 Hi, welcome back to the Future Security Forum. This is our last panel for the day. It's entitled, As the Coronavirus Spreads, What Are the Implications for the U.S. and the World? It will be moderated by Peter Bergen. He is Vice President of America, CNN National Security Analyst, Professor of Practice at Arizona State University, where he co-directs the Center on Future Four. He's the author of many books, three of which were New York Times bestsellers, as well as a number of documentaries based on his books, and several have been nominated for M.E.s and one M.B. for a documentary. Thanks so much, and I'll turn this over to Peter. Well, thanks, Daniel. So a very timely panel, unfortunately. As a coronavirus spread, what does it mean for the United States and the world? We now have 200,000 Americans dead, hardly predictable, or perhaps all too predictable, depending on your perspective. We have a wonderful group of panelists to discuss this. Dr. Haleen Gale, who is the Chairman of New America, also the Co-Chair of the National Academy of Sciences Committee on how to more equitably distribute potential vaccines. Dr. Gale spent more than two decades at CDC working on HIVA, so it brings a lot of experience to this issue. We also have Dr. Daniela Blamas, who is at Brigham Young as a critical care doctor. She's a frequent contributor about her work to the New York Times and the Washington Post. She's also on the faculty of Harvard Medical School. We have Dr. George Post, who's a professor at Arizona State. He's a virologist who's had a long career in public health and expertise in the issues relating to viruses. And finally, Dr. Mike Osterholm, who joins us from the University of Minnesota, who is one of the nation's leading infectious disease specialists. So I'll begin with Dr. Gale. I'm going to basically ask everybody the same question, which we could just spend the whole hour on, which is, where are we? How do we get here? Where are we going? And what do we do? So very easy questions. I'll start with you, Dr. Gale. I think one of the things that has been a hallmark of this is that as soon as you think you know something, something else happens. And this has been such a unprecedented and clearly something that we were unprepared for. And that said, we've always known that something like this could occur, not only could it occur, but would occur and that we should have been better prepared for it. And I think that's the big lesson is that although these situations are incredible and catastrophic, we could do much more to be prepared and could have been much better prepared, particularly had we had the right kind of national leadership and coordination in place. So one, we can always be better prepared too. I think we're still at the beginning of this. You talked about the numbers. We're not seeing the kind of slowing down globally that would convince us that we're really at the tail end of this versus continuing to experience growth in infection rates and in death and the corollary economic consequences. And so we're still in the, I don't know if we'd say early days, but we're clearly not at the end of this. And I guess I would just finally say that there's already a lot that we could do. We know the ways in which we can protect ourselves. Unfortunately, there's been so much confusion around what works and what doesn't work that we're not, and not having a consistent overall message around this, that we're not putting in place as aggressively the things that we know can make a difference like mask wearing, social distancing, hygiene, etc. And so I think that while we are all looking forward to the day when there will be a vaccine, when we have more testing in place, etc., I think we shouldn't forget that there's a lot that we could be doing today that could make a huge difference. And many people on here have run some of the numbers that show us what we could do if we were in fact putting in place the things that we already know work. Hello, Dr. Post. Okay. Hi, Peter. No, I think clearly, as Dr. Gale outlined, it's a complex, multi-dimensional failure both historically and currently. Historically, we've got here on the basis of multiple decades of neglect, the stark failures which have been revealed in all aspects of our current capabilities have been outlined in numerous reports which sit and gather dust on shelves. As Mike Osterholm knows, the Defense Science Board study, which I chaired back 25 years ago, is essentially a blueprint for the myriad deficiencies that we're seeing now. So I think in part it's an out-of-sight, out-of-mind problem, which is very much a curse of contemporary society. Anyway, there's only an immediate reactive rather than a proactive posthum. We have a sort of reflex episodic response when something occurs, whether it be Ebola or Zika or Chikinyunga, whatever is the culprit of the moment. Obviously, we've not encountered anything on the scale of COVID-19 and all of the pandemic preparedness, as everyone is aware, was primarily directed towards influenza. But even if we had had the appropriate infrastructure in place to deal with influenza, we would of course be far better prepared to deal with SARS-CoV-2. So I suppose both historically and in the current situation, the watchword would be consistent inconsistency. And it's certainly been compounded by quite substantial, underinvestment long term, but now complicated, of course, by an unwillingness of society to either take this seriously, the consistent inconsistency messaging that we've spoken about, both from the White House, multiple public agencies and the media, we're now left with a situation where probably the most corrosive element beyond political divisiveness in Congress is the issue of the impact on public trust. And I think we're going to see that played out most importantly as and when we get a vaccine as to what will be the level of uptake of that vaccine. Dr. Lamas, you're on the front lines of this. I mean, are we prepared for what Dr. Roosterholm said publicly? You know, we're in the second inning of a nine inning game. I don't know if he's changed his view since he last said that publicly. But I mean, what does this fall, what does this winter look like for you on the front lines? I mean, I think in terms of the question of whether we're prepared, we're more knowledgeable now than we were in March. In terms of many things, sort of small things and large, you know, we at least are knowledgeable about the impact of wearing masks. I think it is extremely worrisome and obviously extraordinarily sort of sad and frustrating that we continue to fail to do so in a sustained fashion. You know, within the hospital, we are better at managing patients with COVID-19 and severe COVID-19 pneumonia. That being