of that is vaccine development. you can put a lot of money and effort and resources and brilliant minds towards developing an effective vaccine. there's no guarantee that will work. and the most glaring example is hiv. hepatitis c. there are no license vaccines against any parasitic disease. a lot of research has been put

forward. for example, to developing an hiv vaccine. i only say that because there's no guarantee we'll have a safe and effective ebola vaccine. hopefully it's going to be safe and do some immune response. t cells that will be protective. the last thing i want to say is using the model, trying to learn from the past, one thing we have tried to do for almost 30 years. it's to look for a protective response that occurs naturally. that almost never occurs with hiv. but with ebola, it seems that it does. in this outbreak, approximately 50% depends on how accurate numbers are and only time will tell. but approximately 50% of people have survived. they are feeling bad but some are feeling better than others. one of the points here is that

person who is are cured of ebola that are underappreciated from multiple points of view. i would argue it would be potentially valued if we were able to better understand the immune response that's been induced in terms of antibody and what type of responses are induced by the natural infection and try to mimic our vaccines to reproos the natural immunity. >> and hope that the virus doesn't mutate. >> which it already has. this is almost a different species. >> that's another question about whether it would be effective across the range. >> can i add one comment to that? before figuring out the immune

issues around the survivors, now engaging the survivors in the control and the response having survivors tell iing the story, having the survivors potentially play an important role in safely providing care in areas where can be scaled up. that's an underappreciated public health -- >> once you recover just scientifically for the audience, immunity to reexposure? >> it's thought that recovered persons are immune to reinfection. certainly in the short run. the duration of that and the species variation may be different, but there's no reason to believe that people will be repeatedly infected in the same outbreak or epidemic. >> thus far what we have talked about in terms of response to

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

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

been used, and it was just lifted, i think, today or yesterday from west point. and what it might look like, would it be effective, could it be effective, what role would it play in relation to all these other therapeutic and public health interventions. >> and i guess i would just ask marti in particular to just share with us the current public health recommendations in the space and your experience. i think that's also -- >> sure, this is an area that there's been a lot of thinking about in preparation both in terms of preparation for a devastating influenza pandemic, in particular, and then the other things. i think that the tool, the public health measures, traditional public health

measures are based on the principle of isolating the sick, quarantining those who are exposed, but not yet ill and fully separating the unexposed or the well and creating that space around the principle of breaking transmission. and clear ly the two huge primay goals in this epidemic is to stop transmission inside the epidemic zone and prevent spread, prevent seeding of new locations. >> and also prevent preinfections. but to stop transmission inside. so we have highlighted how much we are a globalized world and how much mobility and interdependency there is. that is a formidable challenge in contrast to 14th century leaving a ship off the shore of v venice for 40 days where the idea comes from and letting it burn out. both in terms of the speed and volume of mobility, that part of the modern challenge as well as

the ethical challenge thankfully we don't live in the world where we sacrifice the victims for the benefit of everybody else. so the question you asked, what are the principles, the ethical principles behind using that tool in an effective way? and i think that some of them that have been written about by others as well as the papers that i published on this involved proportionality, making sure that the measure is proportionate to the threat, involved using the least restrictive means necessary to create that goal and dialing them back and minimizing the duration as the need for that no longer exists. a process that inside the ring, and this is probably the most important thing, the incentives need to be aligned between the victims and the communities that are being protected. they have to have a common set of incentives. and there's nothing that could

propel an instint to flee more quickly than armed guards and bashed wire locking someone into a space. that just goes against your primal instinct that if it's so bad, i better get out and get out quickly. so we can't confuse those incentives. i think that part of what is essential in a modern context is delivering effective services inside, not choking an area off from food and medical care. the treatment centers have to be adequate and sufficient. the work services, the compensation, the permissions, all of what would need to happen to align a community to voluntarily in some ways if the incentives are designed right, you don't need a perimeter guard. what you really need is a compelling argument, public trust and community engagement to voluntarily participate.

