 Good afternoon, I'm Steve Morton from CSIS. We're delighted to welcome you all today to the forum here on the Obama Administration's Global Health Security Agenda, which was launched amid the snowstorm just over a week ago, on February 13th. That welcome is extended, of course, to the many people who are joining us online today, including staff from the World Health Organization that we were in touch with earlier today who are coming on as well. We're delighted to be able to bring this event to you today as a collaboration among ourselves at CSIS and four partner organizations who have agreed kindly to cosponsor. And those include the American Association for the Advancement of Science, the University of Pittsburgh Center for Health Security, the Nuclear Threat Initiative, and CORDES organization, Connecting Organizations for Regional Disease Surveillance. Several people worked very assiduously over an extended period to bring this program together successfully through the blizzards and the sleet and the rain and an extended holiday. Beth Cameron of the National Security Council, White House staff, was indefatigable, Jessica Daley from the Center for Disease Control and Prevention. Ambassador Bonnie Jenkins, the Coordinator for Threat Reduction Programs at the Department of State. And from CSIS, a number of folks. Matt Fisher was particularly important in pulling all of the pieces together. Beverly Kirk in pulling together a number of videos that we've organized for this. Ian Gottesman, Travis Hopkins, Ryan Sickles, Joe Jordan, Carol and Shrout, Jesse Swanson. They've all really made a major effort and we're very grateful to you. We'll be joined as this event unfolds by my boss, Dr. John Hamry, who will be with us. He's the President and CEO of CSIS. The GHS agenda, we believe and I think we'll hear more about this today. It's a very important step forward on a very important and timely topic. Laura Holgate and Tom Frieden and others in the administration are to be commended and congratulated. To get to this point that we saw last week in which we'll discuss today required an enormous amount of exertion, thought and perseverance. The numbers of you here today, the numbers online, the over 140 press stories over the last week are all testimony to the awareness of the challenge and its significance. That is, how are we going to operate in concert with others to accelerate progress in building the capacity, particularly in low and middle income countries to prevent, detect and respond to outbreaks of infectious diseases, epidemics and bioterror threats. Global health security is a shared public good, which an increasing number of people acknowledge is critically important, but for which a clear coordinated international mobilization has been less than fully realized. The requisite political will, the resources, the finance, the technical support, the essential joint strategy have all been far too weak against the challenge and it's the GHS agenda I would argue that represents an important step forward in trying to seek some solutions to these complicated problems. Now, and we'll hear more today about the world's vulnerability and the scope of need, if only 16% of the world's countries actually have the capacity, the full capacity has laid out in the international health regulations to manage these threats. We'll hear more today about the two year $85 million commitment to build capacities in 12 partner countries. As said against an $8 billion annual budget in global health, that may seem very paltry, and in some ways it's proof of how difficult it can be to muster resources for global health security and how underfinanced relative this sector is, but also that just putting forward that commitment has triggered just the commitment to make that sort of incremental progress has triggered people to really sit up and pay attention in a new important way. So we're going to combine two goals here this afternoon. First we're going to hear from the two principal architects of the GHS agenda on its genesis, its key elements, what transpired during February 12th session involving 26 countries and three major international organizations, WHO, FAO, OIE, and what will come next. And Dr. Tom Free, my director of the CDC, who will speak by video link from Atlanta, will open up with a presentation, approximately 10 minutes. You have on your seats slides that CDC has prepared in hard copy, which accompany his presentation. And so please join me in welcoming Tom and thanks for taking time out to join us. The second administration architect is Laura Holgate, senior director for WMD terrorism and threat reduction at the NSC. She will speak from a White House perspective on the policy, goals, expectations, and how the GHS agenda fits with the White House foreign policy and international security strategies. Immediately after these two presentations, we'll move to our second goal, which is to hear from representatives of the non-governmental sector in scientific research, biosecurity, and global health. These three speakers represent our three of the cosponsors of this session. We'll each speak for up to five minutes on how they view the agenda and how their organizations and affiliated organizations can contribute to the global health security agenda. Kavita Berger, associate director, Center for Science of the American Academy of the Advancement of Science. Tom Inglesby, chief executive officer and director of the Center of Health Security at the University of Pittsburgh Medical Center. And Debra Rosenblum, executive vice president at the Nuclear Threat Initiative. Regrettably, Nigel Lightfoot, of course, our fourth partner today, could not be here to join the panel. After we've rolled through this first session, the front part of the program, we'll have a moderated back and forth for 15 or 20 minutes, and then we'll open as quickly as we can to the wall. We really want to hear from you, and we will move as rapidly as we can to that portion of the program and welcome your participation. And we will be able to draw to a close by 3 p.m. So with that, we're going to move right ahead. I'm not going to go into detailed bios of our speakers. You have those in hard copy on your seat. Tom, thank you so much for joining us today. It's terrific that we could have you here. Have you here? Please. The floor is yours. The floor is yours. Great. Pardon me? Is the audio okay? Can you hear me okay? Everything's fine. Everything's fine. Great. Terrific. Let me just frame this with what I think of as 3-3-3, and you have something on your tables there that outlines this. We have three risks. And there is now, I think, global consensus of what those three risks are. Emerging infections, resistant infections, and intentionally created infections existing in the context of globalization that means that a threat in any part of the world becomes a risk in any other part of the world. We also have three opportunities. One of them is societal commitment. We heard at the launch from FAO that H5N1 has cost the world more than $20 billion. We know that SARS cost the world more than $30 billion. Leaders around the world have seen that if there is a poorly responded to epidemic, not only do they lose credibility with their own population, but they may lose investment, they may lose tourism, they may lose credibility. There is a recognition that this is a critically important area, and there are, of course, the international health regulations, which require countries to comply with effective detection and response. We also have some exciting new technologies. And I'll talk about one of them in a moment. But between the laboratory and communications technologies, it's a new world. And there are things that we can do quickly and relatively cheaply today that we couldn't do or couldn't do quickly or couldn't do affordably just a few years ago. And third, success leads to success. And we have examples from Thailand, from Vietnam, from Uganda, from China, from Haiti. And I'll talk about some of them later, where there are investments in this space. It leads to a safer country, a safer world, and a stronger and more resilient health care system. And success, I think, can lead to further successes. And we have consensus on the key priorities. There are many important areas in this space. Some of them are going to take a long time to address. But there are three areas where we know we can make substantial progress and it will make a big difference in prevention wherever possible, in rapid detection and effective response. And that kind of 3-3-3 approach of here's the risks, here's the opportunities, and here's the direction we're going in is, I find very helpful to understand what is global health security and to understand that it's not a vague or generic or general approach. It's a very specific effort that will lead us to have a safer country and a safer world. It also is closely related to the concept of resilience, building systems that can withstand a shock, that can identify a shock, and that can make sure that society can keep on building and growing despite that. So we prepare for future disasters, as well as improving well-being today. The second slide or handout is on Uganda. And what we did about a year ago is say, how can we make very rapid progress and learn? So we did pilots in Vietnam and Uganda. Both of them went well. Uganda went particularly well. And this is simply one of the areas where there was real progress. And in that, there was a move from sample collection. This is all over Uganda to a courier on a motorcycle picking up the samples and bringing them into hubs where they're dispatched by overnight bus service actually sealed to a centralized lab where there's biosecurity, biosafety, quality assurance, barcode identification of samples, so very high quality. The results are then printed on a GSM printer which prints locally in the rural area, the hospital or health center, from which the specimen was sent. That has cut the time to identify infections down from months or weeks to a couple of days. And that results in both better individual patient care, as well as a response that's coordinated by the Emergency Operations Center, which was also created in less than a year as