 esteemed panelists that we have here about lessons learned from recent outbreaks of infectious disease so that as government and NGOs are looking at the various priorities of GHSA that we can glean from the experiences ongoing with Ebola, with MERS, with the annual flu in the area of detection to help inform the work of the GHSA over the next five years. There'll be no formal presentations. We very much want this to be a conversation and done through a question and answer and then as time permits then opening it up to the audience. But let me tell you a little bit about our panelists who have agreed to join us and I'm going to be going down the line. To my left immediately is Dr. Mark Smolinski who is currently the Director of Global Health Threats at the Skoll Global Threats Fund. I always don't want to confuse it with Skoll Foundation but he's with the Global Threats Fund. He was previously the Director of Predict and Prevent, the initiative that Google had in this area and prior to that, something near and dear to our hearts, he was the Vice President at NTI for the Biologic Programs and he really throughout his career has led a variety of global efforts on early detection and rapid response to emerging threats. To his left is Dr. Tom Inglesby, another close colleague of NTI. He is currently the Chief Executive Officer and Director of UPMC's Center for Health Security and he also serves as the Chair of the Board of Scientific Counselors for CDC and their work in the Public Preparedness and Response side. His work is known internationally where he's recognized in the fields of Public Health Preparedness, Pandemic Flu and Epidemic Planning and Biosecurity. Next to him is Dr. Nigel Lightfoot, who is currently the Executive Director of Cords, which is an NGO and it stands for Connecting Organizations for Regional Disease Surveillance. He's also a senior consultant at the Chatham House in the United Kingdom. Previously, he was the Director for Emergency Response at the UK's Health Protection Agency and led many of their efforts on pandemic influenza and emerging health threats. He has a long and well-established career in public health, global health security, as well as biosecurity and does a lot of work at the nexus between terrorism and public health. And finally, but not least, we have Franca Jones and she is currently at the Department of Defense where she is the Director of Medical Programs in Andy Webbershop, the Office of the Assistant Secretary of Defense for Nuclear, Chemical and Biologic Defense Programs. And she currently continues to serve as an active duty naval officer. Previous to that, she was over at the White House in the Office of Science and Technology Policy, where she led many of the administration's efforts on biologic research, defense and technology. She herself throughout her career has made significant strides towards developing national security policies on coordinating interagency within the US government on research and defense policies in the area of chemical and biologic defense. So with that, I'd like to start off Mark with you and we will hopefully bring out through our discussions a variety of different themes that we as a panel feel are critical in looking at the area of detection. And certainly foremost on that is the area of improved diagnostics. Mark, both with your work now at Skoll as well as previously at Google, you have always reminded us that it's as important to know what the disease is that people are looking at as it is what the disease is not. And as we've seen in a lot of the work on Ebola and MERS, the symptoms, particularly in the initial stages, will present as a variety of different diseases. And we've also heard from Andy Weber that it's moving from the big laboratory diagnostics to point of care. So could you talk to us a little bit about that and reflect not only on what you're doing, but also what you're hearing out in the field? Sure. Well, thank you and thank you for the organizers for inviting me to this event. While I was at Google, we started looking at point of care diagnostics. My colleague Larry Brilliant and I were very concerned at the point where you go into most countries and even though we were focused on new emerging diseases and pandemics, it's so that when we see these multiplex things that literally are going to be out there in the next five years at a cost value that I think we can move into developing countries. But the question is, what are we doing to get the human capacity to understand, use those tools now so that we have more complicated diagnostics coming down the pipeline? Those will make sense as well. So did any of our panelists want to comment on that briefly? Yeah, I just would like to sort of come in. Two weeks ago, I went to Tanzania to convene the countries in chords in that area, sort of to try and learn the lessons from previous Ebola outbreaks in DRC Congo and in Uganda. And we invited traditional healers into that meeting as well, as well as the media because in chords we try and include everybody with the locals in what we're doing. And what was coming out of it, Mark, was that 60% of the population with any illness go to a traditional healer first. So the cry from the traditional healers was, give us more information about what we're supposed to be doing. And the Tanzanian government are saying, right, let's work with traditional healers so that we can give them a trigger when they think, because people with Ebola will go to a traditional healer. And why? Because the traditional healer will say, I am called by God and I'm going to make you better. And he believes that and the patient believes that. And you're to take this herbal medicine and you will be cured, you will be better. Whereas if you go to the other route, which is the westernized approach, you go to the clinic, they watch people dying. They go in, their bodies are put in polythene bags. And there's a lot of messages to get to people. And it includes those traditional healers. And I think that was one of the things that we picked up from it. Can I just also add to what Mark said about the importance of diagnostics? I think if you go back to the Ebola, the early days of this Ebola response and you trace it back, if there had been rapid diagnostics at any of many potential points of intervention between December when the first case occurred and March when it was finally diagnosed by MSF scientists, I think it could have had an incredible impact. Who knows? We'll never know that. But there were multiple times when health teams went to evaluate what was going on in Guinea looking at the situation on the ground and they didn't have diagnostic tools. Even those health teams didn't have those tools to make that diagnosis in Guinea. So it took somewhere along the lines of three months from the time it began to the time we got a diagnosis. It's also really important what Mark said about the importance of accurate diagnostics. About February in that response chain, a doctor in Guinea suspected that it wasn't cholera as everyone else was thinking these cases were. And both because the cases had fever, which is unusual, and also because one of the cases had bleeding. And he was beginning to make a move in a direction to suspect something else, but then the lab came back with false positive tests for cholera. So in some cases, bad information is worse than no information because it turned off his alarm and another month went by before the world found out. So I completely agree with Mark and what with our earlier panelists were saying about the importance of reliable point of care diagnostics in detection. Yeah, and I know from our work in the Middle East, it's not just with Ebola, MERS that there was a great deal of difficulty in the beginning phases of that, particularly in Jordan, where two or three of the initial cases were presenting to try and understand what it was that they were looking at. And we know the path that that infectious disease has taken. Another major theme. Oh, I'm sorry. Yeah, I'd actually like to comment specifically on Tom's last remark. I think that one thing that we've seen has been a lot of vendors who are coming out now with their technology for doing point of care diagnostics. And especially here in the room with all of the NGOs here, there is a big desire for everyone to help. But I really want to make sure that everyone understands that when we're talking about accurate diagnostics and the importance of putting accurate diagnostics out there that we have a coordinated way to validate what it is that we are spending our money on to try to help with to be sure that we aren't making things worse. So one of the