 Thank you very much for coming and thank you to Dr. Osterholm for doing this. He's a very busy guy right now as you can imagine We hosted him in 2017 for this amazing book deadliest enemy, which I reread last night And basically it predicts pretty much everything that just has on as it's unfolded right now Dr. Osterholm is one of the world's leading experts on infectious diseases He's at the University of Minnesota And so I was we're gonna I'm gonna have a Ask him some questions that I'm gonna open up to you and because we have limited time. Let's just dive straight in so, Dr. Osterholm The head of the World Health Organization last night said we're in uncharted territory Is that a reasonable question or way of framing this? It is relative to the conditions that we see in the world right now meaning not just the cases of COVID-19 infection but also in terms of just this global relationship we have with Manufacturing with supply chains with transportation and so even the 1918 Pandemic didn't present those challenges that we see today With the combination of disease and in economic social and political conditions in the world We've had other coronaviruses, which you worked on extensively like SARS and MERS. I mean, what's the difference between this? Coronavirus and those coronaviruses which although they were highly problematic didn't really kill very many people rather be speaking Yeah, well, thank you. And and let me just take a step back. I think this might help set the table for this discussion We have quite convincing evidence right now that this virus emerged in the Wuhan area in about the third week of November and we can actually tell from the genetics of the virus that that in fact is the case because we can predict the Kinds of changes that occur over time and I'll come back to that later Why that's important is because it sets up our understanding of where we're at right now note that the Epidemic wasn't even really identified in Wuhan until towards the end of December even though as I mentioned it had to likely Jumped and almost like potentially a lightning strike kind of jump from an animal to a human and I do believe that's the case I don't believe that there has been man-made interference whether unintentional or intentional in terms of the release of this organism And the reason it took almost five to six weeks is because when we even think about infectious disease Transmission we often come back to that concept of our not or how many people on average does someone transmit the virus to and What we see with this one is it's a probably about an R not of two to two point five It's surely dynamic if you think of regular influenza It's about one point four if you think about pandemic influenza tends to be about one point eight people So this is quite different It took yet that number of weeks before it was detected because you go from one to two two to four four to eight eight to sixteen Sixteen to thirty two and when you think about we now know that probably about eighty percent of the infections are very mild If not asymptomatic and so before you could get that you might say tip of the iceberg to emerge You had to actually build case numbers up during that time period and then when by the time it got Detected in Wuhan in December. We are now talking about big numbers going from five, you know hundred to a thousand to two thousand to Four thousand and these were occurring about every six to seven days So today what we have happening right now is that we've are seeing this kind of transmission around the world That is occurring much like Wuhan did early on the Chinese have clearly suppressed this activity there with The most I would have to say aggressive if not you might say authoritarian efforts in terms of population movement Quarantine and so forth and yet we still see Today the numbers are down slightly But we've been average about four to five hundred cases a day in China for the last ten days So it's still activity there and I want to emphasize that I'm convinced that that activity is going to in a sense Have a major resurgence once China releases some of these population control measures to get the economy back working And so that from that standpoint We really do have a challenge in terms of of even there Expecting to see this resurgent the rest of the world got seated after Wuhan And so we had actually here at our center had put out a document that actually said The last week of January in that time that would be about one month and the rest of the world would pop And the reason we said mean that was is it would take that much time before case numbers would build up in other areas Around the world and that much of what we were doing to try to stop transmission from China was pretty much useless because in fact This is influenza virus like transmission. It's not Merz or SARS which gets me back to Merz and SARS What's different here is the fact that SARS and Merz both and I was very involved with both outbreak investigations I've actually Again was that it spending part of my time at the US government at HHS during the SARS outbreak with Merz I've investigated outbreaks in the Arabian Peninsula as well as having been at Samsung Medical Center in Seoul Korea when that outbreak happened in 2015 their patients are most infectious day five or later and It allowed us the opportunity to identify these patients early get them into protective isolation Make sure that there are not even though they're blowing virus out is zero meaning that you don't have transmission And when we didn't do that We had a hospital outbreaks and we quickly realized that that was going to be an important thing to stop And then we could get a hold of the contacts and actually follow up with them And if they started to develop symptoms We had time to get them into protective isolation and make sure that they didn't get infected So this is so different than Merz and SARS here virus transmission is occurring early in illness Likely even before symptoms show up similar to influenza The other two coronaviruses Merz and SARS were ones we could stop SARS obviously was stopped because we both got rid of the animal reservoir in the markets of the Guangdong province primarily palm civets We can't get rid of the animal reservoir in the Arabian Peninsula Nobody's gonna you know basically put down a million point five camels And so there we're constantly dealing with once a human gets infected making sure that they don't transmit to others So but this is a very very different coronavirus think of this as an influence of pandemic caused by a coronavirus and you're thinking about this in the right way What do you think the let the fatality rate is if Or do I mean is there a kind of approximation? You know first of all it is variable from the standpoint of Who the who is actually getting infected clearly we know in China That being older and having underlying health care Challenges as well as being a male actually were risk factors were up to 14 to 18 percent of that group were Not