at podiums because i am kind of short but i will get up on my tippy toes for you. when i first started writing a few years ago i did not predict we would be living through a pandemic of a new kind of pathogen washing over the americas right when the book came out. yet here we are with the zika virus washing over the americas. not my talk, hang on a second. over the past 50 years, we have had over 300 infectious pathogens either newly emerged or reemerging in places where they have not been seen before. the zika is really just the latest one in a plethora of pathogen's have been doing this. in west africa where it had not been seen before. a new virus that came out of the middle east.

pathogensof avian coming out of the middle east and the whole range of airborne pathogens, dengue, -- of mosquito borne pathogens, dengue, chikungunya, and zika of course. so the question i wanted to ask is how do microbes turn into pandemic-causing pathogens. you think of an microbe is a little thing with no locomotion, but it can cause these huge amounts of death and destruction. i wanted to look at that was a two-pronged approach. first i looked at the history of one of our most successful pandemic-causing pathogens. that is cholera. it has caused seven global pandemics since it first emerged. the latest one is still going on off the coast of florida and haiti.

with reporting from places where new pathogens were coming up. went to places like new china and -- south china and new delhi to try to see how cholera could shed light on where these new pathogens might be going. choleraearned is that emerged in many ways in the same way a lot of the new pathogens are coming out today. it came out of the natural environment. cholera is a bacteria that normally lives in marine habitats. it lives in conjunction with days will clinton -- with a zoo plankton. of cholera are full bacteria.

salty.alf fresh, half this is where the major rivers are draining into the bay of bengal. for the longest time, people did not live in areas like this. they are covered in men growth swamps, tidily flooded twice per day, there are cyclones and tigers. people did not really live in cholera-rich environments which all changed in the 19th century. the british decided to turn these into rice fields. of 19 centuries, 90% of the aurea -- of the area is settled. and our bodies, it does not perform very you -- ecological function but it can kill people within a matter of hours. 50% of people infected will die

if not treated promptly. it certainly into russia and of into the industrializing cities of europe. this is the same thing that is happening today. of our new pathogens are coming out of the bodies of animals. it come in -- it happens when humans invade wildlife habitat, forcing wild animals to come in to our territories. from bats we have ebola, from monkeys, hiv, malaria, and most likely zika as well. birds, we have the west nile virus, and others. provide these new pathogens great opportunities to amplify which allows them to better adapt to prying upon human populations.

we first started doing this the .9th century people were abandoning farms and coming into the new cities for factory jobs. in places like new york and london there was not suburban transit to take people outside of the city to sprawl. in places like manhattan, there were 77,000 people crowded into every square kilometer. 1/12 of the city was covered with cesspools and outhouses. people were ingesting but two teaspoons of fecal matter every day which provided a great

opportunity for the cholera bacteria to explode. of urban expansion that started in the 19th century is really reaching its peak now. 2030, the majority of the populations will live in cities. i like stockholm or washington, d.c. -- not like stockholm or washington, d.c.. they will be cities like monrovia. about 2 billion people are expected to live in slums by 2030. new pathogens have already decided to take advantage of this process of urbanization. consider ebola. we have had ebola outbreak since the 1970's, but it had never affected a place with more than a few hundred thousand inhabitants until 2013. within a few weeks of emerging reacheda, ebola had

three capital cities with a combined population of nearly 3 million. why the major reason outbreak was such a huge concentration. you can also argue that sica is capitalizing -- that zika is capitalizing on urban expansion. rarely infected people because it was carried by a forest mosquito that mostly bites humans and doesn't bite people very much. what we see now in the americas is being carried by a different kind of mosquito. this is a mosquito that has dramatically expanded its range with human, urban expansion. people andving near will breed drop of water. all of our plastic garbage

provides perfect breeding sites. unlike forest mosquitoes, egypt only bites humans. we are not only crowding people together, we are crowding animals together. we have more animals under domestication right now than in the last 10,000 years of domestication until 1960 combined. huge number's of livestock we are keeping right now and many live in these factory farms. they are basically the annual equivalent of urban slums. this similarly allows pathogens to amplify and change in ways that can make them more relate .- virulent intothe virus is dropped

these factory farms where these captive animals are crowded together they start to change. they replicate and mutate. they become more virulent. we have had an increasing problem with these more. went forms of influenza -- virulent forms of influenza. we have started carrying path annuitants -- pathogens around anymore efficient way. steam travel. we started skimming across the atlantic and with clipper ships. steaming around the rivers and waterways. we used steam engines to build canals and it connected all of our waterways together. we had this nice international network which is perfect for cholera to take advantage of, which it did, again and again. -- the erieanal

canal in particular. we do it even better today. weh our flight network, don't have just a couple airports and capital but hundreds of airports with tens of thousands of connections between them. spreadvery rapidly across the rest of the planet. so flight network is influential in shaping the epidemic, that you can calculate where and when an epidemic will strike next just by measuring the number of direct flights between infected and uninfected cities. a map that plus that same food pandemic i just showed you but this is a map of cities connected by direct flights. you can see that the flu pandemic resolves into these perfect series of waves.

these are just some of the ways in which the way that we live allows microbes to turn into pandemic causing pathogens. we don't just take these things lying down. we put up political defenses and medicadefenses. it is only when political defenses fail that pandemics occur. in 1830 two, doctors in new york state collected this data that we know. it shows a pretty clear picture to us today. cholera is coming down the hudson river and heading straight for new york city. response would have been to consider a quarantine. closed on the traffic on those waterways and protect the city. nobody wanted to do that. quarantine was considered too disruptive to trade.

