 But I think the failings in the West Africa response, the roots of those failings were established years before and, like all things, it's usually something many, many converging vulnerabilities and risks. There was a failure of containment in West Africa for sure. I've been involved in 17 Ebola outbreaks. No one really heard about them because they were contained and that failure of containment does very much sit at WHO's responsibility. I left in 2011 but it's also a donor responsibility. My program was a $189 million program in 2011 of which the core funding for the program was $5 million. We raised $185 million every two years. I had a target every week of $2.5 million to raise from self-money in order to maintain global response. So when the crisis and the crunch came, a lot of that self-money began to disappear. There were many other failings. WHO effectively dismantled its internal outbreak response mechanisms. Under pressure from member states who felt at this point global mechanisms were no longer needed and we needed to focus on building national capacities. So we didn't need the fire engine anymore. We needed to work on fire prevention. I would have argued you needed both. We also had another massive failure which is a systemic failure of investment and governance in the three affected countries. We've had 30 years of bilateral investment in the three countries and when the systems came under pressure they completely failed. They didn't even fail. They never worked. Who's responsible for that? With all of the swaps funding and basket funding and the hundreds of millions of dollars that were invested in these three countries by multiple donors over the years, why did the health system completely fail to react, respond and cope? And then why, when containment had failed, did it take so long for everybody to get their act together in scaling up a humanitarian response? The UN using a DPKO model, not a nacho model, many other things. So you have this very strange confluence of risks. It was a disaster. 10,000 dead people is a very high price to pay. Three collapsed economies and an organization rightfully put in the crosshairs for absolutely justifiable criticism. And we're trying to fix it. I'm back for the last three months. Peter Salama came in a year ago from UNICEF and we are trying to put back and not put back what we had before but to try and build a credible health emergency response program within WHO because we believe WHO has to be relevant and effective in this area. It must be. That's just a map pulled off our event management system of our executive dashboard as I left the office. And all those dots are health emergencies and graded emergencies currently in various spots around the world. You can see Africa is the epicenter of most of this. This is a very busy business, one of constant demands. And health is now the single biggest impact of many, many disasters and conflicts. And we move on a daily basis from managing thousands of cases per day of cholera in Yemen with colleagues in MSF and many, many others which are biblical style events in the context of massive conflict. It's very interesting that that huge uptick in cases occurred not necessarily because cholera entered Yemen. Cholera is in Yemen endemicly but the targeting of core infrastructure, water treatment plants, the targeting of basic municipal infrastructure in urban areas is what drove this. The water stopped, the water treatment stopped, people on the move and we had the four horsemen of the apocalypse coming together, population movement and the lack of basic facilities. But we move from managing the thousands of cases today to as we speak, tracking an individual, one person crossing a confirmed case of Maraburg from Uganda into Kenya who in 36 hours managed to travel over 400 miles within Kenya, multiple contacts with health care, multiple contacts with traditional healers, multiple rides on the back of motorcycles. So the scale of what we do is going from the biblical to the forensic on a daily basis. Globally, I'll focus on outbreaks for a few minutes, I'll come back and talk about the broader emergency context. The last six years more than 1300 significant high impact epidemics in over 168 countries so nobody's safe. This is happening everywhere, it's happening all the time. We're currently screening 3,000 health emergency signals a month through our epidemic intelligence from open sources of multiple events so we're constantly tracking the globe. We're actually physically following up on 300 of those events a month after we sift them and we're actively investigating boots on the ground, 30 events per month and conducting formal risk assessments and I don't mean risk assessment but your finger in the air, formal risk assessments with the countries in over 91 of those cases. But I mean, epidemics have shaped our history, they're part of mankind's origin, wars have been won and lost by epidemics than ever by armies and those diseases have lived with us since time immemorial, plague killed half the population of Europe in the Middle Ages and it's interesting how disease change, disease move with people and they move with animals and the pace at which disease moves is often reflected in human technology and human civilization. It took hundreds of years for diseases like measles to emerge from Central Asia and track their way through the system. In the Middle Ages, because of sea transport, it was the ability of disease to move huge distances and then infect the great merchant cities of Venice and Marseille and others and allow diseases to transfer quickly and it's very much based on the capacity of a disease and its incubation period. Can it survive long enough on the journey to reach the next destination? So our ability to move more quickly and it's interesting if you look at the 1980 epidemic of influenza, it went in four weeks through the whole of the United States. What do you think was the driving force for that spread? Trains. This was the first intense national network that could move disease. The other thing that moved disease was the mobilization of soldiers within the US. So you had a mass mobilization of young men, fantastic vessels for moving disease and you had an infrastructure that