part of this project. And that's already been used for a wide variety of infectious disease threats in Uganda. It started out on the backbone of the PEPFAR system for early infant diagnosis of infants born to mothers who were HIV positive. Extended to color, drug resistant to birth photosis and Ebola. And then it's been used for a variety of other conditions as well. The goal of detection is key and there we have very specific goals. So each country would establish one of the five pathogens that you're most concerned about and then we would work collaboratively with them to make sure that they can identify those pathogens at least 80% of their territory. That would reduce the number of blind spots out there in the world and make us all safer. We also would improve ability to monitor for syndromes like watery diarrhea that might be cholera, like a severe acute respiratory infection that might be a new strain of flu or other respiratory illness. We also are looking at the expansion of workforce, particularly at least one epidemiologist for every 200,000 people. That's a measurable concrete outcome and in countries that have expanded their epidemiologic capacity we find them finding outbreaks sooner, stopping them faster and preventing them better. The second ball area after detection is response and here the handout just gives you a sense of what's happened with coronavirus, a tale of two coronaviruses if you will. SARS of 2003 and coronavirus of 2012 won three months of reporting and detection and notification of WHO after multiple clusters. The second, three weeks after just the second case was detected. The process was delayed, the characterization took a long time in the case of SARS whereas it was immediately deeply sequenced in the case of coronavirus of 2012. PCR capacity was very limited 10 years ago. Within days of having the coronavirus we and others had developed a diagnostic technology, a PCR test for coronavirus that we've disseminated around the country and around the world. So with response we were able to move from that detection to response. One of the key areas is an effective and operating emergency operations center that can marshal within 120 minutes and have a cross-government infrastructure. The third area has to do with prevention and we've used as an example there measles vaccination rates of at least 90% and you see we're at 84% in 2012. Incidentally, measles vaccination prevented 13.8 million deaths in past decade but a country that can do measles vaccination at 90% can administer other vaccines, other countermeasures, engage in public health activities throughout their entire area. Prevention also includes biosecurity, identifying where dangerous pathogens are grown and reducing the risk that they will be either accidentally or intentionally released from there and better addressing antimicrobial resistance. Now some people may think that local health security is in some way in conflict with or less important than disease specific areas or less relevant to low and middle income countries. I think in fact that epidemic threats are potentially devastating in terms of economic dislocation, decreased productivity, medical costs, loss of revenues from tourism, travel and investment, but most importantly that if we don't improve global health security, lives will be lost that could have been saved. And by building strong global health security systems, very importantly, we're strengthening the health system more generally and that's a very potent, if you will, strengthening that can be used for any health threat that a country chooses to apply it to. The agenda that was launched last week coordinates across the US government. It's a partnership with the World Health Organization, the FAO, the World Organization for Animal Health and the Directors General of all three of those international organizations were there as well as a collaboration with private and NGO partners. Part of what we need to do is to optimally align existing resources. Part of what we need to do is to identify new resources. Those from within the US government, from partner governments, from development organizations, as well as from host country governments. And what we found in many countries, Thailand and Vietnam and China being three as examples, is that when there's a small investment in this area, the country is willing to step up to the plate and make a substantial investment. So China, when it identified H7N9, did that with all of its own infrastructure. But we had provided the technical assistance that allowed them to do that and do it promptly and effectively. As Steve mentioned, we are currently well underway with DITRA going from two countries in 2013 to 10 to 12 countries in 2014 with existing dollars and then the President's budget for 2015 includes a $45 million proposed increase for CDC to increase activities in 2015 to catalyze further progress. We recognize that global health security didn't come out of nowhere. It builds on many other organizations and many other commitments and many other frameworks and it supplements them and is able, we think, to focus on a specific package where we can make meaningful progress. There's a lot more to be done, but we're confident that with this consensus on what are the risks, what are the opportunities and what are the approaches and what can we do to measure and move them forward, we're going to make rapid progress. So thanks very much for all of you for your interest. Thank you. Thank you. It's always a challenge. It's always a challenge because he's so passionate and so committed to this mission but he's been a wonderful partner as we've built this global health security agenda in the U.S. government across agencies, across sectors, across bureaucratic levels to a really high powered and very invested concept within the senior White House leadership. As you heard from Tom when we talk about global health security, what we're talking about is making the world safer and more secure by strengthening global ability as an international community to prevent, detect and respond to infectious disease outbreaks such as the ongoing H7N9 influenza outbreak, the Middle East Respiratory Syndrome and other diseases that have the potential to cause health emergencies of international concern such as Ebola, plague, dengue fever, whether naturally occurring, deliberate or accidental. The challenge with global health security is based on the interconnected nature of our world. We're all vulnerable. Increased global travel and trade makes disease threats, disease threats can spread faster than ever before causing loss of life, grave economic challenges and political instability. And as was emphasized by Secretary of Health and Human Services Sebelius during our launch last Thursday, outbreaks anywhere in the world are only a plain right away. Globally, a lot of progress has been made over the last decade since the SARS outbreak in China including with great partners in China and Indonesia. In particular, China has been a model of transparent reporting and information sharing on the current H7N9 influenza outbreak and that has enabled us to be prepared, be prepared to manage that outbreak if it were to occur here in the United States and protect our own people. Here in the U.S. we do take these threats quite seriously. We've worked across sectors and we invest hundreds of millions of dollars each year across the government to promote global health security objectives with partner nations around the world. But we have a lot to do. While we've made a lot of progress, we still have much ahead. 80% of the countries in the world failed to meet the World Health Organization deadline to be prepared for disease threats through compliance with the international health regulations. As you know, disease threats know no borders and no country can address them alone. And that's why this is not a United States agenda. This is truly a global agenda. We can't achieve these goals without sustained engagement from our partner nations and across sectors, but we can achieve these goals together. We also want to emphasize that this is not a health issue or a security issue. It's both. Global health security has to be addressed synergistically across all sectors whether we're talking about health, agriculture, defense, development, international security, science and technology, and others as well. Stove pipes are our enemy when it comes to health security. Success will also depend on our ability to work effectively with the non-governmental and private sector. And that's why we're especially pleased to be able to participate in today's forum. We've looked across all of our programs and we are committed to aligning U.S. government efforts in addition to working closely with others against the nine objectives of the global health security agenda. Just to give you a little bit of a flavor about how this effort was developed, we've been working on this concept at the White House for several years. And I can tell you that our leadership, Susan Rice, Lisa Monaco, the president, are quite energized by this issue. Just as an example, we had already been working across my directorate of WMD terrorism and threat reduction, working together with directorate headed by Gail Smith, who leads our development and democratization team at the White House In part, we were energized by the dismal showing on the International Health Regulations compliance. But then we were already launched on that collaboration when the H7N9 and Middle East Respiratory Syndrome outbreaks began last year. And that started us on a fairly regular basis of almost weekly meetings in the situation room with Lisa Monaco, Tom Frieden, USDA, DOD, DHS, Pick Your Alphabet Soup, and we were there. Talking about the outbreaks, talking about U.S. pandemic preparedness, but inevitably also talking about the way we'd be ready to deal with this next time is through the global health security agenda and making progress against each of these nine objectives. And we really challenge ourselves to define in concrete terms what does global health security really mean and how will we know when we get there and how do we measure our steps along the way. So that added urgency to our effort