that we're dying from this infection One of the challenges we have today is understanding that well with men China in China smoking is still a very very common Habit and so from that perspective We think smoking played a big role in in the increased risk, which we see with even influenza in our own country One of the challenges we have today is this when that moves into a new population What is going to happen? You know we saw in total about 2% of the cases of all does all of the COVID-19 illness is in kids or up to teenagers up to 19 years of age So it's very rare there and just grows up goes up as you get older One of the things we're concerned about as this moves out into other parts of the world is one of the other risk factors We know for having this kind of response to this type of pneumonia, which we call acute respiratory distress ARDS is that also Obesity plays a very key role in that and so now that we're laying this out into parts of the world We're obesity in itself is an epidemic problem We think we could see a very different kind of case fatality rate than we're seeing in China That is less gender specific And could be something of real significance. So we don't know at this point The number of two to two point five percent has been used We've seen it as low as point seven that the WHO report put it between two to four percent in the Wuhan area and point seven percent to the rest of China I think these numbers are still very suspect. We just for example had an outbreak that occurred in a Facility a hospital in Korea where seven of a hundred and one Patients in one psychiatric ward who were infected died now There was an obviously a much higher number there and so I think it's at this point It's it's not nearly like SARS, which is close to ten percent It's not nearly like MERS, which is twenty five thirty five percent But it is somewhere between seasonal flu in a bad year, which is point one percent in the 1918 pandemic which of course preferentially it took out young adults of 2.5 to 3% so this is this is clearly in that range of what would be considered a severe influenza pandemic if this were the influenza virus So if in a regular year in the United States the lethality rate of flu is zero one point zero point one percent You're saying that this is what? 20 to 30 times higher easily could be Okay, and if and so for zero point one percent kills Between 30 and 60,000 in any given year in the United States. What are the implications? for in this case Well as you are so good at asking questions Peter you you ask an answer in such a great way I mean it's obvious that this is a very serious challenge and I think that you know It was unfortunate that we had a number of public health people who early on when this happened kept trying to compare 10 poins in a way of saying well look at flu kills many more people in this country This is a much bigger problem But they hadn't understood was that they were just watching in the opening scene of this particular Corona winter as I call it and I think that in this regard we can expect to see a large number of deaths moving forward And we're going to see a lot of Morbidity one of the challenges we have with this illness is that when you do get sick and in the Chinese data Which again is the best we have suggests that anywhere from five to ten percent of people will get severe illness Of those five to ten This is where we come up with the two point five percent to die But what's been challenging is these patients need intensive care medicine and many of them don't die for two to three weeks After they've been hospitalized after they're consuming health care And in fact the the hallmark case that so many of us painfully remember was the young 34 year old physician in China who really brought this to the public's awareness by having the the His email or his internet Website basically taken down by the Chinese government when he posted on it that these cases were occurring and He died three weeks into his illness And he actually took a selfie of himself the last week before he died and then continued to go downhill and eventually died so one of the challenges we have here is these people do use a lot of health care and That makes it even more of a problem relative to influenza in terms of how are we going to respond? well that raises a question of so There obviously going to be a lot of people with pneumonia who don't die But they're going to be coming into the hospitals. Are we equipped with the ICUs and the ventilators that to kind of deal with a large-scale Group of people coming in with these kinds of symptoms Absolutely not and that's what we've been talking about and actually when I did the the briefing that you very kindly noted at the beginning of this Session in your facility there Addressing the book that I wrote Nothing's changed since I wrote that book in terms of better preparedness. We're not right now today in Minneapolis, St. Paul every one of the beds that we use for ECMO this very high level Heart-lung type machine that is very helpful in terms of of keeping people alive who have this illness are filled. They're all filled We have really no open beds as such given that We are just coming off a real or moderate to severe flu season and that has stretched things on top of that We have a number of hospitals right here in the state of Minnesota as is national nationwide that right now have five to ten days of Personal protective equipment available for health care workers, and that's it and they've been ordering and ordering and it's all in Backorder because everybody wanted it all at once and so we're I very think I think very likely facing a crisis In terms of protecting our health care workers in the next several weeks in many parts of this country What can be done? Well, I think first of all we have to utilize the Health services we have in different ways meaning we need to stop elective surgeries Anybody who's not severely ill with something else clearly needs not to be hospitalized We need to be preparing our pandemic plan To the point of now thinking through what we do if we had a 20 to 30 percent jump in the number of hospitalizations We needed remember in Wuhan We had a number of people there who were desperately ill who needed hospital care who couldn't get into a hospital and Although the numbers varied there was it was clear and compelling that many people were dying at home Not in hospital not because they didn't want to be there. They couldn't get in We also have not yet fully understood the impact that this had on people who had heart attacks people who had acute asthma attacks Things where they really had medical crises and couldn't get health care in China because the hospitals were overwhelmed With with these cases, so I think we're going to run into the same situation here and our jobs going to be triaging This in a way that that allows us to make sure that we do take care of the sickest patients The next thing I think we're going to have to do is of course think about how we're