could move influenza. So despite its short incubation period, it could move quickly enough so a person could move from an infected population to an uninfected population within the incubation period. So this ability of diseases to move has more to do with human behavior than it has to do with the bugs we fight. We've had huge deadly pandemics in the past, black death, measles, a disease we all see as a disease of early childhood. Measles, most emerging diseases when they cross the species barrier are extremely lethal. Measles when it started and was a lethal disease, still for those of you who worked in Africa, a lethal disease. If any of you have seen children in Africa with encephalitis and other things from measles, you'll know that. Smallpox obviously, Spanish flu and many at SARS, we've had all the various things. But it's not just those diseases. We've over 1,400 species of infectious organisms known to be pathogenic to humans. But beyond that, with all of the biomic surveillance that's going on, study after study is showing. You go to Umbalisk, you can now find hundreds of RNA viruses in every single animal in the world. The amount of biodiversity in the microbial world is quantum more than we thought it was. We know about 1,400 infectious organisms. We know that about 175 of them are considered to be emerging. In other words, the diseases that are on the rise, and most importantly, three-quarters of them are zoonotic. Their origins is animals. The animal-human barrier is being persistently and consistently breached. And in effect, human disease is very often within an epizawatic. We call epidemics in humans, epizawatics in animals. And in effect, humans sometimes are the collateral damage. Humans are wrapped up in a biomic cycle of disease spread. So we have all kinds of factors that are driving the emergence of disease in animals. And then we have all kinds of factors that are driving the transfer of those diseases to humans. And we have all kinds of factors that are driving that amplification. So now, where we are, as we stand today, we have the emergence of newer and newly recognized pathogens. We know them, the sarses and the ebolas, the marbles. But sadly, plague in Madagascar, I'll talk about it later, cholera all over the place. These are ancient diseases that are reemerging, measles. We're not in control of even the diseases for which we have vaccines, even the diseases for which we have antibiotics. We're talking about sepis and developing new countermeasures and investing hundreds of millions in dollars in exotic vaccines. We can't even make the ones we have work. So the issue is in just technology. The issue is delivery and our ability to deliver these countermeasures to the right place at the right time. And sadly, we face the prospect of accidental or deliberate release of a biologic agent. I remember a survey a few years ago on China, I think there were 32,000 P2 or higher level labs in China. We did a containment exercise for polio in Pakistan recently and we looked at the number of labs in the country that could have polio-containing materials, stool samples and very just to see what the containment effort would be like. We found 3,100 labs in Pakistan that could be storing samples that could contain a polio virus. That's in one country. So the issue isn't necessarily the nefarious release. The issue is our human technology, our academic centers, our laboratory centers, it's the accidents. In the last three, two clusters of SARS cases, which no one really knows about, after SARS, that nearly started SARS again, were two laboratory accidents, which lab workers infected themselves and nearly infected their own communities. So the accidental release of pathogens is probably much more significant. So in summary, we have factors driving disease emergence. Human encroachment into pristine systems, exploitation of those ecosystems, translocation of animals, either legal or illegal, the whole climate variability and change, humidity levels, temperature levels, their driving vector distributions and density. This whole ecologic pressure is growing and growing and growing and it's putting pressure on that animal-human interface. When those diseases then manage to get across the barrier, most of the time in history the day out. The ball crosses from a bat to a primate. The hunter hunts the primate. The hunter goes home, gets sick, infects his family. The family is 50 miles from anywhere. Nothing happens. The problem happens when that person is sick and they go to a health facility that has no trained health workers, or doesn't have gloves, or doesn't have basic hand washing facilities, and then you see the amplification. So our own technology, the very things we've designed to help often become the means by which these things amplify. So dense populations, if we look at peri-urban slums now in most of the world, even Africa, the health problems and certainly the epidemic health problems going forward aren't amongst the rural. It's amongst the undocumented peri-urban massive mega cities in which you have literally billions of people living in right now who have no access to healthcare, no access to basic sanitation, water, or services, and they're packed in often within 10 or 15 kilometers of an international airport. So we are bringing the risks closer and closer to the point of departure or propagation and the third process is propagation or globalization. So when we talk about what drives this, we can't say it's one thing or another thing. It's a mixture, a converging series of vulnerabilities and risks from which occasionally we get the SARS, or we get the MERS-CoV, or we get the Nipah virus, or we get the Ebola virus and they pop up on our radar. They're just the international airline routes of the world and showing the hubs around the world and saying, if it's somewhere, it's everywhere right now and we've seen that in SARS. Within 72 hours of the SARS event at the metrical hotel in Hong Kong, people have gone to 28 different countries. But it's not just epidemics. The natural disease risk map of the world is getting redder and redder and redder. Ongoing iron conflicts around the world, the world is getting redder and redder. And migration and displacement is both driving the humanitarian crisis but it's also driving the infectious disease risks. 