efforts that that we've been working on as early as four o'clock this morning is getting together with the WHO and we'll start to bring in some of the other foundations to make sure that we can put together a standardized set of specifications that we would want rapid diagnostic tests to actually have so that when we put those out that all of the NGOs and other governmental agencies that want to help in this regard at least has have something to put their effort towards. Thanks. But I just wanted to come in again because talking to people in Africa, it's a bit different to the Western idea that we're actually conceptualizing here. There's currently an outbreak of Ebola in the Congo, in the Democratic Republic of the Congo. It is not a disaster. The way the Congo works, because they've learned from their previous outbreaks from 1976 onwards, is that you can't place all these things all over the country because there's never been an Ebola outbreak in the same place in the Congo. It's always a different place. So what they've done is train the local health team, which consists of three people only about the symptoms and the other things. Like Mark was saying, try and rule out some of the other tests, but they have to then report it right to the center where the government makes a decision with its crisis response and sends out a team of about 20 people, experts, psychologists, whatever, to that rural area to actually confirm the tests, set up a laboratory, which is nowhere near a BSL2 or anything like that. It's just what can they do? And that's the way it works. And it's the same in Uganda. They have a central team that goes out to support local people. And I think what we need to do is work out how we would use the rapid tests in systems like that. So let's step back for a minute, Tom, because one of the things I know you throughout your work and your discussions have really been encouraging is the need to change the paradigm in the way in which we think about surveillance. Now, everyone traditionally thinks very much about surveillance in the front end of a crisis and in trying to get the detection, the diagnosis right. But I know you've been advocating the need to really look at surveillance throughout a crisis. And so talk to us, help us to think about this. What does that mean for workforce capacity? What does that mean for looking at the anomalies that would be coming in during a crisis that may encourage us to look at surveillance throughout? Sure. Well, I think many in the surveillance community have been doing this for a long time. I think in just in terms of our discussions today, for detect, I think we definitely want to make sure that we include in the concept of detection, not just initial detection or discovery of the first case, but detection and ongoing surveillance for what happens over the course of an outbreak or the course of a disaster. For example, I think you'll hear from Joseph Fair today more about the details of what happened in Sierra Leone. But in May, the number of cases got down to a few. And if we in future epidemics can get a better understanding of the ongoing case burden throughout the course, we don't lose track of where the illnesses are. We keep close tabs on and have systems for relying that relaying that information to health authorities. Then we won't find ourselves kind of always behind chasing the epidemic from behind. There's surveillance questions like who else has the disease? What's the scope? What's the geographic spread? What's the what are the risk factors that we're learning about as things evolve? These are these are common themes. They were common themes in West Nile virus in New York City. They are they were common in the SARS outbreak. I mean, these are the information systems that way. I think we all need to focus on in addition to which help us manage the outbreak in addition to all the things and the energy that we put on initial detection and discovery. And I know you and I have talked a little bit also about empowering the workforce to be speaking up and the critical role than the doctors and the nurses and the lab. Absolutely. Absolutely. So I mean, if you look back over the course of how outbreaks have been detected, the big ones, what you'll see is that nurses and doctors are often the the the very first indicators of what's going on. This isn't an automated function. This requires often typically requires human beings to make a judgment that something abnormal is happening and to pull the available fire alarm fire alarm that's that's nearest to them. So for example, in the anthrax events in 2001 in this country, it was an infectious disease physician in Florida that first suspected anthrax in a person in Florida. There had never been a case of anthrax in his hospital or in his state as far as we know, at least in modern times, but he suspected anthrax did the appropriate testing in his own laboratory and then pulled the national alarm. There's a case of anthrax in the United States. That's a common story and outbreak discovery. And so not doctors and nurses need to be part of this discussion, not just technology. Great. Nigel, like to ask you and you had made mention already that you just come back from Ethiopia, but you also had spent some time bringing together countries in East Africa, as well as Southern Africa over the past month to talk with them about crisis communication and risk communication and really the importance of cross border work and cross border communication. And I'd like Mark also to comment on that with his work, particularly in Southeast Asia. Can you tell us a little bit about some of the lessons you've learned from that? Yeah, working with those countries in Southern Africa and Eastern Africa, which are part of our networks. We got them together and as I told you, we had traditional healers there. We also, we also had the media there, but we had the experts there. And what came out of it all was that we can, we can give lots of information to people which says, don't do this and don't do that and don't do this and you must do that. They're telling us it doesn't work. You've got to give people information that means something to them. So the natural thing in Congo and Uganda is don't eat monkeys. But they tell us you cannot say that to those populations, those rural populations. They are hungry. There are no sources of protein really for them. And it's been traditional. They've done it for thousands of years and someone will kill a monkey and then it'll be butchered and then eaten. So you have to tell them all the truths about it, which is, it's been noticed that monkeys die off before an Ebola outbreak. So if the monkeys are dying, stop eating monkeys because they've got it from the bats. And if, so don't pick up a dead monkey. If you're, one of your people kills a monkey, then the person who's doing the butchering is the one at risk because that's what's happened in previous outbreaks. So you have to give them the information to do that. And if you cook it, if you cook Ebola virus and have your monkey roasted, we would recommend monkeys should be stewed really for a long time. There's no risk of infection because the virus is destroyed. And we got that from the virologists. So it's a lot of common sense in all of that, which is trying to get them to do it. And you can't tell them just don't do it because it doesn't work. And I think they come back at you and they will say to you, it's getting down into the communities and working with the people and the local people with the right sort of information and building a relationship with them. And I think that was agreed through all the countries that that was absolutely the way to do it. Now, when you talk to the Western people involved in Ebola crisis response, you mentioned communication. They said, but we've done all that. What they mean is they've done the crisis communication, which is saying, this is terrible. This is a mess. And you must do this and you must do that. What we need is something that's going to be sustainable, and which is information there, which means doing things in schools, doing things with music teachers, doing things with community leaders, not just the way we do our own crisis response. So that came out as really, really important thing to do. I think also the feeling is that they can do it themselves. They need a lot of help. And I think that if we if we if we can get people in terms of detection of events and outbreaks to communicate early and with fruit because they're trusted, then it really works. And this group of people will communicate across borders. They'll send teams to help each other. They will work together