said, it might look like it's coming down the river, but actually it's being carried by -- this was based on that0-year-old theory diseases like cholera were spread to the smelly heirs that rose up just smelly airs that rose up -- these smelly airs that rose up from decomposing things. violentlye were scapegoated during cholera epidemics -- epidemics. there were countries making money selling cholera contaminated water to 19th century new yorkers. the epicenter of the epidemic of cholera in new york was a slum called five points, pictured here. it is actually the subject of

the movie the gangs of new york, if anyone has seen that. that slum was built on what was once a pond. it was filled up with garbage in the slum have been built on top of that. the ground underneath was very low-lying and unstable. the groundwater was easily contaminated by all of the leaky privies and outhouses on top of it. the company that the state of new york chartered to deliver drinking water to the people of new york, instead of tapping clean them a upstream sources of water, which the new would taste better and be cleaner, they sank their well in the middle of that slum. that water to one third of the people of new york. the reason that they did that is the same reason that people in flint michigan -- flint, michigan decided to change their water intake. they wanted to save money.

they wanted to save money because they wanted to build a bank. does anyone know the name of the bank of the manhattan company today? j.p. morgan chase. the biggest bank in the country. eventually, new york did move there well from the slum of five points up to westchester county. cholera ended for good then. what is interesting is why they did it. they did not do it to protect the public health or because they throughout their theory of the air and decided that cholera was in contaminated water. the did it because the city brewers demanded better tasting water for their beer. tasting water put them at a disadvantage. i think it's better today, but we can do a lot better. the question is, will we find

the political will? that is something i hope we can talk a lot more about. thank you for listening. we have a great panel of speakers today. our first speaker will be dr. lipkin. for thee director center of infection and immunity at columbia university. if anyone has seen the film "contagion," i will add that the scientist in that film is modeled on him. dr. lipkin: i am also the john snow professor which is particularly apt given that so much of this concerns cholera. i was told about this meeting and i generally accept these

invitations. i was told that i could just skim the book and i began with that intent, but i read it cover to cover. i thought it was a beautiful book. for those of you who have not looked at it yet, you saw a bit of an example. au have burr versus hamilton, whole description of the london underground and slumming. it is an elegant book. what i've decided to do today is something a little different, though i hope during the q&a we can talk about some of the interesting aspects of the west nile virus, and mers, and sars, and talk about things that may be of interest to you and talk about sonia's next book. that is the future of infectious diseases. the emphasis in this particular book is on the q diseases.

the ones are associated with severe illness. pneumonia, hemorrhagic fevers, things that kill us. then we have these other disorders which are typically thought of as noncommunicable. there is a part in the book where you talk a little bit about this. the ways in which microbes have modeled us through evolution. the have contributed to our ability to become mammals by having an impact on whether or not another -- a mother will reject the fetus. what is a fetus but a tumor growing inside of us? there are retroviral elements that prevent rejection of the fetus. if you look at the genomes, they are riddled with retroviral sequences, and others as well. these have important impacts.

when you basic sense, look at microbes and sells, what you are really doing is examining the ability of the body to recognize something as self or not self. we are always dealing with an onslaught of things that may represent nutrients or microbes. and developrow, this relationship we have had with microbes. there is a wide variety of these "noncommunicable" diseases which i will show you shortly, have an infectious trigger. they range from coronary disease, stroke, diabetes, psychiatric disorders like autism, autoimmune disorders like rheumatoid arthritis and many forms of cancer.

treated to cancers infectious agents may not be fully appreciated by many of you. particularly, when you look at sub-saharan africa and represents one third of these cancers. most people who have cancer are under 50 years of age. hepatitis b and c have human papilloma viruses. here is an example of hepatitis b which causes a carcinoma. an infectious lymphoma also found in africa and human papilloma virus described as recently as yesterday as being largely eradicated as a result of vaccines. hiv, cap are ceasing, lymphoma -- hiv, as you begin to look at these other infectious causes of

cancer, as a "think more broadly, it may be possible -- as we begin to think more bradley, and maybe -- more broadly, it may be possible to eliminate them. preventableccine illnesses. we can literally eradicate human papilloma viruses through vaccination programs which means that we can probably eradicate cervical carcinoma, and many other forms of carcinomas as well. most of the diseases that sonia be alluded to can probably prevented by using a variety of vaccines. these are diseases which are fairly straightforward to approach. infection is likely to be implemented in a wide range of diseases of the cardiovascular

system, including stroke and artery disease. inflammation is the leading attribute. we now know that something as simple as bad periodontal disease can result in an increased risk of stroke. ce times,y in the scien some of you may have read this article that appeared. to donald mcneil several months ago, when we started talking about autism. then we started talking about microcephaly couple weeks ago i said, this is probably just the tip of the iceberg. discuss, i to presented him some of the data that i will show you now. disorder that we tried to model in mice. this was a disorder that has been associated with

streptococcus and dramatic heart by ase first described british internist. what we found is, that there were a group of children who were thought to have schizophrenia, but did not have it. they had an obsessive-compulsive disorder which we associate with the sorts of repetitive behaviors such as you see here. were treatedildren with a plasma to remove intravenousor an treatment, we were unable to remove the disorders. we could not identify the trigger. we replicated it by injecting streptococci and then went back and found these children were affected.

this was worked on by our group in new york, and by paul patterson, who died a couple years ago who was at caltech, to look at historical associations between influenza viruses and other pandemics and stressful environments, and later occurrences of schizophrenia, autism, and other neurodevelopmental disorders. what we found is, if you look at the association of these disorders, it made sense. you would see, outbreaks or what looks like outbreaks of schizophrenia following outbreaks of influenza and other viruses. if you look some four to seven years out with autism, you would find examples there, too. we were able to model this with mice. that if you could examine mice

that were halfway through the animals would be withdrawn in the cage, as opposed to the adderall's that has -- as opposed to the animals that had some sort of a normal -- just two thirds of the way through gestation, these animals become hyperactive, running all over the cage. indicating that, what was important is not so much the infectious agents per se, but the host response to infection. the other thing that we have begun to learn a great deal more about is the micro biome. there is an excellent exhibit literally across the park at the museum of natural history. here, we try to cover through

the course of this, to understand something through that micro biome, the implications of disease. we have begun to understand now that the micro biome is important in tuning the immune system, is probably important in thinking about algae. it has a role in colon cancer, obesity, and cardiovascular disease. the flipside of the contagion hypothesis, sonia was talking , as a reciprocal relationship, we see that as we know longer have those risks, we see an increased risk of asthma and a wide range of other disorders. it is becoming clear that we cannot only think about pathogens. have to think about balance between microbes and humans.

