that -- at a minimum we hope you have been formed and perhaps entertained. guests.o thank my thank all of you for attending. i encourage you to follow the mccain institutes in its work. thank you and join me in thanking the panelists, please will stop -- please. [applause] , michael cox and robert mcdowell discuss merger proposals and several other issues before the fcc. >> the issue with consolidation as you have these huge come raise who are not only in control of distribution, but of content increasingly and they're getting hammerlock on the news and information in the structure that we as a democracy rely upon

to govern ourselves will stop >> the adoption of smartphones is faster in minority communities than suburban and affluent white communities. fantastic news for america. you see the developing world about such technologies very rapidly. that's fantastic news for improving the human issue and allowing people to have the benefit new information. lyrical ando change economic expectations of a positive way. that monday night on "the communicators" on c-span2. but now a look at the ebola out break in the resources available for fighting these which has affected more than 2000 people in west africa. this discussion with doctors and global health experts was hosted by the georgetown university law center. it's an hour and a half.

>> think you. it is an honor to be here. it was one of the latest honors of my life to work in sierra leone. i just returned from sierra leone 48 hours ago. i did not shake a single person's hand. let me say that there are three primary things i tried to focus on. i had many opportunities to do many good things. the first thing was the compassion and care and evaluation of patients at any boulevard testing center in freetown -- and ebola testing center in freetown. one doctor from spain worked there for two months and is there now still.

another 27-year-old british physician from kings college london. it had a profound effect on me, to be able to help provide care and evaluation of patients with the ebola virus disease. closely related, i participated in the training in how to put on the personal protective equipment and then most importantly is how to take it off safely. when you take it off, that is when there is virus on your gowns and gloves and goggles and 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. in the u.k. physician and a sierra leoneian colleague. together, we trained trainers. who then went on to train more people after we left. in freetown and in other hot spots. our goal was to organize a working group. the major hospital closed well i was there and it has not reopened as of august 18. there are many children with terrible diseases who are not able to get medical care as a result. just briefly, i did bring handouts on the pediatric situation in a publication called the program for emergent diseases. there is a second article that i had a small role to play in. this is an article i wrote and i take full responsibility. it may be controversial, but

many people read it and distributed it to colleagues, more than 30 professional colleagues in freetown. it is simply 18 problems and 18 solutions for how the ebola solution could be much better and provide better care for individual patients and citywide. i would like to say that this ebola outbreak has a more profound impact on me personally and i think it should on many of us because it is going to get much worse. the who announced that a larger outbreak is going to occur in a large oil city in nigeria.

links to a physician who died and had many close contacts. in my opinion, it is certainly controversial, but i truly believe that after three weeks of being there and 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 ebola outbreaks, contact tracing, isolation, quarantine, is going to be effective perhaps in most of the cities. if this outbreak is on longer than a year, we are going to have to have vaccines, drugs, antibodies, and first exposure prophylaxis to stop it. we should do everything we can to slow it down, to stop it, to start to decrease, but i'm not confident we will be able to

stop it without therapies and vaccines. this is much worse than anything i remember from aids in san francisco in 1982 or anthrax in 2001 or sars in hong kong, bird flu in indonesia and egypt, and murs last year. i'm very happy to go back to liberia to work with doctors without borders ince -- for six weeks. >> thank you for those remarks. thank you for your service. i think we want to start with the human picture. this is a particularly terrible virus and disease. let's step back 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 of the affected countries and populations, if you could give us an overview of where we stand.

i think we know we are not at the end. are we at the beginning of a control of the kinds of epidemics or individual epidemics? if you could give us an overview, that would be great. >> sure. thanks for the invitation and i appreciate the opportunity. i do need to provide a disclaimer to the heaping introduction. i am one small part of this response in an agency that has mobilized several hundred people engaging 70 deployed and more will be deployed internationally by the weekend. it is an unprecedented response for our agency. there are many brilliant minds and talents dedicated and engaged, not just from cdc. in terms of context, i really

appreciate the opening comments about perceptions on the ground. what i would like to say is what are the characteristics of this epidemic? this epidemic is very much out of control in some areas. what are the characteristics that make it unique in that regard compared to the other ebola outbreaks of the past since its discovery in 1976? one of them is the location. poverty is pretty profound. we are seeing painfully the face of poverty and disparity and so on and the impact of the intersection of poverty with a devastating, merciless virus. it is staggering in that regard. weak and fragile health systems

that have been suffering in states that have only recently emerged from years of civil war and infrastructure challenges. another unique aspect. compared to the original outbreak in 1976, it is very isolated, this was unconnected. the tools of detecting an outbreak, isolation, contact tracing, and beginning to alter unsafe practices in burial, which cause a huge amount of transmission, happened in a very remote area -- it was not very connected or globalized. the success and/or failure in the trajectory of the outbreak -- the outbreak gets contained. here we have an outbreak that probably emerged at the intersection, at the boundary areas of three countries that

are highly connected culturally and ethnically, with many zones of commerce and exchange, with community practices that involve marriages across boundaries and burial practices that are often distant from the original religion and so on. the degree of human mobility is a factor that plays into the spread. this outbreak is unprecedented, both in geographic spread, scope, and magnitude. this outbreak is occurring in urban areas, which is unprecedented. the strategies and thinking about how to control dents, crowded urban slums like west point in the capital cities, the whole concept of how to deal with a lethal outbreak in these urban settings with large population centers and

connectedness, both regionally and through other places on the continent globally is a very unique circumstance. the health infrastructure was fragile at its start. but epidemics of disease like this, horrible diseases like this, are often followed by epidemics of fear and epidemics of stigma. the fear and the stigma combats and conflicts the attempt to get the epidemic of disease under control. misperceptions, lack of understanding about means of transmission, suspicion, lack of trust in government, suspicion of outside folks not understanding how the disease is spread or who was bringing it. these things contribute to a level of resistance in communities and anger, which is

