 Mae'r bwysig yna i chi'n ddweud o'l panel, oherwydd mae'n gweithio'n ddweud o'r panel yn ymlaen yw mewn. Oherwydd mae'n ddweud fe gyddion gwybod yma o'r panel, oherwydd Arman yn ei ddod ymlaen i Michelle Van Herp. Susan Eldon, dyfedd, rydyn ni'n rhaid i'r Jay Socomosis y Llywodraeth, rydyn ni'n rhaid i'n gweithio'r ysgrifennu. Rydyn ni'n gweithio'r ysgrifennu i'r Brithys. First of all, I just have to congratulate MSF, as I'm here at MSF event, on the fantastic work in this area. So I work, as John said, in the product development team, I focus on vaccine development at WHO, and I'd just like to highlight just a couple of points that WHO, with the international community, are working on in vaccine development. So firstly, this is a sideline in the context of the current Ebola outbreak but it could be really very important for this question preparing for the future and that's the vaccine development. Mae'n cychwyni wneud o wahanol gyda'r swyddfa yn O'r Lystiwn, O'r cychwyni ymlaen ffordd yma i gwybod y c tasion, a'r swyddfa y maen nhw ar y cywethaf, y bydd y cyflwydd o'r lle ddioleth yma i gêmwys ar y cyflwydd. Mae'n cyflwydd sydd yn fawr, ond mae'n cyflwydd yma, mae'n cyflwydd i'r lle ddi soldiers yn y lle ddioleth yma i gêmwys i gêmwys i gêmwys i gêmwys i gêmwys of clinical trials that went from the idea to initiation completion of enrollment and many of those have reported many of those have already been published in the 20 years that I've been working in this is far far in excess of anything that's ever been done in vaccine development for for any disease so let's just acknowledge this is clearly too late for this outbreak but for the question is preparing for the next outbreak there is going to be an I fath yw'r pwyllt yn naddwyd i wneud hynny o'r gweithio'r hebizedd o gweithio a gwneud ffeithio'r leidi psychiatrach. Mynd Gaergymeth trafodon ar gyfer debyg mewn gweith яw ffordd presidu cyflonau a gyweithio, mae'n ei gallu effectiliaild gan gyfan Gweithregen i'w'r leidio cerdyn ffawr a gweithio'r leidio yw'r leidio, dyl yn gweithio'u gweithio ac yn cyhoeddech am ffarnwseng yn gweithi'r leidio. A oedd yn y pryd yn y pethau gweithio, dyma y maen nhw, gyda'r cynyddoedd sy'n cyfnod ar gyfer. Rydyn ni'n mynd i chi, rydyn ni'n mynd i gyd y bydd. Ond mae'n bwysig cychwyn i'w rhai cyhoeddfeydd y ddyliau ar gyfer y cwmwysig o'r ddeithasau ymddangos yma o'r gwneud eich cyflugiau i wneud dyn ni'n gweithio ddechrau sydd wedi'i gweld fyddion i gyrtwyngau'r awsiau ddechrau ar gyfer y syniadol... ..y'r panthogyn o'r panthogyn nhw i ddweud ar gyfer y lluniau sydd yn bwyd yn hynny'n ein unig ffordd ar gyfer y syniadol... ..ynddyn ni'n ei wneud i'r perio ffordd â'r syniadol o'r cyfnodau yn gychwynio'r cyfnodau gyfer y syniadol... ..y'r cyfnodau o'r cyfnodau syniadol yn lle ychydig o'r cyfnodau sydd yn ei wneud i'r cyfnodau... er mwyn gyda y bach i gynedd armaeddiad a bydd y drieddau. Yr unrhyw ddechreuwyd yn dweud. Yr gweithio'r cynghwyl o'r prif, a'r hoffa gael weithio'r cyfriddau sy'n gwael amser yma. Mae gennym ar y mynd yn y Llanfaidd Cynlluniau Cynlluniau, sy'n rhywbeth gweithio ymrhywbl yn cydweithio. Mae'r newid yma am y cynl Ethiopia, mae dyma o'r cymdeithiau sy'n gyfrwyng fuddaw. notation. maen nhw'n diawn mult o Gymryd Filia, Mae'r whole unrhyw, ddifodl, yn 10 dweud, ysgol y ddau a'r rhesaith hwn yn y context ar y mynd i'w diwylliant, a cyhoi bod yna'n hynny'n dwylo. Mae'n ddylch chi'n ddull, mae'n ddull iawn i ddweudio'r ddweudio'r ddweudio'r ddweudio, mae'n ddweudio ar WHO ac yn ddweudio'r ddweudio, wrth gwrs, y targed profiwyl yn gweithio'r 我 filtering forward looking guidance to put all these measures in place before the next outbreak. Not only about the Ebola, but other public health emergencies. Thank you. Finally, I have a laundry list of things I could talk about, but in two minutes I'm going to have to put them aside. We could talk about how to engage the populations, but Ombarto has touched on that. I think we can say that he's going to do better. He's done better with that than I will quickly. We should talk about how to deal with mobile populations that move around faster than we can keep up with them. We could talk about how to improve our delivery of care. And we could talk about how to capitalize on what we've learned and how to be ready for next time. But I'd like to address something that I do advisedly in this room. We need to solve the problem of doctors and epidemiologists. We have yet again been in the field, gone through a number of coordination meetings where the well-intentioned person at the head of the table wearing the official hat engages us in a discussion of what has happened to the three motorcycles that were ordered last week and where they are. And then we move on to the discussion of the per diem, which has not yet been authorized and might get paid next week. We need to learn how to coordinate a diverse range of partners with variable amounts of experience and Ebola outbreak activities. The people who are in charge of supervising these activities need to know how to set good objectives for what they need to be done, mobilize the appropriate resources to do that and monitor the way of progressing and achieving those objectives. And I know that when I was in medical school, this sort of thing was not taught. Nor when I did my public health training or my epidemiology fellowship was any of this stuff taught. We have a naive assumption that the people who should be running public health interventions are always doctors or epidemiologists or nurses. But management and coordination is a skill set. These things are learned. Some people are better at these than other. And the system that we have in