it's not impossible to create that. we saw the vast majority of quarantines globally applied during sarz were under recommendations with good advice. we didn't have a direct medical counter measure. we didn't have a vaccine to rescue, but there was a compelling argument and alignment. it was a different circumstance, absolutely. but i think the principles of that obligation, and then in addition inside the area, you don't want to create a hyper transmission zone. you still have to identify the sick as they might become sick need to be pulled out and separated. so you need safe space within a community or village where the sick can be isolated, where people can provide safe care. where food and water and nutrition and other structures can be in place. and those are the concepts. now those are not easy to do and the risks of doing it wrong are exactly what we saw in west

point. the simple military enforced with guns and barbed why in communities that already have a tremendous amount of distrust in authority, that has the potential for real catastrophe. >> imented to ask a follow-up and have steve come in with this. one of the things that's perp x perplexed me. most of the things we have said today, there seems to be great am anymorety. but i have heard some diskor dan si about the role of the military. some have said that the military is the only group that has the operational capacity to deal with something this big. others have talked about the need for security. securing ebola treatment centers, securing doctors without borders, other ngos working in the field.

and yet from a public health point of view, having the military involved is jarring. >> i want to qualify my comments were about military, armed military enforced. not the logistics or the guaranteeing of security forces. >> i just want ed ed to get a w discussion about that. >> i think those are different roles. >> what's the appropriate role of the military? i think steve and others -- >> what military are you talking about? >> i think particularly in the context of post conflict states where we know there's continuing challenges. >> also the international -- so there's several questions or dimensions to this. keep in mind in liberia and sierra leone, these countries involved particularly heinous abuses of civilians at the hands

of armed entities, some of them official armed entities. others malicious or op silgs on sigsal ones. it's hardly surprising that the creating in the parrots beak area in the remote area where 70% of transmission that that has failed. that it's permeable. i think the idea that the militaries can win the trust and confidence of their populations is a pretty dubious proposition. we have seen it in west point where what looks like basically creating a death zone or a tomb and saying those inside, good lu luck, and those outside, thank your stars. i mean, that's sort of the

militarized thing. what i meant about mel tears was the fact that there needs to be some kind of mobilization that can bring into this -- that can create the lift capacity, because the lift capacity has disappeared on the civilian side in terms of air. and it's highly disrupted. and we know from countless natural disasters and post war spags situations that blue helmet deployments are critical to restoring security and making it possible for all of the civilian-based things to go forward. this is a situation that says, okay, it's genesis is a virus, but it's morphed into a multisec tomorrow crisis and there has to be security restored and it would make sense to turn to that model providing you have the will to put troops into that. a request was put out to 53

yesterday. 53 countries on a quiet request through the u.n. channels as to who might be willing to entertain donating troops. and one country of 53 said possibly they would consider it. keep in mind also you have today 4,600 blue helmet troops in liberia part of the original peace keeping force and that is in a phase down. it's supposed to be down to zero in 2016. they said they want to get out for the safety and protection of their forces. you have a force there that if you could hold that force and build upon it within liberia and rethink its mission and give them confidence that they will be protected, you could begin to move in the direction that i'm talking about. but it's going to be hard. it's going to take an enormous political investment to make this work. >> you're thinking of international peace keeping forces. >> yes, they could be white

helmets. they would have to have a different look, but why is it that the president of msf is out saying that this has to happen. the reason that joanne is saying that is because they are shouldering two-thirds of the burden of delivery of service in three countries. one ngo. s that gritty, determined, disciplined and remarkable institution that does not shy away from brutal, violent, broken places. they are in eastern syria, they are in myanmar and west africa in the center of ebola. but they have reached the outside limit. they have a thousand employees. some other force has to step in to take things to the next stage. >> steve, would you say, if you could, just two sentences for the audience of distinguishing the types of roles that

international peace keepers can play, different roles the international troop cans play? >> i was making up the white hat thing. but the blue helmets, it's the color of the u.n. it's troops that are on a volunteer basis placed under a u.n. flag and u.n. command in order to play under the protocols and different functions. the functions are negotiated with the countries in question. and the duration and the rules of engagement and the deployments and the command structure and all that gets negotiated out carefully. it's not easy, but at any one time over the last two decades, the u.n. has deployed upwards of 20 peace keeping missions with over 120,000 blue helmet troops into conflicted sites. i see no reason why this situation should not be looking at that option and asking the