biomelook at the micro over the course of a lifespan, you can look at individual types of bacteria. the normal progression which we see here has become subverted by this modern life, where we formula feed babies, treat ourselves with antibiotics, we have obesity, and a wide variety of intervention, which has led to all sorts of outcomes which have a tremendous impact right andon the way that we live, the types of diseases that we begin to see. if you look at the composition --the gut microbe biome microbiome, it is still very different from the fiber-rich diet that you see in africa.

there are consequences of this. we have begun to see the appearance of diseases associated with some of these bacteria which are killing people. we have been unable to eradicate these now with modern antibiotics. fecal beginning to use microbiota transplants as a way to address these problems. because there has been so much success of treatment with using these microbiome transplants, people are beginning to use them for a wide variety of other applications as well. i am not advocating this, but that thereting out are theories they can reverse autoimmune disorders, irritable

bowel syndrome. their efforts to use it to treat multiple sclerosis, autoimmune diseases, as well as some form of colon cancer. , as youorward, sonia begin to think of what your next book. not to say that we have resolved all of these issues with respect isacute infectious diseases, important to think about ways in which we can bring microbes back into balance, when we can begin to understand the role of microbes and our responses to of a widehe genesis range of disorders ranging from autism to cancer. [applause]

ms. shah: thank you for that, after lipton -- dr. lipkin. for my next book, he has already done an outline. doctor whost is a was one of the great sources for my book "pandemic." if you pick it up you will see there are a bunch of pages about him and his fabulous work which he will share with us. thank you. about this book that other authors have not touched on is the repeated cycles throughout history we have gone through with pandemics that we are still in. we aree the point today, still doing the things that led to cholera around the world. we think about these issues of these badd lives, and conditions as being "over there." but we are connected to

everywhere on the planet by less than a day's flight away. that is what microbes do. the exploit new niches that we put up, adapt, and infect us. we created this perfect system. i would like to hope we are at the end of it. i would like to propose in a more positive and optimistic way, that in 50-100 let's think about the ways we can work together to get rid of the pandemic trap. then we can deal it other issues we are discovering. all, i am in an organization, a nonprofit in new york. we work on emerging diseases to

try to understand what drives them and what are the underlying causes of pandemics. what is the science behind it? can we prove something is attached to the driver of a pandemic that leads to the spread, and then can we do something about the driver? first of all, we need to know if they really are a big issue. the book lays it out clearly. what is the science, the real evidence that emerging diseases are on the rise? a few years ago, probably about a decade, a group of us sat around and studied this. i had just finished working at cdc. i was working on wildlife diseases, including a global the emerging disease of frogs that spread globally that wiped out species. even more significant in the 1918 flu.

it actually caused extinction of species. it is something going on on the planet that has a similarity between what is happening in wildlife, with the rise of diseases in those populations, what is happening in domestic animals like livestock, and what is happening in our own communities. we realized these things are connected, of course. we call it ego health. -- eco health. it is the ecology and environment of the ecosystem that drives these problems. the human micro by them disrupted by modern life, and so are our ecosystems. you don't need to take a trip to the black forest to say, where are the wolves? where the passenger pigeons? completely disrupted ecosystem. what happens when we disrupt

ecosystems? disruptistract -- or the microbiota. we sat around and said, let's take every single example of emerging disease, one that go pandemic, ones that cause a slow cluster of cases. and let's build a database and analyze it. we started this price -- project, and we thought we were very clever. we got we could do it in a few weeks. it actually took two years. it is not straightforward. the data on where and when a disease first emerges, where the first case of a new disease is, is very hard to get hold of. after a couple of years, we had a database of something like 450 emerging disease events, new pathogens, newsstands that moved into the populations for the first time, or that were already

there and began to spread for some reason. we plotted them out. this is a part of that decade by decade, from the 1940's to the 1990's. it is clearly rising, but of course, so is our effort to find them, so we have to correct that. then we have to build a database of every single author of every paper of every infectious disease, to see how that is rising. later, the points gis coordinates of every office, we could correct the rise and show, yes, there still is a significant increase over time in the number of new diseases emerging in people. this is a problem that is increasing. not only that, the really big ones that go pandemic, as sonia points out, other ones that come from animals, usually.

usually they come from wildlife, like ebola from probably bets -- ats, or hiv, which emerged from chimpanzees. the ones that go pandemics are almost exclusively from wildlife, some intermingling with domestic animals like avian flu. they are the yellow bars on this graph. they are increasing disproportionately dramatically compared to the rest. pandemics are on the rise, emerging diseases on the rise. the really big ones, hiv, ebola, 1918 flu, increasing overtime. how many newt emerging diseases we will see next year, which is about five. true.are showing to be three of those will originate and animals. that is the bad news. what are we going to do about it, is the question. we set about to look at, what

are the big questions to deal with this question --problem? first of all, we don't really know how many viruses are on the planet. and to get a handle on dealing with it, we need to work that out. it took us a few years to come up with a strategy. this is what we did. we used well is used in conservation biology. if you are trying to count the tigers in bangladesh, it is really difficult to count every tiger. they don't particularly want to come out and say hello. is,hat conservationists do you find a tiger, track it, tag it, and release it. then, you try to catch more. eventually, you start recapturing some of those tigers. there is a simple equation too used to work out the size of the whole population, including the unknown sizes, based on the number of recaptures against number of captures.

