 Fe'r cymdeithas diwethaf i ddweud o gefn español yma yma. Fe yna ddweud ar draws ffordd ei wneud a ches premium ac rwy'n bwysig wedi'i ei wneud gan y dowod diwethaf chi'n thwyviousnau.isticallynd, rwy'n haf pwysig cymdeithas yw rhai yn ffath i ddweud. Yn pwysig yw Peter Pelt, ysgol y Lund i'r ysgol, ysgol ffoddf yma. Ac yma ydych chi'n olygu ar gyfer fynd i Ibola. Jeremy Farar, ymryd y Swinfyrdd yn dod y Llywodraedd良 ar y cyg. y bydd y cyfnodwch yn ei dwylo. A'r byd yn y bydd y bydd yn ymgyrch yn y ffordd a'r bydd yn y ffordd yn y bydd y ffordd. Yn y bydd y bydd yn y bydd y bydd yn y ffordd, y dyfodol ynyddu fel y cyfnodd, o'r cyfnodd ar gyfer y cyfnodd, yr adroddau sydd wedi'i ffudio'r cyfnodd ar gyfer y cyfnodd ac eich bydd y bydd yn y cyfnodd ac i'r bydd yn dweud. Rwy'n dweud ei bod yn y panel. Rwy'n ddigon i'n gwybod a'r bydd yn cael ei ddysgu encouraging to begin with, which we will have between the three of us. I want to spend as much time as we can opening it up for discussion. Both to you and the audience here and worldwide to the social media audience who will be sending in questions and to frame those questions, what we have been asked to address is what are the most important changes and that is the very important word change is needed to improve global health security. Mae'r ddaeth ddysgu'r ysgolwyr yn ymweld i'u gwirionedd, ac rwy'n meddwl i'w ddweud yw'r ysgolwyr, ond rwy'n meddwl i'w ddweud yw ddweud hynny, dwi'n meddwl i'w ddweud yw'r ysgolwyr. Ond rwy'n meddwl i'r ddweud hynny yn ffawr o'r ddecharedd, llawer, ar y ddweud â ddecharedd yn y bobl yn gyffinio bwysig o'r ddweud. bywyd adrolygu ar y executive bros ei gweithgwr ar hwnnw, mae hynod o'i gweithio'r hynny yn y bwysig o'r byd, a rhaid i'r cyfrif feddwl, rhaid i'r cyfrif roedd yn cael eu rhanu, sydd wedi am ffyrraedd o'r bwrdd o'r Cyfrif yn ystafell. beyond the individual disease we're talking about. So the first is the epidemics in the context of emerging infections and non-endemic infections, and also with the rise of the non-communicable diseases and how do we balance those? How do we better prepare and better respond and those two things cannot be divorced? We cannot just prepare. We have to learn how to respond. And you cannot do any of that without some discussion and debate and challenge gyda'n gallu ei wneud o gyflwyno'r gyflwyno ac mae'n gwybod i'r ddweud yn ysgrifennu a chyddechrau. Rydyn ni'n gwneud hynny fel y Mydd Llyfr Siwn, byddai'n gwneud ychydig y ddweud o'r cyflwyno'r gyflwyno'r gyflwyno a'r mynd i ddweud y llunio'r cyflwyno. Mae'n gwybod i gael i'r cyflwno'r cyflwyno, ac mae'n gwybod i'r cyflwyno'r gyflwyno'r cyflwyno'r gyflwyno'r cyflwyno'r cyflwyno. I'r ystafod o'r ffordd i Peter yw p'r hynny, y fyrdd yn fawr yn rhaid i'r ffordd i ymgyrch i'r gwybod o'r ffordd i'r ymgyrch, oherwydd gallu y dyfodol ac yn ôl y gwrthu busau gweldol. Mae'r ymgyrch yn ymgyrch i'r ffordd i'r gwrthu busau gweldol, yn rhyngwisio'i gweldol ymgyrch i'r gwrthu busau gweldol, oherwydd y gwrdd yn ymgyrch i'r gwrthu busau gweldol, oherwydd ymgyrch i'r gymhagwyd, and the other partners and a contingency fund to pay for it. That was written a decade ago around SARS. Ask yourself if we've done any of that in the intervening ten years and let's make sure we do those things in the next decade. So Peter, pick up that challenge. Thanks Jeremy and I could add on a small scale after the first Ebola epidemic in 76 I attended my first ever WHO Beij richtig ddechade i was in London also for the first time I went to London School of medicine. And there was also a whole plan was designed for epidemic preparedness. This was in January 1977, so last century. And we all know what happened. First maybe a few words about Ebola itself. Together with the Swiss Frank, this was probably the black swan event of the last 12 months. You know that was totally unanticipated and we could not have predicted on the basis of what happened the 37 previous years. And just two other points. One is that what we read in the newspapers today is that it's over. That there are more hospital beds than patients and so on and so on. Don't be fooled by that it's not over yet and it's going to be probably a long tail and a bumpy road before it's really finally over. In other words when the last person with Ebola infection has either died or has recovered without having infected anybody else because that's what it will require. And that means that we need to rethink at this stage go to the next phase. Now what is new and Ebola for me is an opportunity as with every crisis. And we have to make sure that 10 years from now we won't be able to sit here as even older men, I mean elders, you're young. That we will have learned from it and that we are better prepared. And I think the global health context has changed in several ways. One, the what? I mean there are not only epidemics and there will be new infectious diseases, emerging diseases and new Ebola and other epidemics will continue to appear even if the non-communical diseases, chronic diseases are the main causes of death and morbidity in the world. So we need to make sure that we are far better prepared. Secondly, we need a new paradigm. It's actually mind blowing that today with Ebola we still have the same kind of medieval approaches as we had in 76. Isolation, quarantine, safe barriers and they