leadership of liberia why this would not be acceptable. >> the reason i asked you is i think it's important that every one of those steps has a history and a process that would have to go through with the countries. countries that are in crisis by all the things we talked about here. i'm going to take a little liberty here. we have about a half an hour left. one of the things -- this panel has been amazing. we have identified multipleazm8 issues. just we have talked about quarantine and issues relating to that. we have talked about various kinds of medical treatments and vaccines and talked a lot about public health interventions. we have a crisis of extraordinary proportion. it's not clear the trajectory, though there are things we can do, but we are at the tough part of beginning the control at a minimum.

as steve notes, we don't know that. there are a lot of unknowns here. so my question to the panel is before we turn to questions is, a number of you cited a number of things from the lessons we have learned in the first five or six months of this. one, what could we apply in the countries rugt now? and i think marti and dan have alluded -- let's not make the same mistakes twice. what have we learned, what can we do differently? and looking on a global stage and steve's identified several ideas that the use of peace keepers, the taking advantage of the health security agenda meeting coming up, i ask people to think on the near term and the longer term, what can we do with the kickoff to that being that w.h.o. put its road map out. $490 million. and that's an under estimate. that's their first guess. does anyone have a sense of the prospects of that happening and

how does that fit in? so near term and long-term, anybody who wants to say something in the next few minutes before we turn to the audience. steve? >> on the w.h.o. road map, it was released on the 28th, $489 million. it was hastily concocted. it didn't answer a bunch of questions. it's now up to $600 million target margaret chan this morning. it's not clear where the $200 million might fit. it's not clear where the african development banks $60 billion plus might fit. it's not clear who is in charge and it's not clear how to raise the money. so how are you going to fix that? w.h.o. in the midst of this crisis has been enfeebled by staff and budgetary crises. this has been a terrible,

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

but to actually operationalize that is not yet clearly defined. and that, i think, is what we need to focus on. >> anybody else want to add? >> i think that i'm going to stay away from that specific topic and suggest that right now in the setting of a crisis, there will be plenty of time. but i think right now in the setting of what's needed to move ahead and get things under control is a coordinated international effort with a lot of partners. i think one of the areas that's been perhaps underutilized is the importance of communities, community level engagement, social mobilization, messaging and communication, the use of

survivors, even community mitigation and community control strategies that are better al n aligned with the cultural acceptability in the areas where the control has to go on. and i think that increasing role we need to the major drivers of the epidemic. this is not just, you know, one epidemic. it's multiple epidemics that probably will require multiple tailored strategies to appreciate. it's one strategy that's applied when you have a single introduction into nigeria or another country. and you can stamp it out a chain where you have the numbers and the capability to recognize and detect and try to snuff it. it's probably a different strategy when you're on the accelerating growth phase in an urban area.

and i think that we need to be able to look at this as a multifaceted epidemic and engage the understanding, the public trust, the community support to help break the chains of transmission. because many others have said repeatedly, it's not that we don't know how to control a disease like ebola. we know how it spreads. we know if you can reduce contact and you can use personal protective equipments and safe means of interacting with one another in those who care for sick patients and in the setting, we know that will work. but we feed to scale it and we need to engage some community level involvement in building that support. >> so kevin? >> i was going to say one thing that you were talking about the drivers, and you were absolutely right. one of the things we haven't emphasized very much is the fact that one of the drivers is the population's response to an

ebola epidemic. survivors don't want to be identified. those who are potential victims don't want to stay put. the reason it's spreading, in fact, in some of these areas is people who suspected they were infected fled the treatment centers and brought the infection elsewhere. and that will make it extremely difficult for us above and beyond the usual public health problems. >> it is a challenge, but the antidote to the anger, which is a mask of fear and vulnerability, is education and empow empowerment and that is the vaccine that can help turn around behaviors that are clearly not only individually counterproductive, but socially counterproductive. we have to do a lot more in understanding the cultural context in which this epidemic is spreading and engage solutioningses rather than trying to imagine that we understand from outside exactly how to impose that. >> i think that's a point well

taken. and so i think the panel has given us a rich number of questions. so let's -- we have about 25 minutes. so the way we typically do this is we first take questions from student who is are enrolled. so i guess you're not self-identified here, so i'm trusting everybody. i know a couple people in the front rows are not students. beyond that i don't know who is. let me see if we have a question. >> i think we should take several questions. before we get the answers. >> let's do three. we have one here and i have one in the back and one other here. i don't have any oven on this side of the room. let's start here in the front. >> hi, i noticed for the last few months and actually right on the top of your list one of the ined inadequate sis.