so we did that with viruses. working with the research group at columbia and the global network, we started catching newals that we knew carried pandemic type viruses. we caught the same species over and over, and tried to discover as many viruses as possible. we could actually be capture the viruses. this is what it looks like. the first graph is one viral family, looking at the number of samples we collected. this is about 1000 individual fruit bats from bangladesh. these are the giant tropical fruit bats with a wingspan about this big, and the bodies are this big. they are really cute animals. they are like puppies with wings. the problem is, they have big teeth and a bunch of lethal viruses. but they are really cute. they pollinate tropical trees,

especially fruits. they are very important pollinators. we had to catch each that individually. each bat individually. we have a whole team to do this. and then we but the samples onto liquid nitrogen, which is not easy in bangladesh, and getting all the way back to the lab at columbia university. the veryrepeatedly did best type of pathogen discovery. something that the lab is world famous for. what we found was after a well, the samples, we started seeing the same viruses. the discovery curve went up and saturated. we can use the saturation points to predict how many unknown viruses there are. we repeated this for i think allt 12 different samples, of the ones that caused nasty emerging pandemics and people.

the predicted number of unknown viruses in this stock was 58. it is simple extrapolation. if you multiply that by 320,000 6000 known mammal species on the planet, you come up with 320,000 unknown viruses. that sounds like a lot, when we only know of about 4000 so far. there's a lot of work to do. but, it is not millions, and not tens of millions. if you look at the rates of viral discovery and the increased speed and decreased cost of technology to discover the viruses, we can easily change this. we can discover all the potential pandemics out there. i think this is great. we came up with a figure, because we know how much it costs to do this work. about $6.8 billion, a lot of money.

but you don't need many samples, and you still get 85% for about $1.4 billion. spread that out over a ten-year period, $140 million per year. still a lot. but how much does an outbreak cost? the cost of sars has been calculated. if you look at the drop in gdp of southeast asian countries during the sars outbreak against the market fluctuations, you get a figure of something between $10 billion-$50 billion for one single outbreak. it is mind blowing. one single market, one person in china, who put an animal in a cage, and that infected other people and led to a global pandemic. the real cost was because it disrupted the trade network we rely on for a globalized pattern of trade.

these cost so much if we wait for them to emerge. what i'm calling for now is a global viral grace to the man approach to find as many of these new viruses we can, using the best technology we got, and save ourselves money, as well as thousands of lives. we hader big question is, where will these viruses originate? where will the next pandemic emerge from? 10 years ago, that was not known. everybody kind of new -- knew. there were lots of maps where , for ebola,in on hiv, sars. but we did not have science to back it up. we set about trying to do the science. we have a database of every non-emerging disease. we knew where and when the worked with that

word so we can get the reporting biases in the database. we knew there a lot of people working about it. when you look at the raw data, you can see a lot of european outbreaks, north american outbreaks, but we have to correct for that. we did that in our analysis. the other big issue is, when you that the pandemics -- we knew that this pandemic tend to originate in wildlife, but we had no idea whether one species carries the same number of viruses as another. we made the assumption that overall, most animals will have roughly the same number of viruses as another species. on everycredible data single mammal species on the planet. so we knew where every mammal species was. we made the assumption that we don't need to know how many viruses a god, we just need to know relatively -- viruses it

got. we just need to know relatively how many. we got around the problem and were able to show, convincingly, that there is a correlation between two things that tends to be the driver of emerging diseases. first of all, where people are on the planet. not just where the populations are densest, but where we do the most to the environment. land-use change is a correlate of emerging diseases. changes in population density are a cause. disruption to the environment. the other big issue is where wildlife is. when you look at the hotspots for emerging diseases, which this map shows, where the next pandemic will most likely originate, and includes areas where there is high david -- high biodiversity, and growing human populations expanding into the areas, hunting wildlife farming animals, bringing animals into the markets, trading them, and disrupting the ecosystem balance.

this is where we work now. we work only in hotspot countries. we focus i'm communities who are at risk on the edge of the forest, people who work with wildlife, in markets, people who work in farms. we interview them about their habits, take samples, and look for the evidence of viruses that we find in wildlife, spilling into people. we also sample wildlife from all these hotspot countries, and work to find where the new viruses are and what the risk of those becoming pandemic is. recently, we were able to show clearly that in parts of southern china, there are still present that still carry viruses almost identical to sars. there are still people who hunt them, live near them, and eat bats, which is how sars originated. we are able to show a clear and present danger, and we work with

the populations to try to change behavior and make the things you -- they do ar risk bit lower risk. i think all of this is positive, and i think we will correct the problem, but it is not going to be straightforward. as sonia says in the book, we have to deal with underlying issues that are hard to deal with. global equity, poverty, food supplies, clean water, really well, not simple, but not high tech issues. at the same time, we and the west tend to look to high-tech seclusion's -- solutions. a drone, and new test kit. perhaps what we really need to do is reassess where we are with our own microbiota. ourssess our relation with ecosystem, and try to restore the balance to where it should be. thank you very much. [applause]

ms. shah: thank you so much. next, we have carl, from -- coming back from south sudan. he will talk about his work with shots he did -- and also on hiv. >> i spent the last few weeks doing two films. about the ebola a break in liberia. i was therefore two months. i look at how the community dealt with the outbreak. previously, in the documentary on the origin of hiv. i tried to piece together where the viruses came from, and how the virus actually managed to cause a global pandemic. in that talk, i will talk --

touch on what peter has been saying. about the geographic origins of a virus, the cause of the dynamic, and what conditions there were. it's a bit like looking through feelsifying glass how it to be there, and what conditions are there on the ground. the as you know, is one of worst pandemics we have experienced in recent history. hiv is a virus that comes from chimpanzees. virusndemic form is a that is the similar form in chimpanzees. since the 1980's, we have known it has come from chimpanzees, and tried to figure out where exactly it originated. where did it jump from chimpanzees into humans, and how did it subsequently spread? you have to know little bit about chimpanzees. they live in rain forest areas in western and central africa.