work to certain extent. But one of the things I've learned from dealing with HIV is that you need a very comprehensive approach. You need of course prevention. You need cultural approaches but you also should not neglect what modern technology offers us both in terms of vaccines and treatments and I wish we had been better prepared so that we could have tested them earlier but also in terms of sequencing and so on to follow what is going on. And thirdly we need better instruments and we'll come back to that. Tom I'm going to turn to you and I should have told you about this before but I forgot to do it but anyway March 2013 you said without doubt we're better prepared today than we've ever been thanks to better coordination innovations. We need to detect in real time lives because lives and economies will depend on how quickly we can detect threats. Do you still think that is the problem or do you think it's our inability to act having detected something? Where do you get this balance right? Fundamentally there are three things we have to do. We have to find things quickly, respond effectively and prevent them wherever possible. Any way you break it down it comes back to those three things and for each of those things there's a lot more that's needed at the national level where we need networks to monitor at the global level where we need a much more robust ability to assist when something exceeds national capacity and also at the coordination level between not just public institutions but also the private sector and others. So if you just go back to that triumvirate of find, stop, prevent for each of those things there's so much progress that we need to make and can make it's within reach but it's hard to predict. Some of it will require or be benefited by new tools. I think we'll have new diagnostics for Ebola within the next few months. They won't be perfect but they'll be better more usable in the field than what we have now if things go as we anticipate they will. But still you need a system to track. You need healthcare providers who are reporting to public health. You need a reporting system. You need a laboratory network to get specimens in. A few years ago as a proof of principle of global health security in Uganda we worked with the national government. We used some of the backbone that was established through the PEPFAR program and we established a country-wide national network so that if an undiagnosed condition occurred anywhere a motorcycle courier would carry the specimen to a hub it would be transported overnight to the central laboratory. The central laboratory would be safely, accurately tested and then the result would be sent by essentially a GSM printer and print at the local clinic and also print at an emergency operation center. This was not particularly difficult to put into place but it required roads, overnight couriers, laboratory systems, trained staff. This is all hard work that can be done. It's within reach in the Ebola funding authorization which Congress just approved in the U.S. We now have hundreds of millions of dollars to begin to do things like this in more places but there's much more needed from countries around the world and the private sector. Those monies and the U.S. government should be credited because they have played a leading role in this. How do we ensure that that monies which becomes available in the context of a crisis is continued when you stop the crisis because if I go back to SARS and if I go back to bird flu and if I go back to EV71 and if I go back and I could go on and on. We've been good at doing that. What we haven't been good at is we've cut your budget. We've cut the WHO's. How do we ensure that politicians understand that it's, you have to be in this for the long term? Well it's obviously impossible to ensure but there are a couple of things we can do to increase the likelihood. One is success. Success breeds success so when you have examples of programs that are working they tend to recruit more support for themselves and the second is accountability. We don't currently have something like the Transparency International Index for Global Health Security but we need it. I'll come back to you in the second bit but I'll push you on that one again Tom. Success, you never get credit for things you prevent because they weren't going to happen anyway. In fact many of us were very heavily criticised for the pandemic because we overreacted apparently. How do you get credit when you stop something which somebody will say well it wasn't going to happen? You know there is a theme in public health where people say oh it's hopeless because when we succeed nothing happens nobody sees it. I don't think that's right. I think we need to be more creative, more effective at communicating what happens. I'll tell you a story. Three years ago an 11 year old girl tragically died of Ebola in Uganda. That's the end of the story. There was no outbreak because we and the Ugandans and WHO and others had trained the hospital how to do infection control, had trained the laboratory how to test for Ebola, had motivated people so that they would rapidly isolate someone who had fever and cough and assess them and so it's the only example I know of in nature of a solitary case of Ebola. So there was no outbreak but that story can be told