going to protect our health care workers We need solutions that are not ideal, but that may work for example rather than having one patient in one room Where if you come in and out you have to doff and don or take on or off the protective equipment And we know that for example in many institutions that'll average 20 to 25 times a day a health care work will get out of a room Well, what we may need to do is with the right engineering So we're making sure that from an airflow standpoint We're not sending air to other parts of the hospital, but open up wards where everyone in the ward is infected And therefore what you do is you don't go in and out of rooms and doff and don your equipment You use it constantly for potentially a much of a shift and so there are things we can do that way But we still have a great likelihood they're going to face shortages and we don't have good answers for that right now What do we do and we'll be reverting back to surgical masks as opposed to in 95 respirators surgical masks We know are ineffective There's well now an estimated 4,500 health care workers in China who have become infected providing care Many of those were early in the outbreak when it wasn't completely understood just how infectious this virus is But there have been a number since that time and a large part of it's been tied to the absence of adequate respiratory protection Are you saying that the end 95 respirator is not available in any meaningful quantity? It's not and part of the problem is is this is when you asked me early on why you know, is this different? you know In the quote-unquote olden days just a decade or two ago when you were looking at storing or stockpiling Equipment that you needed for your institution. You counted it taking some time to arrive even if you ordered it may have been an order via an E by mail or a telephone call Today we just assumed that when we go on our computers and we get onto a site and we put in an order for X something that it'll arrive the next day by FedEx and and Unfortunately far too much planning has been done making the assumption supply chains would be stable that they could handle surge Capacity or need and they can't and so manufacturers right now in North America are manufacturing as quickly as they can this equipment but basically health care has been so financially in rough shape here in this country no Health care organization has gone out in stockpiled lots and lots of protective equipment They have always bought it on a just-in-time basis and so now we're paying the price for that Some have said well This is in part because it's all made in China and there are many things which for which we are Heavily dependent on China including our critical drugs we use in this country But believe it or not actually a fair amount of personal protective equipment actually is made right here in North America But no matter we can't catch up and so you know if we had six to twelve months to get ready And people understood the severity of what we are facing then we might have had enough on hand But you know the estimates are right now that we are many many fold below what we would need To reasonably get through this situation as that we expected might unfold in terms of the respirator Respirators and Tessa respirators and potentially some of the other protective equipment goggles and so forth but but so this is going to be a challenge and I think that I wrote a piece in Washington Post several weeks ago about protecting health care workers as our frontline activity Because I believe as goes our health care facilities our hospitals our long-term care facilities goes the sense of how much the country believes that we are actually Handling the situation and when health care workers start dying and they or they get severely ill and they go from being care providers to someone needing care And hospitals are not able to handle patients because of reduced number of health care workers I think that's when you run the risk of people losing complete confidence in what's happening You know and at one area I worried desperately about is kind of a perfect storm as we know today long-term care Which we have major? Needs here in this country for that that there's been a challenge finding workers to work in long-term care and If we overlap this virus with workers and the outbreak in Kirkland, Washington right now in the long-term care Facility there is a classic example. You take out most of the workers And you have sick patients who takes care of them and so I think this is going to be a huge challenge What did you that you saw the news about the million tests by the end of the week? What do you make of that? I? Think that's true. I think we will have that many tests available and When I say available at the end of the week will be gearing up to that we expect this week itself to have about 75,000 tests available, but by the end of the week with all the new Sources of testing we're going to get geared up for that And where were those tests and where will those tests happen? I mean what's the kind of tests for the test is it where I mean is it going to be geographically centered on where these outbreaks are randomly? We're going to see most I think State health departments clearly having the capacity to test in all 50 state health departments and at least 12 or 15 large city health departments in addition other Medical centers are bringing on their own tests that they are very used to doing with PCR These are the ones that will be applying for the additional emergency authorization to do that So I think you're going to see a variety of different places one of the challenge We had with the CDC problems with this test is when they first applied for emergency authorization use by the FDA requirements that gave that test the only Access for people to use a test to that particular CDC test and the FDA has had to respond to that and Basically relax that requirement and allow others to also apply for emergency authorization use And so I think it's a combination of factors. We'll see much more in the way of public health laboratories We will see much more in the private sector Coming forward and again, you know, it was a really very unfortunate situation We didn't have the kind of testing here in this country that much of the rest of the world has enjoyed for at least four to five weeks Why was that? You know, they had a problem with plan a and nobody had a plan BC or D and this was really a Terrible situation. How do you grade the Trump administration on this? Well, you know, I think it was I'll say right now a CDC However, you know could have happened under anybody's administration but there should have been a plan to deal with it when it happened and There wasn't and that's what I think frustrated the people out here in the field is that we knew we had Transmission ongoing and that we unfortunately were in a sense reinforcing this Almost I call it fantasy that we somehow would stop transmission coming into this country And what I have said multiple