said, because of our lack of preparation and sort of the way the response and sort of broader clinical trials work in this country, there are many answers that we don't have that that we could have had. You know, we don't and likely won't have an answer to whether convalescent plasma is useful. We do understand the benefit of decadron. We have thought a lot about early intubation versus being able to wait a little bit longer. These are things that will be different as patients continue to come through with coronavirus. And if there is a broader surge, you know, that being said, I think there have been opportunities to be able to really ask and answer sort of in a systematic fashion questions about what works and how to benefit patients that we don't have the answers to. You know, I think there was a huge emphasis initially on ventilators that emphasis was important. But really, I think the emphasis should have been on things like like masking instead of, you know, really pushing this ventilator question. So so there are things that will be different the second time around if and when that comes. But I think that there are also ways in which we could have been better prepared then that we are now. When you've done sort of back at the envelope math using certain kind of common assumptions, you've said that we're probably looking at 800,000 deaths given the kind of, is that kind of where you still are? And kind of what should we be doing given what your other panelists or other panelists have said so far? For me, I didn't quite hear that. Was that for me? Yeah. Yes. Okay. Thank you. Okay. Thank you, Peter. Well, first of all, thank you for having me. And it's great to be with this August group of experts here. At this point, I think that the number 800,000 hopefully will be high. And I think part of that as you just heard is been some dramatic improvement with regard to treatment and the fact that we've seen mortality rates dropped by almost a 40 in terms of what they were in the early days of the April house on fire in places like New York, Lombardi, region of Italy, and so forth. And so we've done much better that way. I think what people don't yet understand is if you had cited the earlier being third in, I think maybe fourth or fifth. But let me just say there's a lot left to go. We don't, I don't think quite get this yet. The fact of the matter is, is that this virus is a real challenge in terms of something as simple and yet as everybody's critical is durable immunity. We're not quite sure yet just how much vaccines can or will protect for the long term. We don't know how much immunity we're going to actually really realize as a result of natural infection. And we're already seeing breakthrough cases where we happen to have the isolates from the first infection and the second infection, or at least the genetic material to be able to determine these were truly two different infections. The fact that we even have eight of those already, given the likelihood of having one patient with a viral isovalone two, it says that this is a much more common event that we recognize with our work with SARS and MERS that this was likely to be a challenge. So we've got more curveballs to go. And I guess I would say the one thing that I find deeply challenging with this is still what I would call a unwillingness to basically think about this in a way that is different than past pandemic. We need really to be our creative imagination is to come to play here. But I think that we could be dealing with a pandemic for like this for many, many more years to come. Not saying it's going to be exactly the same as today, but this virus isn't going to go away soon. Dr. Gale, you're working on kind of the committee at National Academy of Sciences that's trying to find a way to more equitably distribute vaccine or vaccines. To be said, then you can talk about your work publicly. How do you do that? Yeah, thanks. And the report will be out in October and we were asked that we had a pretty tight deadline because, you know, as everybody knows, there is a pretty brisk effort to try to bring vaccines online and to try to have a vaccine available, perhaps by as early as the end of this year, early next year. And that it was pretty clear that there will in the beginning not be enough vaccine for everybody. And so there needed to be some way of thinking about how would you allocate this and what would go into thinking about an allocation framework that was in fact equitable and took into consideration the populations that have been most hard hit, most vulnerable populations who already had faced health inequities, et cetera, and looking at a way of thinking about this. And so, you know, what we tried to do, and as many people know, the National Academy do a lot of different kinds of studies and always bring together a wide range of people with different expertise. So we had demographers, we had economists, we had lawyers, we had epidemiologists, virologists, et cetera, all coming together to weigh in on these issues. And what we tried to do was to come up with first a principle of kind of ethical foundational principles based on this particular epidemic and what were the things around, you know, maximizing benefits, fairness, equal regard for life, et cetera. So we came up with a range of kind of guiding principles and then developed an allocation framework based on risk, both risk of getting the infection, risk of getting severe disease and mortality, and then risk of having a negative impact on society because we know that, you know, while this is a public health crisis, it has also had huge economic and social implications as well. And so we put all of those things together and came up with four different phases for allocation. And again, with the idea that ultimately when there's enough vaccine, you know, everybody should get it, but that in the early phases we had to make some hard decisions of who would be in that first phase. And, you know, I won't go into, you know, all of it in great detail, but it does look at, you know, putting in the very first phase, for instance, healthcare workers, because we know that healthcare workers both, you know, even though there is more protective equipment now, still are putting themselves at risk doing their jobs and that if the healthcare system, you know, crumbled, we wouldn't have people around to take care of those who are sick. So, you know, we made decisions like that, but even within healthcare workers, you know, it wasn't, this is all going to doctors and nurses, you know, there's a whole range of people, you know, including those who do home care or people who take care of people in nursing home facilities. Oftentimes, those are women, often women of color. So we weren't looking