what's the breakdown in get iti this to the health personnel? budgetary? if it is budgetary, what do the units cost? >> next, i think let's take a couple. i can't see your face. >> hi, one of the questions i have. i think a theme that's been alluded to a lot here is in countries that have the resources to deploy and help deal with these crises, there's a not a sense of urgency. either with the public or with our elected officials. so how do we go about trying to change that tone in the public discourse? >> excellent question. in the back there. >> last row there. >> the question would be why does it appear that despite the historical nature of how we dealt with diseases like hiv and

stuff like that, why are we seeming to have to reinvent the wheel when it comes to community-based response? it seems now we're having this conversation again about using that response rather than pressure on people. >> those are all good questions. let me suggest, if i could, that maybe marti you could address the ppe question. steve, on the sense of urgency. everyone can jump in to answer. i'm just thinking. in terms of just starting. and the last question, i think, everybody but maybe dan in particular from your experience. but why don't we -- marti? >> i think the ppe issue is about logistics and scale and supply. in the areas it's most needed, most urgent. so the supplies are desperately short. and that can be --xhgññr that c

is being scaled up. and i think that getting that stuff in and providing the logisti logistics, some of the response is being hampered and choked by the reduction of commercial movement. it may take u.n.-based support lifts to continue to move goods and services and people into the areas to make sure there's adequate supplies. the other, quite frankly, is figuring out how much of it is that you need? and i think that a lot of thinking has gone into that by a numb of agencies including w.h.o. that's sort of coming together. that should be an achievable result. that's not where it stops though because it's not just about -- i think dan said in his opening, having the stuff is one thing. distributing it it is another thing. but training in its proper use and training in how to take off the ppe in a way that you o don't contaminate yourself and

scaling up the training around infection control practices is important effort. that is something that's going to take more time than buying goods. >> dan, did you want to jump in? >> i can't emphasize enough that i don't think it's a money problem. it's logistical. beyond that, there's ppe in the capital of sierra leone, but it didn't get to where we needed it. more than 240 health care workers have been infested with the virus. more than 120 have died. so the largest testing and isolation facility for ebola in free town where i work in that hospital, we did not have gloves that i felt safe with. fl flimsy gloves that tore easy that just came up to your wrists. we didn't have face shields until a few days ago.

we had these goggles that had been reused and washed through bleach that you couldn't see through them. plus you sweat like crazy. you sweat so much because it's so hot. there's no air-conditioning. it's so hot. you're sweating like crazy before you step into the ward. it's hard to see. it's very hard to see out of your goggles. so you walk into a unit and can't see and you have gloves and not feeling that confident in. why is that? i did everything i could, talked to everyone i could in the administration and see colleagues who were helpful. one took to a hotel room and said you can have anything you want. it was very kind gesture. i did take some face masks. so it's for the record. but as an example, i took those back and you could see through them. you could see through them. so you can draw blood safely. so now there are some face shields.

they are still not ideal because they have ties that tie back here. you reach back there and if you have your gloves on, maybe you have a little virus in your scalp. there's no shower. so personally, i think there needs to be something below the emergency operation center, a clinical public health command center that makes sure that people that get -- that need the personal protective equipment and the appropriate training. it needs to be done one time so people are confident and prot t protected. otherwise, they are not going to put their lives at risk. >> anyone else want to come on, otherwise, steve and kevin can talk about how to create a sense of urgency given where we are now. >> it's a great question. the first thing i would say is that americans and others outside of west africa have been certainly bombarded with news

accounts around this. media every day, our media coverage has focused on this in great detail and considerable depth. we have seen a lot of very important voices, the secretary of general, bonn ki-moon speaking. powerful and eloquent statements. tom has been infatic. in his eloquent and powerful way, david from the u.n.ñr msf president constantly. there's no shortage of people trying to break the barrier and bring this to people's attention. and i think for a lot of americans, the polling data shows that people are scared. they are scared by this. they are alarmed by this.