to elevate this issue around the world to enhance the multiple existing structures that are already working on this to improve their capabilities and their capacities to join with us in launching and pursuing this agenda. So this all came to fruition last Thursday despite the snowstorm. Secretary Sebelius, Assistant Secretary to the President for Homeland Security, Lisa Monaco, representatives, senior representatives from the State Department, the Defense Department, the Agriculture Department, and moderated, of course, by our own Dr. Frieden, launched this initiative with 33 partners from around the world, 29 nations, three international organizations, and the European Union. We all joined together in Washington and Geneva to step up our global game on this issue. I'm going to stress that this is not some new strategy. It instead builds on existing strategies and a lot of existing work already underway in the U.S. and around the world. It's intended to elevate this issue to senior level attention, energize and empower partners around the world, and focus on specific objectives where corrective action can be taken to achieve measurable results. The launch on Thursday also included the multimedia links to the WHO in Geneva where Director General Margaret Chan and ambassadors and representatives from participating countries also joined the launch. We were also able to link directly to New Delhi and Rome. So, you see, we really had no choice but to persevere through the snowstorm with our partners ready to go in non-Snowy venues elsewhere. During the launch, partner nations like China, India, Uganda, Indonesia, Finland, Argentina, the Netherlands, Vietnam, Republic of Korea, and so many others made a commitment to accelerate measurable progress across these nine objectives organized under this framework of prevent, detect, and respond. This work is built to support the World Health Organization's international health regulations and is conducted jointly with the WHO as a mechanism to accelerate progress towards achieving the goals of the IHR. All of the nine objectives relate in one way or another to the IHR agenda. Partners during the launch discussed the elements of the agenda and we heard about commitments from other countries to take specific action against a whole range of biological threats, whether naturally occurring, deliberate, or accidental. We heard about national efforts, regional capacity building, activities to assist others, and commitments to transparent outbreak reporting. These are all components of the global health security agenda. During the launch, we also announced our own commitments to this agenda. First, we announced that the White House will assemble partner nations again in the fall to highlight commitments and review collective progress. This will be a larger group we anticipate than those involved in the initial launch and will help reflect the diversity and breadth of the collaboration that's needed to make progress on this issue. Second, we announced and published the specific global health security targets that we will be aiming for in our own programming and international connections. We committed to partner with at least 30 partner countries to meet specific milestones in support of the global health security agenda. As you can see, the global health security objectives themselves are not quantitative, so we worked across the US government to develop indicators of success so that we would know that we were making a difference and we went to work with partners for them to develop their own indicators based on their own programmatic and other activities. For example, we set a specific target to assist others in developing public health emergency operation centers with trained staff that are capable of activating a coordinated emergency response within 120 minutes of identification of a public health emergency. That kind of effectiveness has capability and benefits across almost any kind of health event that you can imagine. We also set a target that countries that we assist should be able to conduct surveillance to monitor and slow antimicrobial resistance with at least one reference laboratory capable of identifying WHO priority AMR pathogens. These are the kinds of specific indicators of success of progress against the objectives that we have pulled together to guide our own programming and our own interactions. And as you heard from Dr. Frieden, we announced some increases, financial increases in our own activities. First of all, highlighting some fiscal year 14 resources that will be targeted towards this effort, as well as new resources for the first time in the U.S. government really aimed at the global health security agenda in the President's budget that will be presented later this spring of $45 million for CDC and their work. Of course, now that the launch is over, the hard work begins. The GHS agenda effort is not about reviewing what we've already achieved. It's very clearly about what is left to do. The partners participating in the events last Thursday called other nations to join this effort to develop and deliver measurable commitments. And we asked all of the participants to consider the issue of global health security as a national priority at the highest levels of their government. We're working with partner nations who are planning commitment development meetings in early spring and summer. And I can report to you that Finland has just offered to host one of these meetings later this spring. This first set of commitments will be highlighted and reviewed at the White House meeting to be held later this fall. So ultimately what we see in terms of the success of this effort would be a world where every nation has the capacity to prevent epidemics when and where we can to detect threats early and to respond quickly and effectively as countries and as an international community. This means we need to get to the point where outbreaks are reported in real time, where nations have the skills and resources that they need like safe, secure laboratory systems and where the world has an interconnected network of emergency operation centers that can mobilize rapid response. Every step of the way, we will be working closely with WHO, OIE, and FAO, as well as countries around the world to develop new actions, work across sectors to align activities, measure progress and replicate models that work. Before I turn to the microphone over to the next speaker, I really want to stress that we see a vital role for the non-government community and the private sector as the Global Health Security Agenda develops. This agenda is not a government-only effort. It will require a whole-of-society approach and to achieve this ambitious goal of a world safe and secure from infectious disease threats, stakeholders across all sectors of the challenge will need to participate, including the global health, biosecurity, life sciences, agriculture, research and development communities. I know there's people from all of those communities here today and I'm really grateful for your interest and participation in this. We really need to have access to your advice, your experience, and to hope for some alignment of our efforts as we work together. You can often see paths that those of us in government haven't considered or are not able to take based on our government status. And so you're already contributing across these activities through the science research, through developing novel vaccines, ensuring rapid detection and response through better diagnostics, building biosafety and biosecurity capacity. Going forward, we really see a critical role for the non-government sector to develop a dialogue surrounding the efforts, the elements of the Global Health Security Agenda, which could proceed in parallel and greatly inform our government efforts in this area. I really look forward to the discussion. Thank you. My name's Deborah Rosenblum and as Steve said, I'm from the Nuclear Threat Initiative. Before starting on my remarks, I did want to thank Steve Morrison and John Hamry for convening such a diverse and broad group of individuals to learn more about this new agenda that we think is a very exciting step in helping to promote global security and public health. We also want to thank the United States government and in particular Tom Frieden and Laura Holgate, as well as the World Health Organization and its sister agencies for having brought this leadership to spotlight such an important issue. From our perspective as an NGO, we believe this agenda holds enormous potential to improve global health and security by reducing the threats of infectious disease, whether from bioterrorism, an accident, or naturally occurring. Now I know you all are wondering why someone from the Nuclear Threat Initiative is here today to address this important public health and security issue. But our mission and our mandate is to reduce risks that come from weapons of mass destruction and certainly biologic threats are one of them. Over the past decade, we at NTI have worked on reducing biologic risks by helping to develop regional and global capacity on early disease surveillance. Specifically, we have set up cross-border networks in the Middle East, in Southeast Asia, and in Africa that bring together public health practitioners to train together to exchange data and to conduct joint, excuse me, joint early disease outbreak investigations across border. We've witnessed the positive impact of this cooperation and how these relationships have sped the exchange of data, information, and leading to joint response. I remember one example very vividly in the Middle East. It was 2009. The World Health Organization had just raised the influenza pandemic level and had called for global solidarity against the H1N1 disease outbreak. The MISIDS, or the Middle East Network, which is comprised of senior Israeli, Palestinian, and Jordanian public health officials, were ready. They had already, over the preceding years, developed a joint action plan and a regional response that helped to save lives, reduce panic, and become a helpful partner to the WHO in their global efforts. Based on our experience, we would very much encourage this global health security agenda