 So I'm David Sturman, a policy analyst here at New America. Today we have Dr. Michael Ostrom, who's a regents professor, and Drugs the Center for Infectious Disease Research and Policy at the University of Minnesota. And Mark Olschacher, who's co-author, who's also a documentary producer. We're here to discuss their latest book, The Loyalist Enemy, about infectious diseases and the threat they pose. So without much further ado, I'll turn it over to them to give you a sort of opening presentation. And then there will be moderated back and forth and questions from you. Oh, thanks. Well, thank you. Good afternoon. And thank you for being here. Normally, if I give this talk, I go out into the audience and I usually say, this is two separate talks for this group and that group. And I can only see a limited number of younger people here today because one of these talks is really aimed in for you and the other talk is aimed at those of us who are turning our world over to that younger generation and what it means. And so hopefully through this presentation, we'll get a sense of that. This will be a very brief overview of what we really attempt to cover in Deadliest Enemy. And it reflects really my 43 years in the field and what I've learned and what I know and, more importantly, what I don't know, which I come to understand a lot of things I knew a lot better 10 years ago than I know today. And so I'm very honored to have all of you here with me. Now, if we had to look at the world we live in today from an infectious disease perspective, this is probably the most important slide I own. Last count, I had about 85,000 slides in my electronic slide file. I had a slide fired today. This is the slide I'd try to save. In a sense, it basically explains the nature of the modern world of infectious diseases and why in the world of technology and all the enhancements we have, we actually have a greater risk today of catastrophic infectious disease events than we might have had even several hundred years ago. If you look, this is a bet of an old outdated slide from 2000, but it really makes the point. If you look here, days to circumnavigate the globe, and this point is not working here, but you can see it was over a year in transit by fast-sailings vessels 150 years ago. Today you can get around the world literally over in 30 hours. Just not that long ago as a perspective, early on one morning I was in Hyderabad, India, I gave a lecture at the University of Minnesota that night. Not long ago, late one morning I was in Seoul, Korea, and I gave a lecture at the University of Minnesota that night, and it gives you a sense. Now, this line looks to be very flat from 1950. This is actually the most dynamic part of the line. I'll share that with you in a moment and what that means for infectious diseases. If you look at world population, today we're at, you know, 6.6 billion people on the face of the earth. The growth is not uniform, though I'll show you also. That has a lot to do with the potential growth factors for infectious diseases. Think about this, one of every eight people who's ever lived since the caves is now in the face of the earth, and that number is gonna only escalate greater. So there's a lot of implications for that, including the food animals that we have today. For many species of animals, we far, far have many more today than of any time in history, and that plays a role in infectious diseases. Now, if one looks at world population, I mentioned earlier that the growth is there and it's not equally distributed around the world. This slide from the World Economic Forum shows you that the OECD countries, the Organization of Economic Cooperative Development, those countries that we traditionally think of in the United States, Europe, New Zealand, et cetera, very little growth there as such. But look in the BRIC countries, Brazil, Russia, India, China, South Africa, as well as the other parts of the world, and you can see this very rapid rise in world population, which is, again, having moved from largely an agrarian society to a mega-city society, you'll see what that means for infectious diseases. Now, the other issue that's changed dramatically for infectious diseases is how do we conduct our business in countries today? What do we do? Let me just take a step back and say that 25 years ago, I was in charge of the 50th anniversary of the School of Health University of Minnesota, and it was a very poignant moment because we had Bill Fagy, then the former director of the CDC and at the Gates Foundation, coming to give the keynote a lecture. Bill calls me up and says, I got a problem, I can't come, I have a solution, however, President Carter will come in my place, which wasn't a bad option. But the reason Bill couldn't come is because President Carter actually bartered a ceasefire piece in the Sudan for 72 hours so they could vaccinate the entire country against measles because of a major measles outbreak occurring. And you know what, Bill had to go and oversee it and they did it and it wasn't one shot fired for three days and they vaccinated virtually every child in the Sudan against measles. Today, we'd have a hard time doing that in a single city in some of those countries. And so what's happened is a change of, prior to the fall of the USSR, there were basically two world powers and Peter were here and he is coming, he can talk about that. And when the USSR and the United States decided to do anything, everything happened because every country in the world was abdominal behind either one of those two countries. And so when we decided to eradicate smallpox, besides the fact we had a great vaccine, it was a disease which we could easily recognize, we had time to go in and vaccinate in the kind of strategy we used, basically that worked because the USSR and the United States decided to do it. Today, who's in charge in the world of what? If something happened today in South Sudan, in Nigeria, in Somalia, who's there to be in charge? We have a catastrophic event going on just right now at the famine. And I could go through this. Well, in this fragile state index in 2016, take a look at those areas of the world which are basically in major governance strife, if not complete outright lack of governance in those burgundy and red country areas. Many of the same areas of the world we have some of the highest potential for these emerging infectious diseases to occur. We're all talking over 100 polio eradicators have been assassinated in Pakistan and Afghanistan in the last two years, just trying to bring about polio eradication. That would have been unheard of 25 years ago. So we've got the setup now, not just the world population, but we also have a governance issue. Then along comes Ebola. And Dan Lucy's here today, and maybe you want to comment on that, Dan was on the front lines in Ebola in West Africa when it occurred. The after action reports occurred just like every other crisis we have. We have to have an after action report. Standard line, we're unprepared, crisis happens, we throw the kitchen sink at it, and then we do an after action report. And then the question is, what happens with that after action report in many times, nothing. Well, the World Health Organization did a self critique which was actually quite thoughtful as well as the National Academy of Medicine did a critique of the world governance and WHO's performance in the Ebola, as well as the London School of Tropical Medicine in Harvard. And all of them came up with this incredible set of answers as to what could have or should have been done. And I can tell you today, and I just came from a meeting in London on this very issue, there have been surely some changes made at WHO. But imagine if you ran an organization that 194 board members on your board of directors. Imagine if you had an organization from a governance standpoint, when it was first invented, they made the regional offices virtually stronger than the central mothership. So the regional offices kind of tell you to go take a hike if they don't like what you're doing. Imagine an organization whose dues have been frozen for so many years, we can't even remember back when they got a dues increase. So from a governance standpoint, we've got real challenges here. And in fact, people like Bill Gates who have come to really fundamentally understand global health as well as any of us in the public health-trained world will tell you that today, his big concern about a catastrophic event is not another war. It's not an asteroid. Climate change, yes, is coming, but it's not here. It's an infectious disease epidemic or pandemic worldwide epidemic. And he very clearly elucidates that in this journal article right after Ebola, but more importantly in the last five weeks, he's also had two different discussions of this issue about both the risk of pandemic influenza and bioterrorism. To give you some sense of how people seem to always be caught by surprise, and you'll hear more about that as we talk. This was the assessment that came about at the UN following the Ebola crisis where there was actually a request made to look at the health threats from a UN perspective. And this report, which was issued in January of a year ago, basically laid out again many of the same issues about what needs to be done, what could be done, what has to be done kind of thing. And it was really well summarized in the panel chair when in his report he noted as a preface to the big report, following his extensive consultations, the panel notes that the high