and they will get on top of every Ebola outbreak before it becomes a terrible response. But for some countries there's still a lot to do. Some countries haven't really done their Ebola planning yet. Uganda's got the best one, but we'll see what happens. And it just raises that question to me, is that if in West Africa, which is a very, very poor area and recent wars, there had been a network that was building between countries and between other parts of Africa, would it have turned out differently? As you point out, would there have been some help in diagnostics early on? It would have made a difference, I believe. And you mentioned Ethiopia to me, because I flew in for Ethiopia yesterday, because I wanted to turn on to the security aspect, if I may, Devin. Please. IDTOPOL has organized a series of biosecurity workshops, and this was the fourth one. And they asked cords to help them, because we have the public health people that we can bring to these convenings. They asked the International Federation of Biosecurity Associations also to help, because they can bring the biosecurity people together. So I've been working in a room of ten countries, and each of the country tables are the police force, law enforcement, security, public health and biosecurity. And some countries, like Uganda, they know each other and work together, the other countries are saying hello for the first times. And these sessions are about explaining a lot to them, motivating them, and then giving them a scenario to play through, and they give them simple scenarios to play through, and they love it. So one of the things we also did on Tuesday was give the opportunity for discussion on Ebola, because these are interactive sessions we have with them, and ask them what were the security implications of Ebola. And the security implications of Ebola are for them, that you've got to rethink the threat assessment of Ebola that we have done for the past way in the Western world, because it's now man as perpetrator going into a community who could spread Ebola and problems. We talked through MERS coronavirus, and we thought, I mean because the Sudan and Somalia have the biggest population of camels in the world, and all their camels go to the Gulf states, so they all have MERS virus, but nobody tests for it, because there aren't any tests in that part of Africa. But they were worried about MERS for when it does appear, for when somebody does test it, and when it does begin. And they concluded they needed generic responses between police, security, health, safety. To make that whole package work together, so that there's a faster response to those issues. Thanks, sir. Thank you, Nigel. That's a good reminder to us that it really is a multi-sectoral approach that's needed, and that's something that really is very much at the heart of the GHSA, and we see that in the action packages, and also tomorrow, when the various ministers come from the 44 countries, they will be representing agriculture, they'll be representing the human health, the public health side, but also the security, as well as the diplomatic communities as well. So before we leave this theme, though, of cross-border work and cross communications, I want to ask you Mark a little bit in terms of all of the work that you have done and your various professional incarnations in terms of developing cross-border networks that are very focused on the detection side as well. Thank you. So one of the approaches of global health security that we feel very strongly about as Gold Global Threats Fund, along with some of our colleagues and other foundations, is that neighboring countries really have to work together, and I remember one of the first interviews about this Ebola outbreak that I had seen on CNN and somebody, I think it was Steve Morse from Columbia, and they had asked him, you know, what was different about this Ebola outbreak? And they were like, because it happened at the interjunction of three countries that were not coordinating on infectious disease, which brought me full back to when I first joined NTI in 2003, it was to start a project to get Israel, Palestine, and Jordan to create a regional disease surveillance network that the criticism we got at the beginning was, doesn't WHO already have regional offices? Israel, Palestine, and Jordan in 2003 belong to three different regional offices for WHO, yet they are neighboring countries that share a common water source on top of that. So they wanted to develop a regional disease surveillance system, and to the comment earlier this morning, it's not about our agenda, it's about theirs. And, you know, I think back about the leadership at NTI Board at that time, it was, it didn't matter. That country, those three partners wanted to develop a dire real disease surveillance system. Great, if that's because that's what they all suffered from, they knew they were spreading it to each other. And from that became such a solid union between those three partners that I remember in 2006 when the World Health Organization asked every country to develop a plan for bird flu, the Middle East presented the first regional plan that Israel, Palestine, and Jordan cooperated and said, this is how we will do it together. So from there, I got very involved in Southeast Asia because the Rockefeller Foundation had brought six countries together in a very similar main Kong based and disease surveillance network. And we went at the time, I was still at NTI, and we said, okay, you know, we're a new foundation, and you've got this great organization of six countries, China, Vietnam, Cambodia, Laos, Myanmar, and Thailand. What if you had a new source of funding? What would you want to do that would be the most important thing you could do, reminding them that pandemics and and emerging diseases were sort of what we were interested in. And they were like, we want to do a tabletop exercise for bird flu. And we want to do it with the Ministers of Health environment and the agricultural community. And I remember going to David Nabarro at that time, who was the advisor at the UN for flu, and we said, hey, we're going to bring these six countries together in Southeast Asia, and they're going to do a tabletop exercise on bird flu. We'd love to have you involved. And we still joke about this today because David's like, you can't do that. And we're like, well, what do you mean you can't do that? And he's like, you're never going to get those three different ministries from six different countries to come together for a meeting. And we're like, oh, no, they're going to do it, David. We want you to be part of it. And sure enough, it was a phenomenal event that really brought people together. And then Nigel now is the executive director of an international organization that NTI with Fondassio Miro really helped us and it took about four years maybe to think through what could an international organization that brought together these informal networks of real people who talk to each other because they're the lab director in Jordan who talks to the lab director in Israel. How could we start bringing them together so they could share best practices, innovate, scale of ideas, and that became courts. And there are six different members networks of courts. And so at the School Global Threats Fund, we're still trying to prioritize how do we fill those holes in sort of the global hotspot for emerging diseases. And we have on our radar screen, South Asia and West Africa. And I'm here to apologize to say we chose South Asia as a priority over West Africa, mainly because, you know, and we had a meeting this year with Nepal, India, Pakistan and Bangladesh with the same idea. You guys are neighbors. Now again, we believe WHO needs to lead the global health issues around the world. I couldn't say that stronger. You need a leader. And I think the regional offices serve some function. But if neighboring countries can't talk to each other in some manner because they belong artificially to some sort of structure and not just able to talk to those people that really matter across the border, we are now, you know, obviously going to ramp up efforts and try to help as much as we can in West Africa as well. But that's the goal is to really have these neighboring countries working together in real time because I think that can make a big difference. Good. Well, thank you. Franca, I know tomorrow when the action packages are discussed, real time bio surveillance tools will be front and center in that. And I know that defense has been doing a lot of work on that, particularly from an electronic perspective surveillance. And could you talk to us a little bit about