times over the past six weeks is all we did was fix three of the five screen doors on our submarine And that in fact we knew that we had cases coming in border control as was set up May have slowed down new cases coming into this country To some degree, but surely was far from stopping it look at the situation in Seattle There was a case that was detected in January The individual was put in isolation, but not before he had been in the community and in fact This was written up like this was a great success In terms of stopping ongoing transmission Well as you know at least one of the patients who was tested in Seattle a 19 year old Individual some six weeks later has virtually the same strain which by all scientific and Agreement is in fact a progeny of that original strain meaning that's likely where it came from Meaning that there had to be at least six or seven generations of transmission between the time that the Individual first arrived in the United States from China back in January in this case now Who who it was ill this past week? So we've had ongoing transmission in this country We should have had testing that could have picked it up And while any organization can have a problem with a test like this The fact that there was no plan B. C or D is really unfortunate. How does this unfold and what's the kind of timeline here? Well, you know This outbreak from our perspective has really unfolded on time and what I mean by that is back in Even even the second week of January It was very clear that this was no longer going to be a merge or SARS like situation with transmission It was much more dynamic Clearly it was acting very much like a flu virus and so we have a group here at the Center for Infectious Disease Research and Policy Called the SIDRAP leadership forum which involves a number of organizations and companies that we advise on a routine basis And we've we've actually been having daily update phone calls on what was going on dating back to the second week of January And at that time we said all bets are off. This is no longer a merger SARS like situation. We're not going to control it This is influenza and it's going like transmission and it's going to continue By the end of January we actually Put out to this group that it was just a matter of about probably four to six weeks And we're going to see this pop internationally and it was going to happen in a big way as we went through the same kind of phenomena That we saw in Wuhan where it took five to six weeks before it really in fact took hold Well, you know, I said the earliest we're probably going to see this will be Last week of February, but then don't be surprised you see many countries and Where you have transmission it'll be widespread and it'll appear like it's brand new when in fact It's been going on for generations meaning of the virus transmission. So I ran Italy, Korea, none of these surprised us They they were what you would predict when so when we go from 26 countries Fifteen or 14 days ago and we're now up into the 70s, you know This shouldn't have been a surprise much of it was more a detection issue than it was even brand new transmission So for our country we've been saying for some time There is widespread transmission going on in this country right now It's just being missed and as soon as we have testing. We're going to see it I was on a public television show last Friday night Knowing that certain states had received their test kits that we're going to begin testing and I actually Said on Friday night, you know within the next 72 hours I think you're going to see this thing pop in the United States and we're going to see it in multiple Locations and some locations were probably going to dock Document extensive transmission without any knowledge of what had happened in Seattle So I think that this is really playing out in time. So now where do we go from here? I think a couple things. This is a challenge in terms of where does it go by time? Let me make one point really clear, which I think has has not received Sufficient discussion we keep hearing that this is going to die out with the spring warm or weather in the northern hemisphere somehow as if we're the whole world and part of that is based on what has happened with the MERS and SARS coronaviruses and and SARS in particular which SARS ended in 2003 in June But you know having been very involved with that outbreak of a situation Let me just say, you know, we first detected it in the quote-unquote non-guandong province area in February of 2003 and It took us some time meaning at least a month or the half to two months to really understand the epidemiology Of what I described earlier where transmission was occurring much later in the clinical course And so that we could identify isolate these people we could work with their contacts And also understand what the actual reservoir was in the guandong markets So that they could be eliminated which was largely palm civets and that really stopped the virus from pinging humans Then we just had to clean it up in the human population Which took until literally June, but it had nothing to do with the seasons at all I've investigated outbreaks of MERS on the Arabian Peninsula, and I've stood outside of hospitals when it was 110 degrees and Inside was going a ravaging outbreak And I've seen transmission from camels year-round. There's nothing in the MERS literature I know the outbreak in Samsung Medical Center, which was hundreds of cases In a hospital transmission occurred in May to June of that year So so don't think that that means it but let's just take a look at flu Even if we want to use that as a model because that's what the other thing people do they say well See there's no flu ends remember Yes Influenza is at its peak in the northern and southern hemispheres during their respective winters But it circulates year-round in the tropics. We've never understood that it's always in the tropics And if you look at the last 10 influenza pandemics that have occurred over the past 250 some years two started in the winter three started in the spring two started in the summer and three started in the fall and Every case the second or the big wave was always displaced by about six months If you look at 2009 with H1N1 We knew that activity started there or probably late February early March we picked it up in April early April and We had that initial peak of cases that occurred in April and May around the world But the second big peak occurred in this north in North America and in many parts of the world in Mid-September to mid-October when it was still very warm again just placed by six months And if you go back and look at all the other pandemics that happened in the same way So there is no model here that says this is going to go away You know if it does it does and you know It's obviously a new phenomena for us But I would say we have to be prepared to see this run a course for at least months yet The other thing that we have ahead of us, which is a challenge is that within