to garner political support and the resources to work across borders. This is particularly important in regions where political tensions are high and cooperation is limited or non-existent in a collaborative way. Multilateral efforts will play a critical role in improving and building global capacity. We would also encourage you in particular to work with a new organization that has been established, both as NGOs as well as as governments, with the organization that Steve mentioned earlier, connecting organizations for regional disease surveillance, which is based in Lyon, France. They are regularly convening public health practitioners from all over the world to develop best practices and look at innovations in early disease detection and response. We also hope that the momentum from this new agenda will encourage non-traditional partners to come together on global health to work together. In particular, I'm thinking about security, public health, and scientific communities, including NGOs. This is very important as there is needed work to be done on biosecurity, including the development of global norms on dual-use research of concern, as well as biosafety. For example, there may be important work on sample sharing that can be done in the coming years. Now with this agenda, we along with other NGOs look forward to helping government to accelerate these efforts. We can do so by bringing forth ideas and sharing our experiences from the field that can help to accelerate these important governmental efforts. So with that, I'll close and turn it over to my other fellow colleagues. Hello, I'm Tom Inglesby from the UPMC Center for Health Security. I want to start off by thanking Steve, as well as John Hamery if he's here. And thank you, Tom and Laura, for joining the community today for this agenda. So I'm going to start with just giving you my sense of how this agenda benefits the fight against infectious diseases. First, it elevates these issues and what needs to be done about them. Many of the people and programs working on infectious disease preparedness around the world are doing so without notice and without much encouragement. But now, they're working on issues that the White House cares about, that the World Health Organization is caring about, and that other governments are caring about. And that will matter. The agenda builds political momentum in the U.S. and abroad around these issues. There's nothing like a public commitment meeting in the fall to get countries to dig deeper and to reach higher and commit more. Our center collaborates with ministries of health in various parts of the world. And what we've heard over time is that officials in other countries face the same quandaries that we do here. This is a work that is deemed to be critical around infectious diseases, but often it's under-resourced and doesn't receive the political attention that it deserves. They face the same challenges that we do. So more political attention helps them just as it does us. This agenda encourages countries to share their successes. We've heard about Uganda and Vietnam today. We've heard how China is leading the way with age seven and nine. The U.S. CDC's Emergency Operations Centers and the ITP program among others are admired around the world and the list goes on and on. All countries, certainly most and probably all countries that are part of this agenda and that will become part of this agenda will have something to offer. And the agenda shines a light on biosecurity and biosafety in a new way. These are issues that are not necessarily taken on by the infectious disease community, but also that it will lead to international biosafety norms for research with the potential to cause major epidemics in the event of a lab accident or a diversion. Such as the age five and one gain of function research that has been so controversial. These norms could improve biosafety for everyone. So how can NGOs help move this agenda forward? We've heard a bit from Laura and Deb. My sense, NGOs can shine a light on leading practices we see in our work. In this case in this past year we've seen on the ground how Taiwan, motivated by its SARS experience built an outstanding infectious disease preparedness system. How Saudi Arabia has developed the state-of-the-art preparedness effort around mass gatherings. How Shanghai has created an electronic health record system for the city that really should be a rival for the world. It's amazing. As a community, NGOs can and will share what we learn. We need to take out the professional communities on the front lines. Because much of the work that needs to get done to move this agenda forward is going to be done by the medical, public health and scientific community. So engagement of these fields on the front lines is going to be a key ingredient for success. NGOs can bring new thinking to this process. For example, a number of the organizations that are in the room today participated in the creation of the National Health Security Preparedness Index and we've learned together in that process could be helpful in developing measurement tools around global health security in the future. NGOs talk with policymakers. Congress will ask us what we think about this over time and many of us can be effective communicators about how successes are emerging from this work and we can also sometimes be useful in talking to political leaders elsewhere in the world even more so than official government officials, official government representatives can do themselves. NGOs will pursue new research and create valuable new programs. If you look around the room here today there are 100 good ideas that have come from the groups in this room in the last years around these issues. AAAS and NAS have been doing science and security work for years. Doctors Fisher and Katz from GW have been doing work around the IHR which has been really important moving it forward. We heard from Deb around NTI and we've been working towards the Griffin Foundation here today has been working on biosafety in new and innovative ways. Our own group has worked on exercises and guidelines that have helped shape government programs. There are many ways that we all can help. And NGOs will publish and communicate professionally about these issues. On this note our own journal is a peer review journal named Biosecurity. It has readership around the world and authorship of the world we're announcing a call for papers today and we're going to be dedicating an issue of this journal to global health security to be published before the commitment meeting in the fall. And handouts on that I think we brought in the back of the room if anyone's interested. So lastly we can be strong direct partners with governments and want to be. We can do the needs assessments we can identify the gaps we can evaluate projects we can create new programs for our countries. We can help do the work that the agenda calls for and needs to get done and we're all truly in this agenda together. Thank you. Good afternoon everyone. I feel so short at this podium. My name is Kavita Berger. I'm with the American Association for the Advancement of Science. I want to first start by thanking Laura Holgate and Dr. Frieden for their leadership and advocating for this and for her strong interest in bringing the NGO community into this whole discussion and of course to Steve Morthen and John Hamery for the wonderful venue and putting this together. So I am here representing the science and technology communities to discuss how natural social computer scientists and engineers can all contribute important roles to implementing the nine objectives of the global health security agenda. Often we think of the S&T community as a major producer of vaccines, drugs and diagnostic tools needed to protect the populace from infection from biological agents, whether introduced naturally, accidentally or intentionally and in fact producing these tools is extremely important function of the scientific community. However, scientists and engineers also play important roles in preventing characterizing and controlling emerging and unusual infections. In fact, infectious disease researchers often in collaboration with other scientists around the world can help identify and characterize pathogens that cause outbreaks. In 1999, a veterinary pathologist at the Bronx Zoo correctly identified West Nile virus in the United States which initially infected birds and then humans. In 2003, scientists from several countries around the world worked together to determine that SARS was a coronavirus that infected and was the original coronavirus that infected many people in China and Canada and elsewhere and also to develop pre-clinical vaccines to prevent future infections. In 2011, German scientists determined that E. coli 0157 H7 outbreak in Germany was of natural origin based on computer-based comparisons of sequences that were posted on the cloud by a Chinese company, BGI. And in 2013, scientists from Columbia University worked with the Ministry of Health in Saudi Arabia to characterize the pathogens and strains of the coronavirus which has already been discussed. And these are just a few examples of the basic functions of pathogen identification and characterization that scientists have been involved with. But the S&T communities are much more diverse than this. Social, physical, chemical, computer, engineering, material, and non-infectious disease life scientists can all contribute to global health security in very different ways. I will provide four examples of how the broader scientific community can contribute to global health security. In Dr. Frieden's remarks, he mentioned Uganda. In this particular example, CDC used blood samples, blood spot samples to identify the pathogen and GSM printing to inform local health facilities of diagnostic results. This could only have been done because genomic and chemical scientists developed newborn blood spot sample collection and genetic testing. And physical scientists and engineers developed global systems mobile communication. In the second example, efforts focused on enhancing existing cultures of responsibility in the life sciences towards greater biosecurity and biosafety have depended on