some of the work that you're doing and lessons learned, particularly as it relates to having to do this in a world in the community where everyone is throwing good ideas over the transom and coordinating that is a little like coordinating bats from the earlier presentation. Sure. Thanks for the question. Just to take a step back for a moment, one of the concepts that we discussed at the GHS meeting in Jakarta was with regards to implementing of electronic bio surveillance tools and this tying in a little bit of the conversation. When we were talking to different countries about how they would implement real time bio surveillance electronic tools, we realized in the group that they were a variety of different countries with a variety of different capabilities from no capability to some capability. And the most important thing for us was to make sure that that countries understood that there was a place for them in real time bio surveillance regardless of where they currently are. And that could be whether they were doing paper bio surveillance right now or had some sort of a tool and that we needed to think about this from the country level, the neighboring country level or regional level and a global level and how each country could think about their role in participating in electronic bio surveillance based on whether they were right now just comfortable working on it within their country or then branching out and working on it with neighboring countries like Georgia and Kazakhstan and Azerbaijan, for example, and then regionally, et cetera. And I'm mentioning that because it goes towards the technology development side and what we mean when we're talking about electronic bio surveillance. So to me, real time bio surveillance is happening in multiple different sectors in many places. Sometimes those sectors are coming together through electronic bio surveillance and sometimes they're not. So I'd like to think about the kinds of tools that we can work on for electronic bio surveillance as fitting a couple of different needs. Most people think of electronic bio surveillance as being disease surveillance. So I can put a tool in a hospital and that a hospital can use that tool to log in syndromes, maybe laboratory, patient contacts, and that information can be housed in an electronic system either only just at that hospital or it could be networked with other hospitals. So that's one area. Certainly laboratory generally would be considered something that might be a useful way to capture electronically. But then there's also information sharing, which I think is really big that not everyone maybe thinks about as an electronic bio surveillance tool. It's just as important to be able to share information between the patient contacts and the laboratory data or between the patient contacts in one country and the patient contacts in another country. Collaboration tools to me are also part of electronic bio surveillance. So it's one thing for me to be able to share my patient contact data in my country with another country. But if we have little mechanism to collaborate over the information that's been passed, then that presents potentially a challenge that can be resolved with electronic or and that includes telephones and and other mechanisms there. And then I also like to think about how these kinds of tools as a collective can be used in the agricultural community and the environmental health community and the law enforcement community. Of course, in the public health community and how those tools can come together to ultimately provide an integrated picture. So in the DOD, we do think about these things and we think about them not just in terms of how we can inform the force health protection for our military forces. We work on this collaboratively with a number of other countries is how do we bring the different sectors together with the different tools in a collaborative environment where they can share information. And again, that goes all the way down to laboratory data, patient contact data, to the collaboration side of the house. So I think at the end of the day, I like to think about these tools as a collective. And in terms of the global health security agenda, I think one of the most important pieces of of these tools is that it doesn't have to be the same tool that's implemented in each sector. But at a minimum, each sector within a country should be able to speak to one another through these tools. And if we can start there in a country and then branch out to the neighboring countries and to the regions, then I think that that we will have implemented a nice set. And my final point here is as as you mentioned, as a number of different tools are available and are in development in DOD and CDC and certainly in the private sector. The question is, is how, how do we decide? Who decides what what tool? I think the biggest point here is that all of us working in individual countries need to talk to the country. What do you need? What do you have? What what needs do you have in terms of of the public health community and the agricultural health community? Can we get your ministers together and agree to share information between those communities through a particular tool? I also think that we need to have a plan. I think even within the United States, we've all recognized that DOD has tools and maybe we are having programs in different countries and present those tools to different countries. And even the Centers for Disease Control has some tools and they go to different countries and present tools. And potentially many of you have tools and are working in different places in the same countries that are using multiple different tools just to conduct disease surveillance. We all need to have a plan on how we're going to engage countries. How are we going to determine what their needs are? What are going to be the criteria by which we collectively offer a suite of tools to do these numbers of things. And I think that's really going to have to be an effort amongst governments, industry, NGOs, and the intergovernmental organizations to come to that so that at the end of the day if we really want to achieve the vision of a multi-sectoral nature by which we can detect events early by combining information from multiple different sectors that we have systems out there that could in fact do that and promote eventually the early detection and ongoing biosurveillance of events. Mark? Yeah, I'd like to just share with you sort of the approach that our foundation has been taking about moving some tools into other parts of the world. So at the School Global Threats Fund, which there was the comment about not confusing us with the School Foundation, both foundations were started by Jeff Skoll, so I don't think he would care that much. But he created the School Global Threats Fund as a new foundation five years ago. And one of the things we're trying to do is because we sit in Silicon Valley is we're trying to figure out how do we take technology that already exists that's helping companies and universities and others and move that to parts of the world where they don't even know about this technology. And it's not like it's difficult or anything. It's just not even available. So what we've been doing as our approach and one of the things we're really interested in because we are working in these hotspots for disease surveillance and as we said a lot of them don't have diagnostics. Many countries have come to us and said couldn't we try to figure out disease and time and space. So if you think about I was an EIS officer, CDC and you always did a spot map and you'd put you know where all the things are you know you're looking at time and space. Well now we can do that so much better. And just to give you an example. So our approach is to not bring any developers from here. But what we do is we bring all the developers we can find from the region. So we just did what we call epi hacks and I know like hackathons can have a negative connotation but hackathons are also very positive. And so these are epi hacks where what we do is we bring we just did one in Chiang Mai. And I love the comments earlier because one thing that's unspoken in our foundation is One Health. Everything we do is about One Health. We just firmly believe that you've got to think about the environment, the humans, and the animals especially for talking about global health security. So our approach is can we put the public directly into surveillance. So for example in Lao Dr. Boon Lai who's part of the courts network came to us and said last year they had 89,000 cases of dengue and 90 deaths at the time he talked to us. And he said