often the mask of that fear and former ability. -- vulnerability. the extent to which this is a fresh ebola outbreak in west africa contributes to that. a lack of understanding of the disease and where it came from. that context is really important to understand how we got to where we were. some people refer to it as being caught off guard. it is more important to think about where we are going and not finger-pointing or blaming. this is a massive public health emergency of international concern and a humanitarian crisis which risks civil society. we're seeing the collapse of some of the key aspects of civil society to keep it functioning in areas hard hit like liberia and the capital. in those areas, when you ask about the trajectory, we have not turned the corner. the virus is winning the battle. it has outstripped the human

resources. the numbers treatment centers that are needed, the number of health-care workers that are needed, the degree of personal quantity effective equipment, the quantity of body bags, the people and the stuff that are needed to be able to get an outbreak of this magnitude under control are just not there. 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 the health sector response, but a full response. it represents a significant global health security threat, as new countries become introduced and have a single introduction, like nigeria. we are still trying to snuff out one chain of transmission from one introduced case since july 27. you think about the possibility of epidemic in lagos or into one

of the world's largest mass gatherings coming up in saudi arabia. the consequences and the concept of having introduced ebola into these other types of settings, mass gatherings, or mass communications is hard to fathom. larry's comments are very poignant. i think it is a long road ahead. i think the who roadmap is very much welcome. 6-9 months, i hope we are there. in the best of circumstances maybe. right now, we have not seen the band did not epidemic curve. i fear it could be much longer. we really are going to need all of civil society to be fully engaged. >> i think we have got a sobering picture on the human-patient level. thank you for that overview.

if we are in a situation where the epidemic, we have not turned the corner, it is growing exponentially, at least in some of the key areas. i'm going to ask steve -- as we think about a crisis like ebola growing, particularly in capital cities and on a regional basis, you might want to reflect more generally, if you would, on the impact on politics in africa, global politics. a little bit of the larger frame. this has moved beyond the public health sector issue to a much broader potential set of issues around security. >> i was also hoping to talk about the security implications and the role of the united nations and the security council. >> i think in the last six weeks

this epidemic, the surge of this epidemic has forced us to recognize that it has moved beyond being a public health crisis. it has become fundamentally a security crisis. it has triggered, for the states in question, particularly liberia and sierra leone, it has triggered an agate -- existential moment. the states which were acutely week before hand, the functionality of their vulnerability to worsening civil conflict is magnified tremendously. they have seen their already marginal health systems eviscerating and overwhelmed. they have seen in security touch well over one point 5 million people. they have seen their markets, their production, their economic

integration disrupted. they have seen their integration into global airline systems disrupted. pretty much halted. they have seen the sudden exodus of talent out of the states, across multiple sectors. they have seen in the health sector and the emergency response sector, they have 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 are outside of work in what is supposed to be a more normal situation. would you are seeing is the insertion of teams that get exposed and they get suddenly and immediately pulled back. my first point is that this is not a health crisis, this is a multidimensional security crisis

within this region that now threatens neighboring and nearby states. it threatens another 10 states. where you have the likelihood of transmission. the second point i would 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 the knowledge -- acknowledged as a global security problem. it has not been brought forward to the un security council. why is that? why is that? if you have the kind of implosion that i have described and the implosion that now threatens the surrounding region and the human magnitude of the crisis on a skyrocketing trajectory, where we were told

last week that 3000 dead, 1500 -- i mean, 3000 cases, 1500 dead, but we think it is probably 2-4 times that level and we think it could hit 20,000, there is no confidence whatsoever that 20,000 is a stop point. you are now in a world of great unknown. of trying to think about what the two deck three -- trajectory will be. you can see this lots of bullets going to 40,000 or 100,000 or beyond -- being plausible of going beyond 100,000. this has been a very hard set of lessons for public health experts. why have political leadership not grabbed onto this? a couple of answers.

this is the unknown. we did not know that there would be this cascade of catastrophe. 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 in public health officials that the methods that have worked in earlier settings could be applied and would work in these settings. there was excess confidence in those tools. when pleas were made to political leadership, those went unmet. there was overconfident and an inability to penetrate the higher levels. i think that in this last summer it has been a terrible environment to get a virus driven security crisis onto the agenda of the security council

when you have the islamic state in syria and iraq, you have the israeli-palestine war, you have the russia-ukraine war. it is an exceptionally crowded environment to push this through. the last thing i would say is that it is very hard to walk the sovereignty minefield 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 peacekeepers into this setting? the model of responses failed. there needs to be another model of response that treats this as an emergency, humanitarian catastrophe that requires the deployment of protected authoritative forces into this setting. to get to that point requires consent. it requires sovereignty.

it requires sovereignty be respected and it requires political leadership. there has not been political leadership on this matter. i fear that what is going to happen is that we are going to do with the who is suggesting, which is draw up a list of 12 things and ask people to do more of those 12 things, versus seeing the big picture and coming up with a response to address -- we need to transform this exponential crisis, this escalating runaway epidemic and we are not going to transform it by doing more of the same. thank you. >> now we have aired all three. the individual country level -- individual, country level, geopolitical. before we turn to a couple of the issues that have emerged so far, i want to invite anyone from the panel who wants to comment on steve's point. i want to emphasize the point that marty made in its relation to steve's. in the middle of a public health

crisis, there is a lot of information and a lot of people may look back and wish you had done things differently, faster, or sooner. the really important point is given we are today, one of the things we can attract attention and the actions of the players in the world that can make a difference in this dynamic, because i would argue this is a maybe not unprecedented, but a rare place for us to be in as a global community. i would like to turn to a couple issues that have received attention in the media, particularly around his quarantines and access to medicine. let's start with both larry and dan mentioned the issues around treatment of vaccine. i'll ask kevin to kick us off.