research conducted over years by social and behavioral scientists and education experts. Social and behavioral scientists have informed efforts to seek that seek to prevent risky behaviors and to lead to that lead to infection or chronic diseases and more recently, social and behavioral scientists along with neuroscientists have started to inform the way we think about personnel security or personnel security. In the third example, computer scientists have enabled the numerous fields of big data which in the context of global health security provides tools to conduct global infectious disease surveillance and facilitate rapid sharing of data. The World Health Organization's global outbreak alert and response network, and this is just one of several of these tools, relies on advanced computational science to not only collect information about potential outbreaks, but also to identify ways of continuously mining through huge amounts of data collected from both official and unofficial sources. And the final example is the use of iPod iPads and solar powered backpacks to both facilitate system wide upgrades for facility biosafety and biosecurity and sharing of best practices or problems at remote and urban facilities. This project, which was carried out by the Elizabeth R. Griffin Foundation, sponsored by the Department of State, relies on computer scientists, engineers and physical scientists to make the iPod applications and lightweight solar powered battery packs. In addition, this project required biosafety and environmental health and safety officials to identify laboratory safety and security problems and possible solutions. So these are just a few examples of how the broader S&T community can play tangible roles in helping to implement the objectives of the global health security agenda. And this does not include the importance of science cooperation and science diplomacy in facilitating partnerships, ongoing dialogue and transparency of research activities. The efforts of microbiologists enhancing microbial forensics, the role that scientists and statisticians, mathematicians play in developing and conducting risk assessments and the significance of institutional administrators supporting their scientists as they conduct important research and promote at the same time safe and secure research environment. And so this is, you know, so I hope I've given you a really good picture of how many different disciplines in the scientific community can actually contribute to this area. And one thing I also want to point out is that the BWC, the Biological Weapons Hoxons Convention, is actually a very good venue to have these discussions. Because over the past decade, pathogen surveillance biosafety biosecurity response efforts have become an integral part of the BWC and government, intergovernmental and non-governmental organizations have all under the auspices of the BWC shared best practices, new tools and lessons learned with both scientific health and security counterparts. So if there's one message I want to leave you with, is that strong partnerships between the S&T, the broad S&T health, security and policymaking communities throughout the world are an integral part to achieving the goals of the Global Health Security Agenda. Thank you very much for your time and I'm happy to answer any questions. Come on, let's grab a seat. Whichever you wish. I'm going to sit in the middle. Please. Hi, Tom. Well, thank you all for being so patient and thanks to our presenters for a really rich and eloquent set of presentations. I'd like to bring it back to the actual agenda, the GHS agenda and ask a few questions starting with Tom and Laura around some of the requisite parts of making this successful. Fundamentally it seems it's an ambition to launch a new form of diplomacy, an accelerated or intensified form of diplomacy that is calling on WHO, it's calling for a new relationship to the, it's elevating the IHR it's speaking to some of the earlier initiatives with the G8 and there you get into some delicate lines. You don't want to duplicate, you don't want to be parallel structures you need to be supportive and leveraging those. You also need to prove the value to these partner countries fairly rapidly that this is a branded and distinct and valuable new initiatives that you can get some momentum behind it. And maybe you could say a few words around how the conversations went on February 13 with those partners around this whole question of making sure that this is new value added, that you're respectful of these other things and that folks see those values and that you can continue to come back in the coming years and reinforcing the value of this. Laura perhaps you could start off and then Tom I'd like to ask you to add your thoughts. Well it's a critical question Steve and I'm glad you asked it because it was referenced by several of the participants in the event about that as we proceed we need to avoid duplication avoid overlap, avoid excessive layers and so on of activity and that's certainly been at the heart of our concept from the get go. As both Tom and I have said there's been a huge amount of work already done and so we're building on that foundation and looking to enhance and elevate it, not replace it not supplant it not distract it and I think we saw just this week of an example of how raising the political visibility of this agenda can be just absorbed very organically into an existing structure we had a joint statement coming out of the North American Leaders Summit just this week that highlighted that they would work together on global health security issues in that summit process and its normal activities and so this is one exactly the kind of thing we're looking for. We saw already in the G20 statement from last year some seeds that we'd already planted knowing the global health security agenda was coming down the pike that looked at antimicrobial resistance. We're working with the Russians right now in the development of this G8 meeting in Sochi for later this spring to have a global health security component to that it's one of their highlights in fact it was a Russian initiative and so we'll have it not only in the concept of the global health piece but also a continuing focus within the global partnership that is associated with the G8 although it vastly out numbers it has I think 25 members now and biosafety biosecurity elements of the global health security agenda are explicitly addressed there in the context of matching funders and needs and so there again it'll provide a focusing effort and the agenda of that biowork within the global partnership has an uncanny matchup if you will with the objectives that we've laid out in the global health security agenda thank you Tom, thank you Tom I guess a couple of observations first in the host countries low and middle income countries where we explore this we get pure enthusiasm there is in virtually every case an understanding once we outline what the concept is that yeah we really need this there is sometimes a sense of we've done more or less but there's really as close to universal as I've seen in a global health issue recognition that this is important from the global partners we have the sense that as Margaret Chan said at the opening we need new energy to get progress in this area where the health minister from China pointed out that this is being launched in the year of the horse and this is a year known for speedy progress and that's what we need here so really we've seen a remarkable consensus on the need to do this and to do it well and quickly I think Steve you asked what's necessary for success I do think getting aligned is never as easy as you'd like we've worked really hard with the White House playing a key role there to do that within the US government actually colleagues from the Department of Defense are here today at CDC where we're getting into the nitty-gritty details of who's going to do what in 10 countries in this in the coming months and across the international organizations as well there are existing partnerships that can be built on and a lot of it involves making sure that we're able to communicate clearly and outline this is what it is, this is what it's not and now that it's launched it becomes much easier to do that Thank you I in talking to folks in WHO and elsewhere it seems to me that having the the 10 that now 12 country initiative was very fundamental in showing that there's some forward movement on this and the commitment of those resources to that I'd like to ask our non-governmental as well as the administration folks to comment a bit about looking ahead what do you see as a sort of resource strategy for moving forward on this because we do know if you make the proposition to the American people, to Congress to security analysts and others that this is really fundamental to US national security and you make the proposition that low income countries are really really important in this area by definition you're going to have to show a higher commitment going forward and if you're also saying that the non-governmental sector in the different areas that we've heard from today and the private sector matter significantly there's going to have to be some kind of structured incentives to pull people in and fund them at a higher level so how do you see this let's start with our non-governmental folks on how do you think about the future I mean there's some value in saying we need to spend existing resources smarter and with a greater focus in these areas so getting an agenda like this begins to pull people that away but we also know that this is a very ambitious and complicated agenda and it's going to take over the long term much higher levels of resources so what's the strategy and how do you think about this Tom a couple thoughts I think we all share the observation that funding US government strategy often responds to fear of consequence as opposed to other more lofty goals that we might have so at least as part of this discussion we do need to be able to explain as you just said Steve what happens if we let things go as they are and what are the consequences of a world like this as ill prepared as it is for major sudden shocks of infectious disease so