place does not, it's not a meritocracy. We do not pick the most appropriate person to be sitting at the front of the table. And as I'm sitting next to somebody from WHO, I will say that this is not our problem alone. And if we cannot learn how to manage an outbreak of this scale and this complexity effectively, I think we risk repeating a number of the problems that we ran into. So I'd be happy to talk at length about any of the other things that we could have talked about, but I thought I'd get that one out there because it's not something that we bring up often enough, perhaps. And I have plenty of anecdotes of people who want to cringe. Okay, thank you very much. So that's the opening gambit. And now it's over to you. So who would like to ask a question? Yeah, my name's Rob. I'm one of the public health trainee. I guess from a public health perspective, wouldn't the best simplest and also most difficult way of preventing another outbreak be to improve the capacity of the health protection systems in the countries where the outbreaks might occur so that actually cases are identified early and then actions are taken to prevent spread? So a little while back when we were talking about how we were going to prepare for the next outbreak, I mentioned to somebody, the issue of better surveillance will be brought up yet again. We say this after every outbreak. We came late. If we detected it earlier, we would have been able to respond earlier. And I'm not against surveillance. But if we had detected this outbreak a month or two earlier, we could have arrived in Gekidu and failed to control the outbreak that much sooner. The problem was not that we were necessarily late, is that when we got there, we were ineffective. We did not engage the community as a partner in outbreak control. We went on with the same messages we'd used before. Unfortunately, we failed to employ lessons that we'd learned in the past. And I don't know that we've ever figured out the best way to engage communities, although we're getting better at it, but we certainly did not get them on board. Cases hid, contacts were very difficult to follow, and we didn't go in with enough people to get things under control. And surveillance would not have improved that. I still think, yes, we should detect these things sooner, but the problem is what do you do after you've detected the outbreak? How do you get in there and get it under control quickly? A gentleman down here first, and then up there. Bertie Squire from School of Tropical Medicine, Liverpool. One of the things that struck me a lot all through today is the issue of the need for person time. I've tweeted about this, but actually none of you have mentioned this. The human resource that is going to be required to respond isn't sitting ready. It has to come from somewhere else. So there's something that we need to discuss, which is about how we get sufficient human resource across all of the disciplines, all of the skill sets that you've mentioned. Management Administration Coordination is clearly one of them, but the whole business of interacting with patients, interacting with communities, needs numbers of people who are able to do this and mobilise this. And it's not just a question of the international community, it's also about local communities. I think that hasn't had enough attention. I don't know what the panel thinks. Mitenin, would you like to tell them? And probably you are right. I think that in our case, we managed to engage... I mean, we have plenty of national staff working with us, and we had a fantastic response from all the international staff that we had, but it's true. I mean, the workforce was the one... The workforce was the one limitation that we had whenever we were asking for hands-on activities. So it's something that for sure needs to be well prepared in advance. I think that we engaged quite a lot in training that it's something that MSF was not used to. So we were aware of that need, and we were aware that to have someone ready, hands-on to be able to treat patients was going to take us quite a long time. So we decided to invest in treatment, and I think that that had a good result probably late, but it had a good result. And I think that is something that we should take as an example for the next one. Susan, do you want to start? Maybe just a couple of practical examples that I can give from that. On the first question about surveillance, one of the things we found really effective was community-based surveillance. So people from those local communities that actually knew where things were happening, and that is an area where you can really mobilize local resources, and that was seen to be very effective. The other thing is, I think, is to recognize the downside. None of the teachers were working at the time, and so they were massively employed, and all the TBAs, the traditional birthday. So they were all brought out in mass to work in the Ebola response, and there was a massive backlash at that time about what happens about all of those other services. So it wasn't simply straightforward to just bring in massive amounts of local people into Ebola, and so there's something about... I think that's my point, is that you're stealing from somewhere else where there's a hold. Yeah. There's a whole dynamic that has to be addressed at that. Okay, the gentleman at the back with a... Bruce Reeder, MSF Swiss in Canada. Two questions if I could, both in a sociological anthropological dimension. What should be the future in terms of changing traditional practices, for example, around bushmeat exposure, traditional burials? What is the role of the local community and the international community