risk of major health crisis is widely underestimated and the world's preparedness and capacity to respond is woefully insufficient. Future epidemics could far exceed the scale and devastation of the West African Ebola outbreak. The panel was very concerned to learn that the emergence of a highly pathogenic influenza virus, which could rapidly result in millions of deaths and cause major socioeconomic and political disruption is not an unlikely scenario. Now, you know, we say this over and over again, but what have we done to get better prepared for flu since that time? Virtually nothing. And I'll come back to that. This is the world we live in today, where we have not just close proximity of people living together, but it's where germs, quote unquote, can go from one population and spread quickly to others. These people here don't fly in planes much. Okay, right in front. But the people just live back their due. And so one of the challenges we have today is this mixing and matching of the potential for infectious disease spread is very real. And that's what we have to deal with. Now, if one looks at what I'm talking about, here is an example of what's happening just in Africa itself. And people don't often realize that the fastest-growing part of the world today is actually in Central Africa to Western Africa. And take an example of Kinshasa, demagogically from the Congo. Dan, we were just talking, I've been there. You look at that, 13.8 million people. But what they doesn't show you is about six million of those people live in the most dire living conditions of slums in Kinshasa. If West Africa was a gas can waiting for an Ebola match to hit it, Kinshasa is a gas tanker waiting for an Ebola match to hit it. And you're gonna see that we're not any better prepared in many ways to deal with what happened today with Ebola than we were in West Africa. But look at four other cities in the DRC, over a million. Lagos, 13.2 million. Five others, Nairobi. One of the most memorable experiences of my public health career was spending time in Kibera outside, in part of Nairobi, the slum there. And I, with no disrespect to you, it took a good day to get the odor out of my nose after having been to that particular location. Again, if you saw what was going on there, you'd understand the potential for infectious disease generation and transmission in Ghana, and Akra, and then, of course, Monrovia, Freetown, and Conakry. I wanna point this out because there are actually more people again living in the slum in Kinshasa and living in all three of the capital cities of what happened in West Africa. And in an op-ed piece that I actually had in the Washington Post in the summer of 2014, where I was trying to energize people to do something about Ebola, saying this was a big deal, we're all asleep at the switch, one of the lines in there was, the Ebola virus hasn't changed, Africa's changed. And that people didn't understand the urbanization of Africa fundamentally changed the epidemiology of Ebola and forever has. This is Kinshasa. If you've ever been there, you understand the issues and the confront us in terms of living conditions and what that means for infectious disease spread. Now this is a story that really is a perspective piece that could be retold for any number of disease conditions in the world. This is 80s Egypti mosquito, the vector for yellow fever, dinghy, chicken gunia, and Zika. And a very efficient transmitter I might add. It's a mosquito that basically won't fly across the city road, it won't fly across the park and open field. Where it lives, it lives. And it requires basically closed habitat environments we call them, little small breeding sites. Basically out of the light, sequestered from what you'd normally think of the big swamp mosquito type things or that. And this mosquito was introduced into the Americas with the first slave ships coming from Africa. Not native to the Americas. By the 1930s you can see where this was located. It was widespread throughout this part of the Americas. And where it was we have pretty good evidence on population levels. Well over a period of 30 years the Rockefeller Foundation and the Pan American Health Organization made it a priority to eradicate this mosquito. Now we'd probably say eliminate, eradicate means it's completely gone. But by the time in the 70s they had not only gotten it out of most of the Americas but the population levels where those slides are green was very, very, very low. And that was when some of us went into infectious disease and people were saying, how are you going into infectious diseases? Where's some buggy trade, okay? It's done over with, it's gone. Well look at where it's at in 2015. And I'll tell you that in many locations it is hundreds to thousands of times higher in mosquito population per square mile than it was back in the 1930s. What happened? One is once we may accomplish something we gave up and said it's done. Infectious diseases you are never done. Every day is a brand new day. We do the genetic red table or at basically the human intervention level or what we're not doing. And so you can see the change there. We were on America set up for this problem but so was the world. Some of you in this room are very old and I can remember the graduate, the movie. What did we tell Benjamin to go into in the graduate? Plastics. We now have a modern world where non-disposed or non-biodegradable garbage has become the norm. That and rubber. And so today it's all the plastic garbage of the developing world that serves as the primary breeding site for this mosquito. One little bottle cap basically thrown off into a ditch is more than enough to serve as a wonderful incubator for the 80s Egypti mosquito larvae. So think about the challenges we have today. This is the new world order and I could show this over and over again for a number of other diseases. This is probably one of the saddest episodes and chapters in public health. Venezuela and malaria. This is a wonderful piece I'd urge all of you reading the New York Times that really details it. Venezuela was the first country in the world in 1960s to eradicate malaria out of all of its populous regions. Think about it, the first country in the world. They beat everybody including the United States. Today it is a disaster. What's happened with economic downturn, high unemployment rates, et cetera. These people now are all illegal workers in the mines of gold mines of Venezuela. Many of our architects, lawyers, part of the 40 to 50% unemployment rate that occurs in many of these areas. And what's happened is malaria now where it wasn't completely eliminated from Venezuela has come back to infect these people but guess where they go? They go back home and they get sick. And we are now seeing a major change in epidemiology and malaria in Venezuela where it's urbanized malaria. It's in the major cities. Something which again was the big accomplishment of Venezuela. So this is the part that we're talking about where it's not just that we've made gains that we surely have from a technology standpoint but we've had a lot of backsliding that is very substantial across the board. If you wanna know about travel and trade, this is an indication. Last year about 1.5 billion people beating even the projections here traveled across the political border for just the purposes of tourism. We have eliminated mountain ranges, oceans, big valleys and political borders as any kind of a way to keep infectious agents out. And I will guarantee you right now there isn't a wall that can be built high enough, thick enough or deep enough that will do the same either. So basically this really is a critical issue of movement around the world. This is a slide that I took from yesterday. We monitor every hour on the hour. These are all the major shipping vessels in the world. They report their location in the weather. There's about 62,000 of them. This is where the warehouse of the world exists today. A fast freighter from Shanghai to Long Beach is about nine days. They're in port 22 hours. They unload, reload, refuel and they're gone. They're under Panamanian or Liberian flagship status which I don't know what that means. They help for it. And the reason I show you this is because today this is where many of the critical goods that we use every day are located. Let me just illustrate that. Several years ago we did a study at our center where we interviewed a group of world renowned farm deans, all areas of medicine, doctorates and pharmacy. We said what are those life saving drugs you have to have every day or people die? Not cancer drugs, not lifestyle drugs, et cetera. What's on the crash card in the emergency room that if I don't have that I got a dead patient right now? We came up with 30 different drug, drug categories. And of those 100% were generic, 100% were made outside of the United States. For none of them was there any kind of stockpile whatsoever just in time delivery. And if there is a influenza pandemic that impacts India and China right now, we are so screwed. The collateral damage that can occur to us will be remarkable. In 2009 when in fact the H1N1 pandemic of influenza emerged, one that was much milder than the 1918 emerged. There was a discussion on the very first day we got to shut the border with Mexico. And my reaction on these calls was this is nuts. It's already gone, trust me. And in retrospect it turned out it was already in 40 countries by the time we knew about it that it was even happening. I mean it'd be like fixing your screen