at, you know, only those who, you know, had the high status jobs, but looking at people who were at greatest risk. And then we went on to look at older adults, you know, who we know have also had most of the severe illness and death, as well as people who live in congregate settings who are at great risk, etc. So anyway, without going into all of the four phases, we really tried to take into consideration, you know, who's at greatest risk, who's at greatest risk of getting the infection, greatest risk of dying and greatest risk of having severe consequences for the society. Dr. Post, you know, obviously, if we had better diagnosis, faster diagnosis, wider diagnosis, some of these issues would be ameliorated. So what is, I mean, what, what can we do about that? Well, again, here comes, I've long argued and sadly confirmed by events in the current pandemic that I view diagnostics as the most neglected component, the true orphan in the myriad patterns of neglect across the entire bio preparedness spectrum. So, if you could indulge me in a little bit of alliteration, I think there are six S's here. The first is situational awareness, real time situation awareness, because without that, you're flying blind. And unless we understand the prevalence of the beast, its patterns of spread, we are simply flying blind. It even is even more proactive than that. The second S would be surveillance, global bias surveillance. What is the likely threat spectrum? What is likely to be coming at us? What is the most likely zoonotic opportunity? The third S would be speed, that once the beast is in our midst or is suspected, we need to be able to mobilize rapidly. And I think what we've seen is an object failure of the CDC, both as a combination of technical incompetence, as well as dubris and arrogance to believe that they could produce a superior test. We lost an entire month during that period. That notwithstanding, the fourth S will be scale. Even if you've got a robust and reproducible test, you've got to have this produced at scale. And the planning must be in place for the infrastructure not only to manufacture at scale, but to distribute at scale across a network of centralized mega laboratories capable of very high throughput and also distributed point of care and point of need diagnostics. The challenge, the logistical challenges are daunting. You'll see various estimates, but let's say a target of six million tests per day is probably going to be needed to guide us through the upcoming fall and winter session. The CDC, in addition to its initial ineptitude, should have been far more proactive in engaging the private sector. And there's a critical lesson here, not just for diagnostics, for therapeutics, PPEs, wherever you look in the preparedness equation, U.S. government agencies have been negligent in not engaging the public sector in a suitably proactive way for rapid mobilization. The fifth S would be standards. Unless you've got a stringent regulatory oversight of test performance and once again now another government agency, the FDA, dropped the ball by offering multiple emergency use authorizations without adequate scrutiny. As a consequence, it became a wild west of testing with regard to what are the limits of detecting floodgate of tests of dubious value and widely varying accuracy. And there are different parameters for centralized lab tests versus point of care, but we still haven't really got our hands around that. And hopefully the new NIH Radex initiative will deal with that. The last element is with apologies for the illiteration symptoms systems. Diagnostics are but one part of a very complex integrated matrix that must be mobilized in a pandemic. Interagency coordination is fundamental in that and once again pointed out in multiple prior reports. It is literally non-existent, notwithstanding any additional complexities which have been created by the intrusion of the political apparatus into this. We have unclear accountabilities and decision authorities and in short these problems not only pervade all elements of the domestic response, we need far better international coordination not just of diagnostics but in taking a systems-based approach. Thank you. Dr. Osterholm and anybody else who also wants to jump in, I mean so the CDC just last night kind of took off this guidance about aerosolized transmission which is a widely recognized scientific fact at this point. In fact it seems to be the most important fact about this virus. So I mean what the hell is happening with the CDC and also you earlier Dr. Lamas you mentioned the plasma issue which they seem to have rushed through and then you have Michael Caputo who's kind of a conspiracy theorist who's the chief spokesman of HHS who's taking a well-deserved leave of absence. Those are some comments that he made about you know there being a fifth column of scientists inside the CDC that was trying to undermine the president. I mean what is going on here and who is in charge and what could be done if anything. I'll start with you Dr. Osterholm. Well thank you. I just have to make one comment on George's answer just now. That was so elegant. I hope that's recorded for posterity. George that was so comprehensive and so well stated. Thank you. You know I had the good fortune to work with Tom Clancy a number of years ago to thank this author who unfortunately has now passed on but one night at dinner I'll never forget he said and said Mike he said never forget there's one really important thing he must remember the only difference between reality and fiction is that fiction has to make sense. Right now I feel like that's the world that we live in that in fact we couldn't make this up. Yesterday you saw that it turned out that the NIH had inside its public relations office the National Institute of Allergy and infectious disease. One of the individuals was actually perpetrating one of the blog sites that was so anti-government anti-NIH public health and he was employed right during public relations at NIH. I mean you can't make this up but and as much as we I might sound like I'm taking light of I'm not this is really a very critical aspect of where we're at and I think some of the speakers have hit on this about the issue of trust. We have to trust our public health agencies and our government to lead us through this as confusing as it is and so I think the CDC has all but disqualified itself in the minds of many in the public and I would love nothing more than to see that change because we need them. The fact yesterday it flowing on the days after of what was clearly a intervention by the White House yesterday I believe was just truly a truly administrative challenge where somebody put up something that wasn't yet signed off on that should have been