and such potential social change? And based on what Amberto had mentioned, to what degree can we incorporate anthropologists, sociologists in the early response team? And are they quick in response or does it take weeks to do such assessments to help field teams? You want to say that? That's a very good point. We learned the lesson about the need for anthropologists a long time ago and anthropologists have been part of our outbreak response for at least 10 years now. Yeah, at least 10 years now. There are a couple of tricks there, though. One is finding the right anthropologists and finding a way to make use of what they say. Sometimes we get very great ethnographic analyses that explain the root causes of the problem and it goes back hundreds of years and you can blame colonialism and the problems between the capitalism. But then you say, well, yes, but what do I do all of that operationally? How do I change my actions or engage in some activity that makes use of what you've done? And that's a little bit trickier and we've had a bit less luck with that. I don't know that we often try to change what they do as accommodate some of the things that can't be changed and leave it to them to change the things that they can change. These people, they're not stupid. They understand what's going on after you give them some time and you engage in a dialogue with them. And often they will, if you explain the risks in terms that work, often they can propose ways that will be the least burdensome change to what they do that is acceptable within their community. And we often find compromises where we get the opportunity and time to engage in that dialogue with them. So we have had some successes there. Unfortunately, we're often overmatched in these outbreaks and we focus on the things that we do well. We build fortress management center and take care of the patients and have a very patient-centered approach and we figure we'll get to that anthropologic stuff when we have the time because we're short on staff and what have you. So I think we need to push that as a priority earlier and figure out how to engage with the anthropologists in a way that is operationalizable if that's a verb that I just made up. Most sure it is, but I'm going to drift. I've got a question, I think, for John and probably for Susan as well. So we heard from our keynote speaker about the importance of an early response and he also showed the picture of the academic timeline for getting proposals out there and maybe funding of project proposals. Just from the two of you, maybe, how can we overcome some of those barriers for next time? Okay, I think that's a tricky one. I mean, at the moment, of course, so you get a real epidemic that goes up and comes down and then you get a research epidemic that goes up and comes down and they're offset by some considerable period of time. So at the moment we're in this rather unseemly scramble for the last few cases and it's really, you know, and quite political. And so we have to move that. So I think it's up to me, I think it's up to a number of other things. The funders who need to be much quicker off the mark, there are certain things you can do up front so you can plan certain trials. For instance, there should be, or plan certain studies, but you only really get to that stage having properly analysed the data that's come out of, say, this epidemic. And I don't think, I can see that happening now that the data that's available will fizzle away and we'll lose that opportunity to analyse it properly. And then line up the potential things that should be done rapidly in the event of another outbreak. Ezra was talking about different anti-malarial treatments, you know, there's an obvious clinical trial that could be done there if, you know, and why not plan that right now? You know, do the analysis of the observational data we have and then plan that right now. You know, there's no reason not to. Well, John mentioned that the funding needs to be there so that's where I come in. So we were the, you know, one of the key donors at that time and what we can't do is address the sort of stuff and the staff and a lot of those things. But on the funding side, I think one of the most important lessons was having flexible funding early on. So trying to have a small pool of resources that we could then mobilise for people who could say, actually I'm trialling this with a community or actually I've set up a little bit of an isolation facility. I can do a borehole here, I can do this and that. So can we make that funding flexible and fast to those people already on the ground doing that? And I think our ability to mobilise that quicker and to seed out that innovation was probably key. The frustration came with not being able to do that fast enough and at scale because it did take us longer than we wanted to. The other frustration was not being able to get the actual massive logistics of the stuff, sheer amount of stuff and staff that need to come in. Okay, quick couple of last questions. So I'm Vicky from MSF UK and I think the question is to the non-MSF people on the panel, including you, John, because it's a follow-up on what you just said. So there is a very large number of samples, Ebola samples that are spread around the world, held in a significant number of hands. So does that represent an opportunity for us to continue with research and development in order to prepare for the next time? And if so, what is the best way to manage that multiplicity, if you like, of opportunity? I'm going to hand that to Vazig himself. I think that's a potential role for WHO there. Well, as it happens, I know a meeting is never a solution to anything. But