I have five messages I need to get out to my population. What about this tool you have in the United States called flu near you which is a participatory surveillance tool that our foundation supports with Harvard that allows anybody to report symptoms of flu. You see the map we're trying to figure out how do we learn more about a respiratory disease that spreads around the world and around the United States and we really don't know about who gets the flu. How effective are the vaccines? We can answer those questions now. Well that same kind of technology they want to move to developing countries where they're saying OK why can't I have everybody in my country this is in Lao reporting dengue and then I as the minister of health can send them back the messages like dengue is on the rise in your area. Here's what you should do. So in Chiang Mai they want to do one health surveillance. They don't want to just have just the public. They want the farmers. They want the market workers who are in contact with animals on a regular basis to be submitting their symptoms to be submitting like any concerns that they see. They're taking a one farther. They know that pharmacists are probably the first point of entry in Thailand for health care. So they're getting the pharmacist to report unusual illness. The point is they're trying to take technology that with GPS on almost every phone that you have. And in Thailand of course we're doing these pilots because 90 percent of the population has a smartphone more than one and you can start thinking about even without diagnostics you might be able to find acute outbreaks just by looking at things in time and space. And more importantly if we're looking at human populations that have high direct contact with animals that population is important and maybe someday we'll get to the point we're actually looking at the diseases in the animals before they move over into humans. But I think that's really important and so what we do is we just have the developers in those countries develop the technology with advice of people we know and we can help them. But like the system that they built in Chiang Mai web based smartphone SMS and an automated hotline. So if you are living in the country and the only thing you have is an old fashioned phone on the wall you will get a phone call every Monday and it will be automated and they'll say hey how are you feeling today? Did you have any symptoms push one? If you feel great push two. So it's really exciting to see what other countries are doing even with limited resources they see the power of connecting to their population and it's not just the power of finding early detection and important information they see the power of reaching back to their populations through those same channels and that's really exciting for us and having them build the technology to solve the issues they want is how the ministers buy in right from the beginning and it's how you get other organizations within those same countries and literally it's their agenda even though it may be part of the global health security agenda. That's great. And in fact the next EpiHack is in early December in Tanzania where the African countries are coming together and they're looking at a massive project using mobile phones in the animal community and in the human health community to report not surveillance of diseases and laboratory results but to report events happening people dying animals dying and to get those into a system because that really is rapid detection. Can I just say one last thing? So just I think these three last three comments really underscore a really good movement for surveillance in this country both in the government and the NGO community. If you went back five years, 10 years people were talking about building surveillance systems for us here to learn about those countries. I think there's been a change. Franca talked about it about how important it is to understand what countries need. We need to be building systems that are it's information for action. It's not just information for us to know it. And if we build systems that create information for action in those countries, those are the systems that are going to work and that are going to take. And these are two great examples of it. I want to ask one more question and then we'll open it up for the audience because I know there's a lot to talk about in the whole area of detection. But and this is for all of our panelists. You know, one of the things that whether it's in government or outside of government is very important is metrics. How do we know that we're doing better at what we're doing? And particularly in this area of detection, there's a lot of information out there from governments, the World Health Organization, CDC. How do you think about having, and Mark, I think you may have mentioned this, kind of a global baseline where information is coming in as much from the local communities and non-governmental organizations to really know whether we are, as a global community, moving that needle on detection. So moving it further to the left. So I open that up for any comments. Well, let's see. I'm going to leave it to others to talk about the specific metrics. I think on a larger story, I think we could look at some examples in the world, the difference between how SARS was detected, for example, in H7 and 9 in the same part of the world. In the case of SARS, there were cases of atypical pneumonia going on for months. And they were known by people in some parts of the world, and they weren't shared with other parts. In the same place in the world now, we have very, very rapid discovery of H7 and 9 and then sharing of information about H7 and 9 with the global community. I don't think it's uniform. I think we still make mistakes. I think in the case of MERS, there was knowledge in the system for at least three months that there was a new virus in Saudi Arabia in the Middle East. And that information wasn't shared with the Ministry of Health in Saudi Arabia or with the World Health Organization. I think that was a terrible mistake. But I think the kind of the world, the international collaboration around surveillance and detection, I think, is improving at a global level. I think your question about metrics is very important. And that's another level of detail. Yeah, I think the metrics. I mean, you would say the time to detection of outbreaks, we should be measuring it now. And in fact, a few people are measuring it because it, I mean, the history is littered with bad examples of things happening. And the thing that's happening is, and what has changed, is the internet and media. So you will find that the first report about the outbreak of viral hemorrhagic fever in Guinea was in the Guinea newspaper just a couple of days before everything started to happen. And that was when it broke to the world that something was happening. I mean, there may have been communications internally through other systems, but that's when the world knew that something was happening. So looking at that newspaper and looking at what's happening elsewhere are really important tools. So data mining becomes important information. And I'll tell you why. If we want people to talk to each other across borders about new events that they don't understand in what I call the period of uncertainty when the diagnosis is not made, but something is happening. If you want people to do that, you have to push information to people before so that they get continually being informed about what we know is happening around the world that might have global public health significance. Because if you're being given things, then you begin to say, oh, I've got something similar to that. I've got that. I'll report it into the system. You create a big club. And it's about event-based surveillance. It's a totally different way of doing it. And it's a totally different paradigm. And I think it's one that we all need to work on. Sure. You bring up one of the biggest challenges in this entire space. As you know, many of the programs within DOD and others have struggled to identify what are the metrics to determine that the work that we're doing, the capacity building that we're doing, the implementation of biosurveillance tools, how are these things working? Are they working? And I think that the earlier comment is that we obviously need a baseline. And we can use an example of SARS as the baseline for knowing that H7 and 9 came out a lot better. But I think that the issue is that each country has to be baseline so that we know that we're getting better. I think that there are other areas to look at. So for example, one could say