the good thing about chimpanzees is they don't move a lot. they don't like water, they don't cross rivers. for many generations, they stay in the same place. is, theyntists did looked for chimpanzee populations. they collected fecal samples, they looked at whether they were infected in the chimpanzee version of hiv, and compared it to the human version that caused the global pandemic. by measuring the genetic distance, they could figure out where the virus must have originated. that brought them to central africa, to cameroon, which is here. more specifically, to an area in southeastern cameroon, bordering countries. the central african republic, republic of the congo to the south, and cameroon. this is a very, very remote area, and we went there for our film to document the work of the

scientists there. there's a lot of science going on, looking at what peter has been talking about, looking at viruses,ence of new because a lot of the factors and drivers that drive viruses into human populations are at work there. it takes about four days by car to get there it is a long journey. . you end up at this place. is the river network that flows congo the condo, and the flows out to the big capital of the congo. area thathas been an has always been remote, but since the colonial opening up in there was a lot of input of people and a lot of economic activity. we know from then -- genetic that hivtimates,

originated in the area around 100 years ago, between 1880's and 1920's.if you look at the history of the place and the geography, you think, why they are and why then? but that's only looking at the historical developments. then, everything starts to make sense. all the major colonial powers were operating in the area. they went in there mainly for rubber, but also for timber. there was a huge disruption going on off of the original lifestyle, a huge movement of people, because they had an enormous demand for workers, and over the decades, there were networks being built, river networks, and railway networks, and growing cities. placed all the drivers in that hiv, once it managed to

jump from chimpanzees to humans, could expand and gather the momentum to finally make the leap out of africa and into the rest of the world. we also know by now that by the 1960's in that city, there was already an epidemic of hiv-aids. there were hundreds of thousands of people infected. but of course, because of the postcolonial chaos that was there in the 1960's and 70's, the house infrastructure collapsed, there was a civil war, nobody noticed. it wasn't until the 1980's that we took notice of hiv here, in new york and on the west coast. was the place where hiv m originated. we went there because we wanted to understand whether they have the potential to basically breed

another virus or facilitate emergence of a virus. these are santos -- scientists collecting fecal matters from chimpanzees, where we can analyze them in the u.s. , there hee area remote area, it takes about four days to get there, it is a rain forest area. there are huge logging operations going on. it is not going on at the edges of the forest, but it is going on in the middle of the forest. the cameroonian government is auctioning off to international companies, certain areas in the rain forest where they log. this is an italian company, looking for timber. networks, where they timber bring out these to the next part. the next part is miles away to the west. au have roads where there is

confluence of trucks bringing hard work and timber to the coast. so, you have networks again. secondly, you have a lot of people coming into that area to work for the logging companies, first of all, and also to provide services for all these truckers. there are no supermarkets or anything there. it is just bush tracks, and little settlements like these. the people that -- live exclusively off of bushmeat. these are pygmy hunters. these are women slaughtering an animal. we were there for almost there for three weeks and we could not get any protein except from bushmeat. we were eating monkeys, snakes, parking fines. all of these people were eating them there, and all the people were coming in close contact with wildlife, either through

slaughtering it -- here is the preparation of a monkey over a fire. here you have constant exposure to wildlife, and constant opportunity for viruses and pathogens infecting wildlife to jump over into humans. went are doctors -- we there with a cameroonian army medic, working with a team of scientists in southern france, but also here in philadelphia. they are actually monitoring these populations. first of all, what you see is very high hiv rates. spreads alonghiv the trucking routes. the truckers have lots of relationships with the population there, so that is one way of hiv to spread. it is almost 25%. almost every fourth person has hiv there.

they are analyzing blood samples. they have evidence of transfer of pathogens that normally only in fact monkeys -- in fact monkeys and apes. hiv, they have indirect evidence that these populations have these viruses through antibodies, and some of the people actually are infected with the pathogens. they don't make them sick, but we don't know whether that happens, if that happens, but the first steps are already taken. in a nutshell, this is one of the areas which peter pointed out in central africa, where you have all the drivers their. you have mobility of population, a population growth through an input of population working there, you have a very slow and intimate contact with wildlife, and also, you have networks that can bring pathogens to the big cities in west and central africa.

i am a biologist, and what i realized there with chimpanzees, is, if you look at evolution and you look at the selective factors going on, it was like hiv found itself in a chimpanzee population that was dwindling. any virus at the moment in japan sees has a population of maybe 250,000 chimpanzees left. that makes the jump into humans, it has another expanding population of 7 billion people, so the selective pressures are therefore viruses a human and go into host and survive in a human host. listening to peter, i find it very interesting. some of the efforts are going on to understand which viruses are

circulating, which viruses can make the jump into humans, and of course, if we can prepare ourselves, if we had genomic sequences, it would have a huge advances -- advantages. these areas, remote as they may be, have to be on the map so that we can react early enough, or actually asked preventively before it is too late. finally, i just want to say with ebola, it was basically the same thing. ebola, the outbreak in west africa, originated in guinea, and they call it the forest region of guinea. this is not a forest region anymore. it is a deep forested region. there has been a lot of deforestation going on. from an evolutionary perspective, if there is a virus

there, and the habitat of the the is destroyed, then population dies out, or it manages to live next to humans. bats are mammals and are very adaptive in that sense. that is probably what happened with ebola. living in veryts close proximity to humans, and that made it very easy for the ebola virus to jump from bats into humans. of course, it was in an area where the next capital city was not far. with ebola, everything was in place, as with hiv. isknow the factors, and it probably a matter of looking closely and thinking very hard about how we are in touch with nature, and thinking how we can use knowledge to prevent this in the future. thank you. [applause]

ms. shah: thank you, carl. next, we will share some recording from amy on ebola. she is a scientist who has been supported by the pulitzer center. hi. i am a science journalist. i'm going to talk -- my talk is a little bit different. it will be a lot less sciencey, actually. the u.s.lk about response to epidemics in the developing world, and also what we respond to and don't respond to. i had gone to sierra leone to cover the ebola outbreak, and i was just going to cover science, because that is what i do. i have a background in science and i wanted to cover treatment. what i was really stunned by was