that really needs to be done by all of us and I don't want to for lack of a better word I might use the word campaign that sounds too political it's more of an educational process and discussion that we all have to have with our elected officials and that others in other countries have to have with their own elected officials and as I was referring to before I think we can sometimes outside of the government help make that case as well as people inside the government who are already doing the work and I think we all people in the room today probably already are showing the commitment to do that so I think I have two thoughts one is that we need to think about leveraging the resources that we have we have so many different leverage so many different resources so many different individuals and organizations that can play a key part in this and I think the example with Uganda is a really good one because you're leveraging resources that were not traditionally part of the global health security but actually played a big role in that one of the other things to sort of think about when doing this is that our funding cycle is year by year and in terms of the non-governmental community who are trying to achieve the goals if the goal is a five year goal and we are able to work together as a community maybe not all at the same time but in a sort of stepwise manner throughout that five year plan then we might be able to achieve that end goal and we are better able to leverage those resources that might exist and then the second thing excuse me the second thing is that we really need to think about better evaluation criteria and metrics and I'm heavily influenced by the academies when saying this but the metrics that we have are very discreet and they don't catch some of the things and some of the examples that have even been presented today and so we just need to be able to better to figure out how to evaluate the benefit not just the short term benefit but the long term benefit of the activities I would just add quickly that to your question Stephen in terms of resources I mean I think over time and this is not a surprise either to Tom or Laura it will require more resources not only here in the US but abroad but I think what this agenda does is it puts a spotlight on how resources that are existing are being used not only financial resources but also human resources and I think a point that Tom made is very important that he is sitting down with his department of defense colleagues to look at how to marshal the resources that they have in cooperative effort together in 10 pilot countries and so I think that the agenda is not that people haven't been good stewards of resources to date I'm not suggesting that but it's really putting a focus on making sure that the key priorities against which resources are being put are being done so in a systematic way not only here but also abroad and in other countries Laura this agenda cuts across both the humanitarian and development agenda and the security agendas and you could make a case that because it envelops so many different things it could get lost in a budgetary argument or in conveying to the ill what is this and why is it so important and what is it going to take and having that long-term multi-year vision becomes very important I mean saying five years 30 countries okay that began nine points and three three so tell us a bit more what's your thought on how to build the enthusiasm and support around a longer term much more serious and heavy investment well defining the agenda as you indicated is our first step we've got to say what we're going to be focusing on everything's important but you can't do everything so we're saying these are the things that we're really going to focus on the other piece of it and you're exactly right is the cross-sectoral nature of the solution set is both the strengthen and the challenge particularly when it comes to funding particularly when it comes to how Congress funds projects and programatics in this issue I mean we have a dozen or more departments and agencies that join me around the tables of the interagency meetings at the White House and they each have their own congressional staffs they each have their own appropriations particularities they each have their own pet rocks that their congressional keepers expect of them and so what this allows us to do in a way that we haven't before is to have each of us as well not the White House but each of the agencies as they go forward to their appropriations process to say this is a whole of government effort and here is where I fit in and this is why my resources that I'm asking you for today for this piece of it are part of a whole and to be able to explain that connectivity I think much more clearly the hope is it will make it easier for Congress to see how their particular roles as committee members and as appropriators relate to supporting the overall agenda over the last decade we've learned a lot about communicating to the American public in the hill and how these help matters and we've learned how important it is to have data and to tell stories and to visit where the money is being spent and Tom I was going to ask you you've been exceptionally focused on telling the story in a clear and lucid way of what this is all about in telling the story in the next three to five years in the places that really matter what's the advice if we're going abroad and trying to focus and we know how important travel and visits are and data can you say a few words I think the fundamental concept here is that we're going to have a safer country and a safer world and to illustrate that through the very concrete approaches that are being used we know that there's a need for more resources there's a need for better aligned resources we also know that we're never going to have all of the resources we need and so it's particularly important to focus them in the areas that are going to have the biggest impact and it will not only find, stop and prevent outbreaks but even if we don't have outbreaks we'll make the system stronger so it's more resilient and more able to find any health threat and respond to it so to give you an example in Uganda they had their emergency operations center and they had a mass gathering with tens of thousands of people coming together they were worried about all sorts of things that can go wrong when that happens this was a few months ago when there was a rare eclipse that could be seen from part of the country there were people converging from within and outside of the country they were able to use that infrastructure to deal with safety in that particular context so to make the point that not only will we be safer and more secure as a country not only will the world be safer and more secure but even and though we know there will always be new infectious disease threats coming even if we didn't have those things I think that's an interesting assessment thank you let's invite some quick comments and questions from our audience what I'd ask you to do is put your hand up we have microphones which will come to you sir here please identify yourself and please be very succinct Bill over here gentlemen over here what we'll do is bundle together those pieces that are relevant to them sir thank you very much Jerry Martin from DAI we're a development company that runs a 90 million dollar emerging pandemic threats program called Respond that operates in Central and East Africa and Southeast Asia it's funded by USAID my question for you is I'm struck by the fact that to date none of the speakers has mentioned USAID and I'd like to have a better understanding how you see that role I'm going for it for GHSA thank you Bill right out to your other side there to your left Bill Lirely, DHS at least for the next week till I retire from government I've had the term the three words global health security in my official title for the last eight years and global health security has been in my official job description for at least the last 15 years given one of the critical lessons that we learned during the HIV AIDS epidemic was that we have to take a multi-sectoral interdisciplinary approach we learned that AIDS was much more than just a health issue or just a security issue how will we look at this new initiative or this emphasized initiative in more than just a health and security context thank you there's a hand over here and there's a hand there we'll come back I'm sorry, we'll come back I'm Nathan Paxton, faculty at American University I would be interested to hear what you think given the way that Dr. Berger has posed the role of science and technology in this what role could more targeted basic and translational research funding do for the health security agenda given that a lot of it seems to be well, we happen to have GSM, so that was a good thing to use but what role can we do with targeting and integrated basic and translational funding thank you, Brie can we come down to the front here Juan Manuel Sotelo I'm the president of Global Health International Advisors and former WHO representative in four of our countries three comments number one I share the enthusiasm for this initiative I think it's fantastic that we're all here together learning these plans but the world already has an instrument that's international health regulation that has been approved through a complex process throughout the years I understand that this is a major departure from what we already have is it an evolution I have heard something about a new diplomacy involved when you talk about diplomacy from the political science perspective you are talking about the go hand in hand by the interest of a specific nation but if this initiative is global we are talking about all nations so United Nations should be involved definitely and I'm glad that you have approached WHO and other UN institutions to work around this global initiative my second comment has to do with the need that it was a stress here of a synergistic approach among all sectors this is not an easy task as we all know I'm going to give you three examples the first example is just the building up of this international health regulation this has not been easy to be bought by more than