similarly in Uganda also. We have a rapid dip stick test for plague, 20 minute test, determined plague, worked with local healers, referred to health centers last year, a year before young man, a farmer with a family came in with a cough and fever referred by a traditional healer, diagnosed with Ebola, put on a clinical trial because we're not sure, I'm sorry, diagnosed with plague, pneumonic plague, put on a clinical trial because we're not certain the optimal treatment, three days later it's back at work in the fields. So I think telling those stories to the audience would have heard of that probably nobody or the Ebola case in Uganda I guess and that is a problem with communication. Peter, do you think we've still got a problem also with the way we construct the education of young people such that we call somebody an epidemiologist and that's a very traditional, dare I say, 19th century because we haven't done very many different things to what John Snow would have done in the 19th century in fact and that we've separated from that the more genetics, the clinical, the social sciences, the anthropology and that we don't see all the those together in being the modern epidemiologists. Yeah, I should disclose I have zero diploma in epidemiology or public health and I'm an infectious disease person and a microbiologist is it. No, I think that we need to rethink also how we approach public health and it was really good for the times that in high income countries, infectious diseases, malnutrition and so were really the predominant causes of death and disease today that's completely different. We have chronic diseases that are really also outside sub-Saharan Africa in the rest of the world so for me that should be part also of global health security but it requires very different types of approaches. On the one hand very strong policies I mean tobacco is still the biggest killer and like in Africa there is a huge opportunity to keep Africa at the very low, low level of use of tobacco. That's going to prevent millions of deaths but maybe nobody will say thank you but that's but then secondly we have to integrate far more what science has to offer today and I think that you know if you're just coming back to the current Ebola epidemic but also the same story with SARS with the you know pandemic flu and yeah the if we would have been ready with protocols for testing out new experimental drugs, new vaccines when the epidemic started we could have had a bigger impact I think by combining the classic public health measures and you know what modern science and technology is offering so we need to rethink that paradigm. I just want to stand up for a minute for epidemiology because one of the single most important things I think that CDC has done around the world is to train thousands of epidemiologists in field epidemiology. How do you establish and evaluate a surveillance system? How do you find and stop an outbreak? I travelled last month with a field epidemiologist from Uganda sent by the African Union to work in rural Liberia helping to stop the outbreaks there. He had worked on Ebola outbreaks, he knew surveillance, he knew infection control and we need many many more trained epidemiologists. We also need to incorporate new tools analytics, presentation, data transfer, looking at big data, looking at other data sources but the bottom line of training someone rigorously how to think about data and how to use it to protect health. That's a skill that we need to get many more people trained. I stand up for myself here because we've been looking at your program, in fact we've both been looking at your program over the last few weeks to see how we could replicate it and be there to improve it because we see it as the model globally for the training of young epidemiologists in the future. We're absolutely onside and we'll be coming to see you anywhere about it but that's another story. Right, because our school also, we've been producing thousands of epidemiologists but I think it's necessary but not enough. It's necessary for the field work and for example what we need now to deal with the final find the last mile of Ebola will require very old couture I call it epidemiology, really, really detective work in the field but when you think of the big global health threats we need more than that and we need to bring it all together and that schism between public health, the world of prevention and clinical medicine and science, I think that is one of the big obstacles that we have to overcome. Something I've certainly talked on regularly with a title of public health, clinical medicine and the rest of health being divorced for too long and I think it has been but Tom fear not it is the model that we hope to follow and emulate. Peter, everybody likes to kick Geneva and WHO and I think it's been unhelpful in many times but nevertheless they are the leading authority for global public health. Where is their future do you think? Well the world needs WHO let's just start with that and I think the last thing we need would be to invent and set up yet another organisation just to deal at the global level with emergencies but we need a much better WHO that's for sure also. One that has the capacity and the courage to intervene where epidemics arise because that's a global public good and where