up there. There are many outstanding people in CDC we need them we need them badly but we need as a leadership to make it possible for them to be involved in the way they can be and we need people to take accountability when problems do occur and not only accept the issue of what happened but what they're going to do to change it and I think that's true with the FDA. George hit on the issue earlier about challenges about some of the emergency of authorizations and the validity for which they were issued. What does it mean you know can we have confidence in future ones going forward. So I think that we have a lesson here that public health is more than just action is trust and action and if you don't trust the action then the action is not going to be very successful and I think that's where they're getting right now. So I'm right now I'm no longer going to write factual books I'm going to fiction it's easier easier. And I would just like to maybe add to that you know I think it is easy at moments like this to doubt these agencies and to really worry about the competency. I worry less about the competency. You know I was a career CDC employee for several decades four and a half presidents etc. And you know there is a core of career people who are incredibly competent and trying to do the right thing. I think when you leave agencies to do what they do well I would say the same for the FDA and the NIH who I you know work closely with throughout my career. You know there is a core of incredibly gifted dedicated public servants and unfortunately we've seen a situation where the same competent people and agencies have not been allowed to do their job in the best way they can. So I just don't want us to in this confusion not separate out you know the competency of those organizations versus a situation that has made it very difficult for them to do what they did that what they do best that not standing there were mistakes made and you know George you you pointed to some of those and there are mistakes made but there will always be mistakes made when we're trying so rapidly to figure out something but those mistakes will will be most easily and most quickly rectified when organizations are allowed to do what they do well. Can I switch gears here a little bit which is you know there's sort of a puzzle which is why are some countries that with terrible public health systems doing surprisingly better than countries like the United States and the United Kingdom with actually pretty good public health systems you know we can trust you know globally speaking. So I'm thinking about you know I mean there should be a catastrophe in in countries like Pakistan maybe it's something under reported but is there any you know we there's been a discussion in the scientific community about BCG vaccines and the extent to which they may have played a role in immunizing populations around the globe in certain countries and being a sort of prophylactic to this virus. Does anybody have any thoughts on on BCG vaccines and where the science stands on that issue? President's third to am I on? Yes. Yes this issue of trained immunity whether it be with BCG or some other formal army license in the term broad adjuvant based response clearly has got some intriguing dimensions to it but in common with the points that have been made throughout the panel that we're dealing with so many moving pieces here and assembling the right type of clinical trials to actually evaluate this. There are several prospective clinical trials now being either underway or being planned particularly looking at high risk cohorts in nursing homes to see what effects BCG may be having because as you know the US did not I have having grown up in England I have a fairly substantial scar on my arm from BCG but I think we also need to look at the fact that there are two major categories of BCG at play here one is the Japanese strain and the other is the Danish strain and the Japanese strain is far more potent in terms of the nature of the immunity but there are so many black box elements to the immune system going back to influenza as a pandemic threat there is a fascinating concept that originated in the 60s called original antigenic sin namely does the first strain that you get exposed to in early childhood actually create an immunological imprint in that gives you a superior response to closely related influenza strains and there is at least some circumstantial evidence to that but again these are threads blowing in the wind from which we can't yet create a definitive rope. Dr Lamas earlier Dr Osterheim said this is something that we'll be living with for years as somebody who saw on the front lines as a critical care doctor of Brigham Young I mean what does that mean for you as a practitioner for your colleagues for the nurses for the people who work in hospitals how do you I mean reconfigure the system so that it kind of allows for the fact that this is not going to go away next year or in 2022 and it's kind of just a fact of life that we'll be living with for probably decades. So I mean the way it exists right now in Boston where I work we have here in Massachusetts a fairly you know low burden of coronavirus right now and sort of low transmission rates and in the hospital we have coronavirus is something that we think we think about for patients who whose symptoms might fit so everybody in the emergency room is tested for COVID-19 if they are going to be admitted to the hospital. We wear surgical masks all the time we wear N95s for patients for whom we are ruling out coronavirus. So it has become it has become something that we think about even as we treat patients for their cancer even as we you know have ramped up elective surgeries and things have normalized to some degree. Coronavirus is there in the background we have patients who are very sick with it we have patients who we think might have it and then ultimately end up testing negative. You know I think I think on the sort of human level everything still feels in limbo. We still don't let families come nearly as much as they did before and that is every day that is a poignant and and rather sort of tortured issue. You know we have patients who if we decide to rule them out for coronavirus families can't come and see them. Why is that well if they're maybe being ruled out we don't want families to be exposed these are rules that come from sort of on high in the hospital and things that I think we haven't really worked out quite yet because I think we are still doing a disservice to our patients and to their families. So you know as as we prepare for this not to be transient as we sort of come to terms with that reality I do think that we are going to have to in the hospital stop being in this sort