preventing cross-border spread of disease might be a metric, not just the early detection and reporting of such disease. But are we able to use that detection to have action to prevent cross-border? Are we able to use the information from the detection event to improve our countermeasures, for example, which certainly isn't the topic of this panel, but the information used from detection could tell us our diagnostic assays even working on the currently circulating strain, for example. Or if we had therapeutics or vaccines, for example, the information we're getting out of that detection and characterization of an incident, are we sharing that information so that those countermeasures can be improved? So I think part of it is in the actual detection ability to detect, the ability to report, but then what actions are actually taken and the response to those detection events and characterization events that could also be leveraged to determine what kind of metrics could be used. Yeah, I was really glad to hear this morning that when we will see the lines of effort, I believe they were calling it or the action packages that they stated they would have measurable objectives because we're very curious to what those are. We've been struggling with that, obviously, as a foundation. I mean, our founder is a businessman and he started eBay. So when we talk about investing money in training programs and diagnostics and so forth, the question that Jeff always says, well, how do I know that I'm having any impact? So we've spent a lot of time on specific metrics and I thought you were teeing up for our posters. So there's a poster upstairs from school. We firmly believe that there are probably multiple metrics because you're going to have different, you know, cross-cutting institutions and partnerships and you're going to have to find metrics that work for people. But as Nigel said, we think the time to detect is a really simple metric. When we were at Google, we funded a research project called the Global Baseline because at that time, we had no idea how long did it take countries to find an outbreak. OK, that paper was published in the national, the proceedings of the national academies. The lead author was Emily Chan. It's called the Global Baseline. And the data was so poor in doing that research, but at the same time, it was the first time it was ever done. So that data basically showed from 1996 until 2009 when the study was done that basically the time to detect outbreaks and they only limited it to outbreaks with pandemic potential. So not foodborne local outbreaks. These were serious outbreaks, cholera, you know, MERS, SARS, those kinds of things. We basically improved by half. So we've cut our time to detection overall globally by half, which is a really great positive direction. So that was really exciting to our board. But the question is, how do we then measure progress? You have the international health regulations that all the countries are aspiring to. But even if you look in that, what are their metrics that they're following? They're supposed to find an outbreak and report it in X amount of time. OK, but everybody starts at a different point. I mean, we saw countries in Africa in that study, you know, that still we're taking 169 days to find an outbreak. And then there were countries that were finding them as quickly as two days. So can you have a metric that's not just a target, which is what a lot of people do, but something that you actually can monitor progress. And we think time to detect, which the methodologies can be improved upon from the original paper. And we've been working with a group of people across sectors, including the government, academics, and foundations, to refine that methodology. And we just put out an RFP for many grants to all of the field epidemiology training programs across the globe. Because our feeling was, when you are a trainee, and I mean, when I was a trainee at CDC, you know, you had to do a surveillance project. You had to do, you know, all these different things. And we're like, well, why don't we throw that out there and make that, you know, a possibility as a first year or second year FETP, you measure the baseline of how fast it takes you to detect outbreaks in the country that you're in. And four countries stepped up to the plate to be the first ones to do that. And the information's up on the poster if you're interested to know who those are. But our ultimate goal is to have each of the countries measure their baseline because it doesn't matter what it is. It then gives you a benchmark to say, OK, it takes us 40 days to find an outbreak on average, all right? So you invest money and so forth. And three years later, you find out, like, now it only takes us half. So it's not like you're trying to get every country in the world to find every outbreak in 72 hours by five years from now. That's unrealistic. But you could have a metric. And we think, like, time to detect is pretty easy for most people to understand. You can look at the methodologies. But I agree. I think, like, other metrics could be added to that. And you could have, like, some sort of global health security agenda, you know, I don't know, index or something. But we've got to get started on specific metrics because otherwise, there's nothing for these countries to even the countries that belong to courts. It gives them a starting point if they know the six countries of Mankong Basin. Here's our time to detect in each one. And it's like, OK, let's all get to the best. Great. Thank you. So let's open it up with the remaining time that we've had, recognizing that we stand in the way of lunch for you all. Thanks. Sure. Yeah, I'm Mike Eichberg with the University of California at Berkeley. I've got a lot of really excited and interested engineering students who really want to work on novel diagnostics, particularly those that are applicable in global health. And one of the challenges that we have is, how do we tell them what the requirements are? And these are, see, these could be technical requirements about limits of detection for particular infections that are relevant in a context, et cetera, et cetera, on the technical side, but also bleed into workflow questions and how things are going to be operating in different types of environments where a diagnostic might be deployed. And I guess what I'm asking that the panel is, what is the best way to be able to communicate these requirements to innovators and developers who might live in first world countries? Well, I'm sure everybody has something to say about that. I think the first thing, just a couple of observations, one of them is that there is amazing science going around going on in diagnostics around this country, in many countries. But there is a big falling off or a valley when it comes to translating that to practical applications in field settings. So there are many tools that are built that will be delivered in a big box, but without the reagents or the training or the QAQC systems or the repair shop that you need for the big box. So in addition to your list of limits of detection and operating characteristics of the test, you need to make sure that the test actually fits the field conditions where the disease is actually prevalent and needs to be measured. So you have to work with people who are in the field working on that disease in that part of the world. The Gates Foundation has a lot of that. Mark's Group does that. Quartz does that. So you have to find the actual intended users and work with them. I don't think it's easier to do that than to try and start with a general rule about a particular disease. I think practical use is really high in the list. Can I just add something for you? Don Francis at the Global Solutions for Infectious Disease, who's a colleague there in the Bay Area, is doing an amazing program right now in Zimbabwe where literally they are using all of the point of care diagnostics that already exist for HIV, for malaria, for other things. And they've created an automated system that literally uses a BlackBerry or a smartphone or some other way with software that takes an instant photo and reports the test in addition to the nurses and the other health care workers who are using that. And you should talk to him because his experience and figure out what would work in that system and the feedback that they're getting from those health care providers to actually feel empowered that their test is like not only helping them but actually going somewhere. And they figured out a way where these tests go immediately to the ministries of health as well as to the health care providers. And so he's