we have a strong central body entity whatever you call it within WHO that is protected and that can be deployed together with others with CDC and with whoever and of course the countries and can be deployed immediately and I'd rather be accused of overreacting than of underreacting. But these sound good but the truth is it will be protected for a while until the Ebola becomes a distant memory particularly to those in Geneva, Washington, London, Paris etc and then it will be reduced so that has been the track record over the last 20 years. Yeah and actually I think that many countries don't want a strong WHO they don't want strong multinational multi lateral institutions but I think that with growing awareness I think the danger and the risk of epidemics I think that the understanding for the time being until as long as Ebola is in the news and then the next epidemic there should be a protected budget in WHO associated with a strong reform movement and one of the problems is the WHO offices in countries who are weak and some of the regional offices. The regional office in Africa should be the strongest of all because that's where the biggest health challenges are. It is the weakest and so we need to find a way of strengthening that but also be no compromise on quality and where the health of the people should come first. I was seconded to WHO for five years so I've worked with them and I don't think you should just whole cloth say it's a problem. There are also terrific people within WHO who work very effectively, who are very knowledgeable. The challenge is as with people, as with organisations, your greatest strength is often your greatest weakness. With WHO the fact that they do have the political buy-in of countries is also their greatest weakness. So how do you insulate from political influence the core technical issues that need to happen including selection of regional directors, selection of country directors, staff decisions and so on? Would you keep the regional offices? I think they've either got to be greatly improved or their authorities have to be greatly reduced. This was a summary previously either completely decentralised to very strong regional national offices or centralised but the current hybrid doesn't quite get there in either. Just to put on the record I am a very strong believer in global bodies and absolute believer in WHO being strengthened so that it can serve its purpose because I think otherwise a fragmented healthcare system globally is would be far, far worse. I think that in case of epidemics you need a global approach and it can't be, of course the action is on the ground, one country or multiple countries regional but it is a threat to the rest of the world and again coming back to the notion of global public good that's why you need a central type of body that can intervene and that can do the analysis etc and not decentralised. I believe that for health systems strengthening and so on I think that should be decentralised and that's something that has to be built up country by country but epidemic preparedness is something else. I agree with that however I don't think we should expect WHO to be able to do it all. It needs to have a coordination and intelligence function greater capacity than it has now more ability to reach in to regions and countries but we need to build on entities like the global outbreak and response network to bring in MSF, to bring in London school, to bring in CDC, to bring in other partners. The African Union has been phenomenal in West Africa. They've got 700 people there now close to 100 of them have been trained to your epidemiology programs and they'll make a difference. Correct me if I'm wrong Tom but I think I'm right in those so-called non-state actors which is not what I like but don't have any voice certainly not on the executive board of WHO. They have no voice within the governance structure currently. At least they should have a voice in how to get things implemented and done and they should be determinative in making sure it happens right. Okay I'm going to open it up now. Questions on any subject. The price of bread, epidemics, global governance. If you could just introduce yourself quickly and then to whom you want to. For blood tests which give laboratory quality so we think that technologically we are there for the rural areas of the emerging markets. The technology is there. We don't need as Thomas said the couriers, the roads, so the cheap technology there. We can do that. We can do that cheaply. Now then the second problem we had is the distribution partner because in these places it may not necessarily be the healthcare partner. It might be food distributor or even churches organizations like that. What we are struggling with is that how to educate the population that they actually need to do those regular checks. How to raise awareness among them because it's just something they have never done before. That's something we cannot realize actually. We cannot get it. I think this is a major problem because when the W Show, I don't want to just talk about the W Show it also applies to all of our organizations. The state itself was the deliverer of all things in many many countries. That's no longer true. How do we reach out to the non-state actors, the churches, the community leaders, the