the largest -- large distance versus whatresponse you see on the ground. i was very intrigued by that. that is what i really spent a couple of months reporting on. we maybe thinkt about. white tents, biohazard suits. where i spent a lot of time was the hospitals, which is where people go when they are sick, and they go seek medical care. that is before international response shows up. this is a photo of exhausted nurses.if you go to hospitals, you find underpaid and overworked staff. often, there is no electricity or running water. specifically, i spent a lot of time in the west of sierra leone. there is a large district on the border of guinea. in april 2014, that is when doctors without borders was

chatting about the terrible about thehouting ebola epidemic. at that time, they were worried, saying we have never seen this before. at that time, dr. khan, a leading biologist in west africa, he was at a big effort -- hospital in western sierra leone. this hospital in sierra leone. he's worried, because they are on the border with guinea. he called all the young doctors he has trained to come there. he convinced a lot of nurses to come for training on what should they do should ebola show up in sierra leone. within a few weeks, there was a pregnant woman who came to the hospital. she miscarried, and she could not stop bleeding. she kept bleeding and they moved her to the surgical ward.

she had a hemorrhagic fever, that is pandemic in the area, and also for ebola. she died, and then tested ebola positive. at this point, it blows up in the region. ebola spread rapidly, and it is tough to care for it. they don't have gloves are protected here. -- or protected in gear. commercials stopped flying, so it is hard to get there. they just have tarts on the walls. this is one of the walls, plastered with flyers for memorial services for nurses and technicians who died, because gear,on't have protective and they are doing the best they can. this is one of the morticians from the hospital. he convinced me to come into the more. ebola -- into the morgue.

ebola was not so strong in the area at the time. but at the peak of the outbreak, there were more than 3000 ebola tests done at the hospital, and he just slept. he showed me where he slept on the other side. he slept on the ground, because around the clock, he needed to prepare bodies, and there were piles of corpses. by the time i got there, around august, in august in the west they are dealing with expanding. there are a thousand people who have died by august 2014. that is when the world forth organization decided there was an international health crisis. that is one fundraising begins, and countries start donating money. -- takes aen starts lot of time, because they had to decide how they can implement it, are they getting the army? it all takes time. the whole time, the virus is multiplying and spreading, and it hits the capitals.

by october, there are 3000 people dead, and still, not a lot of international aid. andof the white tents biohazard suits, they are starting to show up. late november and early december, that is one finally, mid-december, they decide there are enough ambulances, and the white hands and treatment -- white tents and treatment centers. when i come, the plane is full of aid workers. at that point, when you go to a public hospital, you will see strikes across the country. in sierra leone, liberia, and ginny. -- guinea. part of the problem was when the staff was working, they were told they are going to be paid $50-$90 per week for risking their lives. some people were paid, but a lot of people were not paid, or they were paid half, or extremely

late. there were protests. somebody had dumped three corpses on the ground in protest. part of the anger was also, headlines were reading, obama donates $100 million.there were huge donations , and it is clear people are donating, why aren't they getting it? you can see there is money. there is united nations helicopters flying back in forth -- back and forth, and the capitals are full of new cars donated, they have plastic wrap still on them. there are ebola treatment centers being put up. there are lots of donations. it is clear, some of those things are going to good purposes, other things are little questionable. but what people keep asking me as i visit there is absolute oath -- hospitals, is who is getting the money, because we are still not being paid. this is a chart from may 2015.

these are actual donations made to west africa. the u.s. was the biggest honor with $1.5 million. the u.k. had $30 million. biggest.s. was the donor with 1.5 billion dollars. the u.k. had $30 million. when governments make donations, they make donations and the money goes to either the united nations agency, to their own agencies like the cdc, or big ngos like red cross or save the children. there, they might hire contractors, who hire the next level of people, and maybe they hire other ngos. there is a whole hierarchy. where it does not go is to the public hospitals, or to the nurses who are within the

system. it doesn't go to the government of the country. it goes outside of the system. however, the government of sierra leone, one of the poorest countries, they asked for money to help them cover hazard pay for health workers in the system, and they did donate money towards it. in an investigation i did, less than two points -- 2% of the $3 for thewas earmarked staff in the international health system. so, very relatively small amount. of the 2%, why are still -- people still not being paid? one of the u.n. agencies, the development program, was asked to implement this kind of awesome way of paying people through mobile phones, because very few people have bank accounts.

you get text message that says you have $90, and then you go to a vendor and pick up the cash. but it is notdea, simple because you still need a system. you need administrators and the human resources department to keep track of who works where, and when, things like that. , atnt about trying to make least in this one hospital in the west. in the end, the sad conclusion is, i don't think anyone really cared if the system worked or not. i don't know if there is a lot of -- if the system doesn't work, i don't know if it ever comes back to the people who are supposed to implement the system. that is the end of that. i think the reason why it bothers me now, is because it is a question put out there.

there will definitely be other epidemics. what would have happened had in that, when dr. khan knew ebola would cross over the border, what if there was a hot with running water -- hospital with running water and electricity, and gloves, and gear, and nurses who were supported and paid, what would have happened if they were prepared to take care of the outbreak themselves? i think the cdc might have dropped the ball for a minute, but nonetheless, there was not a spread of evil in the u.s. u.s.spread of ebola in the cap, she in the hair was the head of ebola treatment in the hospital. they built a new nurses quarter, and i visited her in july.