250 international migrants, 760 to 1 billion, 1 in 7 people on this planet right now is a migrant. These aren't a minority anymore. These are becoming a massively important population. They're driving economic growth but they're putting huge pressure on systems politically, socially and from a healthcare perspective. We have 66 million people who've been forced from their homes, 20 people every minute. So by the time we finish our hour together, we'll have 1200 more people on the move. So 1 in every 100 people have now been driven from their homes by persecution, by conflict, violence and human rights violations. Half of these people are under 18, 86% of them are being hosted by developing countries. If you look at the likes of Syria, if you look at the likes of Pakistan, if you look at the likes of Uganda, Uganda has 1 million refugees currently in a country that can barely provide for its own. Imagine if 1 million people arrived in Europe or 4 million people arrived in Europe. We can barely manage a couple of thousand. And it's interesting to me, I think it's gone out there, but the average length of displacement would really shock me, 17 years. These aren't people moving for a day, a week, a year. These are people moving generationally. When you move now, you don't go back. So this is a huge issue in terms of what we do. So with that in mind, what do we do? What's our job as we see it in the Emergencies Program? Well in the end, we have to coordinate international action to prevent, prepare and respond to these events. Our core mission is early warning risk assessment and response, but also prevention and control strategies for these high risk pathogens. We can't just keep knee jerking response. We have to have the vaccines, we have to have the control programs, and to have all hazards preparedness at country level. We have to focus on building national capacities. We can't have a pure fire brigade approach. It's a multi-annual hazards approach, and it's very complex. I mean, on a given day at our nine o'clock meeting, we could be talking about the collapse of the tunnel in North Korea to the individual moving around on motorbikes in Africa to what the hell are we going to do about cholera that's from Nigeria to Yemen. They're just on WHO's side right now are great in emergencies, emergencies for which we are currently responding in the world actively, and that is either through money people and stuff. We're structured very much around emergency operations, health emergency risk assessments, infection hazard management, and country preparedness. So it's a big program, it's got about 350 people in Geneva, it's got about 900,000 people dispersed through our country offices and through our regional offices. Budgets, our core budget is actually not bad. This is the first time in my memory that we're actually our core budget is 485 million and we have a good bit of it. And also our outbreak crisis response, which is our soft budget for response, is well funded and we have a contingency fund of 100 million dollars, but it's only funded half funded and we've been constantly dipping into that to respond and support over 41 countries with with money to respond to these crises. That's currently the donor base for our contributions to the CFE and we can't do this by ourselves. There are hundreds of partners in the global outbreak alert and response network, including many CDCs of the world, even here NDSC, the universities, NUIG and others, MSF. The whole principle of the global response network is that that technical capacity exists. It's out there in the institutions. Our job is to leverage it and get it to the right place at the right time. So this idea of a collective hive mind globally and we can access plague expertise, we can access Ebola expertise, we can access lab expertise and we can put that in the field. Currently we have 116 international staff in Madagascar for plague from 12 or 14 different organizations doing different aspects of that response. It's a worldwide network of institutions and increasingly it's a network of institutions who are from the south as well as the north that has deployed almost everywhere. You see the big blue dot there, that's in West Africa, they were the deployments for Ebola. We also have emergency medical teams, which is a slightly more specialized version of what we do and these are specialist surgical and medical teams who can be deployed particularly in natural disasters. And I think Ireland is getting involved in that now. This is a way for us to deploy very intubated teams who can do very specific work in the aftermath of earthquakes and other things to support colleagues in MSF and Red Cross who do this work all the time as well. But it's not just about response. A lot of our work now is around trying to build national capacity. And this really means working with countries in the long term both to identify their gaps, develop strategic plans to fill those gaps, identify multi-sectoral, long-term domestic funding for national health security supplemented by international investment. So we do everything from national planning to joint external evaluations, we do workshops with the veterinary sector, we do multiple simulation exercises after action review. So after every outbreak that you see on the previous screens, we go in afterwards and we do a rapid after action review to identify the weaknesses. We use them to do that. We're doing that much better now. And they're the external evaluations that have been completed and the ones that are in the pipeline and we hope to reach about 120 of them by the end of next year. And this is the basis for multi-sectoral national planning to improve core capacities for health emergency response at country level. But also for all of these different diseases you see here influenza, cholera, yellow fever, meningitis, we have to build prevention and control strategies and programs in order to be able to deal with them. And there's a tremendous amount of work goes on in the program coming up with specific strategies to fight these disease, driving the upstream development of countermeasures, putting in place the coordination mechanisms for the