society which is often actually delivering healthcare with nothing to do with government? In the case of AIDS this has always been a given. Not always in the early days but that was because the state didn't want to be involved with AIDS so we went to the non-governmental sector or whatever civil society business or what have you. It has not been without its problems but there you build local coalitions and in some cases that's more like church-affiliated organizations that are providing healthcare. In others it's more for profit business. It can be in the case of epidemics MSF just as Tom says but I think that that's something that has to be organized within countries and then I think at the global governance level we have the example of the global fund where you have representatives in this case of people living with HIV, NGOs and so on and business. I think it's not impossible and it's one of the issues that will be debated in W H O also and I think that W H O should open up itself as well for that so that you have a very pragmatic approach to delivery to setting policy although I know at the end of the day it's the state that has the responsibility for policy for health security and so on but it cannot deliver everything. Also the state has a facilitative role for new technology. We've seen all over the world totally inaccurate technologies marketed to the poor who pay top dollar for them and are not benefited by them so the combination of technologies that lead to real health improvements that people can recognize and a government infrastructure that without impeding innovation facilitates the delivery of reliable services in whether it's public or private. Thank you. I'm Gary Cohen with BD. I'm also a member of the board of the CDC Foundation. Simple question. You mentioned Uganda and Kenya. Ebola outbreaks were quickly brought under control. Nigeria during this recent outbreak I think in large part because CDC already had emergency operation centers there partially funded by Gates or largely funded for Polio quickly brought under control could have been a disaster. What needs to be done so Guinea Sierra Leone Liberia goes out of control. What are the fundamental things that need to be put in place who should fund it and who should implement it. Tom, do you want to start? I'll start. Get to zero stay at zero. Get to zero by tracing every single chain of transmission and that is the traditional epidemiology. It's a public health response. That means putting public health teams in all 62 of the subnational areas, breaking the urban areas into wards or units and working really intensively so that every single case is tracked. In September, October it was impossible. There were so many cases it was impossible but now with the waters receding you can see the streams and then you can stop the spread but that also means going into every forest community of Guinea to identify whether there are cases. That's where it came from. That's where it's got to stop and that's going to be very challenging. Dealing with resistance means on the one hand providing good sensitive, timely, respectful services. On the other hand dealing with community perceptions or misperceptions of causes of illness. Having public health structures, having laboratory capacity, having treatment capacity, burial capacity when needed in every single place. We've seen tremendous progress in Liberia in the past couple of months. We are hopeful that we can see that kind of progress in Sierra Leone but Guinea is a cautionary note because they've oscillated in cases. You let up your guard and it comes roaring back. There's nothing there that I would absolutely endorse all of that. The only thing I would add to that is your only opportunity to change this and future epidemics in a different way are to conduct research during this epidemic. You cannot work out how to treat an individual with Ebola unless you do that research within the context of an epidemic because there are no human cases outside an epidemic. You can't work out truly whether a vaccine is both safe and efficacious and effective unless you do that research during an epidemic and this is a unique opportunity to ensure that we do everything that's on just said but in the inevitable future epidemics that we do not have no access to medicine, diagnostics, decent treatment so we change the communication around coming to a treatment centre and we have vaccines that at the very least would mean that no healthcare worker dies of Ebola again. So I would just add that. Peter, do you want to add anything? No, I agree. Yeah, and then. Seth Berkley, Gaby, a comment and then a question. I couldn't agree with you more about ring fencing, infectious disease, funds, you know, evolution is going to occur. I know some people in my home country don't believe that but evolution is going to occur. We're going to continue to have new bugs, new infectious disease outbreaks and once and for all, and you're absolutely right, the history is over 20 years as we go up and down, we need to have that adequately resourced, we need to have the laboratory facilities etc. The question for me is in development speak, we're about primary healthcare, we're about primary education. Critical to this is getting graduate education, strong university, strong research institution. You