during your submarine after 100 feet down. It ain't gonna work, okay? But what people also didn't understand is the critical importance of Mexican manufacturing to our health. One example, ventilators. Those things that keep you alive when you need to breathe in an intensive care unit. Well you have to be attached to a ventilator by a thing called the circuit. It's kind of like the plug-in to your iPhone or your Galaxy, whatever, they're all different. And you can't get on a ventilator unless you have the circuit that connects you to it. And circuits right now are just in time delivery commodity in this country. And in Minnesota where we have a number of different circuits used, 30% of all of our circuits were coming in daily from trucking in Mexico City. Had we shut the border, we would have run out of circuits quickly and we would have had people dying because they couldn't get mechanical ventilation. People understand the nature today of the just-in-time delivery model and how an infectious disease could impact that. So several years ago Mark Olshaker and I, Mark is here, my co-author and true companion on this document, said, you know, it's not enough to write a story that just scares the hell out of everybody, okay? Because we could. You can't scare people out of their wits, you have to scare them into their wits. There are some huge challenges coming down the pipe. And as we said in an op-ed piece, which I'll come to in a moment, in the New York Times last weekend, if there was ever an issue of national security, it's this, the potential to cause great harm and to cause the kind of mortality that's unimaginable really occurs with infectious diseases. So this book was really, if I can say from my own perspective, this was in a sense, a kind of love statement to my kids and grandkids. That's why I go to work today. You know, it's no longer, you know, salaries are nice, titles are okay, but in the end, what kind of world are we leaving our kids and grandkids? And so what we tried to do here was actually lay out why the problems were existing in a rational way so people could see, this is not just, you know, some kind of scary thing that you, and what can we do about it? And that was the important part. And we actually came up with a critical agenda, a crisis agenda that actually says, if we do these things, this will make all the difference. And let me just, in the remaining moments here, just quickly just review a couple of these with you. The first one, and these are in priority, we think of what really has the potential to change the history of our world, both in terms of morbidding mortality, but also even governance and economic current. The first one, influenza, influenza, influenza, just like real estate, location, location, location, there's never been over the history of humankind a disease that had more impact on humans than influenza, and that includes smallpox, which was a very serious disease. In this case, think about this with influenza. This is a virus that is natural home is in the gut of a wild aquatic birds. That virus can't just infect humans, but there are times when that virus goes through genetic changes, either passing through an animal species that can be affected by bird viruses like pigs, or it changes in such a way through mutational changes that can directly infect humans, but then humans, not only can get infected, but they have to then transmit it themselves. What we worry about is a world, and this goes back to antiquity. There have been at least 10 influenza pandemics just since the 1600s that we know of, where a new virus emerges out of a bird population, gets into humans, and now humans can transmit it to other humans. The most notable of those epidemics, of course, was the 1918 swine flu, where at a time when the world was one third the population was today, over 100 million people died, more than all the major wars of the 20th century. And today, we are not any better prepared to handle influenza than we really were 50 years ago. One is the risk for this has, we believe, grown dramatically, and it's in part been due to the fact of the need to feed the world. What do I mean by that? Today, the most efficient transfer of energy to the protein is in poultry. And so today, we've seen an explosion of domestic poultry production around the world. One example, just take Shanghai, China. Today, to feed Shanghai, there's 100 million chickens born every month in the peri-urban region of Shanghai just to feed Shanghai. From the time that chicken is hatched so it's a chicken breast on somebody's plate or in somebody's soup is 35 days. Every month, 100 million chickens are born. This supply just Shanghai. You look globally, the implications are huge and we need this food source. So we got a problem right now because we have had a pandemic of influenza in birds occurring the last several years. Unprecedented, what we're seeing right now with H5, H7 viruses, et cetera that are really very scary. And so if you're a bird today, you are in the middle of an influenza pandemic. You've seen it in North America right now. Asia and Africa and Europe are really getting hit hard. Every time one of those viruses transmits between the birds and one off transmission to humans or the pigs, we have another throw at the toilet table again that could give us a virus we're concerned about. Well, we may have one. Actually, ironically, we wrote about it in our book 10 months ago and if you followed the news the last six weeks, the scenario is almost identical to what we put in the book of a virus called H7N9. It started in China four years ago with basically seasonal occurrence of transmission to humans, no evidence of transmission to human to human as such. This is a virus that unlike previous viruses in birds that transmitted to humans didn't cause the birds to get sick. In the past we've always called these high path viruses where the chickens got sick too. So we knew that there was something going on. Well in this case, people started getting sick about up to 40% of the people died when they got H7N9 infection but we had these low level several hundred cases a year kind of thing. Well now this year something's happened very different. We don't know what it is but we've had more cases in this last wave over 500 than we had in all the previous activity today. What's also disturbing is we had three instances now of evidence of ongoing person to person transmission in the cluster and are we sitting on the edge of the next pandemic? I hope not. Do I? Could it happen tomorrow? Yes. Finally, for flu, we're still using a 1940s flu vaccine. Our studies were some of the first to document it doesn't work the only as well as public health that it did. Some years it doesn't really work well at all. And it takes months to make. Well when a pandemic hits it's now and even if the second wave occurs which could be three or four or five months down the road we'll never have vaccine for even our country let alone most of the world. Think about this and again this is a priority issue. I very much support the fact that we've been spending a billion dollars a year for HIV vaccine research for the last decade. Last year we spent $35 million globally on new influenza vaccine research and that's it. Seven years ago Francis Collins at the NIH said we would have a universal flu vaccine in five years. He has said it multiple times since then we're not any closer today to a universal flu vaccine than we were seven years ago. And yet I believe very much that we can have one. And take this as the voice of pessimism saying that. In 1984 I got in a fair amount of trouble with my colleagues because when Margaret Heckler was in the secretary of HHS and at that time Bob Gallow who was the co-discoverer HIV had a press conference they said we're gonna have an AIDS vaccine in two to three years. And I was quoted in the papers the next day saying we're not gonna have an effective AIDS vaccine in my lifetime. I don't know how we're gonna do that because what we know about retroviruses would take a beam-the-up Scotty machine technology to make that happen. Well I said here in 2017 and I say by my statement I don't think we'll see an effective AIDS vaccine in my lifetime. Now just to pose that to the fact I think we can have a universal flu vaccine in the sense of H1, H2, H3, H5, H7 if we just put our mind to it. We are not only not doing a Manhattan project we are basically not even doing a project period. So this is one area. The next area that I just have to comment on is antimicrobial resistance. Think about this you know the bugs have been here for a long time and from the very first moment they have been competing with other bacteria et cetera for the purposes of living, survival, space and food. So what did they do to do that? They created things called antibiotics. So the bacteria make the antibiotics for example a kill other bacteria. We have only been late to the show to make that happen where we have antibiotics. And so today basically we're living on an entire evolution process in micro bacteria going back millions of years. But what we did is we jump started it like nobody could imagine because we suddenly start using antibiotics by the tons and tons and tons and we put this hyper evolution in place. And so from the time of the 1930s to now we've seen this massive increase in that bacteria which reproduces every 20 minutes has genetic mistakes. Most of them are deadly to the organism but some of them actually are advantageous. Like now I don't need to worry because