this is the nurses corridor for the isolated -- isolation unit. it is the rainy season. there is a soggy mattress in the corner where the nurses can share. all 15 of them have to huddle in there when it rains. the files are completely covered in water. that is the state of the public health system there. it may be a challenge and a question for before and after the crises, is, is there a way to support the system inside these places as opposed to outside? i have an e-book that tells more of the story, that you can download, or there is a shorter book on they website -- on my website. thank you so much. [applause] >> thank you to all our

speakers. we have a little bit of time for discussion. if sony has questions for the panel, she gets to start. if you are interested in asking a question, because we have limited time, if you can make your actions as brief as possible and indicate when the pedal they are indicated to, -- indicate who on the panel they are indicated to, if that is appropriate. thank you. >> is it working? ok. concerning trying to identify mammalianllion viruses, as we know, there are many viruses that are nonpathogenic. way to parse that down to make it more

economically productive? also, we know there are non-mammalian viruses that can cause disease. are we limited ourselves? ino, concerning water manhattan in the 19th century, they weretarted -- interested in developing a bank. they applied to the state to get a charter, but the deal was, and ehrenberg was one of the people involved, -- aaron burr was one of the people involved. the deal was, in order to get a charter, they had to develop a water system. they were not really interested in water at all. my point is, i think it is the profit motive and greed that drives a lot of people here. i don't see a solution to that, unless we change our whole society. i think we are so driven by the profit motive.

winston churchill said that americans try everything first, and eventually they will do the right thing. i think that applies to human beings and gentle -- in general. i don't know how long it will take rest together, but i'm cynical. >> thank you for the comment. >> you go first, it is your book. [laughter] ms. shah: i think it is a huge political challenge. i go into some detail about that in the book, if anyone's interested. it's a great story. certainly, the political challenges are huge. we talked a lot in the panel about pathogens that are coming out of distant parts of the world, but it's another point to keep in mind is that it is happening here, too.

a great example of a political challenge and pathogens, coming out of our inability, is antibiotic resistant bacteria. 1940 that if since we use antibiotics in ways that are not medically necessary, we will get super resistant bugs. foryet, decades later, decades we have been using the majority of antibiotics used in this country, 80%, used for commercial purposes. they are not for medical uses at all. this is obviously can trading to the increasing problem with bacteria. resistant we have only taken baby steps to address that. the political challenge on our size is the rise of private interest. the political challenge is building these systems in plac that were some of the pathogens are most likely to come up.

varynk it is going to place to place, but the political challenges, to me, is one of the top ones. >> great question. i will continue in reverse order with your questions. why mammals? if we do the math on the previous emerging disease events, the mass majority of the viruses that come from animals, they tend to come from animals. mammals cover the vast majority . you should probably include birds, because of avian flu being such a threat. but that does not increase the cost to much. the first question is more difficult. you are right, it is a stamp collecting exercise. some of those stamps are penny blanks, and you have to throw them out. some of the viruses will be killers, and some of them won't.

how do we work that out from a viral sequence? it is not straightforward. first of all, we are only looking at viral families that include those that have gotten to people from animals. we have narrowed it down from there. then, when you get a sequence, and it looks like a relative to the known nasty pathogen, just like we did with sars -- we found viruses in bats. some of them looked very similar to sars. we sequenced the spine protein, the protein that attaches to and then you create pseudo-particles, insert proteins from the viruses that combined to human cells. each step of this, you move closer and closer to could the virus become pathogenic in people? you narrow down the field. you reduce the cost, and end up with a small number of viruses that really do look like

killers. and you look at the people, and the people in the region that live where the animal lives, do we see antibodies to that virus? is -- inhe group cameroon a new virus coming into people. what is the activity, and can we find the alternative? it's not straightforward, but there are ways to hone it down. we had just got to do it. it makes sense economically, and for humanity's sake. >> i have one comment on the absurdity of things. i asked the company of the people who do the logging in cameroon, what the timber is used for. it is used for matches and toilet paper. >> we are not going to have a lot of time to go into this, but

if you would like the details on precisely how we do this in a laboratory, i will be happy to talk with you about it afterward. >> thank you very much for talking about the most likely origins of the next pandemic. perhaps the highest risk, any comment on bio hacking or intentional man-made pandemic's? >> this came up after 9/11, when we had the anthrax attacks, with a big emphasis on developing a program here, focused on bio defense. it was subsequently spend it to include emerging infections, because it became clear that the majority of emerging infections were not designed, but in fact, came from nature.there has been a shift

back now again toward consideration of deliberate biological weapon hearing -- weapons. i still don't feel that this is a huge risk, because it is easier to find these things in nature. but it is something we are all concerned about. which actually then leads me back to addressing your question, anyway. one of the things, what we tried to do, is try to find out whether or not a virus can bind to a self. viruses -- bind to a cell. viruses can only grow inside of a cell. the next thing the virus has to do when it enters the cell, is to find some way to evade what is known as the innate immune moleculesich are inside itself that decimate viruses so that they can't otherwise grow.

we look for these evasion and the innovation systems these viruses have. if you have a virus that has the ability to get into a cell and evade the invasion immune system, then you know it is a serious candidate for causing disease. typically, the closer host organism for that virus to a human, the more likely it will be to be able to infect human and cause disease, which is why , andcus so much on apes lesser extent, other nonhuman primates. that is not necessarily the only indication of disease. for example, with west nile virus, its ability to replicate inside of native species here in north america allowed it to exclusively grow and become the source of the virus in mosquitoes, and gave rise to the

epidemic. the last speaker was talking outbreak, anda how -- the lessons learned in terms of rapid response, and so forth. 2005, peter and i had an award together from google.org that was designed to address proactively some of these things. outposts foret up this sort of disease monitoring. one was in bangladesh. that system has become quite robust. the other one was in sierra leone, at the general hospital. how ironic is that? we actually placed into a hospital there, equipment that was monitoring, set to go. the first thing we ran into, was we were trying to bring in the

machinery. people hit freetown, sabotage the equipment, because we didn't have bribes. the u.s. government allowed us to allocate money for brides. we had to bring in the missing parts in personal luggage thereafter. after three or four years, google decided they no longer wanted to support this particular organization. as a result, the whole thing collapsed. -- a resource request from the obama administration to congress for $1.8 billion to address the zika virus. the information that came down yesterday, or maybe today, we are not going to give you any money, spend the money from ebola. the major problem that i see in much of the world is poverty, and a lack of infrastructure.