know, has a vaccine testing unit that has a really good set of scientists and they played very importantly in this. So how do we shift the mindset to say, you know, yes, we have to have primary healthcare, university healthcare etc. But we also need to have in parallel, very strong local institutions with high level people and the incentives in place, you know, to be able to keep them because otherwise, you know, we're going to fly in and fix things and fly out again and that's a problem. Yeah, huge. Peter, do you want to start? This is a very, very important issue from the perspective in the development world when it comes to education was first, everybody primary education and then secondary education and tertiary education and this kind of institution is kind of a private luxury type of thing. And particularly for sub-Saharan Africa, as long as there aren't institutions that are producing the intellectual property lawyers, the engineers, not only I mean all the other professionals and so on, it will risk to remain an extraction economy or cash crop economy and won't be ready. And I think the example of certainly East and Southeast Asia is that shows that the other way is possible. And so we need to invest in that, you know, just at the same time as we invest in health system strengthening and so on. So it should become part, integral part of the international development agenda. I couldn't agree more. I would just add in addition to the health system strengthening and the educational at every levels, public health system strengthening has really been neglected. And if there's one lesson from Ebola, it's the need to have resilient public health systems around the world, they're a best buy, whether it's for a vaccine implementation or outbreak detection response. I would be a little bit more optimistic than your question sort of implied but I know you don't feel and that is I think there is a growing awareness of this and we mustn't just stop either primary or secondary or tertiary. We have to, there has to be a career path for people to stay. I mean I'm not a development expert and there are many in this room who are but it can't just stop at what has traditionally been PhDs and then nothing because brain drain will take people away from. So we have to think. Absolutely and that has to be. But give credit to many people in this room who I know who have played a major role in that and as Tom said, CDC have played a huge role in this and training epidemiologists around the world, whatever you all think of epidemiology. Yeah, sorry, sorry. No, you were first. You were first, sorry. Young Morgan from Korea and then I'm the president and CEO of National Medical Centre in Korea and then I'm very much great for your great opinions and then I'd like to ask you panellist, all of you, that how we can do improve health issues in terms of global health security by using ODAs like from north to south transferring all kinds of know house and to help them out in terms of funding as well as technologies. ODA as you know that under OECD countries you have DAC to improve ODAs but I don't think they are doing really systematically in terms of health issues for the global health securities. What's your concrete ideas about that? This is a, we could have another session on that. Has ODA improved actually the health of the people in the world in low and middle income countries? Yeah, sorry, overseas official development assistance. Thank you for the question. So, and when you look at where the fastest and the greatest improvement in health has occurred, it has occurred in countries that have basically not benefited that much from this development assistance, particularly in Asia and in Latin America. However, I think that the time has come also to rethink that. I believe that many of the solutions or achievements in health will come from no longer just from the classic countries in North America, Japan and Western Europe that every epidemic will be an opportunity to learn that how we deal with chronic diseases that that's something that can, you know, the ideas will come from all over the world today. So, we need, yes, we need to share the wealth. Korea can share more of its wealth with countries that are less well off, but I don't think that the old paradigm where the problems are in a number of countries called the North and the, sorry, the solutions in the North and the problem in the South, that is also changing. A lot of excellent research is going on today in countries that were not on the map, you know, and we see that also when you look even at the world ranking of universities, Korea, Singapore, I mean, you know, coming up in a big way, China and so on. I would, I also feel more optimistic about it. There is a tendency to be cynical and say, well, it's not working anywhere. Having spent the last 18 years living in Vietnam, having been born in Singapore when there were open sewers in the middle of what is now called the Central Business District, and that wasn't many decades ago. And countries in Sub-Saharan Africa that are on absolutely the right trajectory, I think there is a tendency to say to be really gloomy about it. And I think that is in itself counterproductive. And so I think there is, whilst there's need for a form, as with WHOs we talked about, but there's not a need to