they are less clear, i think, in their minds of what we should do. they are less clear about what are the strategic choices that powerful governments face in this period? and in that sense, i think, bringing forward the next layer of communication from the president, from samantha power at the u.n. security council and from other like-minded personalities, including president johnson, including the nigerian head of state and minister of health. including many others would be very valuable at making clear the urgency of what needs to happen and why does that tie to u.s. national interests at this moment? we are having, obviously, when you look at isis, when you look at the other crises areas with crimea, with ukraine, putin,

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

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

a very important next step when there's widespread transmission that's community based and hyperindemocratic in educating and empowering and providing kits and thinking about how that strategy meshes. it's not a substitute. i mean you played it off as an either/or. i don't think it's an either/or. it's an and. we need to scale up for all the traditional approaches for fighting ebola and we need a level of preparedness and areas of high risk. we need creative engagement in areas where some of those other things are just really too hard or can't be accomplished quickly enough. itis an all of the above. i think, you know, unicef is playing an important role as a partner in the social mobilization efforts. that is amplifying. there's encouraging things going on.

the ebola wrath that some of you read about that was brought on by someone who didn't believe it was real and engaging the music community and the social networks. the hero stories of the burial boys that appeared in the new york times. the heroic stories of nurses on the front lines. these are glimmers of hope and inspiration that many crises actually have buried within them. we need to be able to tell those stories and tell the stories of the survivors and tell the stories of the courageous people and all of that. that's also part of the social fabric of this response and elevating those people rather than stigmatizing them, elevating them as heroes that they are, rightfully so. can't help change the community dialogue around how we engage and what we believe. i think it's really important. >> let me ask dan a question, if i may. you have been over there. should we be thinking of

community in that location in the same sense that we think of it here? i mean, there may be people in this room who might not react well if there was a knock on the door and someone said i'm from the government and here to help you. it seems like there it's much less likely. >> that's true, but i can't say i'm an expert from three weeks being there, honestly. >> i don't know that it's the government that needs to do the knocking on the door. >> i have a white helmet. i'm here to help. >> it's a grass roots evolution inside out rather than top down. that's also desperately needed. nsf has been working on controlling the ebola epidemic for decades as has been pointed out have always said if there's not a public trust in community participation and engagement, they are hard to control.

in particular because there needs to be burial practices. in some belief systems, improperly honoring and appropriately honoring the dead could bring this on. we need to understand that from a medical perspective and figuring out how to meet the deep seated internal needs in a way that is safe. i think it can be done. it's been done in euganda. this is happening in a new area where that level of community education hasn't occurred. >> marty, i would only add in a crisis, listening is often one of the hardest things to do, especially theóc,v communities aren't right in front of you. it's true for political leaders of all levels. we have ten minutes left. i didn't see other hands in the earlier round from students in the class.

i'm happy to -- oh, i see more. let's try to do -- let's try to do a couple more, two more students and try to do two more to the open group. then we'll have to bring it to a close. are you a student in the class? start here and then this lady back here. please. >> i'm a student from taiwan. i noticed many of you mentioned international mobilization global involvement and effort. if i were chief officer of department of health or regional hospital in taiwan and i do want to contribute something either money or material, manpower to join this battle, what would you suggest we do to get started to

institutional label or individual label. >> excellent. your question, please? my name is vickie -- >> can't hear you. speak up a little bit. >> my question is about the borders in the region where this epidemic is happening and the nature of mobility and traffic, you know, human traffic. i know some airlines stopped flying into these countries, but many people cross borders in places that are not well publ h published. how do you think that is treated considering the epidemic is spreading to places like nigeria which is hard on the continent. >> let me suggest process wise. i'm going to take two more questions from the larger audience. >> they will be at the end of the time. this is not fair at all. i'm going to try to take one from the left