I can skip that step that the antibiotic impacted on and now I survive in the face of the antibiotic. So today we are literally beginning to enter the post-antibiotic era. And I could show you a whole list of diseases today for which we are having a hard time treating them. Now our grandparents and great grandparents grew up in a world where a scratch or even a surgical procedure could mean automatic death. And we're going back there. And what have we done? Basically we have made some effort but globally right now in human and animal use and animal use today is the predominant use in agriculture. And we are really not taking this seriously. We talk about it but if you look globally we have done little to curb the use of antibiotic. We've done little to bring new antibiotics to the market. Imagine a day I'm a pharmaceutical company and I tell you I want you to invest a billion dollars in a new antibiotic and I want you to take the risk it might not work. But if you do, it does work and it's ready to go once you sell it I want you to basically sell it to nobody unless they absolutely need it. And then I wanna be sure they use the least they can. You like a car dealer saying I'm gonna sell you this great car but you only drive it between eight and 10 on Sunday mornings. You know they're gonna say well I'm not gonna sell that car. I'm not gonna get that car. So we don't have a market today for new antibiotics in any meaningful way we need to change that. And finally we need to make new vaccines which we can for some of the diseases that we're treating today. Wouldn't it be nice if we could prevent it? One of the recommendations we've made in the book which I don't know today given the politics of the modern government structure in the US we need an intergovernmental panel and climate change like group that basically keeps track of where all the resistances what's going on who's doing what about it how much antibiotics being used where is it being used what are the changes we need data and we have very little of that. Quickly just vaccines and diseases of critical importance today we're sitting here with Ebola. We have three major vaccine manufacturers that put forward vaccines. One just got out of the market completely after having spent $400 million and there's a $5 million pot at the other end of the rainbow for buying vaccines. I mean granted there's a government support and foundation support for these vaccines but you know if we had a problem tonight in Kinshasa we don't know how we'd use the vaccine. I've been very involved with this I co-chair a group called Ebola vaccine team B group with Jeremy Thur from the Welcome Trust. We have 26 international experts on this group. We just issued our last report saying there are so many unanswered questions about Ebola vaccine and we got to go there. So this is the area we need it. Finally let me just last to here in mosquitoes. I've already shown you the slide on that. We already know that we have a real challenge with mosquitoes. They are still the number one deadly enemy you might say in a living form and that's going to huge and let me just say one last word in bioterrorism. This is one where we know that in fact this future is unfortunately right for this to happen. It's just a matter of time. The difference is every day that we live we are finding that technology more and more and more favors somebody doing something to organisms that they couldn't do before. I was very involved in the 1980s with the big debate discussion about what's about smallpox virus. We were supposedly left in two laboratories in the world USSR at that time in the United States and should we destroy it or not? And the argument was they don't destroy it because we might need to do research on it. The other said no, get rid of it if it ever shows back up again we're going to be climbing against humanity. Well in the end there was a compromise. We now had the new technology at the time to genetically basically sequence the whole virus and this was a huge, huge virus. So nobody even thought about somebody using that for nefarious reasons. In 1990 no one could have imagined that in 2017 there are laboratories in the world now that can make smallpox viruses from the public sequences. There's no longer necessarily to have the virus which is something that we've been working on to fight against it, anybody get their hands on it. Now do I think anybody will make smallpox virus? I don't know, but they could. So this just gives you an idea of the preparedness levels we need. All the other priorities are in descending order for us but you'll note that it's about doing genetically engineering in the bug. We still have to deal with HIV, TB and malaria. Right now we've made great inroads in HIV treatment in Africa but the problem is we have now more people being infected with HIV than we're treating and that number is growing. Climate change is clear. It is going to impact infectious diseases, particularly the vector-borne diseases. There are many cities in the world that actually were established back in quote unquote ancient times to be above the yellow fever of the malaria belt. And with the global climate change we're seeing those mosquitoes go higher and higher in elevation like Mexico City that are gonna have big impact. And then it's about the animals. In the book we talk about today we have to understand so many diseases we deal with are really all about the interaction we have with particular food production animals and the jungles of the world where we're still seeing new viruses emerge. So in this book we actually talk about what we need to do. Now our book probably comes out of here a very opportune time, a very inopportune time. This was our op-ed piece in New York Times last Saturday in which it's really talking about if you really wanna deal with national security the last thing you wanna do is cut in this area which is what has been proposed and you wanna invest in it. Let me just conclude by saying I kinda put this in the perspective. The ancient church once said it's no use saying we're doing our best you gotta succeed in doing what is necessary. And right now we're hardly doing what's necessary. Lewis Carroll once said if you don't know where you're going in a row get you there and I feel like sometimes we fight all these reports. I don't know which road we're going or where we're going or why or what a priority is. And we tried to offer priority. Finally I am an optimist by nature and I think maybe that's just human nature for your kids and grandkids but are these the shadows of things that will be or are these the shadows of things that may be only? And as our hope that may be only. Let me just conclude with the last paragraph from our book that I think it really defines it all. If we do start questioning and demanding as we should and our leaders start rising to the responsibilities and public health will everything we propose and endorse completely neutralize the threat of infectious diseases and severe even terrifying impact on modern life around the world, of course not. But what we can do with the necessary collective will and the resources is to give many more people throughout the world, our children and grandchildren the chance to live our normal healthy and productive life and we can trade innumerable bad deaths for good. And that is all we ever hoped for. And that's what this book is really about and the issues and infectious diseases. Thank you very much. Thank you. Thank you. Well thank you for that brilliant presentation and we'll open it up for a discussion and I had a couple of quick questions. So one question I had about the 1918 virus was it particularly, I mean the number of deaths is it related to the fact that there have been a world war at the same time and it's somehow collective resistance was lower? Well not that collective resistance was lower necessarily but you had a large concentration of people together and you had them moving across the world. But we call this the Spanish flu primarily because Spain was one of the few countries that had an open and free press and they admitted that they had this. Probably started wearing it, Kansas would you say? Yeah it could be. I think one thing though that was very instructive about 1918 influenza and there's been a great debate about this and I'd urge you to go back and read John Barry's book The Great Influenza as well as our own. But we actually got a glimpse of this in 2009. This H1N1 virus in 1918 and one in 2009 were kind of kissing cousins but they were not the same. Kind of like the Minneapolis phone book. There's 28 Donald Peterson's in the Minneapolis phone book. In 1918 the highest death rates were actually in older children and young adults. Not in the old, not in the very young which we typically see. And we believe a lot of that actually had nothing to do with secondary bacterial infection which you typically think of as flu. So in a pre-anabotic era you could say yes this was a bad thing and it won't happen again like that because we have antibiotics today for pneumonia. But in fact we think it's actually related to a thing called the cytokine storm which is your own immune system kicking in. It turns out that when you adjust for life expectancy the average age of death in the 2009 pandemic was actually lower than it was in 1918. The number one risk group actually were people who were for example pregnant women, et cetera, died. Whereas if you see the typical kind of seasonal flu with H3N2 and other ones, it's older people. So there's