yesterday hhs announced they will accelerate their contract to get more of the vaccine available for clinical trials. as larry mentioned, nih has announced we started yesterday going forward with the first trials of the ebola vaccine. i think this stark situation has raised a couple of really critical ethical issues, and one of them is that the who can be on a panel like this and does it make sense to provide medications in a context that the who recommended.

how do you allocate what will be in variably scares resources in the context of the catastrophe we are talking about? and i guess i would ask kevin to kick us off with the conversation. larry has written about this. >> also, if you will, differentiate between drugs that have not undergone safety or efficacy trials with vaccines, because you have a compassionate use of a drug when somebody is potentially dying. but vaccines are given to otherwise healthy volunteers. this raises a whole set of ethical questions. if you could reflect on those things, that would be helpful. >> absolutely. we have heard about the humanitarian crisis from the ground, and as a physician, especially if physician who spent much of his career

treating children, it is devastating to hear about this. i cannot imagine what it must be like to be living through that. we heard about the public health response, the inadequate health response, and how we will have to be able to do much more. that will raise a bunch of ethical questions. but i think we have to remember that this is also about people, about the people involved. and there is a tremendous urge to say if we can treat people, even with experimental medications, why are we not doing that? that is one of the foremost ethical questions. i think there are several that are worth thinking about, and we may be able to cover some of them today. that is number one on the list. the other would be when we are

considering the application of those scarce resources, the most pressing question would then become, who should be treated, because we have a whole lot more people who might be candidates for treatment than we have treatments available. and also i think that one of the questions i would like to hear discussed before we are done is if the ebola virus has been known as the cause of disease since 1976, why is there no preventative vaccine or effective therapy? i have my own opinions on that, but i would like to hear everyone talk about that. now, first off, what about experiment treatments being offered? i think we have to consider the pros and cons of giving experimental drugs. they are for the dangers and adverse effects that can neither be known or safety predicted. it is entirely possible they may be ineffective or harmful.

in america all studies have to go through a first stage where the likelihood of harm can first be assessed followed by subsequent phases to look for additional side effects and evidence of efficacy. so far these therapies have been tested only on a handful of monkeys, and not even the first stage that has occurred for human beings. you will be happy to know the monkeys are getting better. but so far six people have received one candidate experimental therapy. two of them have died. this does not prove it is effective and does not prove it is safe. we do not know what harms it may do long term or even short term, and the guiding principle to any use of new medicine is in the first place do no harm. research is designed to answer questions about possible harm and possible effectiveness. but what has been done here is not research, but rather it is

scary, experimental treatment. it was done because ebola is a deadly, scary disease. but if we were to keep approaching this in an uncontrolled way, we may never know if these therapies are safe and effective or at least not know until a great deal of harm may occur. the world, especially that part of the world now suffering most from ebola, desperately needs to know if there can be an effective treatment as well as an effective prevention in the form of a vaccine. we owe it all possible victims, current and potential, to get this right. there have been examples in the past of untested and under tested therapies being rushed into service and ultimately

doing the patients a disservice. some of these misadventures occurred on the african continent. this led to a pervasive distrust of western drug companies using africans as their experimental guinea pigs. so i think that is really an important issue, but then when we hook it to the issue of who should be treated, the civil answer is that all the questions, ethically very important and complex, it will remain moot until therapies are made available. as we have already heard, no tested or approved therapy exists, and we are at least months away before any therapeutic drugs could be even produced again for testing, much less know that they are safe and effective. the happy news is, if there is any, is that, as larry pointed out, vaccine testing has begun.

vaccines may be able to be rushed into service sooner. we would hope. but vaccines will not take anybody who is infected, and will only be effective if large numbers of the population can be vaccinated, which presupposes two things. first, the sufficient amount of safe and effective vaccine can be produced, and, secondly, that we induce the threatened populations to accept this vaccine. you have to understand in these areas we are having people still deny that ebola is real, and those who do get it or are at risk of getting it are hiding from the medical establishment for a variety of reasons, what is making the entire control of this epidemic much more problematic. >> i was just going to follow up on that, but for the whole panel, as well as you, kevin, i know this is a horrible thought,

but it is occurring to me, and i wanted to ask the question. if you think about influenza h1n1, which was a direct threat to the united states and australia, we rapidly got a vaccine within months. here, we are going back to essentially a regional tragedy since 1976. i think public health experts said it one day will come to the united states, but we will quickly contain it. it does not represent the same kind of threat to us. what is the reason why we have not seen the investment to scale up for well-tested vaccines and drugs?

>> the temperate answer is there is an arduous process of developing therapies, developing vaccines. only one out of 10 prove successful, which mean 90% of the candidate drugs and vaccines are not going to be usable for one reason or another. i think there's more to it than that. i think the stark reality is the pharmaceutical companies are a business and the business has to have a market. and there are twofold problems there. the first is, as scary as this is and as tragic as the number of deaths are, this represent a small market for pharmaceutical markets. >> and an unpredictable one. >> and the other problem, it is a poor one. i'm convinced if this epidemic

were happening in other than poor countries in west africa, we would be seeing the attention we have heard should have been given to this a long time ago. >> others? there's no question we are in a different dynamic than a global flu pandemic. >> just to get some contacts. i'm not saying i disagree with all the issues that play, but to be fair, if seasonal influenza will come every year. this is something that is a familiar, recurring threat on the frontline of everybody, everybody globally knows somebody who gets the flu, and somebody who has succumbed to the flu. and that level of our violence and that level of frequency year in and year out, as well as

memories of pandemics past, like 1918, and the devastation of an evolved strain to which the whole world is susceptible is a powerful influence, and we should not underestimate the difference in frequency of occurrence. it is easy to see, and there are many explanations behind this, but i do not want to -- >> but in a pushback, you're totally right, but even with h1n1, and one could imagine this in so many areas, even though you might tell up some good reasons a vaccine, the distribution of a scarce resource still resides, and even for seasonal influenza, the low- and middle-income countries do not have the supplies, do not use them. so you have seen much greater depths.