the traditional health sector the other example is we are talking a lot in recent years about social determinants for health this is not also easy to involve other sectors to work around health taking in consideration that there are other determinants and we are talking about universal health coverage now and again another major initiative in which we need to be able enough to work with other sectors not an easy task which is the glue to do this with a suggestion a suggestion for strategy you need some more action oriented maybe less official oriented but more actual involve civil society involve different constituencies in the countries and do it country by country this is most important different than the traditional official actors and actresses thank you ok so we have a question about USAID question around multi-sectoral beyond health security the translational research question around IHR would you like to start with some of those you and Tom and then we can come back to the non-governmental since many of those questions were directed at the administration I'll hit a couple of them I think the USAID to the degree they were admitted it was by far not on purpose they are a critical component of our team the funding that they provide is some of the hundreds of millions of dollars that the US government uses in support of the global health security agenda and the objectives of it that we have been working on over time and my partner in crime here Gail Smith and her team and the interagency components that work more directly with her team are critical components of our conversation so don't over read anything into that they're a critical part of the government part of the GHS team I just want to the only other things I'll respond to were those from the last question and that is the connection with the international health regulations and just to be very explicit these objectives all connect directly to the IHRs this is in support of execution and compliance with the IHRs it is inspired in part by the realisation that 80% of the countries in the world are not at that level and how do we move that needle we talk about measurements that's one of the most fundamental measurements we're trying to affect and so working hand in hand with WHO in that direction is exactly what we're trying to do but I'll just footstomp the point that was made of more action and less officials I'll definitely second that although Tom as both an official and an action oriented person is not one we would want to rule out from that mission space his presence when he shows up just makes a difference and because his relationships with his counterparts around the world are so critical so Tom I would just reiterate there is zero departure or conflict or difference between this activity and project and the international health regulations exactly as Laura said this will accelerate global compliance with the IHRs I think the comments on multi-sector are very important and agriculture veterinary health there are many different parts of the challenge of prevention detection response even within the health sector ensuring that there is not just public health clinical but public and private clinical coordination for disease reporting and response and prevention all of these are areas that really do require a multi-sectoral approach and NTI has done such terrific work looking at some of the tracking of compliance at least legal compliance with radiological and nuclear material stewardship that kind of civil society tracking of is the government doing what it has promised to do or has said that it is doing all around the world is going to be very important to encouraging progress in countries around the world I would reiterate also what Laura said USAID has been part of the discussions from day one we have a very close partnership with them primarily through their emerging and pandemic threat program and that's something that we are looking forward to continuing to build on in the years to come in terms of the new technologies I think anything that I would predict is not going to be what is going to happen the technological advances are so exciting in diagnostics in communication skills and organizational enhancements at this point we are kind of kids in candy shop in terms of everything video conference facilities to the GSM printer example to dipsticks that can test at remote areas to metagenomics in centralized laboratories but there is a lot going on and I think your question is a good one it would be worth stepping back and saying alright where should we be looking for the things that are likely to accelerate progress more than others that may be a rich environment to look for innovations that are going to make a big difference in this space thank you we are going to take another round of questions and comments but I would like to ask Kavita, Debra and Tom while we are doing that to think a little bit about how in your view we should prioritize the research investments in this next phase because each of you are fit it out organizationally to try and think strategically around the research agenda and how to organize our priorities and it would be just it would be very helpful I think for you to give us a quick snapshot of how you would be how you would argue that we should be prioritizing looking forward in this next phase and why don't we take some we've got about 10 minutes left let's take some additional comments ma'am right here and right there and then Mark had a hand Mark Becker here yes please I represent and just beating off what you were just stating the security side of the house which is probably a lower sector that's really been concerned in addition with public health I'm promoting the universities and the research as far as funding to take back the message to the administration to please take a look at the universities across the board both in the United States and abroad I work in the world of security and innovation technology and now I'm crossing into the sector of biosecurity defense it's a unique area there's not a lot of students out there that do that it's also unique in that there's not a lot of universities the opportunity for students to grow and develop in that area on a global scale and so I think this is an issue that's going to go long beyond all of us in this room and we're going to have to prepare the future by preparing our students on universities that's going to require funding and it's going to have the security sector is going to have to have a little bit more emphasis on a global scale just for thought Thank you there's a hand back here Matt could you help thank you Hi I'm Sarah Rubin from the National Association of County and City Health Officials and I wanted to look at the Uganda example again and think about how this great example could be shared at a local level and what we potentially could do to share both best practices at the local health department level in the United States along with those best practices in countries abroad and hear your thoughts on how that might already be happening Thank you thank you Mark and Tom right here hands up right there Yes please Hello I'm Mark Steinbeck with the International Committee of the Red Cross they've paid me for a couple of years to think on the dark side of science as a medical advisor on the effects of weapons I like a lot of what has been talked about today we've talked about cross border we've talked about regional cooperation I guess the elephant in the room is a true international response for GHS where are you going with that idea Thank you Admiral Cullison I'm Tom Cullison from Uniform Services University of the Health Sciences it's encouraging to hear the term natural accidental and intentional in the same room at the same time there's been a lot of division of the naturally occurring studies and the bioweapons studies I'd be really interested to hear about your discussions about how you got to this point and how you can take this forward in combining all three Thank you why don't we one second please why don't we come back we'll do one more round why don't we start with the question of priorities that I had posed to to Tom Devere and Kavita and then we can come back to these issues that many of which were directed to Laura and Tom Well if you look at the agenda I think there are more basic and translational science needs on the list there are issues around antimicrobial resistance which are both basic science but also changes in practice so I think the research agenda around best practices which countries are doing things that other countries have learned from that's very important research I think the pilot studies and the translation of them the Uganda example that we just heard from Sarah I think would be very useful to translate those things that have already happened and to communicate them more effectively but I do think that there are basic science and translational things as well on the list including access to medicines new medicines that we don't have yet diagnostics diagnostics that we don't have yet Deborah? One of the things that I would say is if we look back over the past decade where a lot of the work has been done there's been a lot of work very successfully on the response and detection side there still is a tremendous amount of work still needs to be done but I would very much encourage on the prevention side in terms of where some of the areas of priorities are be they in the universities as you mentioned in terms of developing a cadre where we have scientists and security individuals that are working more regularly together to understand where some of those risks lay in common cause across that area to then also moving up and this is over on the detect side but moving up that scale where the ability to detect it even earlier is going to be tremendously helpful in terms of a basic research side. Thank you. So I think that I would suggest a few things. One is that we rethink how we invest in basic discovery science there's so much that we can learn and gain from just understanding the world around us and over the years in this push more towards translational science because it provides a product or a thing that we are losing the discovery science that actually