something about this virus that has the potential to kill people that you yourself contribute to. And what we worry about is another H1N1-like agent. And that's what these birds viruses we're seeing today are acting like. If you look at H7N9, you look at H5N1, as any of those, it's affecting younger people. It's very high mortality rates and they're dying more from the cytokine storm when they're dying for secondary bacterial pneumonia. I'd actually be more comfortable with secondary bacterial pneumonia. We might actually have impact. So this is what worries us is that the next one that could come could very well be a 1918-like event. You're in a kind of unfortunate position because being a Cassandra, I mean, if you're right, you're right, but, you know. And then sometimes you are warning and things don't turn out to be as bad as they could be. Well, in this business, it's kind of like what you do, Peter, in terms of terrorism. The best thing that can happen is nothing. So it's very difficult to prove that you did something to make nothing happen. But I mean, I'm struck by the analogies of people who were warning before 9-11. It was a very small group of people that were outside of the problem. And obviously, you know, 3,000 dead is very different from 30 million dead or some, you know. The cost of these events that you're describing is going to be infant orders of magnitude worse. So I guess the sort of series of questions, one is, I mean, to what extent do you think the government administration and that sort of NSC and that strategic planners are the cognizant of this or thinking about this to what extent would the Obama administration be thinking about it, what extent are NIH cuts relevant or not to this, the ones that have been proposed? You want to take that? Yeah, well, I think, first of all, let me just add perspective, I've served roles in the last four presidential administrations. When I was state epidemiologist in Minnesota, I served two Republican governors, two Democratic governors, very-called one-independent Rassler, Justin Ventura. And no one could tell you my partisan politics. You know, I was just another private in the Army of Public Health. And so any comments I make today, please keep that in mind. But I think today it's a very difficult situation, frankly, frightening to me, because we not only now criticize science, we don't believe in science. And so we have always operated out of a science-based approach. And to see these kind of this discussion today we have in this administration. The second thing is, we still don't know who really is in charge. We're waiting for that very high senior executive level of individuality recruited and brought in. President Trump doesn't even have a science advisor at this point. Yeah, we have HHS, et cetera. And the final point I would make is I think our government has done a lot, but still with influenza vaccine as an example, we have not dealt with that issue nor has anyone else. So there are things that no administration really has effectively dealt with the flu. And I think that's a critical point. What we're talking about in this book has the potential to kill more people than any armed conflict you can think of, including an atomic bomb. And yet we're putting next to no resources into it. And if there's, as we said in the op-ed piece, this is national security on an existential level. I mean from a sort of Machiavellian point of view, maybe the ideal thing would be something that happens that is not so big, that it's catastrophic, but big enough so people actually react to it. And that's true. And I think though if you look at influenza right now, that is the one, if you had something happen, if anything, people came away from the 2009 pandemic and said, oh, that wasn't so bad, not realizing how many young girls occurred in this country and around the world. But the second thing is we also have the challenge of antibiotic resistance, which is what I call a slow-moving phenomenon. I mean basically it's coming, and it's worse than we even thought it might be today 10 years ago. And when we have TB, we can't treat anymore. And one third of the world is infected with a TB with sellers. When you have a situation where the number of healthcare, I'm okay, one of the areas our center is doing with a lot right now are device manufacturers. And why? Because they're getting more and more situations where they get drug-resistant infections in an implant and they now have to take back out because they can't treat it other than to take it out and debrief it. And they're all concerned about, we'll be able to do surgery in 10 to 15 years from now safely on these things. So I think we have these things. It's just not one place where it's the obvious, I was just having been in London this week, everybody now is talking about the bridge. We don't have those kinds of events that could be a wake-up. And that's the challenge. What about, you mentioned bioterrorism. I mean, Bruce Ivan's obviously killed five people, called the billion-dollar profit damage in the month after 9-11. He was one of the most advanced microbiologists in the country. To what extent, how would you characterize the dissemination of knowledge about microbiology that could do damage? So meaning that, is there kind of a Moore's Law in this area where stuff that would have been very difficult to do 20 years ago is now something that a graduate in a lab in Indonesia should do? Mike mentioned smallpox and recreating it and maybe even possibly from Russian sources, recreating it in a way that our current vaccines wouldn't work. You mentioned anthrax in 2000 and that was a tiny dissemination. Mike, why don't you talk about what would happen, because we've looked into this, let's, if an aerosol, a crop duster aerosolized anthrax, again, not a new, nothing new about it, we've known about it for a long time, aerosolized anthrax and flew over the Mall of America. Tell us what would happen. Yeah, well let me even paint it in more, I think, clear terms, because it really had something to do with it. Today, we use a bacteria basically from the family of the psilocerin genesis as vector control and we use that in the Twin Cities, we spray things, et cetera, this bacteria, eats the instar larvae of a mosquito and so it's a good mosquito control plant. We've actually been involved with studies where we use today's modern technology for detecting these germs in the air and we've actually put detectors miles and miles downwind when a routine psilocerin genesis event is done so that we can see what happens and even though this stuff is made rather crudely, this psilocerin genesis and it's meant to be heavy particles so they fall down and fall on the leaves and so forth they're in right where it's sprayed, we found that 40 miles downwind, we could pick up a huge cloud in the psilocerin genesis within hours after it's basically washed out of the spray plane, okay? And you know the difference between making the psilocerin genesis and spraying it in the psilocentrasis, about that much. So the technology already exists, I mean it's there, we do it. The other thing though is that we even now have aerosol particle technology for internal sources where if we hit a large mall or a large building or we hit Manhattan, we don't know how to disinfect it. Imagine if we could not disinfect Manhattan, how would you run New York? Okay so the counter-argument, because Al-Qaeda obviously tried to develop anthrax weapons and they never could weaponize it because I mean anthrax isn't actually occurring but it's hard to, well it would be hard to weaponize. Has that changed? I mean this is, I'm doing it now, 15 years ago Al-Qaeda had this program, they had an Indonesian biologist who was going around trying to find weaponized anthrax. Is it easier today now or is it just a problem? No I don't even know it, weaponized anthrax is a term that gives you, all you need is regular old bacillus anthracis, you don't need to answer, yeah. The weaponization occurs when I disseminate it. Okay. You know in Bruce Ivan's work, and I do believe he was the perpetrator, you know what the weapon was there we never realized? It was either the pressure, the sorting machine as the letter went through and it puffed it out was the mere energy of opening it. That was the entire weapon structure of those letters. Today I just gave you an example of spray planes for the purposes which we already do a lot of with the Steloceranginsis brain. Yeah. The only difference is I grew up, you know, 30 pounds of the Steloceranginsis for it, or 30 pounds of the Steloceranginsis for it. The anthrax is naturally occurring, right? Exactly it is. But it doesn't, since it's naturally occurring presumably it's not weaponized in its natural state. Well it is actually, it's weaponized in a sense that Once it gets into the lungs. Yeah, one of the things we learned with the Ivan work for example, was it was nothing unusual about that. You know it basically wasn't that different than any other strain of anthrax we might find. What made it more efficient was just how it was made as a powder so that it basically, when it was being weighed that you samered on the scale, you could actually see the weight in decreasing as it just literally kind of drifted off the scale. It just in the air, ambient air just basically was, you know, it's kind of like think about when you go into a department store today and you're two aisles away from the perfume section that you can still smell it. Okay, it gets into that level. And so where