what we need are ways forward with sample sharing. And this is a really critical question. That, as it happens, there is a major consultation on this on Wednesday, next week, in Geneva. We have a couple of days before that. We have a big group of leaders globally who are coming to begin, move forward with the whole, laying out the blueprint for all of these kinds of activities. So this is one of those. There are many others. How do we better share the epidemiological data? How do we, next time this happens, how do we better get all of the information out there about the natural history of disease when a new pathogen is emerging? The case reports, the clinical trials of preventive therapies, diagnostics and sample sharing. But all of these are really big, very important to actually strategic issues. And we're taking this on. I mean, from our side, what we can do is come together and develop norms and standards for expedited working in these areas. I mean, it's not okay, in my view, for people to be holding on to things, information, information or samples, ultimately against the public health needs. So we need to find a way, incentives and safeguards to enable people to do that. And one of the other issues that I think goes across all of this is how do we get information out there? So we, I don't know if anybody saw it, but WHO launched our public position on aggregate results sharing. This is not in emergencies, but this is the general position on public disclosure of results from all interventional clinical trials. This came out in Plos Medicine just a few weeks ago. And essentially this is in line with the timelines, timeframes for results reporting that are emerging in the EU and the US FDA and just highlighting there's a big problem in general with publication bias and dissemination bias, which is not new, but just this is something that we can actually fix. Funders can ensure that if they fund a clinical trial that the results become available at some point. There's a lot of discussions about participant level data sharing. There's actually a step before that, just ensuring that all studies which occur are reported at some point. And if anybody is interested in, I could send you the list of all of the citations that confirm that this itself is a big problem outside of emergencies. There was a publication in the New England Journal of Medicine recently that showed that even those trials that illegally required to be reported in the USA, only a very small fraction of those that illegally reported comply with a timeframe. So even legislation is not enough if it's not enforced. I think funders could have a big role here. But those timeframes outside of emergencies are way too long, even if you met those. And we're talking about 12 months from the primary completion date. And in my experience working in this emergency, that there are examples of good practice with people sharing information. Obviously, you have to have the information because the outcome of that can be actionable for responses for public health programmes, et cetera. So I think that is a big ticket item that we need to improve expedited sharing. And it's on. I mean, one of the things is, is WHO strong enough to ensure that this happens? And is WHO going to be at the end of this outbreak stronger or weaker than it was before? Well, I mean, that's a big question. I mean, essentially, as you know, we're not a police force. We are the UN Public Health Agency. So this depends on the community coming together and coming to agreement on that. And we are catalyzing that. In some areas, people come together and take really effective action. And you can go to the extreme, like the framework conventions in tobacco control, where all of the countries decide they want to sign up to legal measures. That's where people want to go at the end of what you can do before that. If we will come together and come to agreement on how we can take this forward, then yes, I think we can make major progress in the next few months. Michela, quickly. And then final question from the lady in the back. Coming back to the original question of day, I think that, yes, we can shorten a little bit the research time or the time that we spend in research. And there are two main aspects. I think that preclinical data, we had a pipeline for Ebola and there was no preclinical data. So that could be advanced. We had vaccines. There was no phase one. So we cannot, in the middle of the outbreak, decide to do a phase one. We should have done that before. So I think there are two aspects that we can do for the next hour of breaks to be sure that whenever the outbreak comes, we are at the right time for the right trial. Yeah, very good point. Last question. Now with the decrease in the media attention or in the attention overall to Ebola in a few of the past meetings, there's kind of a trend where history is starting to be rewritten and in quite a dangerous way. So I'm asking, I know MSF is, I know we're doing evaluations and different evaluations of what the response was to Ebola, what the history actually was, what we could have done better, what we need to do for next time. I'm just wondering if the other agencies are doing the same thing, if they're planning to do the same thing and to do a critical analysis of the response so that next time, the response can actually be a better one. I think that's an easy answer. Yes, there's an epidemic of that going on now. So I think with that, I think we're going to have to finish there, unfortunately, it's been a fascinating discussion. I thank the panellists for participating and not all of the questions were terribly easy to answer, but thanks again.