influenza We know we have some natural protection in the population because of previous infections that were close by in 2009 We had a relative absence of cases in those who were 65 or years of age and older And if you look back these were the same people that would have been younger Adults and children that were still on the reminiscences of the actual 1918 virus that continued to circulate into the 1930s So, you know, they obviously still has some protection We have no evidence of any protection with this coronavirus right now in the population And so that to that extent, you know we have kind of a virgin territory here in terms of the number of people that might get infected and So is it going to be like the typical seasonal flu year where 10 to 20 percent of the population gets infected? We don't know it could be a lot more That's why even when we talk about case fatality rate, you know If you have a disease that has a very high case fatality rate, but only a hundred people get it every year That's not nearly the same significance as a disease It has a low case fatality rate of 1% but a billion people get it And so what we don't understand here is how this virus is going to interact in terms of the number of people infected on top of the Case fatality rate. This is surely going to be every one thing we have says it's going to be a lot worse than a bad seasonal flu year How many people died in the 57 flu in the States? Actually, I think it was about 80,000 I don't have the number right in front of me But but if you actually look at that what happened in 57 and 68 with those for outbreaks In a sense of what was seasonal flu, but on kind of a steroid basis meaning H3 and H2 into which caused the 57 outbreak and H3 into that caused the 68 outbreak the pandemics Were basically just seasonal flu, but a lot more of it So I mean the average age of deaths was in the 60s if you actually look at the 1918 outbreak was very interesting the average age of deaths was 29 and of course we know in some locations It was as high as three to five percent of the young adult population died Well, people don't realize in 2009 even though the overall deaths were less the average age of deaths was about 39 years And if you actually adjust in life expectancy meaning that in 1918 life expectancy was about 48 years in 2009 it was 74 years the actual age of deaths was younger in 2009 and it was in 1918 again both age one and one viruses just fortunately a lot less This one we don't know what it's going to do other than it looks like it's kind of seasonal flu and steroids But as they said once we get into the obesity issue and we start to see we can actually see in many of the high-income countries around the world In particular a very different picture Dr. Wilson we have a quite a number of people in the room and also people on the phone So if you have a question, can you hit your microphone so it turns on and we just anybody has a question how to start with Allison I'm collecting the online questions I've got a few here and the first two are somewhat similar Is closing down schools or businesses for a period of time an effective measure to control the spread of the virus? And if so, what would be the optimal length of time for the operation to be closed? Thank you for that very thoughtful question This is where I I probably sound like I'm a bit schizophrenic and if you talk to my kids, they definitely tell you that's true You know we need to start to normalize our response to this and what I mean is is that we we got to be thoughtful We can't we can't just knee-jerk, you know right now We're thinking about this kind of like it is when I play checkers with my ten-year-old grandson You know one move down the board and boy, that's a big deal, okay? We need to play this like a chess master somebody who's thinking out 20 moves down the chess board and And and one of the concerns I have is any action we take there is a Significant reaction and it all should be about obviously reducing morbidity and mortality But let's take schools for example right now We've all been struck by the relative absence of cases in kids in China to two point one percent of cases or 19 years of Age or younger case fatalities rate is very very very low very few cases as such there's only been a couple of Examples where people have actually looked at kids who are otherwise largely healthy and Looking for virus shedding and each of those occurred in family settings where other family members were quite ill or died and The kids didn't appear to get sick And so they actually tested the kids though just to see and in several instances they did find kids shedding virus Well, we've got to really really understand that because I think there's a case to be made We don't want to close schools That in fact it won't have the kind of impact with influence that we want to do that because we have Clear and compelling data that kids can serve as a major reservoir for this virus and seed it through communities And in fact even with seasonal flu when we close down schools for the Christmas holiday often That actually will slow down transmission in communities when you get kids out of schools So and here's a case in point where I'm all for closing schools If we show that kids are important to submitters of the virus But if it's only because we are going to do that now when they're not that but that's what we've always done Then I think we make a mistake because for example school closings have tremendous impact in communities workforce in particular and And in a disproportionately affect the lower socioeconomic status individuals who don't have alternatives They got to stay home with their kids and then they don't get paid And so one of the things that we don't want to do is react like that So that's one thing for businesses, you know, this is one area where again, it's a major challenge You know, we've got to keep the lights on we've got to keep food coming and we've got to keep Really critical drugs coming one of the areas that we have been very involved with has been looking at the supply of critical life-saving drugs in the United States for that matter around the world and We've been studying this now for over the past year and a half and we brought together Several groups of medical treatment experts a year a year and a half ago and came with a list of a hundred and fifty-three different Critical life-saving drugs that people need right now or people die. What's on the crash cart? What's the emergency room that kind of thing and In that list of drugs we found all of them were generic most of them made outside the United States and 63 of the 153 were already on some form of shortage status meaning that just with routine commerce They we didn't have enough when you trace that back and you look at the supply chains many of them originate in China and What isn't made in China is made in India, but in many cases the API the active pharmaceutical ingredient will come from China And so one of the things we're trying to study is that