weaponization occurs is less with the bug and more with how you deliver it. And so today we have the ways to deliver it, unfortunately, which are far too effective, that we use every day for a dual purpose use, i.e. spraying. So are you more concerned about terrorist groups developing these kinds of weapons or a biologist adopting jihadist ideas or choose your ideology? And what's the big, because I've seen, I've been sounded very idiosyncratic police, but he was able to do quite a lot of damage. And I think there's been a lot of attention about, well, can Al Qaeda or other groups develop these weapons? And we've seen ISIS, for instance, deploying crude chemical weapons here. So, but it seems to me that a graduate level biologist in a lab in Indonesia who suddenly decides that he wants to do, make a statement is actually really the problem. Right, and this was actually ironically the question I'd ask you. Because I mean, we follow, as a group like ISIS gonna continue to do things that blow up, et cetera, as a primary choice, ironically, the barrier to them to do this is not about, can they grow the bug or not? We know how to do that today, it's how do you deliver it? And what we were fortunate with, and I say this publicly because it's been a widely discussed area, so we're not giving Al Qaeda or anybody else, intelligence information, it's just matter of linking it up to already existing means of dissemination, and we know we can disseminate it wildly that way with that kind of plain kind of dissemination. Or today, the equipment. I mean, the reason you have touch pads on your microwave is because we know how to lay down a very, very fine thin film now on a touch pad that sends an electrical current that turns on or off your microwave. That's called aerosol particle technology, so when that's made, that film is put on there in a very, very thin way. Well, that same technology, which is widely available today, could just as easily be used to disseminate infectious agent. So, you don't have to invent a lot of the things that 15 or 20 years ago, people were thinking about inventing. Today, they're just routinely available, and that's one of the challenges we have is just putting those together. So, your question is, could it be a rogue microbiologist? Absolutely. Could it be a terrorist group? I think that gives back the motivation in which weapon they find easier to use or wanting it, but I think they could surely do it. And of course, in your field, you talk about what you do with an enemy who's apocalyptic, who doesn't care if he lives or dies, so you've got the same problem. Well, let's go right over to questions. If you have questions, can you wait for the mic and identify yourself, and we'll talk with this lady here? Thank you. It will come on, I think. Hello. Melissa Hirsch, I'm a risk consultant. And actually, two things I want to hit on. One is the national security side, but I think Peter mentioned something about being Machiavellian. And actually, that's the conversation I had with the NSC earlier this morning before coming here, which is in my career, I used the perception of the threat of bioterrorism very early on as a way to garner political and financial assistance globally to build disease surveillance. So there was a clear national security argument that could be made, and this was at the global level, but in terms of antimicrobial resistance, I'm fascinated with the concept of people just using the word security after it. It's a security threat, but nobody's taken the time to actually articulate what that means. So besides coming to some sort of consensus on that, I'm interested in what you perceive as being or who needs to be at the table to make that assertion and to define it, because it does depend on the messenger, not just the message. Well, I think just coming back to the issue of antimicrobial resistance, I mean, again, there have been a series of events that have happened, I think in 1900, average life expectancy in this country was 48 years. Today, it's 78 years, for every three days we've lived in less than a day of life expectancy, which it took us 80,000 generations for the caves to get to 48 years, okay? And that occurred because of largely public health, i.e. sanitation, I mean, now we had electricity, you could pump safe water, you had sewage system, you had refrigeration for food, you could make vaccines, but also is antimicrobial being available. And people didn't die in the battlefield from a simple wound that is what killed them later on. And so from a military standpoint, I think that clearly antibiotic resistance is gonna be just as much an impact there as it's gonna be in any way of everyday health. And that's what we need to come back to. That's right. Exactly right. Well, that's what we're trying to do with this book. First of all, let me say, which Mike can't say, it's a great medical detective story, first of all, which is so, we hope it'll be interesting for you. But the second thing is we are stressing the point that this is national security on the most existential level, and we've got to understand that. We were at a conference at the National Academy of Medicine recently where one of the participants said, if we could show that each little 80s of jip time mosquito was actually a miniature drone controlled by ISIS, we'd get all the money we need. Indeed. Yeah. So I think you ought to get back to what you're saying is that one of the other issues that comes up about this idea though of forest protection, et cetera, and security, this is one where I find, I'm very challenged right now by the tenor of the discussion in our federal government is you can't build a wall big enough, high enough, wide enough, thick enough, that's gonna keep these out. And so what happened somewhere else in the world really matters because that is a plane ride away. So a terrorist event, clearly somewhere is not good, they're gonna happen here in some way, but we're fighting wars over there supposedly to keep them from coming here. That is absolutely the last thing I'm gonna be able to do with infectious diseases if we don't fight them wherever they are in the world. So cutting international support for this kind of work is just Pennywise and Pound Foolish. And we've got to be prepared ahead of time. You don't start a war in the Mediterranean and say, okay, now we're gonna requisition an aircraft carrier and 18 months from now or three years from now, it'll be built and we'll be able to use it. We've gotta have that aircraft carrier beforehand. Come on here. Hi, my name's Dave Price, I'll speak as a grandfather. Thank you for giving me more reasons not to sleep well tonight. I always appreciate that. You have kids with grandkids? Pardon me? You have kids with grandkids? Two kids with grandkids. Okay, there you go. That's your answer right there. I got it, no. Well, they live in Atlanta, so they're new to the CDC, maybe, though, so. But the idea is this. I know you don't really wanna be political, so I'll take that role for a minute. The problem is a troubling thing coming out of Washington now is this anti-science idea. That affects everyone. But here's the thing, if you wanna be an optimist, somebody's gonna have to fill America's vacuum in that sense. Do you see any other nations coming to the fore, whether it would be an emerging nation such as China? I don't think, I mean, Africa's not in a position to do that yet. So is there a, you know, is Vladimir Putin gonna have a religious experience and suddenly jump in? Well, who will take this mantle that really America's had for a long time? That's a very important one. About being a leader in science, and now suddenly, you know, we're back in Salem, Massachusetts, in whenever they were running around. Yeah, that's a- 1693. Yeah, that's an absolutely critical question. And I would say right now that it's been a relative lack of global leadership on part of every country. And the World Health Organization is right at the tip of it. There are wonderful people at WHO that do some incredible work at the way the organization is set up and how it is governed basically makes really leadership a challenge. If you look at countries across the board, I mean, the United States has been, without a doubt, the leader in dealing with these issues, both in, I think, an altruistic standpoint, but also a strategic and force protection standpoint. Norway, surely as a country by size, has done more than its lion's share of work and they continue to be very involved. But I think that globally, just look at the kind of freefall status we're in in the Americas, where Caribbean, Central America, South America, and Zika. And Dengue, I mean, you know, one of the things we talked about in the book, and I surely don't want to be insensitive here, but why did it take young children being born with small heads, et cetera, as it's graphically can be depicted, when many more people were dying every year from Dengue in those same countries with the same mosquito, with the same problems that nobody talked about it because it wasn't young babies. And I think that the fact that they hadn't addressed those and it hasn't been dealt with, where we already had a major problem already, gives you an idea that internally, like Venezuela in other countries, they're just not there able to do it. And so the question is, should the United States step in? Well, you can argue we can't be the public health agency for the whole world. On the other hand, we have to pick and choose and say that these are strategic issues that could