of early pandemic mindset and start saying all right like this is with us how can we still continue to deliver humane non-pandemic care and I think that that's something that we we're still struggling with we're sort of sort of in the middle between the two and and we haven't really found our footing and we're going to need you because I do think and in some ways though we're giving safe care to people um we're we have uh there are some ways in which we're doing our patients a disservice as we're still in this sort of pandemic mindset. Any more questions? I was just going to say I mean I think to your point you know some of this is we just have to stop resisting it and and acting as if this is we're going to go back to normal I mean I still remember uh back in the days when you didn't wear gloves to draw blood you know that was just normal you didn't and then you know you want to be in everything else you know people resisted it at first now you you know nobody draws blood without gloves on so I mean I just think that there are things like this that will evolve and you know we'll be wearing mask and you know it's just normal. Yeah we we have a question from Mark Hagerot who is the Chancellor of the University of North Dakota and is uh associated with New America. He says is there any evidence as to how winter affected populations given that the summer southern hemisphere winter just ended today? What might it say for winter in North America especially here in North Dakota which has hard winters? So how does winter play into this for anybody who wants to jump in? Well first of all let me I just want to say hi to Mark a friend and colleague. First of all it's also important to understand that we came into this preconceived notions that we have waves of a pandemic unfold because that's what we always plan for if it wins it. If you go back and look at the 10 previous influenza pandemics for the last 250 years two started in the winter three in the spring through in the summer and three in the fall and every one of them kind of had a first wave four to six months in length and with a trough and then a second one. Of course we've often talked about the second wave particularly in 1918. We didn't see that with this coronavirus and in a document we put out in April we said you know how might this look might this be waves like influenza for which the first wave ends for reasons we have no idea why it's not because of the limitation even our second wave in 2009 ended before much vaccine was really available and with coronavirus maybe they're going to be very different maybe they're going to just burn constant or burn hot in some areas even hotter for a temporary period of time and I think we've all come to the conclusion this is not about waves you know people use that where there is mitigation you can drive those virus down we just heard in Boston and Massachusetts they've done a quite good job probably one of the best places the world is in New York State which went from house on fire in April to a point now where I think there are 40 some days of all 1% positive rate it's been remarkable what they've done while other states in the United States continue state like Minnesota we're at 23 cases per 100,000 population per day which is six times the rate it is in England right now we're declaring the need to do shutdowns okay I mean it's a relative issue but I think what we're seeing here is is that this will just keep transmitting it's like a coronavirus forest fire and as long as there's wood to burn it will burn and if we suppress it sounds just like a forest fire you can slow it down you can hold it down in some cases it will miss areas and then it comes I mean if you explain to me what happened in L and California in May and June I had more people say to me oh it's because they don't have public transportation they don't have a problem you know people aren't sharing it well then look what happened in July and August everybody has an answer for why some places show up and some don't until it shows up and then it's starting on as a real challenge so I think this thing is just going to go in I don't think there's any evidence seasons themselves are going to make the difference I do believe indoor air it's very important as it is in the summertime by the way for air condition it also is for heat in the winter time but I think you're going to see transmission of the flyers just continue wherever there are people left to get infected and behaviors that result in transmission you know it's easy to kind of obviously there's a lot of good reason to be to be pessimistic about a lot of this but for each one of you you know what gives you some hope I mean what are the therapies the vaccines the public practices the political leadership and where where are you seeing areas where you know hope is the possibility and I'll start with dr. Lamas sure I would say you know here in the hospital we have seen the extent to which sort of good public health mitigation measures can significantly change the face of this disease you know we had I'm sitting as I told people in the call room and outside me is actually our one of our ICUs and in end of March through April through May up until sort of mid-June the whole outside where I am had a coronavirus patient in each intensive care unit room you know you walk through these patients were all prone they were very sick now we have one coronavirus patient down down the hall and the ICU is full of the other diseases but just sort of step back in the setting of COVID and that's hopeful that that we do have you know even without a vaccine we do have within our sort of armamentarium we do have the ability to decrease the transmission of the prevalence of this disease you know I think the other thing that that is can be interpreted as hopeful is you know the extent to which this disease in a way that I have never felt um does show us how we are all interconnected you know I mean I mean to me I felt that in a frightening way at first you stand in a room and you realize that what this patient has is something that you too can have but but there's also something positive about that you know in which it forces and I hope that as a country we can sort of recognize that you know am I doing the right thing uh help somebody who I will never meet and and and I think and I think that there is a power to that that I I think and I think this isn't too much of us from Pollyanna's view but but I think that that's something that we feel and see in a way that we haven't before so I hope that we can recognize that I hope that that can be something that we take from us doctor post I think that the the principal cause for optimism will be on the vaccine front that's at risk of staying the obvious but