until you can address property and lack ofty infrastructure, even though we had great materials and technology, it is very difficult to deploy. you've seen more of it than i have. as you said earlier, lack of clean water. poverty is the big enemy, i think. >> i just had a quick question about prioritizing. we look at something like zika virus, which is at the bottom of the pile of things we are worried about, and then suddenly it was up to the top. as we are discovering new viruses, how are we going to prioritize which was to be concerned about, and which ones to address first? obviously, there are limited resources and we can't take care of everything, unfortunately at the same time. you look at the hotspot map we produced in 19 -- 2008,

prior to west african ebola, although west africa is a hotspot, prior to the so-called aine flu, mexico with hotspot. it is clear from looking at it can't prioritize where to work. it is what you do about it. after-the-fact. it is not good public health. had lousyiabetes, we that pandemic.n ebola outbreak. $5.1 billion was used not to fund the operations. where is the money to move forward? we need the funds to be allocated to the places that would be the next outbreak, not

the one that was the last outbreak. we know where they are, we know how many they are, and we know how to go about identifying them. i think it is good commonsense public health to get out there and do this proactively. prioritization, you go back to which wildlife species are the viruses found in, are they in areas where there are already on -- ongoing outbreaks, other people hunting the animals and exposed. there is a whole series of things you can look at to prioritize, which is fairly logical. it's not rocket science. it is straightforward. we just don't yet have the global will to do it. >> thank you. >> i'm curious, if we do manage to find these viruses and find places where they are jumping over to the human population and we know that, how do we contain

that. knowing is nice, but doing something about it is nicer. >> let me give you an example. a great example, going back to the work we have done in bangladesh, with the old color hospital. -- color hospital. we know there is a virus out there that is really legal. it causes -- really lethal. rate isage mortality around 70%. there are no vaccines, no drugs. it is a nasty virus. it is bat born. people in bangladesh drink sap that they scrape out of a palm every evening. they go up in the morning, bring it down, selling fresh. you can't leave it, because if it cements, you can't eat it.

it has to be fresh. unfortunately, the open wounds on the trees, we know that they into the trees by urinating, defecating, and spitting into them. there is a simple solution. the simple solution that i see is really cheap to make bamboo skirts, very low cost, put them around the place where you tap fromree to prevent bats getting in there. it is about reducing contact and still allowing people to do the things they have done for thousands of years, and make money. , and finding a solution that keeps the concept between wildlife and people. every virus has a different solution, but we need to be creative and find alternatives. ultimately, we need alternatives to logging tropical forests in

these emerging hotspots. selling matchsticks, not a good thing to be doing now. and what ian said as well, poverty. i witnessed that during the ebola outbreak in cameroon. sometimes it's a totally different logic at work. the beginning is the demand created through companies saying, we want to do logging their. next -- there. next to poverty, corruption is the next thing. the cameroonian government says, ok, it we designate the area, you cannot go.the whole thing starts, because the people do not understand causes and consequences. they look for work and opportunity. you have all these people moving, nobody controls them. the pictures you saw during the blood testing, the blood is only tasted -- tested for hiv. who testedal people

positive. the people their diet hiv. they do not -- the people there died of hiv. they do not get medication. there is a corrupt network that and thatk medication, is in cameroon. it is a set of obstacles from the ground, which you need to understand the logic, in order to implement programs that can stop and reverse these things. it is very difficult. >> hi. i am a neurologist. i came in late. describe, with the zika virus, the cases where it was microsoft we was in a single or double digits, content -- compared to the 4000 plus that were identified in brazil? i know that maybe 1500, that they identified for every let's

say, one that they had identified, that is truly microsoft will he -- microcephaly. but the numbers were the >> the question is really what is the mechanism by which is he good virus infects? zika virus infects? isolations, we mean taking infectious virus and pulling it out and demonstrating the growing culture. the other way in which people try to identify a virus as being present in a sample is by demonstrating genetic material or proteins made by that virus. there hasn't been a lot of microcephaly brains

because most of these children are still alive. if they were to die, you would find fossil fragments or genetic elements of these viruses present in the brains. i just don't think we have that information yet. what people are trying to do is to develop indirect mechanisms of demonstrating zika virus infections. at present, there are methods where you look for antibodies but they're not as specific as we would like them to be. the question i want to get it back to, which i don't think we addressed properly, is how we are going to identify which of 320,000 ofes of the

being potentially there. usinga lot of work high-frequency instruments to characterize unknown viruses present in the blood supply. a very rapid and less expensive ways to do this. i have to say that in the analysis we have done thus far we haven't found thousands of new viruses. if we were to look at blood from areas like cameroon where we don't currently have access -- and if anyone would like to provide us with access, i promise you we will analyze them very quickly and let you all know how many viruses are working there. the number of viruses that would need to be characterized and to wet extent i see with the -- see the numbers in the hundreds. that is a fairly simple set of experiments to do. we can characterize them in

culture, look for their ability to get inside human cells, look for their ability to suppress innate immune responses that would normally take viruses out of cells. data done to organ cultures or ultimately, we can move them into animal model experiments. we take it through that whole series of entry points, i would predict we could identify those viruses which pose the greatest risk and we could give you a top 10 list of what we would be americas about in the and asia and in africa and so on. be a staggeringly expensive process to pursue. but someone has to pay for it. there is no way to do the work otherwise. on that note, thank you all

so much for coming. [applause] the book is on sale in the back. we are also having a reception. please do stick around and have more conversation. thank you. don't forget to buy sonia's book on the way at the back. thank you. >> coming up on c-span, the former republican national committee general counsel on the party's convention rules. then a rebroadcast of our landmark cases series looking at the 1803 case of marbury versus madison. been ginsburg looking at the very real possibility of an open or contested convention. explain what this all means.

what is a contested convention? >> it is when none of the candidates arrive at the commission with the majority of delegates. by definition, they have to contest to reach a majority. host: if there is a candidate with a majority of the delegates but not a majority overall, what does that mean? ben: there is a magic number. you have to get more than that. there will be balloting when the delegates get there and to see if and then balloting your candidate can win enough delegates to get over the majority. a lot of attention on the rules committee. here is the quon