>> but let's take neglected tropical diseases and sort of parallel and look at malaria, tuberculosis, etc. there has been scale. it may have been later than we would have wished. but things that are more common that are more recognized and daily routine every year in and out killers have also been addressed. there needs to be more done to combat neglected tropical diseases. so i think when we still look at ebola, we're still talking in the scores of outbreaks, not over a year thousands, millions of cases like neglected tropical diseases like malaria. >> i think we are in two different markets. >> it is important to remember prior to the ebola outbreak in west africa the total number of

cases from the previous two dozen outbreaks was 5000. the total number of deaths was under 3000. you contrast that to the 39 million estimated deaths from hiv-aids and a current population of 34 million living with hiv. those are rather disparate market numbers. and if you are going to apportion resources, scarce resources towards the development of treatments and possible vaccines, then where do you put your money? and i think that cruel reality is with us today, and we are playing catch-up. together think i would say is this has not deterred in this context, has not deterred dgsk from partnering. there has been a willful -- i think this is been a wake-up call across audible sectors for folks.

there is now an urgent moment for trying to accelerate with all of the provisions around preserving safety and the like come up at trying to change the market conditions and move towards treatments and therapies and vaccines. and i think we will see some results. whether we will see results in time to address the immediate urgent crisis is of course totally up in the air as a question, which gets to my second point about ethics, which 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 population in west africa on a safe basis that is ethical,

because the more high-end treatment options are getting washed out. hospitals are closing. personnel are leaving. personnel are not on the ground. so that ultimately leads you to inquire about what are the options going to be for low-tech palliative care can that be provided to people who are suffering from ebola and the other threat from ebola in a context which would be different from what we would do in a normal circumstances. it will raise ethical issues, issues of race, and that is the predicament. that is the biggest predicament we face on the ethical grounds right now. >> i think you're absolutely right. i think what we really have to be focusing on are not the questions that made the headlines initially, which were great, because they made us all pay attention to what was going on over there, but in fact if we

are going to make a difference in the immediate future, it is with things as simple as gloves and gowns and. antiseptics and the public health measures and those are things we need to focus on. soon we will have a vaccine and maybe there will be an adequate market for it. the sad truth is there's probably another reason that we are far along as we are on the vaccine, and that is it was also realized that this might be a recognizable infection. >> that presents another -- it is both a risk and opportunity, right, because it does speak out -- to take a second for my previous stint at hhs -- we moved quickly from identifying h1n1 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 are all incredibly hopeful about the prospects for an ebola vaccine can i do not think we can assume anything, and certainly it is a very competent a situation that does not have the benefit of a pandemic flu context of an annual process of developing a vaccine. >> we are not even to effectiveness testing. >> and makes an argument for the kind of investment, whether global, biosecurity, and to deal with man-made threats and natural threats. it is an argument for thinking about why you need to invest now for what may be something coming down the road. let me ask others on the panel -- dan had mentioned this set of issues. does anyone want to jump in? >> in 2011 -- we're coming back to h1n1, harvey feinberg chaired

a committee that was an independent and sanitation -- an independent examination of there's lots of international health regulations during the first to clear public health one of the recommendations that he made at his commission made, that was prescient, was to have an ongoing health contingency emergency response fund, something that provides surge capacity early on that you do not have to now five months later be asking for funding. as marty said, it should be there on the ground and quickly mobilized. so marty and others will know about the feinberg report. what can we do now to make that

a reality? >> i was on that committee with harvey, and it was a year-long process, and i think there were many good recommendations which was a reflection of how the world responded to the pandemic as well as how -- what can be done to strengthen the international health regulations and position the globe at the ready to deal with these what had become particularly -- predictable -- unpredictable in timing -- current and emerging threats.

the committee report and the committee unanimously felt strongly about the need for such a global emergency fund that could be called in quickly. in addition, i would point out over the last year there has been a tremendous effort to develop a global health security agenda that reframes this up. we could put a lot of -- have a loud conversation about the speed and fairness with which medical countermeasures are developed, but there's really nothing like primary are mentioned, because no matter what there is a lead time for a newly emerging threat to come into the countermeasure arena and we need to invest in prevention up front, where it is possible, primary prevention, the ability to detect rapidly and respond swiftly.

all three pieces, all three pillars of the global health security agenda are critical, and sadly this ebola epidemic is an example of the need for a global set of partnerships so that when these inevitable things are merged in our globalized, highly interconnected, an interdependent 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 and a quick time. those are key aspects. this is one example. there will be more. i hope we will 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. marty raises a critical point for what can be done here in washington, and that is around the global health security agenda. just to remind folks, this was launched by the white house in february of this year. tom frieden played a critical role. it involved a consortium of 27 other countries, and a number of other organizations. it was driven with an awareness of the antimicrobial resistance, fire security threats, and emerging infectious threats, that like we are seeing today with ebola. it has resulted in the aspiration to create a network of emergency operations centers around the world, but it is being done on a paltry budget, a paltry budget. $45 million a year. there is no funding mechanism that is robust, reliable,