then one has to reply all the caveats that dr gale and colleagues are wrestling with with regard to how do you triage activities I think that you know having been the chief science and technology officer smith climb beach and now clack smith climb we have the largest vaccine division one thing I'm very encouraged by is the level of cooperation between companies large and small in this effort but I think there is still a lot of unanswered questions with regard to getting to the to the bug immune response my costa home talked about it earlier what we're going to have to look at is what is the duration of immunity elicited by the current first wave of vaccines will we then be back into a situation logistically if you're a if immunity doesn't have substantial duration will we find ourselves back into the need to revaccinate annually or at least relatively frequently and that has obvious implications not only nationally but globally in trying to immunize seven billion people the other variable which at the moment doesn't loom that large is what is the level of mutation drift in the beast we've clearly got a number of strains which are emerging interestingly some might suggest that they have less virulence but equally high contagion if not higher contagion but I think we're going to have to look at that clearly the mutability of SARS-CoV is less than influenza and HIV so in that sense there is a at least some measure of hope but I think the key issue is going to be vaccines and then I think the other cause for optimism which has a sort of a duality to it is the fact that sadly if the types of numbers that Mike is talking about and today we had the University of Washington suggest 400,000 deaths by the end of 2020 will we actually begin to get a sufficient in-your-face problem that people will begin to really take this seriously at the societal level and many of the very effective containment issues that can be achieved just by people exhibiting civic responsibility can in fact at least reduce that but I think that the key issue is going to reside with the vaccines and again very pleased to see corporate cooperation and at the same time I think we will be looking at a second and third generation of vaccines so this has been so so bad and so awful that you know maybe this will teach us some lessons that we needed to learn as a society and sometimes you need a real wake-up call to you know kind of as a society think very differently so you know I think that one we've talked about having a biologic disruption and we had you know we all knew that it could come but until it came I think people didn't take it seriously so you know one I think thinking um much differently about biologic threats as being something that is going to be with us for the foreseeable future and take that seriously and be prepared differently than we were this time I think you know as George was pointing out about the science I mean we have done things at lightning speed that we often thought wasn't necessarily possible the fact that we can in parallel look at vaccine phases in a way that has really sped up you know the work around a vaccine and that we're using different kinds of platforms than we've ever used before like the MRNA vaccine vector you know I think there's all sorts of new science that's coming out that we would just have done in a different way I do think that this caring about each other is something that has happened and you know I think about how we used to kind of laugh at Japanese tourists who wore masks and thought that that was so quaint why would you do that you know we were happy to spread our germs to each other you know now I think we're thinking very differently about our responsibility to each other and you know how we do that I think that the disproportionate impact that this has had particularly here in this in this country around in black and brown communities specifically we all talked about health disparities we all knew that there was health inequities but this highlighted it in ways that I think has has really shaken people up and hopefully you know we'll think about it and then finally I just think on the you know kind of on the economic and societal side the fact that you know we have been willing to do things to bring financial insecurity hold it to the lowest level possible through things like the CARES Act and things that we you know the idea of giving cash to people so they could pay their bills was something we were as a society we're not willing to talk about we're now doing things that are helping people in ways that I think could be extended further as we think about how do we make you know our country a more equitable country overall and I think our workplaces are going to be different in the future and this is also helping us to think differently about work workplace and some of those sort of things that I think are kind of corollaries to the public health aspect of this so you know something this bad we better learn something from it we better have some things that make us a better society or you know this is all for naught well that's a good segue to Dr Osterholm who wrote a great piece in foreign affairs sort of basically outlining kind of what this might mean for a future flu pandemic or what was that so what's the headlines from the piece Dr Osterholm well I think the key message is that this is not as bad as this has been surely we can envision with reality a much worse pandemic scenario you know influenza will remain the lion king of infectious diseases I believe that be the case the potential for a 1918 like pandemic where the primary morbid immortality occurs in young healthy adults at a substantial rate is surely reality we have created on this world today the perfect mother nature lab for that as we speak there are about 32 billion chickens on the face of the earth one third of all the birds on the earth today are chickens to feed the protein needs of the eight billion people there are 390 million pigs on the face here today to help feed that same eight billion people if you want to create the most amazing mixing vessel or creating flu strains that will one guarantee future flu pandemics we've done that and so I think we have to learn from this pandemic understand that this was as bad as it is not I wouldn't call it a warm up I want to minimize it too much but it is just a first chapter in what surely will still be an unfolding book of pandemics in this world so we better learn from this I liken this to a you know an old 727 going down here but instead of having you pass turns it has 4872 black boxes we need to examine every model so that we really do learn for the future we got to stop putting out reports putting them on shelves and then feel like we'll check that box we