a great resource in your own backyard that has struggled with these things. And he'd probably be great to come in and talk to your class. That's great. Why don't we take because I see a couple hands. Why don't we take three questions and then ask them that our panelists address them behind you? Oh, sorry. Sorry. I was wondering about you talked about using developers in locally in the countries abroad to work on some of these biosurveillance technologies and developing them so they're engaged and they're invested in using them. But once they're built, how do you get them to sustain them over time? Because we're finding that's a really big problem. How do you make them economical and people want to invest in them when they don't have a lot of resources in personnel with experience to do that. Great. And right behind you, I think the woman from CDC. Hi. Thank you for their presentation. I just actually got back from Guinea not too long ago. A few days ago. And you talked about what do countries want and kind of working with countries. And in the past, we've had some Ebola outbreaks and WHO countries actually came up with a framework to which is Integrated Disease Advanced Response to respond to detect, respond to diseases prevalent in the region. Right. And so it was kind of baffling to me. You talk about 90% of people having cell phones, smart phones and things like that. But in where I just came from, from Guinea, actually they have phones, but if they don't have minutes, it's like using the little scratch off. You won't get a message. You won't transmit a message. And so kind of thinking about how do we help countries that actually have, it's a pretty good framework that addresses their issues are prevalent in Africa but have had challenges in implementing it. So my question, I guess, is do you guys know about the framework, first of all, which African countries put forward in responding to their threats? And you're shaking your heads. I would like to know if you worked with it. And how we plan on supporting what... Some of us have talked about it's what they need, not our agenda. So supporting them in the realm of integrated disease events and response. Thank you. Sorry for the long question. One more question over here. Yeah, David Briden with Results. I'm wondering as you look at Southern Africa, when interesting model, I think therefore success in other regions might be what the South African government is doing to bring governments together in that region to really work together for a harmonized approach to tuberculosis that's generated by the mining industry, which is having a huge economic impact. And the Southern African government I think has realized that. So they're actually the global leader now in deploying the rapid diagnostic gene expert, which unfortunately, $10 per test. But that could be a model. And my second question is, here we are in the United States. We have about 10,000 cases of TB every year and then another 8 million people with latent infection. We're not screening people that are coming into the United States as international students. We're not screening people who are coming in on work visas. I just wonder if you think that it might be a good idea to start doing that, particularly from countries in Asia, for instance, where we're more likely to have cases of multi-drug resistant TB coming from. Great, thank you. So we have a question about sustainability. Also one very specifically in terms of does the framework that WHO is putting forward really adapt with the use of the technology? Not just so much that some of the technology's there. And then a specific question as it relates to TB. Tom, did you wanna take a slide at some of the TB or please any of them? Well, let's see, okay. So first of all, if we go backwards first on the last question. On the issue of forming a consortium in South Africa and getting industry to work with governments, I think that is a pivotal area of leverage, particularly in parts of the world like Africa. We know in areas stricken with Ebola and in surrounding countries, there are major industrial interests and they seem to have helped in Nigeria quite a bit in my understanding anyway in really helping control that importation because of the huge, huge industrial stakes that are at play in Nigeria. So the extent that we could find a way to get outside companies to participate in the response, I think that'd be a very valuable contribution. I think the challenge is how to do that. Right now there's still a lot of confusion about where all the donations are going. The simply the donations, are the donations going directly to one fund? They're going to multiple funds, multiple governments. But if this Ebola outbreak unfolds as it seems to be in the next few months, I think it's going to be critical for the large companies in the region to participate in the response. There's some of the strongest organizations there. Gronka, I know DoD has done a lot of work and struggles at time in terms of that question on sustainability. Do you want to take a stab at that? Sure. Two points I wanted to make on that. As I was mentioning earlier about talking about what the country needs are, part of that conversation has to be what would actually be sustainable. And again, we go back to that question about, is an electronic system even sustainable? And if the country best needs to work through paper and cell phones, is how do we improve how they do that? So I think that that has been an issue over the course of time. So I think that first the question is, before we do anything, we need to make sure that whatever it is is going to be sustainable. And historically that's been an issue. I also wanted to bring up something on the previous question about the requirements for diagnostics. Certainly within the Department of Defense, the diagnostics that we develop for our forces, we have a very strict requirements process that takes us all the way through what the user in the field needs for a point of care versus a laboratory-based system versus a reference laboratory-based system. And I think that the way that we do it within the Department of Defense is an exportable model. And that is really what I think Tom was speaking to. I think for the circumstance that we're in now, with regards to the Ebola outbreak or any other outbreak, this goes back to my earlier point that before everyone dives in, we really need to understand what people will actually use in the field. And this gets back to some of the comments that were made earlier. So I will put a plug in that for, when one is looking for requirements for diagnostics and all the smart people out there, for the federal government, we publish broad agency announcements in FedBizops and you will find very often very detailed specific requirements. This Ebola outbreak as well as the global health security agenda has in fact spawned our putting out more broad agency announcements on diagnostics to include the ability to detect antimicrobial resistant organisms or differentiate between bacteria and viruses. So this is an area that not just within the DOD, but within the US government, looking at the diagnostics piece of detect that we're interested in looking for more ideas, not just in the current outbreak, but certainly more broadly. Can I think? Oh, sorry, no, no, please. I wanted to come in and say, how do you make it sustainable? Well, I think you've got to remember that you don't do things to them. It reiterating the message is that you have to go to them and work out what they really need and what's going to make a difference. Because if it's something they want and need and use, it will surely become sustainable. So it's back to that first question from Barclay, which is, what about these students? I would say to them, you go out there. Now in cords, we've got lots of PhD students and postdocs working on various emerging diseases in this. Strikes me, we should think about joining up and putting them in contact, at least by email to begin with, and to think opportunities for cross-fertilization. And I think it brings me back to a theme that is so important for all of this and all of us NGOs, is how do we join it all together? There has to be something at the end of this day, this meeting, which says, and this is what we are going to do. And somebody has to say, and I'm going to help fund that and I'm going to help fund that because we do need that in place because it's about joining up. Because I've heard some wonderful presentations this morning and Scott, I didn't know what path was doing, but we're probably working in the same countries. So we have to talk. And I think there's a lot of joining