durable, sustainable, in the u.s. security budget beyond our borders. and there is no institution that is the sole repository of expertise and responsibility for leading on this. we are very fragmented. to the extent that this crisis stimulates a rethink on that hill and a rethink within the administration, the global health security agenda provides a very good model or set of pilots which could be expanded, built upon, quite aggressively. the summit for this is september 26 here in washington. so that moment will arrive, and i guess ebola will figure prominently in the discussions about why it is you can have such an ignited crisis in a place that really has not looked up any of the capacity -- has not built up any of the capacity of international health relations. >> dan, please. >> i want to speak up about the issue of taxing. an example of vaccine the moment. we can put money and effort and resources and minds into the

loving a safe vaccine, but there's no guarantee that work. the most glaring examples is hiv, hepatitis c. there are no licensed vaccines against any parasitic disease. those are some examples. a lot of brilliant minds and research has been put forward, for example, to developing an hiv vaccine, but we are not there. i say that because there is no guarantee there will be a safe vaccine. hopefully it will be safe. hopefully there will be an immune response. using the model, trying to learn from the past, one thing we have tried to do for 30 years with hiv vaccines is up for a particular immune response.

th\at almost never occurs with hiv. but with ebola, it seems that it does. in this outbreak, approximately 50% of people have survived. they're not feeling really good -- they are feeling really bad when they survive, but some are feeling better than others. so one of the points, point 16 out of 18, people are cured of ebola, but from multiple points of view, one of which is the scientific point of view. i would argue it would be a value to vaccine in the element if we were able to better understand the immune response induced by the natural ebola virus infection itself. and then trying to mimic our vaccines to reproduce the natural protective immunity. >> let's hope the virus does not mutate.

>> this is almost a different species, a different strain of the species. >> that is another question about whether a vaccine for this species would be effective across the range. >> could i just -- even before figuring out the immune issues around the survivors, now engaging the survivors in their control and response. having survivors be part of the social mobilization and telling the story of ebola, having the survivors play an important role in providing care in areas where there are limitations until ppe can be scaled up. that is an underappreciated -- >> just scientifically, for the audience, once you recover, is there a complete immunity to re-exposure? >> it is thought that recovered persons are immune to reinfection,

in the short run. the duration and the species variation on that maybe effort, but there's no reason to believe that people will be repeatedly infected in the same pop wreck 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 we have adequate personnel protective equipment, safe and secure and hygienic

isolation rooms, and public health infrastructure to do the contact tracing, which is massive, and the like. we have also talked about the idea of just lower-tech caring, hydration, nursing care. those are all -- and then to back that up, i think the panel has almost been unanimous in which we would like to see a surge capacity, a standing surge investing in relation to emergencies. but what we have not discussed yet is a more ancient response, but one that we have seen here, which is sanitaires, basically a guarded area where people can go in and come out of. in many cases, it has been and forced through the military, and there had been discussions about food security shortages and clean water, viable employment, travel, commerce, all of that.

but let's -- i would love to hear the panel's view about what role there is, not just for sanitaires, as it has been used, and it was just lifted yesterday from west point -- yeah. but what a smart sanitaire might look like, what role it would play in relation to all these other pub health interventions. >> to ask maybe marty in particular to share with us, the current public health recommendations in the space in your experience, as i think that is -- >> this is an area where there has been a lot of inking about in terms of preparation for a devastating pandemic and many other things.

i think the public health measures are based on the principles of isolating the sick, quarantining those who are exposed, but not yet ill, and separating the unexposed or the well and creating that space under the principle of breaking transmission. clearly, the two primary goals in this epidemic is to stop his mission inside the zone and prevent spread, prevent seeding of new transmission.

>> and prevent spread within the hospital. >> but to stop transmission inside. and so we have highlighted how much we are a globalized world and how much mobility and interdependency there is. so that is a formidable challenge in contrast to 14th-century leaving a ship offshore in venice for 40 days. that part of the modern challenge as well as the ethical challenge. thankfully, we do not live in a world where we sacrifice the victims for the benefit of everybody else. the question you asked, larry, is what are the ethical principles behind using that tool in an effective way. and i think some of them that have been read about by others as well as some papers that i published on this involved proportionality, making sure

that the measure is proportional to the threat, that to create that goal, and dialing that back and minimizing the duration as the need for that no longer exists. a process that inside the ring, the most important thing, the infecteds need to be outlined between the victims and communities being protective. they have to have a common set of incentives. and there is nothing that could propel an instinct to flee more quickly than armed guards and barbed wire blocking someone into a space. this echoes against their primal instinct that if it is so that i have to be locked in here, i need to get out quickly. so we cannot confuse those incentives. and i think part of what is

essential in a modern context is delivering effective goods and services inside, not choking an area off from food and nutrition and medical care. the treatment centers have to be adequate and sufficient. the work services, the compensation, the permissions that all of what would need to happen to align a community to voluntarily in some ways -- if the incentives are designed right, you do not need a primitive guard. what you need is a compelling government, trust, and community engagement to voluntarily participate. and it is not impossible to create that. we saw the vast majority of quarantines hopefully that were applied during sars were voluntary quarantines and recommendations -- we did not have a direct medical countermeasure, did not have a vaccine, did not have a treatment, but there was a compelling argument and alignment. it was a different circumstance, absolutely, but the principle of

that obligation, and in addition, inside the area do not want to create a hyper transition zone. you still have to identify the sick as they might be exposed and need to be pull it out and separated, so you need a safe space within a community or village where the sick can be isolated, where people can be provided safe care, where food and water and nutrition and other incentive structures can be in place. and those are the concepts. those are not easy to do, and the risks of doing it wrong i think are exactly what we saw in west point, that the simple military cordon enforced with barbed wire and communities that have a distrust of authority has

the potential for real -- >> i wanted to follow up and have steve come in with this, because one of the things that affects me, most of the things we have said today, there seems to be great unanimity among the public health community. but i have heard some discord and see about the role of the military -- discordancy about the role of the military. some say the military is the only group that has the operational capacity to deal with something this big. the others have talked about securing ebola treatment centers, securing other centers, people working in the field, but yet from a public health point of view, having a military involved is trying. >> my comments were about military, armed military enforced cordons -- >> i was not referring -- i wanted to get a wider discussion.