have a lot of lessons to learn and I think this panel has done a very good job today of elucidating a number of old lessons that we need to learn and apply to the future you know a political question about the World Health Organization and also about China I remember the World Health Organization at one point publicly saying that this was going to be sort of like the flu and it's not clear to me if that was because they were getting Chinese misinformation or they were just misinformed or it was so it was early but clearly when the World Health Organization is saying something like this people take it seriously because they think that the World Health Organization knows what it's talking about so sort of a two-part question you know was the Trump administration right not necessarily to withdraw funding from the World Health Organization but at least to sort of say that they were you know getting things wrong and to to what extent were the the Chinese clearly were covering up the question is is it just local Wuhan officials who are kind of covering it up or was it a wider systematic cover-up by the Chinese Communist Party so anybody who wants to jump in on either or well I welcome the chance to jump in on this because I find this to be an interesting discussion you know we're just a small little center in the middle of flyover in America okay just a bunch of little colleagues people get together and on January 20th as I said I put out a statement saying this is going to cause our next pandemic that we have all the reasons laid out we had no more access to information that surely our government did you know we had social media we had some contacts with Wuhan we were assessing to the situation throughout Asia that we're seeing by going spreading transmission on February 20th I wrote an outbed piece in your time saying let's get on with this this is a pandemic we need to change the conversation from the fact that we're going to somehow smother this we got to get prepared what's coming you know where I took the most heat from my public health colleagues he said why in the hell are you continuing to scare everybody you just scare people and it was interesting to the extent to which we all were in denial about what might really be happening we didn't want to believe something like this could happen and you know I've moved on from that you know we're we're past that now but I think that there's a part of the human psyche that doesn't want to believe things like this happen and the first statements are denied so did the Chinese officials at the Ube province or I'm not trying to hide absolutely they did but I don't believe that was a systemic Chinese government effort at the time we surely had enough information so I always find people who say well they were hiding it well then how do we know what was going on okay if it was being hidden so what the second thing is I think we're going to have to help ourselves understand that you know this is a challenge some of the talking heads today we're out here talking as experts about this pandemic we're the very people that were highly critical of our work back in February saying we're staring people the flu is much more important a major medical journal in late February published a cartoon a homepage cartoon showing all the reasons why flu is more important than this particular pathogen was and why we needed to get back and focusing on flu so I think let's do over let's forget about all that other to say we got to remember it's the next time and and make sure that we don't dismiss this possibility but I think that's what set us back as a whole it wasn't just one government it was a collective mindset I think it set us back so could I come in on that and not only building on Mike's typically eloquent remarks I think that there's a far more systemic issue we have to address here which is not just the issue of whether the US should or should not withdraw from the WHO I've got views on that but nonetheless it is the fact that what is the actual authority of the WHO to implement the international health regulations and essentially eclipse sovereignty that's that's at the core of this debate and until we actually have a framework in which we actually have a a supranational agency such as the WHO fully empowered to not only investigate to demand transparency and to have site inspection capabilities we will have this level of obfuscation lack of transparency in this case it happens to be the Chinese but we see similar failings going back even in recent years because if you've got a particular component of your economy which is dependent upon not revealing something I mean you can go back to Chile a few years ago if they had if they had not complied with the HR in declaring cholera that they would have taken an enormous economic well in fact they did take an enormous economic hit on their food exports and so we need to look at this and once again there's a sort of multi-dimensional issue but it comes down to funding the authorities vested with supranational agencies and with again apologies for one more deep for diagnostics we need comprehensive global bias surveillance to address the type of zoonotic genetic assortments that Mike was talking about where you've got humans pigs and poultry mixing up a daily basis obviously we've added to that brew now not only coronavirus but there are there are others maybe not with pandemic potential but nonetheless significant economic disruption and let's not forget that just in the U.S. we have a three trillion dollar agricultural economy which could be equally decimated by an epizootic whether of natural or nefarious origin. Dr. Gayle. Yeah I just totally agree with both of the previous speakers I guess I would say you know WHO got some things wrong we all got some things wrong in the beginning that's just the nature of you know a new a new threat and and this is an era where we need more not less of WHO we need a WHO that is strong and able to do its job more effectively we are not going back to the days of you know every nation is isolated we are increasingly a global interconnected world and we need that kind of an organization that has that global mandate and you know this is the worst time to be pulling back from an organization that is you know kind of the global public health organization this is the time where we should be doing everything to support it to build its strength to build its capacity you know because that's the only way you deal with global pandemics. I mean is there an analogy to the International Atomic Energy Association you know which does do you know can do inspections that are sort of I guess mandated by by either Trees or the United Nations I mean it does as the World Health Organization it does rely on the