because one of the nightmares I have is that as we start to see the major increase in cases of this Coronavirus infection in the United States is also overlaps and kind of a perfect storm way with the You know we exhaust the supply chains We do have in place meaning that there was product in the pipeline before this happened But it's only two to three months worth and that even then we're going to start running out of these drugs And so there we need to keep commerce going. We need to keep This is a situation where we can get life-saving drugs and critical medical supplies and things like that and food to people So we need to balance what we talk about when we say that, you know, we're not going to you know Basically have people go to work. Let me just give you one last point Power here's an example. We take that for granted all the time when you're in a low-income country Power is never taken for granted because you never know when you're going to get it in the United States We still supply about 30 to 35 percent of our electricity with coal much of the coal that comes in into this System in the North America comes from the Powder River Basin in Wyoming in Montana. It's high BTU low-sauce for coal It's a kind of coal that you just can't get anywhere else in the United States and you can't use Other coal in these generators Well, it turns out that the coal that comes out of the Powder River Basin is Delivered on coal trains to all parts of the United States and these coal trains are very unique 110 car trains made out of aluminum And the weight is remarkable and it turns out that these are so Specific in terms of the track that they run on that the engineers who actually run these trains go several hundred miles each day One way get off go back home because I mean they drop for take a train back to their original location Because if you're not going 28 miles an hour at this point you won't get over a peak But if you're going more than 32 miles an hour here you tip and so they run these coal trains almost like the old riverboat captains did in the Mississippi and the Ohio River long before we had radar and Today, you know what if those if those coal train drivers go down with this We're in big trouble because you can't put a National Guard replacement on that train and run those trains If you're an airplane pilot, you know if you're an airlines pilot You can find any airport in the world with the book in your hand knowing, you know what the issues are you can't do that here We've had major shortages occur plant shear Which is one of the largest plant electrical generating plants in the world is outside of Atlanta And we've had a number of times when their coal supplies have gotten down to a day or less So we think about that kind of part of business We got to keep those coal train drivers as safe as possible and how we're going to do that is a real question I could go through other examples like this where we just forget about How we depend on that part of our world for existence and if we don't have electricity We won't be running hospitals because not only do they need electricity even with their electrical generators Remember the electrical generators come from diesel fuel which has actually made it refineries that need electricity to make the refineries to make the diesel fuel So that's what we just haven't thought through the consequential what I call collateral damage issues Other questions Thank you, this is really helpful Just to to further your point about schools and businesses and from a research standpoint, how long will it take to know? Whether school-age children are transmitting it or if they're vectors for this and just to know more broadly More about how it's being transmitted to whom and etc Yeah, thank you. I mean I don't know when we're gonna know I we need this research done badly It was clearly one of the priorities that came out of the WHO working group meeting about three weeks ago that these are infuses of data You know, I'm at the point where I think we have to make our best Estimates of what might happen in some cases. We don't have the data one of the things I have been advocating for for Some time weeks in this situation knowing that it was going to get this bad I think this is probably going to get handled ultimately almost on a state-by-state basis where You know, there's not going to be a federal blanket do this or do that They'll say take it back to your local leaders and I think every state right now should have a COVID-19 Task force that's made up of elected officials Bipartisan it's made up of public health experts and public health officials the medical community certain selected private sector people who basically are going to wrestle with the fact What do we do in our state and then have everybody do it? The last thing we want to do is well this seven school district going to stay open these four school districts are not You know, how are we going to make sure we prioritize that we have food? You know, I find this challenging for me because if I hear it one more time from a media person I'll probably scream but oh my god. We can't tell miss a bill panic. What is panic? You know, I've not seen anybody panic yet You know the closest I've seen is you know people going out and exhausting the toilet paper supply at Costco Okay, which makes about as much sense as the gas lines. We had the night of 9-11 as you already call We had gas line, you know cars lined up for two miles to get gas because somebody started doing everybody did it But we don't see the kind of behavior that's riding in the streets, you know Setting cars on fire injuring people You know people take you know doing harmful things to themselves or family members because of this and And and the way we even minimize that is to just tell people what we know and don't know Straight talk and then get consensus. So how are we going to handle this here and make it a non-partisan? science and policy group and I think that's where we're going to ultimately have our best chance now somebody who's on a National in a national company in a national company. So I don't want 50 states telling me what to do But I think what you're going to find is is that for them how they handle workers How they for example, I'm I'm I'm right now Probably not on in the majority voice and surely not popular But I think quarantining people coming back from high-risk countries today is is a misnomer and totally unproductive Meaning that right now. I I think you could just as easily make the case. We should be basically quarantining slash Travel alert to King County and Sonomish counties in in the northwestern part of the United States We do Italy and yet look what we've done to Italy and in Iran and Korea We've got as much transmission around the world right now in many places and it's going to happen everywhere And how many places can you finally? Coordinate off before you say oh, well, you know We're all walled off here in the United States and we're just as bad I was asked this in fact in a in