really dramatically negatively impact. You know, I really care about those manufacturing plants in China and India that are making those critical life-saving drugs that I just talked about, that during the next pandemic won't be available. So now your wife or your brother or your sister are dying in the emergency room because of a simple drug that they couldn't get that today we need to take for granted will be there. That's, we have a strategic interest in what happens in India and China and we'd hope that they would do the same. Right now we don't have evidence that they're doing anything to support that system. Nor are we though. Someone here. Thank you for the excellent presentation and discussion. I used to be with a global network for neglected tropical diseases at the Saban Vaccine Institute and working a lot on political advocacy. The world certainly changed in the past year, but I think at the G7 summit, we had Angela Merkel putting on antimicrobial resistance, Ebola, and neglected tropical diseases, yay, on the agenda. That's about the highest form of political commitment to get globally, where the G7 countries discuss this and commit to this. So I think the point you raise in your conclusion is important, getting the leaders to pay attention to things. So we had it at the highest level of political commitment. We've had diseases come to the shore of the United States, Ebola, Zika, all of that. So with that being said, what's gonna actually turn this around? Because political commitment is usually the big issue that affects resource allocation, and that's certainly not there. And sort of linked to that second point, while there is reason for concern, the progress we made is a double-edged sword. And we have new technologies crisper and finding new ways of understanding surface antigens, et cetera, which could lead to breakthroughs for prevention and vaccines, I think are the answer to all of this. So if you had two concrete wishes to turn things around, what would they be? Well, let me put this in context because you've made a very important point about the G7. Immediately following Ebola, fortunately Andrea Merkel was, as you know, heading up the G7 group, and she actually put a great emphasis on this global security and health in general. And since her term ended, and it went to the Japanese, we've seen it almost melt away. I mean, there is no pressure right now in the way that it was before for G7 to take this issue on. And so I think that's a challenge. Part of what we've always needed in innovation, I think, and around any kind of problem has been what does the private sector get from it? I mean, how do they participate? And what do they do? I mean, we have this industrial military complex that benefits from the fact that countries are worried about going to war. They build airplanes, they build warships, they build missiles, et cetera, et cetera. We don't have that push, pull in public health and infectious diseases. Right now, I think we've seen the last of the major companies get involved with major vaccine because after SARS and now with Ebola and even with Zika, there's no middle major player that's leading the way on this. Basically I said, you know, it's a lost leader for us. We're not gonna deal with this anymore. So my first real wish would be is that we could see this as a strategic security issue and that we had engaged the private sector to say, you know, I know you're a pharmaceutical company, you make a hell of a lot of money on lifestyle drugs, okay? Tell all the viagra you can. But we need these drugs and we need these vaccines which only you are uniquely qualified to make, to do the research and we've tried as a government to make vaccines that have never been successful well. It really, the private sector holds the expertise that we need and that we set up that kind of incentivized outcome where we actually do find ourselves to come up with a new vaccine. We come up with a kind of drug and we put that together. I think the second piece of it is, is that if I had a wish on anything, I would have to say just to take the major one off the table is flu vaccine. We could deal with that tomorrow. I'm convinced of that. And for some reason we just continue not to. And we're gonna wake up one day another flu pandemic and we're gonna wish that we had invested. It would be so penny wise and sound foolish. And just to give you in a sense that, Mark, if you could tell the story about Dr. Sheets and it's in our book about what he said to you in your interview. I may, I've spent a lot of my career as a documentary filmmaker as well as a book author. And Peter, you may remember that you worked with us about 12 or 13 years ago on a series with Ted Turner called Avoiding Armageddon, of which I was one of the producers. I was doing a film, an IMAX film about big weather, hurricanes, tornadoes, monsoon. And my producer and I were at the National Hurricane Center in Miami. Bob Sheets was the director at that point. And I said, Dr. Sheets, in the midnight of your soul, what is your worst nightmare in the hurricane field? And this was in the mid 90s. And he said, oh, that's easy. We all feel the same way. Category five direct hit on New Orleans. So the point is everybody knew it. They knew it was going to happen. By the time Katrina hit, I think it was a category three storm. It wasn't even a category five. And it became the most expensive natural disaster in history. So the point is they knew about it, but nobody did anything. They were warned nobody did anything about it. It's the same with all of this building on the barrier islands and coastal communities. There's no way you're going to evacuate people. You just have to deal with these realities. And we're not. Say it again. Hi, Barbara Vaido, a TQ researcher. I wonder what you make of the $500 million fund that Trump did propose in his budget. Have you talked with anyone about where that idea came from? I mean, it seems like maybe somebody's paying attention. We have no idea where the money is going to come from, number one. And we don't know how much it will offset all the other costs. You can talk about it more specifically. What is this fund for? Well, right now, when you have an emergency in this country, the staff of that oversees that and empowers them to do what they do. And unfortunately, that act actually does not include such a disease-related event. So that in a sense, if we have an emergency situation, we don't have the fund to draw from, we don't have an authority in many cases. And so the intent here was to try to develop a fund similar to what FEMA has, when you have a crisis, CDC and NIH and everybody else in the state health department don't have to somehow wait for an appropriation to go through the Congress and the science as we saw with Zika. And there are still a lot of questions about that, how it would be done with the international only, would it be international and domestic, et cetera. I mean, it's a great idea. We've very much supported it, but as Mark said, what we're worried about is it will rob Peter to pay Paul. And in that case, it will sit there and we could be using it. And what I'm afraid is it could be a justification for further cuts. If you've seen the budget cuts proposed, and again, I emphasize they're proposed, they would really cut at the heart of a lot of public health preparedness. And you know, we don't really have any details on it. I mean, for seven years, we were promised an immediate replacement for Obamacare. Turns out there were no details. I think the same thing could very well happen here. He did meet with the president. Did you get any read out from him about? He said that the president listened carefully. That's about all we can say, which is more than maybe most people get. But as we say in our book, Mr. Gates does have some very good ideas. I mean, one of the things which he told us, which we think is a very good idea is, as Mike said earlier, the war against infectious disease is a constant ongoing one. And the Gates Foundation, the Wellcome Trust, a couple of others have sent people out into the field to try to deal with these huge questions of malaria, of polio, and diseases like that. These are serious ongoing threats. But if we have people and supplies and resources out in the field to begin with, if there is an outbreak and these people are dual trained and supplies are available, like vaccines and preposition, that's a good dual use. That's something that we can really benefit by having these workers shift over from chronic diseases to pandemic diseases or epidemic diseases right away. And there should be much more planning like that, which is why we, in our book, advocate not so much a world health type organization, which as Mike says, has 193 directors. We want a NATO-type treaty organization where, when anything happens, the agreement is already there and the resources are prepositioned to deal with it before it gets out of control. I mean, Mike can tell you, because he studied us very carefully, we really dodged a bullet with Ebola in Lagos, Nigeria. You might want to talk about that for a minute. Yeah, I mean, we came close to losing it there. The one thing we had going for us was the fact that the public hospitals were on strike. And when that individual flew in to Lagos and was seen early on with Ebola, he actually went to a private hospital, which actually made it easier to contain based on the health care delivery of the physician. And there were foreign polio workers. And then CDC had its polio eradication