up to do. And that's how we make things sustainable because if we are seen to be a global force that's working together, I mean, wherever you go, you always find Dittra's been there before you. But one word of warning, I mean, when I talk into the chief medical officer in Tanzania, he says, no more briefcase jobs because everybody was giving Tanzania money and he just doesn't know how to cope with it with his infrastructure and what it is. And somebody will come with a million dollars and it will never be sustainable. And I think you've heard how things could be made sustainable. And I think it's by all of us working together and that message would be very powerful from today. So Mark, did you have a final comment on that? Yeah. I promise one last question. Yeah, the two comments over there. So I think the framework is really important. I read through it and I think it's part of, as Nigel was saying, our approach and doing the EpiHack in Tanzania is to really try to bring some of that technology in the same way we've done to other areas of the world by bringing those developers and so forth, which leads to the sustainability issue because it's been really interesting. I think sometimes we're so in our public health box and we only think about who we work with in public health and so like, if you're a foundation and you help start a project somewhere, the question you have at the beginning is like, okay, if we do this for three years, what will happen when our money goes away? Well, we've never had that problem so far because what we've done is we've gone to the places, brought all the people together and I talked about how we brought the different sectors within the animal, human environment together with the developers. What I probably failed to say is at the end of every one of those EpiHacks, we invite all the business leaders, the community leaders, the telecom companies. So one of the sustainable methodologies that is allowing us to do this in many parts of the world is because the telecom stepped up and said, oh, we didn't know that you just needed like so many minutes for everyone in the population and our plan to do like public health surveillance and they're like, fine, we'll do it. And so we've opened doors between ministers and telecoms that literally they just never talked to each other and they're like, as part of our corporate social responsibility, the amount of time you want on cards and stuff for public health is so minuscule to what we do as a business that those partnerships are just opening. And to give one other example, we started Flu Near You in the United States to really see can we learn more about flu? Carlo Slim came to us, Carlo Slim from South America and said, hey, we'd like to do this, we don't need any money, we even have a telecom company, we just need to know how did you do it and can you provide technical advice? So I think if you're creating tools that people see the value in and their developers created them, that is so different than the minute, I'll never forget a conversation with the Minister of Health in Cambodia and I lived there for a year and I was working at Google at the time and he sat down, he said, Mark, I can't take another person coming in the store and selling me a solution. And that was sort of the old way we did things. Now at every EpiHack, every single piece of technology developed either has to be open source or if you're bringing any intellectual property into that space, it becomes public property at the end and people sign that right from the beginning. So part of the sustainability is if we create a participatory surveillance system for a country with those developers over time because that's owned by them and they're the ones to do it, it can just evolve because it's something they're using and they own and they can do. And I have to tell you, information technology is not expensive when we start talking about vaccines and drugs and so forth. So my comments and sustainability have to be taken with a grain of salt because I probably wouldn't say the same thing if we were building diagnostics or vaccines or things like that because that's a much bigger issue. So one final, two questions that will bundle right here and then box lunch is awake. Thank you. My name is Precious Matsuso. I'm the Director General of Health from South Africa. I just wanted to ask one question. It's directed to Nigel Lighthouse. One of the problems that we've seen in West Africa is the cultural dimensions. And I just wanted to know whether have you thought about in your engagement whether in Tanzania or elsewhere to engage anthropologists or community leaders because you saw last week that we lost six of some of the health workers and journalists purely because of the perceptions amongst communities. So how do we deal with that? I think it's an important issue perhaps that we have to think about. And secondly, just to confirm that we do have a university that will be coordinating the private sector response in South Africa to support West Africa. Great, thank you. Thank you for sharing that. Nigel, did you want to? Yeah, I'd just like to say thank you to you, madam. Also because the team from NICD, which is in one of our networks, Janos Pavesca, they've got the laboratory in Sierra Leone and it's doing fantastic work and they're just getting on with it. And I think that's what it's all about is helping each other. Your question was about community leaders. It's when you actually go to Africa and you get into it and you get into communities, you feel what is happening and you know who makes the decisions. So you don't have to sort of put something there. If you get the community leaders to help with the message, you're almost there. And I think that's what I've discovered from working with those countries. And for instance, in the Congo, in one of the Ebola outbreaks in the past, you had to go to the community leaders to get any changes made with what people did in that rural population. But the local community leaders also thought that dogs as they were dying were part of the problem of Ebola. They're not, but they thought they were part of the problem. So the community leaders said, kill every single dog. And you go back to that village now, there is not one dog. Because the community leaders are so powerful. You're absolutely right, man. My name is Atman. I'm from Kenya. I'm a beneficiary of the Field Epidemiology Training Program in Kenya. And I'm glad to also announce that my country is one of the four that is actually developing a database for measuring outbreaks. All right, we're going to count on you if we're... I think I'm a good ambassador and I'll... I was in Liberia in May in response to the Ebola outbreak too. And I flew all the way from Kenya to Liberia, crossing over 10 countries. And we were the first African country, we were only three to get to Liberia, since February that the outbreak had been there. And we all knew what it will take, maybe the spread and all that. So what is your contribution on this fence sitting? Because I heard you talk about regional cooperation and even this global health agenda cannot go to Africa as Africa. It has to go to regional blocks where people can actually sit down and develop their own packages which they can actually work on more than this broad packages that are brought down there. And there's also this feeling of big brother, this big brother syndrome when African countries are asked, pick one out of this 10 and implement it. Some of them, their biggest problems are still nutrition and cholera and measles. So when they are told to pick about global health security, it's a big challenge. Thank you. Thank you. Your comments remind us that a theme on this panel most certainly has been, it's local, local and local. And that's where improvements in detection and ultimately what we'll hear this afternoon on response will be re-emphasized that, and part of the beauty of the global health security agenda and I take your point is that there have been regions and countries that's part of a region that have taken the aspirations of the global health security agenda and made them real for their region and what's appropriate within their region. And I think for this to have any staying power that's absolutely something that's gonna have to continue over the course of the many years to come. So with that, thank you very much to our panelists. Appreciate all of your advice. Thank you for being a wonderful audience and bringing your fabulous questions and I believe lunch is on the second and third floors. Second and third floor and feel free to find a spot anywhere in the building. Thank you so much guys.