a radio show a week ago And I meant it kind of tongue-in-cheek, but somebody said asked the question Well, wouldn't we know the United States is really in a big hurt big problem with that? And I said it's with the air China refuses to fly here because it's too risky You know, and I think that that in a sense, that's what we need to do So I would actually say now we need to start normalizing Don't do these quarantines because there's just as many people likely in this country Who are going to pose a risk as people coming back from countries with disease problems? That's the kind of thinking we need to start having now. How are we going to get through this? You know public health has got to stop doing contact tracing, you know It works when it's a few cases, but I'm telling you right now You could have all the public health workers in the world Working on this thing and we wouldn't have nearly enough and what we do is not do public health Just just take a step back and think about this while it's not a perfect correlation you know, we've had Almost what 2600 people die from Ebola in the DRC area in terms of of our Outbreak we've had the last several years and every resource has been so Targeted from that local area During the same time period over 7,000 kids have died from measles in that area Because we don't have the measles vaccine campaigns going out like we once did And so we have to start thinking about yes, we want to deal with the problem at hand But we also have to start dealing with the collateral damage And in some cases the collateral damage may actually be worse than the actual disease outbreak so businesses I hope we can keep them running as much as possible You know whether you're at work or you're at home the person who does remote work with their business That's great But then when they go out that night to the grocery store or the shopping center, you know What have they just done? I mean it's not going to be any different So I think this is part of what I I think about when we talk about seasonal flu When's the last time somebody basically greatly altered their work setting the business operations based on flu? This is worse. I don't disagree But somehow we've got to take lessons from that and move into normalizing our response to this or we will we will you know all You know shut up in our homes and and I'm not sure what that accomplishes Hi, I'm tying right into that. I actually have travel planned to Indonesia and the Philippines in a few weeks And so I've been closely monitoring this And I wasn't too concerned until yesterday a time article came out that said it's like statistically Impossible or almost impossible that countries like Cambodia, Thailand, Indonesia don't have cases But so far they are reporting zero So is it a case of like not doing their due diligence of making tests? Or they're covering up and so I'm kind of curious if there is a way to I don't know like not hold accountable, but like how do we combat like governments? Maybe not being a transparent around what's going on in their country Well, you know, I I Thank you again under very thoughtful question. I I don't really worry about governance being transparent I I'm assuming that number one because it doesn't matter Assume it's everywhere. This is a global influenza pandemic caused by a coronavirus happening And even if governments were completely truthful in all regards I'm not sure because I mean we were we were not lying in the United States a week ago When the president got up in front of the country and laid out the number of cases we had confirmed that was true But it did reflect the reality. What was happening? Absolutely not And so I think that many countries around the world may have some of the same problems of testing and what they know So I just assume it's everywhere now given that the the question becomes you still want to do international travel Well, I think there are two things to consider there one is surely being in large numbers of people Anybody's ever been to Indonesia Jakarta, etc. You know, there's a lot of people You're going to likely increase the chances of being exposed and getting infected not depending how long you're there and Your age or underlying health status, etc. If you need hospitalization, do you want to be hospitalized in Indonesia and Then the final piece is is that you have to ask yourself, you know, what's my government going to do tomorrow? You know, I actually raised this issue the the Second day that the Italy cases started to emerge and I thought our Syrup leadership group and I actually said You know, I wonder what it'll be interesting if a week from now We put a travel alert on there and on Italy we did and so there's no rhyme the reason today necessarily when Countries will have travel alerts or quarantine issues Because many of these are being made politically not based on on what I call the best science I mean, we're still seeing the administration taking credit for having quote-unquote limited transmission in the United States With the work that was done, you know with the travel issues with China with the airport screening Which the last number I had it was well over six hundred thousand people had been screened in that one case had been detected And so I think but that made people feel good We were doing something and what I'm concerned about is being an international travel status We don't know what that's going to mean Now I would tell you if you have a chance going to cruise ship right now I'd bypass that one cruise ships have been notoriously a problem with respiratory transmitted agents because we know all the Recirculated air that occurs in the inside cabins and I would hold that long time before that the diamond princess happened So I'd say definitely stay away from that, but if you do international travel I don't think that it's putting you that much higher risk other than large crowds to getting infected But I think the idea of do I want to get hospitalized in country X and do I know that I can get back into the United States? Without a 14-day quarantine. I think our questions that make me want not to do international travel right now This is all really interesting slightly terrifying, but thank you for taking the time My question is that there's a whole lot of people in this country. We don't have paid sick time and I'm wondering What there is that we can do in the short term To encourage those people to actually not come to work or is there anything we can do I Don't know if there is really anything we can do. I think that again, it's People's comfort level, you know one of the things I talked about in my book was you know that which kills us that which hurts us That which concerns us in that which scares us sometimes are all very different and you know people are reacting to this differently Relative to what has having a seasonal flu and there may be some good reason for that relative to the increased number of deaths But again knowing that those to date at least have been largely older populations and