just throw everything out and say none of it's working because many countries actually are on a very optimistic trajectory, I believe. Tom. There are important success stories and it's important to learn from them, whether it's immunisation or training of epidemiologists or outbreak detection control, laboratory networks, the African Society for Laboratory Medicine now has certified laboratories all over Africa. So there are success stories, but there are also failures to learn from as well. And one of the things that I think we need to do increasingly is have a level of contingent assistance. Countries have to create career tracks for people or there's no point in trying to build a system when it's just going to collapse. Countries have to get the match that they choose between public and private sector in a way that's workable so that if five out of six dollars are being spent from poor people's pockets for private sector care, at least the government has to provide some level of oversight of that care. I'm going to bring Hans in here because he's talked about this brilliantly often that we talk about the so-called developing world as a group together when clearly it isn't. Hans. And there is no definition. I came back from three months being a main advisor on epidemiological surveillance in Liberia and I can testify the great help we had from CDC, from WHO and MSF that's been leading. What was the sad thing? Was the way development aid funding made work irrational? That's my reflection on this. The funding from CDC was to take care of the United States and yet it's no great work outside. The only thing we criticized for you before was we wanted more of you and we wanted fewer for longer period. That's what we wanted but you could do what you could within your situation. And WHO had a core budget which is 12% or 14% and they were dependent on other money. It's not rational the way they are organized. The saddest thing was this Ebola treatment unit which was on aid money. There was no way we could stop them from being built in Monrovia. We knew two months ago there would be extra beds. There was not two beds per patient. There are 10 beds per patient, 20 beds per patient and the government had tough times to convince the aid organization to stop building them. In the end they were allowed to build them and they inaugurated them but they didn't open them. It was a waste of money and that couldn't be managed. So what I see... But how did you... You might have known it was a waste of money then. What happens if the epidemic had taken a turn that even you could not have predicted? Where would you be sitting out? No, we were gradually seeing where it was going. That was not the third case. This was the stupid argument they had. The problem we had with data was that data were used for two purposes. Numbers were used to be reported and communicated mainly in the rich end of the world and they were used for research papers, some which were useful, other which were not necessary. But data for management we had very little and we presented the data on the table. They just didn't want to listen because they already had the money and probably the contracts were already written so they had to be constructed. It was very difficult to have the data to work in the managerial way and to swap from this crisis management down to exactly what you say now, the finest and best epidemiologist, to what we need is young snow. Yes, we need new young snows. We do it in the same way and really understand it. So I would think that this control is... I would think that this control is... It has to go out of aid money. It has to be global security money that secure this over the years into the future. Aid money is too unreliable. If somebody could pinch the microphone... I would say, while the next person is asking, the biggest challenge in Ebola was how fast things changed. I went in August and September within one week of leaving things were dramatically different. I went to end of December within one week of leaving things were very, very different. We had got just after Tom was there, Peter and I were there and it was dramatically different from when Tom was there only actually I think 10 days ago. Yeah, preferably not Ebola. Actually, here's my question. I'm a little haunted by the fact that it was 40 years when you were first, when the global health community was first talking about Ebola and we didn't do much. So I guess my question is, is there another virus that the global health community is thinking about at this moment that hasn't captured our attention and that we should be thinking about to get ahead of the curve? I think we would all have a list for that. The list... I actually don't think the list is huge. I think we'd all start with flu. But there is a list and we would all start with flu. I hate to go back to Donald Rumsfield but of course there's the knowns and there's the unknowns and there are in my view a relatively small number of knowns that we do need to learn one of the lessons and one of the lessons for me hates to mention Ebola again is the demonstration that once you've got a vaccine on the shelf don't just wait at the non-human primate level, make sure you've got the safety data if you're likely to want to use it. And the list for that is not that extensive in my