goodwill of the countries that that are part of it you know there is no enforcement mechanism is that what everybody is saying about the World Health Organization they can't they can't come into a country without an invitation is that the right but imagine the following scenario we have an outbreak that begins in the major US metropolitan area I believe that there would be substantial you know transparency but there could be in the fog of early war or outbreak you know confusion now imagine because of that the Chinese and the Russians insisted on sending the delegation here to investigate because they were concerned about what we were putting out and not putting out you think for a moment we would suddenly just say sure God send them in bring WH over you guys investigate this you know so I think that one of the things is also expectation we have an expectation we can go everywhere but we also have an expectation that we're all independent by ourselves and you know don't say that so I think the world of order has changed too if you're going to ask for transparency it really has to be transparent and I think we'd be as guilty as any country not lying someone to come in I think I just want to echo what other people I mentioned like I think we need a very strong WH so it's like you can see this is a time where we really need these organizations we need to build their capacity and when they fail yes we need to be critical but we also have to offer our ways in which we're going to fix it and I think that that right now with WHO you know what they're doing with COVAX the ability to get vaccine to the rest of the world things like that I think are absolutely remarkable and I want to just go on record and say and I hope we're all supporting WHO and what it can and should do I think another feature in this Peter not just for WHO is the disinformation campaigns and irrespective of their origins whether domestic or international this is again another significant factor that's insidiously undermining public trust not only in our agencies but also in the science well Dr. Gale that seems like a huge issue on the vaccination front I mean when you I can't remember the exact numbers but isn't it like a third of Americans won't even take the vaccination even if it's available yeah and you know it kind of divides into three different groups and so you know we have this group of people who just don't believe in vaccines period don't believe in vaccine science and you know they're called the quote anti-vaxxers you know I think that's a group that is a bit you know apart and and they will obviously not take this vaccine or any other vaccine but then I think you know we have probably at least two other categories who because of the confusion because of a lot of the concerns about how decisions are being made whether they're being made politically or scientifically there are people who are rightfully skeptical I you know I give us an example my very closest friend from childhood who was also a physician who was involved in clinical trial work herself says she's not sure that she believes this and whether she would take a vaccine so this is not even you know you're talking about uneducated people you know this is a physician who works on clinical trials who now says I just don't know if I you know trust what's coming out from our organizations that are charged with it and then you also have particularly African Americans and others who have had historical reasons not to trust who have been used inappropriately in experimentation and have had reasons to have this mistrust and then that's the very population that's being disproportionately impacted but also has this very long history of you know mistrust with government government research etc so we've got a lot of work to do to repair that trust and it's going to be an important part of whether or not we get people to take the vaccine and I think it's a big huge issue of how do we make sure that we can have the kind of transparency that allows people to actually have trust in whatever the product is once it's available and peter on the same score I think there is the issue of how are we as a society going to react to the inevitable rare or very rare complications that will come from a vaccine so whether we go back to narcolepsy with influenza but in the current litigious society that probably the very rare events are going to require a vaccine we will not be revealed until we're vaccinating millions of people but at what point will we then switch on our televisions to see one 800 bad vaccine as there's the next element in eroding public trust it's an issue that we've got to pay a lot of attention to Dr Lamas you know a last word from you you know you have to deal with the families and often families who can't even see their physically touch their loved ones when when they're dying how how do you deal with that um you know how does how does anyone deal with that um I think we're all sort of you know still figuring that out um but I think I think um you know one one thing that's important I'm thinking about somebody uh through them struggling with now but you know I'm thinking you know what one thing that's important is that is that we want to be able to know that um that we're able to tell somebody with certainty that uh that we've done everything and that um that and that we have given this person the very best chance to survive and and I think that when you know we really do uh need data and I think that and that we you know we people who get surprised we we owe each of our patients the very best care that we can have we owe each of the families that we tell we've done everything to that this is really true that we know that we've done everything and I think that's why you know we do need as we've been saying sort of high quality clinical trials we need to understand um what the course is of this disease even better than we already do you know and I think and I think it's for these families um who often have their own guilt um perhaps they have been the person who transmitted coronavirus to the loved one who lived with them often that's the case and they survived and this other person did not uh or the person might not you know I think I think that there's a great sense of of sadness um when it seems that this is something that you know had they gotten sort of the correct counsel about what to do um that this this could have been something that would have been avoided and so so I think that there's a great a great sadness um and I think that that's something that you know we're all sort of going to carry forward with us kind of forever and hopefully it can fuel us to make real change. It's been Dr. Oatman for a brilliant presentation. Thank you. Thank you. Thank you.