>> i think those are different roles. >> what is the appropriate role of the military? >> [indiscernible] >> i think particularly in the context of a post-conflict states, but what the international -- so there are several questions or dimensions to this. keep in mind in liberia and sierra leone these are countries which went through decades of internal war that involved particularly heinous abuses of civilians at the hands of armed entities, some of these official army, militias, or operational ones. it is hardly surprising that treating a cordon sanitaire in a remote area where 70% of transmission -- that that has failed, that it is permeable, and people do not trust it, and they flee.

i think the idea that the militaries can win the trust and confidence of their populations is a pretty dubious proposition, and we have seen it in west point where what looks like basically creating a death zone or a tomb and saying inside, good luck, and outside, thank your stars. it is sort of the militarized thing. what i meant about militaries was the fact that there needs to be some kind of mobilization that can bring into -- that can create the lift capacity, which has disappeared on the civilian side in terms of air, and it is highly disrupted. and we know from countless natural disasters and postwar situations that blue helmet deployments are critical to restoring security and making it possible for all of the

civilian-based things to go forward. and this is a situation that says, ok, its genesis is a virus, but it has morphed into a multi sectoral crisis, and there has to be security restored, and it would make sense to return to that model in the first instance providing you have the will to put troops into that or a request was put out, as we heard yesterday, 53 countries, a quite request to the u.n. channels as to who might be willing to entertain donating troops in and one country of 53 said possibly they would consider it to keep in mind also you have today 4600 blue helmets deployed in liberia and that were part of an original peacekeeping force, that was at its peak 15,000, and that is in a phase-down. it is supposed to be down to zero in 2016. the filipinos have said they

want to get out for the safety 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 can begin to move in a direction that i am talking about. but it is going to be hard. it is going to take an enormous political investment to make this work. >> you're thinking of international peacekeeping forces? >> it could be white helmets. they would have had a different look. why is it that the president of msf is out saying that this has to happen? the reason that joanne liu is saying that is because msf is shouldering 2/3 of the burden today of delivering of service today in three countries. one ngo. this is a gritty, determined, disciplined, and remarkable institution that does not shy away from brutal, violent, broken places.

they are in eastern syria, myanmar, and in 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. >> if you could say just two sentences for the audience in distinguishing roles that peacekeepers can play. >> i was making up the white hat thing. [laughter] >> it will be quoted. >> blue helmets, blue is the color of the u.n., is troops that are on a volunteer pieces placed under a u.n. flag and u.n. command in order to play under the geneva protocols to play effort functions, and the precise functions are negotiated

with the countries in question. and the duration and the rules of engagement and the deployments and command structure, and all that gets negotiated out carefully. it is not easy. at any one time of the last decades, the u.n. has to put up to 20 peacekeeping missions in conflicted sites. there's no reason we should not be looking at that option and asking the leaders of these countries why this would not be acceptable. >> it is important that every one of those steps has a history and a process that has to go through with the countries, countries that are in crisis by all the things we've talked about here. i'm going to take liberty here. we had about a half an hour left.

one of the things -- this panel has been amazing and we have identified issues. we have talked about quarantine and issues related to that. we have talked about various kinds of medical treatments and vaccines, and we have talked a lot about public health interventions. we have got a crisis of extraordinary portion. it is not clear the trajectory, although, as marty has laid out, there are things we can do, but we are at the tough part of beginning the control at a minimum, and as steve notes, we do not know that. there have been a lot of unknowns here. my question for the panel, a number of you had said things from the very specific, the lessons we have learned in the first five or six months of this, one, what could we apply in the countries right now? and i think marty and dan have alluded to things -- let's not make the same mistakes twice. what have we learned, what can you do differently? and second, looking on a global

stage and steve has identified several ideas, using peacekeepers, taking advantage of the global health security agenda meeting that is coming up. i ask people to think in both the near and longer term, what can we do, and the kickoff to that being who has put its roadmap out. $490 million. >> and that is their first guess. does anyone have the sense of that happening, and how does that fit in? both near term and long term, anybody who wants to say something in the next few minutes for we turn to the audience. steve? >> on the who roadmap, it was hastily concocted. it is now up to $600 million, according to the statement this morning. it is not clear where the world bank $200 million might fit. is not clear where the african development banks, $60-billion-plus might fit. it is not clear who is in charge, and it is not clear how to raise the money. how are you going to fix that? the big question is what do you do from here? who in the midst of this crisis has been enfeebled by staff and budgetary crises, and this has been a terrible, terrible episode in history of the who.

it has put forward this plan. the question it begs is who is going to make this happen, who is going to the operational details together and be authoritative in directing this and raising the money and getting us forward. i do not feel that many people are confident who can do that.