people underlying health conditions So again, how do you keep people coming to work? You know, we've had Situations here in a very limited way, but it's more case numbers increase that will change where someone finds out a co-worker was infected and You know there is a real concern at the workplace about what does that mean and again? I think that this is where preparedness comes in every workplace setting today should be discussing this right now With their employees. This is what we know. This is what we're going to do You know if they were sitting in the desk That desk is not you know a highly radioactive viral You know cauldron right now, you know, if at the very least it can be just wiped down and it's fine And that from a respiratory standpoint, you may have been exposed What you need to do is over the next 14 days if you develop a respiratory illness This is what needs to be done How you you know don't go into your doctor's office call ahead and I think when you lay out more what will be done People are more willing to say okay. Well like this could happen whether I'm at work It could happen whether I'm at a PTA meeting or it could happen if I have to go to the grocery store I think the one thing that I do have concern about that some people are so reliant right now on Some kind of face protection and thinking that that's going to help them You know, we are urging that all in 95s be used by health care workers or critical Infrastructure workers only not for the general public. We're gonna not have enough and again I've already made the case why we should be checking our health care workers People may then rely on surgical masks, which will play little to no role in reducing transmission It can only help for those who are infected if you put one on when you cough out or you're breathing out in many cases The large droplets and to some degree even the smaller ones will basically stick to the inside of that mask and Reduce your transmission load into the environment, but not not stop it. So I think at this point To come back to the workplace setting. It's just the more information you can give You know people are gonna realize they have to move on with their lives Again if remote working as possible do it if they want to do that But at the same time then warn them at least help them understand if you do that for you know 70% of the day, but then you spend the night out, you know at a restaurant or whatever, you know You've kind of more or less in a sense Minimized all that you did during the day to protect yourself Go ahead Hi, I have a quick question about pandemic communication So I think definitely as compared to stars in 2003 and even MERS in 2012 our access to information like a 24-hour newsfeed on our phone push notifications and social media really lets everyone follow The pandemic as it evolves everything that happens is reported And I'm just wondering if you think that increased access has been a positive thing or how we really affects response to the pandemic And if after covering so many pandemics you think there are any best protocols for reporting and science communication Yeah, thank you for that. That is really a very important point First of all, I fortunately haven't a call really covered that many pandemics You know clearly the 2009 H1N1 was a pandemic and a worldwide epidemic of of a new disease But I'm clearly in the middle of this one. I think you're right about social media and also though You know in 2003 we did not rely much at all in China for many supply chains that we do today So the idea that working together With them was very different back then, you know, it was a different challenge in terms of that I think today so many people portray themselves as media Whether they're social bloggers, whatever their journalists and and they're not and I think that you know a journalist is somebody trained in the Field of communicating Reporting and how you do that and I think that that's a very important point Just as we see with our political systems today the fractionated populations we have based on this issue I mean I have dealt with on multiple occasions over the past couple weeks So many conspiracy theory issues about you know that China intentionally released this it was an accidental release from the virus center there in Wuhan that you know Just any number of different things that are just simply not true And you know, I'm not an expert in this area of Peter is actually much more expert than I am but the idea of the Russian influence on Internet we have some evidence that they were furthering this whole idea of the fact that this virus was made on the Internet and so I think that that has challenges, but I think the other part of it is is that When things get written today and we see this with vaccines, you know science literacy in general People then take it as gospel truth And if you're following a certain type of messaging you're looking at certain websites pretty soon You become convinced this is what's really happening. And so we do have challenges today with the media I have to say it's been somewhat reassuring You know the Sid rap news team here, which you know, they're a part of Sid rap, but because I'm in the news I there's a very thick editorial wall between myself and them. I read the stories the same time you do Has had a remarkable increase and we're now getting millions of readers every month because we're not kind of paywall You know the Washington Post in your times You know Wall Street Journal has done a great job covering this but they're all behind paywalls And so for many people they can't get at it. So there people are trying to get to legitimate reporting sources But nonetheless your point about what's happening on the Internet is continuing I find the challenge is also though about the misleading information that then becomes if it's reported enough times You know, there are some who said that this virus is only transmitted via the hand to the face and so forth And that's simply not true. We have compelling data on influenza transmission Which this is just like this in terms of of ongoing transmission Fine just breathing and air and so I think that that's a that's a Big issue that people don't want to believe that they believe if they just don't if they wash their hands a lot They'll be protected and frankly hand washing may play some role in this but not nearly what people think it is It's all about the air and the area you're breathing Dr. Ross and we know you're super busy So we really want to thank you very very much for taking time out of what is an insanely busy time for you to talk to us and Also want to thank the communications team here Allison and also Melissa and Joanne for putting this together So well and thank you and Peter. Thank you for your leadership and all these topics There are many of us out here in the field who count on you for getting us the information about what's really happening in the world Okay. Well, thank you Good luck. Thank you. Bye. Thank you, sir Thank you for coming