view. Tom, absolutely agree. Flu for me remains the big number one. But I could give you a list of others. And who knows what the next HIV will be? And who knows how different the world would be today if we had recognised HIV decades ago and had containment. And it's not only new organisms or microbes but also untreatable. I mean multi-resistant microorganisms. We have not talked about drug resistance and my view that drug resistance at least, drug resistance has to be put into the same category as the emerging infectious disease. In my view it will be the most important emerging infectious disease of the 21st century. Absolutely. The triumvirate of risk is bioterrorism because unfortunately the great tools we have that allow us to do things for good also would allow bad things to be done. Where do you stand on gain of function studies Tom? Well it's very clear that they have risk and it's not so clear what the benefit is. I would say there are times when they should be done very, very carefully but that risk benefit ratio is something I think we have to recapitulate. The reason I ask that, one of my worries, gain of function studies is where you change a pathogen so that it makes it more transmissible, more further. My worry is the global capacity for conducting surveillance at the level we think it should be and even at today's level I'm not convinced that's sustainable when we have to respond to every single flu epidemic, H7N9 in China at the moment. It's not no idea if H7N9 is going to be a global threat or will just remain a relatively minor avian influenza that infects a few humans and I think understanding the biology of that becomes critical. I don't disagree with Tom's risk benefit discussion. Sir and then come to you. In the case of Ebola there's no vaccine in the case of influenza. Better just introduce yourself. In the case of Ebola there is no vaccine in the case of influenza there was a vaccine and this raises a question of global governance because the vaccine that was available was basically nationalized in every country that produced the vaccine. Therefore nations acted in their self-interest not necessarily in the best interest of the world and how does that prevent it? I'm afraid with only two minutes left of this session it's going to be awfully challenging but I was very, very involved in which goes back now eight or nine years around the as portrayed the Indonesia Ministry of Health opinion why should we share our flu viruses when you'll just sell us back a vaccine at cost price. I don't think even within international health regulations and within the contract that was organised post bird flu I'm not sure still we've got that right and that inevitably countries will go back to national interest when the threat really hits inevitably and that's where global governance comes in. Say the last question. Coming back to the issue of surveillance getting to zero sorry Dr Annie Sparrow from Mount Sinai hospital there are parallels between the appearance of Ebola in West Africa and the reappearance of polio in Syria and I say that in terms of governments tend to cover up infectious disease we saw that in both countries Guinea covered it up Syria covered it up we see these fragile health systems one was neglected one was destroyed in terms of data we have to get it in a timely manner we have to respond to it here the imperative as I see it is the opportunity the imperative to invest in surveillance we depended on surveillance the small box eradication we depend on surveillance and yet we then depend on aid money and we put money into organisations such as say the children Sierra Leone which have neither the clinical capacity to treat Ebola nor the public health expertise to do the contact tracing prevention that is absolutely essential to get data in a timely manner and to convey it to respond and that as he is the issue because we are dealing with the these are issues of global governance this is with this was the year where we saw the two public health emergencies of international concern you need to deal with the government issue where they tend to cover up and then to deal with the actual how do you get that expertise on the ground to do the surveillance that we desperately need to address these I'm just going to take chance probably different and say I'm absolutely in surveillance don't say anything otherwise but unless we add response to surveillance surveillance itself will not solve the problem we are going to have to finish down I'm afraid thank you Tom thank you Peter very and the audience here I'm afraid we didn't go to the social media audience key lessons to be learned inevitably global governance I think our view is a strong WHO remains critical to global governance and we would do everything we can to try and enhance and support it in a positive way to make it stronger surveillance is critical emerging infections diseases have to be put into the context of the society they're occurring in the national systems we heard about the non-communal disease and the endemic diseases that they are there in and if we forget them they will come back to haunt us in future and with that I'll close the session thank you very much I'm staying around for a few minutes I hope you've enjoyed it I'm staying around for a few minutes I'm not sure if Tom Peter are but