distribution of vaccines. For the last 20 years with MSF, we've managed cholera, yellow fever, meningitis vaccine in a process called the ICG, which has allowed countries on a purely epidemiologic risk basis to receive vital vaccines to fight these three diseases. And it's a rather unique idea where organizations who effectively, most of the time, operate independently in these diseases have operated together for two decades. A quick flick through just a couple of events. We have the Bangladesh event and the Rohingya 500, 600,000 displacements. Our big work here has been setting up surveillance systems and mounting an OCV, oral cholera vaccine, massive campaign for oral cholera vaccine. Syria, again, huge amounts of work in health sector coordination, a very, very large WHO presence on the ground with other partners. Yemen, trying to maintain polio eradication, dealing with almost a million cholera cases, as I said, a biblical outbreak of cholera, driven not necessarily by only a failure in the health system, driven by the direct targeting of the very infrastructure that prevents these kinds of diseases. Nigeria, again, we've had wave after wave. Nigeria has had conflict crisis, it's had a food crisis, it's had a yellow fever outbreak, it's had a cholera outbreak, it has a monkeypox outbreak. Nigeria is an incredibly complex environment in which to work. And the Democratic Republic of Congo, again, multiple epidemics, multiple population movements. So this confluence where you have conflict, movement, displacement, breakdown of infrastructure, a lack of governance, and then the epidemics come. Madagascar is one of our more recent responses, as I said, we have 120 staff and 30 Goren partners in the field responding to this. The interesting thing with plague in Madagascar, and again it shows you, you can never really predict. Plague is a disease that occurs indemnically in many countries in Africa, North Africa, and especially in Madagascar. Historically it occurs in yearly cycles. It's very much in the bubonic form, it's driven and mediated by rats, rat fleas, go to humans, when it gets to bubonic disease. Normally, about one to two percent of those cases become pneumonic, in other words they get a chest infection with it, and they begin to transmit the bug to others potentially. In this outbreak, 70 percent of the cases are pneumonic. This is a disease that spread from person to person. It's the first one in my 20 years that spread like this. This is called untold panic. Where did it happen? Not in the normal place plagues happen in the hills and in the small villages. This happened right in the heart of the two biggest cities of Madagascar, why? Because hundreds of thousands of people have moved into these cities and the rats have come with them, and the bubonic plague has come with them, and when they get the bubonic plague, that one percent of people who get pneumonic disease aren't four miles from the next family. They're living 50 people to a room, so the pneumonic form of the disease has the ability to spread. The bug hasn't changed, the circumstances in which the bug exists has changed. Our behavior and our lack of care and our unregulated migration, our unregulated urbanization and our lack of basic health services to these populations is what's driving this epidemic. And you can see this is a pretty stunning epidemic curve showing just how intense this event has been. And again, affecting the central, you know, highly populated areas, not the remote peripheral areas of Madagascar. This has caused tremendous hardship, not only from a health perspective in Madagascar, but tremendous attempts to put in place trade sanctions, travel sanctions, and most of our work, a lot of our work, has been challenging countries to not put in place unnecessary sanctions, because 35 percent of children in Madagascar have already got significant stunting from chronic malnutrition. The country is almost completely dependent on mining, agriculture, and tourism. The fishing ports have already been shut down, flights have already been canceled. So the knock-on effect of this epidemic potentially from Madagascar is a further deterioration in its economic circumstances and a further deterioration in the status of health for particularly women and children in this country. So protecting the economy, protecting the free flow of people and goods is a very important concept as well as controlling the epidemic itself. Marburg, two confirmed cases in a very remote area of Uganda with a very porous border with Kenya. This is on the slopes of Mount Elgan. I worked on the other side of Bacot in 1985 and I always remember treating a man that had fever and bleeding and writing in my diary at the time before I ever was an infectious disease epidemiologist wondering whether he was a hemorrhagic fever case and thanking God every day since that neither I nor all the nurses in the hospital died because we treated that man without gloves and without precautions and dodged a bullet. You can see there that two confirmed cases in Queen District generate 269 contacts in an area that there are no roads. You can't even use motorbikes. You have to use ATVs, you know the all terrain vehicles just to get up the hills and down the hills to find the people. Thankfully no health workers amongst the cases. Highly hostile community, very magical beliefs, witchcraft, huge dependence on traditional healers and we've had multiple incidents where the case for example that I spoke about who went to Kenya was actually going to Kenya looking for treatment. He went to multiple healers who all use scarification and not only did they use the scarification on the case, they used it on the family to ward off the evil spirits. So again the driving and the amplification of this. People don't trust the normal health system, what do they trust? They trust the traditional system because there is no health system in some of these places. So again is the failure the traditional healer or is the failure the lack of confidence in the health system itself or the lack of access and that's just the timeline showing how quickly these things move and develop and how fast we have to be in response. That was the whirlwind tour of global epidemics and emergencies.