team drop what they were doing and get involved and that really helped. Let me just add a follow-up to your point here I think is a good one. This really fits your world completely. I've been very involved with the MERS issue. I've actually been in the Arabian Peninsula working on this Middle Eastern Earthstory Center. It's a SARS-like virus where with SARS, it went from bats to badger dogs and palm civets in the markets of the Guangdong province and the human. I want to realize the intermediary source and that we can get rid of them out of the markets. And we stopped the process. Our job is to clean up what was already out here. OK, and we did. Now we got a situation with MERS, a very similar coronavirus that infects camels. And it's in camels. And it's a challenge because if you're knowing about camels in the Middle East, they're sacred. I mean, you're not going to get rid of camels, trust me. But just think of the following. There are about 14 million dromedary camels in the world. Only 1.5 million are actually in the Arabian Peninsula. The largest number of dromedary camels in the world are actually in Somalia, 7 million. The Horn of Africa has about 9 million completely all over all. Now we have good evidence that this MERS virus, which is in camels, not making them very sick, that is on the Arabian Peninsula is different than similar MERS like viruses in camels in Africa and even some in Asia. And it's akin to likely what happened with Zika, where the virus changed over time. And what's occurring on the Arabian Peninsula is a different MERS virus. The beauty of that is 99.9% of the camel trade is selling into the Arabian Peninsula, not going out. So we never see the virus come back out. It's a matter of time before that virus in the Arabian Peninsula gets to the Horn of Africa. And when it does, all hell is going to break loose. It's going to make Ebola on the west side of the country seem as if it was just another outbreak. Tell them what happened at Samsung Medical Center. But so if you already know that, as your work, where are the hotbeds right now for if you want to look at terrorism activity, et cetera, then now you throw in them on top of the issue of famine and you throw in this horrible MERS situation, it's just a matter of time before it's going to happen. I always thought that the Saudi authorities have nothing very full coming about this issue. They haven't, and they haven't. I mean, it's been difficult to deal with them. But what's more important is here's all the wealth in the world there, and you know what? We don't have a MERS vaccine as far along at all in humans. We've got one in stage, basically phase one study. And they don't see the issue. Mark was referring to the fact, two years ago I gave a talk here at the National Academy of Medicine at a meeting, and I said, just a matter of time before MERS vaccine virus actually travels with an individual and goes to other parts of the world and causes the temperate catastrophic event kind of thing. Six weeks later, we had an individual who traveled from the Middle East back to his home in Seoul, Korea. We've seen the three different hospitals. An outbreak ensued there, and it was a horrible situation where in one morning, a person he infected transmitted to 80 people in emergency in the Samsung Medical Center. If any of you have ever been to Samsung, this is modern as the Mayo Clinic or Johns Hopkins or Cleveland Clinic, and they were closed to new admissions for six weeks. I mean, they had. What happens when you contract it? Basically, it's a pneumonia-like illness, about 30% of people die from it, just like SARS. And so it's the very same thing. The cost to Seoul and Korea and all the trade travel issues that occurred, all the cancellations, what happened with the healthcare delivery that was shutting down the Samsung Medical Center was astronomical. And again, we're gonna have more of this. We could shut down the Mayo Clinic tomorrow. We could shut down Johns Hopkins if one of these individuals comes and transmits here. This is also clear, but we don't do anything about it. We should be crashing a MERS vaccine right now for humans. We're not gonna get it out of the camel. Maybe a camel vaccine has worked too, but the bottom line is we always wait till after the problem hits, and I can see this one is Thursday coming. East Africa one day is gonna be lit up with MERS, and we're all gonna say, gosh, why were we supposed to party? I was just telling someone here, I gave my first lecture on Zika 18 months before the first case of the Zezel was documented. And it was just so clear to me that it was coming. We had the 80s of Gypti there, we saw what Chicken Junyu did once it got introduced into the Americas, it quickly went through there. And I actually said, well, it's a matter of time before Zika comes and when it comes, it's gonna spread just like everything else. And it did. We need to be more creative in our imagination, maybe, and anticipate these things. We don't do it. We wait until the crisis happens, and we go, oh my gosh, we were surprised. And we just shouldn't do it. Anymore, you are a terrorism. I mean, you've done that with your whole business of trying to save what's next, what's right. But this is a really a bigger, much bigger problem. Any other questions? Okay, the gentleman here. Hi, thanks. My name is Jack Kropansky, unaffiliated. I'm just wondering about the role of the airlines. Like, was it with SARS where they first started checking people's temperatures? You know, can the airlines? The BOLA, the BOLA. SARS, they did with SARS in 2003, yeah. Can the airlines improve their role, or is that a weakness or a strength in them? We're getting running out of time. Can we ask you a question as well? Yeah. Can we talk to each other? My question is about, so if everybody is warning about antibiotic resistance, and we know it's inevitable, like sort of, what is it gonna take to actually do something? Is it really just gonna take a pandemic? And is that what it... Well, we could avoid that if people would read our book. No, no. Well, I'm biased sometimes. And your first question here, let me just say, it turns out temperature screening methods are not very reliable. And that, so, you know, there hasn't been the good way to do it. The big thing is that if somebody is sick and he'd be seen quickly, I've actually investigated multiple exposure situations on airplanes with all kinds of different diseases, most notably drug-resistant TB, and it's been a very limited way. It's more moving that person to someplace else that they then transmit to others. The plane itself hasn't been a major amplifying factor, which you might think it would be. And again, we wanna make it science-based. You know, I see this in Asia often. It's a common practice. You'll see them with a surgical mask on, not a M95, which really does nothing to stop it from coming in. But then they wear it below the nose, and it's almost decorative. It really, it doesn't do any good whatsoever. And so there's what we wanna make sure. We don't wanna give people a sense of, they're doing something when they're not. Your question of antibiotic resistance is right on the mark. I mean, we can see this when it's coming. And we need to help people understand the role. Two things happen. Doctors don't wanna disagree with their patients. They don't have enough time to disagree. They find patients and rank them poorly. We need to do a better job of educating patients why they shouldn't get antibiotic. They don't need them. But also if you're a doctor and we talk about this in the book, if you have that one in 10,000 likelihood that the patient coming in today will die if you don't give them antibiotics because of a very rare thing, when the other 9,999 will do just fine if you didn't give them antibiotics, you don't always default. You don't want that one to die. And somehow we've got it. If you're following standard guidelines that have been recommended, you should be held harmless if something does happen where you did document that basically you did everything right. This was the one in 10,000 that was a bad outcome. Otherwise, the losses to the society. I mean, that's why medicine has something called best practices. And if you follow best practices, you should be okay. But just to sum up on antibiotics, it's a two prong approach. We need to support the development of new antibiotics and we've got to exercise the stewardship to conserve what we've got. And particularly in animals. Today we are a washed antibiotic today. I mean, China is forced by the metric tons, antibiotics over a year for use in animals throughout the developing world. And I mean, we're putting that stuff out like candy. Thank you. Thank you very much, both of you, for a brilliant book and presentation. And we were really honored to have posted this and such an important subject. Can I just say one last thing? I just, I never get an opportunity to do this. Peter has been one of my heroes in the sense for many, many years. I mean, his work has been in the center for many of us. And you have been very brave in what you've done and you've stuck your neck out. You've put your life at risk in fact to do this. We need more people like Peter in our business. And if we did, I think that by itself would be a huge benefit to have that. Just tell the truth, you know. Peter is a very good example of why we should support immigration. I was born in Minneapolis. Is that right? Thank you very much, sir. Thank you, thank you, thank you very much, sir. Thank you.