so what does that lead you to? and i would suggest the u.n. security council needs to take this up and create a mechanism, a body charged with doing this, and of course who would be part of that. 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 countries and all the technical pieces and the personnel that exists, and they were staggering. but to get to operational ties that is not yet clearly defined. and that i think is what we need to focus on. >> kevin, marty, anybody else want to add -- marty? >> 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 to look back and do an after-action, but

right now in the setting of what is needed to move ahead and get things under control is a coordinated international effort with a lot of partners. and i think one of the areas that has been perhaps underutilized is the importance of communities, community-level engagements, messaging, and communication, the use of survivors, even community mitigation and community control strategies that are better aligned with the cultural acceptability in the areas where the control has to go on. i think that increasing roles for a medical anthropologist -- we need to define clearly the drivers of the epidemic. and this is not just one homogeneous epidemic. it is one thing that it is deployed into a country and you can stamp it out, where you have the numbers and the capability

to recognize, protect, and stop it. it is a different strategy when you are on the exponential growth phase in an urban area. we need to look at this as a multifaceted epidemic and identify the major drivers and engage the understanding, public trust, community support to help break the chain of transmission. as many have said repeatedly, it is not that we do not know how to control a disease like ebola. we know how it spreads, and we know if you can reduce contact and you can use personal protective equipment and safe means of interacting with one another for those who care for sick patients, we know that war, and we need to engage it and engage community-level involvement in building that

support. >> kevin, did you have one -- >> you were talking about the drivers, and you're absolutely right. one of the things we have not emphasized very much is the fact that one of the drivers is the population's response to ebola epidemic. the reason it is spreading in fact in some of these areas is because 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 health -- >> it is a challenge, but the antidote to the anger and recalcitrance which is a mask of fear and vulnerability is education and empowerment, and

that is the vaccine that can help turn around behaviors that are clearly not only individually counterproductive, but socially counterproductive. and we really have to do a lot more in understanding the cultural context in which this epidemic is spreading and engage solutions rather than trying to imagine from the outside how to impose that. >> that is a point well taken. i think the panel has given us a rich number of questions. so we have got about 25 minutes. so the way we typically do this is we first take questions from students who are enrolled in the colloquium. you're not self-identified here. i am trusting everybody.

i know a couple people in the front rows are not students. but beyond that i do not know who is. so let me see if we have questions from -- >> what we should do is take several questions before we get to the answers. >> let me try with three. we have one, one in the back and one over here. so let's do one, two, three. >> hi. i noticed for the last two months and right on the top of your list was the personal protective equipment. what is logistical breakdown in getting this? is it budgetary? >> let's take a couple more. i cannot see your face -- yes, please. >> hi. one of the questions i have, i think a theme that has been

alluded to a lot here is in countries that have the resources to keep going and help deal with these crises, there is not a sense of urgency, either with the public or with their elected officials. so how do we go about trying to change that tone in the public discourse? >> excellent question. in the back there? yes. >> the question would be, why does, despite the historical nature with that with diseases, why are we seen as trying to reinvent the wheel -- [indiscernible] >> those are all good questions. but he suggests, if i could, maybe marty you could help us address the ppe question. steve, on the sense of urgency in terms of -- and everyone can jump in on the answer. i am just thinking in terms of just starting. and the last question i think

really, i invite everybody, but dan, in particular, from your experience. marty, you want to talk -- >> i think the ppe issue is about logistics and scale and supply, and in the areas where it is needed most urgently, the supplies are desperately short. i think that can and is being scaled up, and i think that getting that stuff in and providing logistics, some of the response is being hampered and choked by the reduction of commercial movement. and it may take u.n.-based support to continue to move services and people into the areas to make sure there is adequate supply. the other quite frankly is just figuring out how much is it that you really need and based on what strategy, and i think a lot of thinking has gone into that a number of agencies, including who and cdc. that should be an achievable result.

that is not where it stops, because it not just about -- i think and said in his opening, having the stuff is one thing, and distributing it is another thing. but training in its proper use and most important in training and how to take off the ppe in a way you do not disseminate yourself and scaling up infection control practices is an ongoing effort and that is something that is going to take more time than simply buying it. >> i cannot emphasize enough that i do not think it is a money problem. it is logistical, but beyond that, there is ppe in the capital of sierra leone, but it did not get to where we needed it.

more than 240 health care workers have been in tech to the virus. more than 120 have died. the largest testing and isolation facility in freetown, we did not have gloves that i felt safe with. we had flimsy gloves that broke easily. we did not have face shields until two days ago. we had goggles that have been washed so many times, washed through bleach that you cannot see to them. you sweat like crazy. it is so hot. you sweat like crazy. it is very hard to see. it is very hard to see out of your goggles. you cannot really see and you have gloves that you do not feel confident in. why is that? i could talk to everyone i could in the sierra leone hierarchy and ministry and see colleagues

who were very helpful. one of them took me to his hotel room and said, you can have anything you want. i did take some face masks. [laughter] i took those back and you could see through them, the surgical gloves, so you could draw blood safely. now there are some face shields. they are not ideal because the have ties that are tied back here, and maybe you are going to get some fires in your scalp, and there is no shower, etc. personally i think there needs to be something below the emergency operation center, some kind of federal public health manned center that makes sure that people that need the equipment and appropriate training, that needs to be just one time so people are protected. otherwise, they are not going to

put their lives at risk. >> anyone want to comment on the personal protective equipment? also some thoughts, how the creative sense of urgency, given where we are now. >> it is a great question. the first thing i would say is that americans and others outside of west africa have been certainly imparted with news accounts around this, right? 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-general ban-ki moon speaking. margaret chan has made some eloquent statements. tom frieden has been indefatigable in his powerful way. others from the u.n. msf president joann liu, constantly.

there is no shortage of people try to rake the barrier and bring this to people's attention. and i think for a lot of americans, the polling data shows people are scared, they are alarmed by this. they are less clear i think in their minds of what we should do. they are the strategic choices that powerful governments face in this period. and in that sense i think bring forward a next lay her of communication from the president, from samantha power at the u.n. security council, and from other like minded personalities, including the nigerian head of state and minister of health, including many others would be very

valuable at making clear 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 area, with crimea, with ukraine, with putin, there is a debate about projection of military power. well, that debate has not happened in this case. we have not had that debate around what is at stake in terms of u.s. national interests, what are our assets, what we can do, what should happen during this next period. >> i think you're right, and i

think it is difficult to have a clarion call when we are still blowing an uncertain trumpet. i think what is happening now is that we are realizing the scope of the problem and getting a clear idea of how the world needs to respond, not just our country.