helps provide the foundational information for those things and those products. The other thing is to keep supporting and to keep sort of looking at that pipeline from discovery science to application to actual technology development and to continue sort of promoting the movement of what we learn to how we can best use it in this particular context. Some things I find very interesting over the last decade or two is that we started to move more into the architectural sciences and not just even in the scientific community but broadly. So the natural sciences, engineering and technology, social sciences, policy, arts, etc. Bring them together new novel ways of looking at things and applying will come out from that and again supporting what you had said about applied research on applied practices. Thank you. Laura would you like to add some comments to the questions put forward? Yeah, just a couple. Building on this conversation about technologies, I want to highlight the point of care diagnostics opening that we have as being empowering across much of the agenda. Not only does it lead to better care for a human as they present in a sick environment we can find out quicker what they've got and how to deal with that. But it makes it easier to do the kind of reporting, disease reporting into the national community. It reduces the requirement to have laboratory-based strains of dangerous pathogens to do the traditional comparisons that you would otherwise have to do. And so you can eliminate many of the holdings of dangerous pathogens that disparate and distributed facilities all over various countries and so it has kind of a three for effect on across the elements of the agenda and I think looking for those kinds of really high payoff technologies as we, it would be another piece of what I would identify as as you think about the prioritization is outcomes that could have benefit not only for patient care for national surveillance but also for biosafety and biosecurity. The other point I wanted to pick up on is the point that was made about the importance of the university sector that's absolutely critical and certainly within our characterization of the objective that relates to biosafety biosecurity we also talk about frameworks to advance safe and responsible conduct and so this gets to kind of where the cross-sectoral research that you talk about, how do we get social scientists involved to help understand how do you influence behavior in the laboratory, how do you create a security culture throughout from the bench laboratory and all the way to the university president of what their responsibilities are to create an environment and a structure for the conduct, safe and secure conduct of science and that will enhance the science but it will also prevent the risks and so I think the university partners are going to be critical to success in this part of the agenda. Thank you, sorry if I just could add one thing to what Laura has just said before we turn to you Tom I apologize but I think you bring up a very interesting point with respect to technology and it's, and when we think about the private sector and their contribution down the line to the global security health agenda here we think about the traditional side of you know this area in terms of vaccines in terms of pharma and others I would encourage us to think very broadly to also be including the high tech and technology coming out of Silicon Valley I mean we're at a point where the technology is changing so rapidly in not only people's daily lives but also in which governments are using that to be thinking imaginatively about the roles for social media in this for crowdsourcing so that we are really using the word non-traditional in a non-traditional way. Thank you Tom. Well just as an example we're already using in the U.S. a form of telemedicine telemicroscopy basically where we're having consultations done with in areas where there's very limited expertise that we can help with diagnosis remotely even in this country so there really are exciting advances being made in a variety of fields. I did want to really perhaps make one final point which is in the answer to both the question of what are the lessons for local areas and how do we get here the bottom line is that what we've learned over the past decade is that to make for a better response a more resilient system we need everyday systems that work and can be scaled up if we have an emergency management system all shrink wrapped in the closet and we try to bring it out in an emergency it's not going to work but if we have a robust system that we're using for real problems every day when an emergency comes if we've designed it right if we're using it right, if it's structured right then we can scale that up for an effective response and the final handout you have is an example from Haiti we don't often use the words Haiti in progress in one sentence but really since the earthquake we've seen substantial progress doubling the number of people being treated for HIV improvements in vaccination coverage and new vaccine introduction mass drug administration all of those things both strengthen and are enabled by a stronger system so the real value of this and why I think we have all coalesced on this core approach of detection response and prevention is because it is the way to keep us safer from emergencies and to make us safer day in and day out from the threats that we will inevitably face thank you we're getting near the end of our hour and a half session here and I apologize to those of you did want to have an intervention but did not have the opportunity I want to come back to Tom and Laura for just a closing comment and I'd like to ask to them to focus on just two things one is we haven't talked much about the private sector and the private sector biotech pharma sector and others there are always going to be difficulties in terms of conflict of interest and confidentiality and intellectual property and the like so how do you engage the private sector meaningfully to bring them in as active partners in this and the second piece is we know there's many parts of the world where there are broken systems and dangerous places where this whole question of control of outbreaks is of a different order of problem here and we know that for polio just look at what we see with Syria with the Horn of Africa with northern Nigeria Pakistan continue to be problematic question there is does something like this translate into a higher level of energy and attention to those or is that just treated by under some other under some other context or rubric Laura to the point on the private sector it's absolutely a critical one and you're right to highlight that sometimes it's difficult for government to have the kind of conversation that we need but we do have forms throughout the US government of how parts of our government are especially established to be able to communicate and engage in partnerships with the private sector one example is under our ASPR efforts in HHS where they're able to work directly with components of the private sector for advanced vaccine development and we're already seeing benefits of that as we prepare domestically for age 7 and 9 so I think the point is to use the tools we have direct them towards this mission space and be sure that we're connecting as well as we can we also really see that as the work of the non-government community as a helpful bridge sometimes who can sanitize the conversations if you will between government officials and private sector in a way that keeps people like me on the right side of ethics rules and keeps people like the private sector on the right side of their profit-driven motives so I think we need more of those but we've got a lot already and we're going to be using those to direct towards this mission space I would just I agree with all of that also there are many businesses both national businesses within low and middle income countries and global businesses which really see it as in their self interest to make their workforce in low and middle income countries safer from threats so I think there's a lot of good alignment here in many different areas we for example had a very nice partnership with GE and others post earthquake in Haiti to respond effectively but we're also really thinking about the innovation space thinking about the communication space and the advocacy space Steve in terms of your question about if you will the hardest places in the world to work we have since less than 20% of countries are even self-attesting adherence to the international health regulations today we have plenty of places to work before we get there so we're going to go where we can make the most rapid progress recognizing that there's some places where it's simply too dangerous from a security standpoint to work today but we think as we as we cone down on the blind spots that there are fewer and fewer places in the world where there isn't a good system to prevent, detect, respond that will help focus the remaining resources on those areas where we may have to wait a while because of civil conflict or other problems right I guess what I was getting at was you could imagine the next meeting or a year from now a focus on the issue of visa requirements the immunization for polio for travel you could imagine things that could be done begin to as a diplomatic initiative would fit very squarely in this and begin to try and roll back some of the regression that we've seen is quite dangerous some of which emanates from really broken places and some which emanates from places where there are fixes even if they have weak institutions but I agree with you you've bitten off a big agenda and that might look a little bit too far but we do know that we're going to have outbreaks of the kinds that we've talked about here today coming from broken places and if those constitute another 30 countries to the 30 that we're working with we're not going to be able to ignore them this has been a wonderful discussion Tom and Laura thank you so much and congratulations Kavita, Debra, and Tom thank you so much for being partners in this and for all of the thought and effort that you brought to this and our speakers here today