that would be worst-case scenario. but it would bring it to everyone's attention. >> there is a fair question about community-based education. >> the point is well taken. why does it take so long? i do not know the answer but i think it is a very important next step when there is widespread transmission that is community-based and hyperendemic and educated in and empowering and providing kids and speaking how that is measured. it is not a substitute and i do not think it is an either or. i think when we scale up for all the traditional approaches to fighting ebola and we need a level of preparedness for leveling new areas and creative community engagement in hyperendemic areas. some of those other things are

just too hard or cannot be accomplished quickly enough. it is in all of the above. i think unicef is playing an important role as a partner in the effort and has been amplified. there is encouraging things going on. engaging someone you do not really think israel on a social that were. the hero story. in occurred and is a glimmer of hope and inspiration that many crises have buried within them. we need to be able to tell the stories and tell the stories of survivors and the courageous people, and all of that because it is part of the social fabric of the response and a limit -- elevating those people rather than sticking -- signifying

them. elevating them as heroes that they are rightfully so can help change the community diet blog and think it is really important. >> should we be thinking of community in that location in the same sense that we think of it here? there may be people in this room who may not react well if there was a knock on the door and said i am from the government and am here to help you. seems even there it is much less likely. >> i do not know it is the government needs to do the knocking. i actually think it is a grassroots evolution inside out rather than top-down.

also desperately needed. also controlling ebola at the septic -- epidemic for decades has always pointed out if there is not community participation and engagement commit those epidemics are hard to control, in particular, because there needs to be education around very sacred things. in some belief systems, and properly honoring the dead could bring on the scourge. so we need to understand 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 has been done effectively in uganda in terms of controlling the ebola epidemics and altering practices to include safe burial. this is happening in an area where that level of community education has occurred. >> i would only add that in a crisis listening is one of the hardest things to do. so i think that is true for comedic -- political leaders at all level. i did not see any other hands in the earlier round from students in the class. i see more. let's try to do a couple more students and then two more to the open group and then we will have to bring it to a close. are you a student and then bring it back here. >> i am a student from taiwan. i noticed many of you have mentioned international globalization effort.

if i were president of taiwan, and i do want to have material manpower to join, what would you suggest we should do to get started? institutional label. >> your question? >> my name is vicky and i am a student at georgetown law. my question is in the region where this epidemic is happening. the issue of mobility and human traffic. i know some airlines have stopped buying into this

country. how do you think that is being treated, considering the epidemic of nigeria? >> process wise, i will take two more questions from the larger audience and then will invite the panel to reply. i think we will be at the end of the time. this is not fair at all. one from the left side. the lady in the middle there. i have one on the end. i think that is all we will be able to do between now and then. let's go ahead with the questions from over here. >> i am a student in global

health ball. -- law. i haven't inside out approach to the treatment of this epidemic. i am wondering why if we are not already doing it, we are not going from the already existing experiences we have that we have had in africa. i watched a lady yesterday on bbc circulating in social media about how the medical staff were recapturing a patient that had escaped.

it says to me the approach needs to be implemented, because you could see the patient did not understand why they have to be inside the facility. if people do not understand it, they do not realize how much of a detriment they are to the community. it is a loss. a loss that we cannot win the war. dealing with experience with hiv for instance. so it made me think about the human rights aspect. it is their right to decide whether to be subjected to treatment. they have a right to be subjected to treatment, or because of institutional problems, the government should

engage. >> the human rights engagement of the intervention. i think that is exactly right. >> my question gets to the sovereignty issue a little bit. how do you measure the risk of controlling the epidemic and countries like liberia asking for assistance and being growth -- so grateful while not undermining the great work that has been done. everyone has the fragile nature and they have often had tremendous games. they have set up financial mechanisms and suddenly are concerned international donors

will find international ngos for the response. so there will be a shell of the ministry left. how do you balance controlling the epidemic with maintaining a small but important gain that has been made since the end of conflict in these countries? >> we have four questions. i am not sure we will be able to touch them all. the one thing i would ask is if maybe marty could talk about the borders and travis -- travel restrictions. maybe you could say a word about the human rights dimension. the issue of human rights and capacity, the end goal is to have a strong functioning state and that is where we need to end up. we have three or four minutes. >> i think we can do this pretty quick. >> the point is well taken.

air connectivity, unfortunately from the three epidemic-from darius is relatively speaking more limited. it is a whole different story if you have an epidemic in another big hub area. i think the reduction in capacity of commercial airlines for a whole bunch of reasons, dollars, logistics, safe place for crew, many things we have been trying to combat, down 50% or more in others. it we will need an alternative way to respond. i think your point is a really important one and understanding the poorest nature and potential reintroduction, especially in the manual river area, the introduction needs to be addressed but i think it needs to be addressed again through more creative approaches. lex i do want to say a word about the human rights.

i think human rights are really critical here. they are critical because i think when you have significant human rights violations, it is really the antithesis of the public response. it is our instinct as people to inflate. there has been violence and fleeing. those of the two opposite things we want. the other thing is human rights includes the right to health, the food security on the clean water and all of those things that are part of a government public health community.

we cannot forget about those in the midst of the disease crisis. as we know from so many hundreds of years back, i were worst instinct as human beings comes forward when we feel threatened by an epidemic and we have to overcome that. >> i think that is what larry was saying. one of the remaining questions is how do we help without creating individual harm for the structures that are in place? >> i would like to address the points around protecting and balancing those accomplishments and programs and achievements that have been made as we get to this urgent requirement. we have seen, of the 3000 cases, 24he