 And if you asked her if she would submit a videotaped message for this conference, which she kindly did. And so we're going to view that right now. It's about four minutes, little over four minutes long. Travis, would you mind queuing that? Great, thank you, Steve. So welcome back to everyone from our little lunch break. And it's my great privilege to be asked to moderate this section on civilian military cooperation in the Mekong sub-region. So with me here on the panel today, starting to my left, we have Major General Ben, Director General of the Military Medical Department at the Vietnam People's Army. We have Rear Admiral Colin Chin, who's a command surgeon in the US of Pekong. My name's Alan McGill, Director of the Malaria Program at the Bill and Melinda Gates Foundation. Here I have Colonel Mark Fukuda, who is an active duty in the US Army Colonel. Who's on succumbent to the CDC as a malaria advisor. President's Malaria Initiative in the greater Mekong sub-region. Then I have Dr. Nipon Jananawit, the Director of the Thai Bureau of Vector-Borne Diseases. And then on my far right is Dr. Ong Ti, the Director of the Myanmar National Malaria Control Program. Their more complete bios are in your handouts. So I'll let you refer to those. But I think one of the purposes of today's session is to talk a little bit about the global significance of malaria in the greater Mekong sub-region. In particular, P-Falciparum Malaria and the threat of Artemis and in resistant P-Falciparum Malaria. And what that means both in the region in terms of making the operational difficulties of dealing with malaria harder there, but also the threat to the global eradication program that we might all be envisioning. And that part of this is understanding that the military, the militaries in all these countries actually play a significant role both in the potential control of this, but also as a risk population because a little bit separate from the civilian populations and not necessarily always included in the discussions that we've had in our civilian counterparts. And so that these individuals may be at higher risk because they're deployed and often into border regions for exercises and such, and then can return to the non-indemic areas harboring parasites. And we really would like to highlight the possibilities of civilian military coordination and cooperation in this group. And then we also don't wanna forget that it is about greater elimination of the P-Falcifrim in the greater Mekong sub-region and that is a regional area if you remove the political boundaries of the map and we just see mountains and forests and valleys and rivers. Well, that's the way the parasites and the mosquitoes see it as well. There is no national boundary. And so at a certain level we recognize national sovereignty as probably the only true constant in terms of the global health architecture, but how do we rise above national sovereignty when needed for these regional cooperative efforts? So let me just ask Admiral Chen to start off the discussion with some remarks. Okay, Dr. McGill again, thank you for the introduction. I'd also like to thank Dr. Morrison and CSIS for one inviting me to come to the seminar you're having but also to be a panel member. So I greatly appreciate that. So you may be wondering is, why is US-specific command, why is US-specific command surgeon interested and involved in this problem, this Artemis and resistant malaria problem in the greater Mekong sub-region? So over a year ago we were approached, my office was approached by the Global Fund to see if we can assist in the overall effort that they were leading. And I said absolutely once I found out more about the problem because I'm a gastroenterologist. So last time I was worrying about malaria and learning about it was over 30 years ago when I was at medical school or where I was at the Hopkins School of Public Health learning about that. But when you become a gastroenterologist those things sort of go back to the wayside but luckily I still had some brain cells that remembered my malaria teaching. So that brought the focus back to me, the importance and it has become one of my priorities as the Pekong Surgeon to be involved in this because if you look at it the US military has been involved in malaria for decades. It goes back to the turn of the century and then the start of the 20th century that we realized in the areas that the US military operates as well as today in exercises and operations that we are operating in countries that have a malaria problem and that potentially could be a force health protection problem or challenge for us as you heard from Dr. Smith this morning. So that is a basic reason why Department of Defense is interested but also it's also important for us at US Pekong because we're also very interested in health engagement with our allied and partner nations as well as to help them to build their capacity to address problems such as this. So those are the major things and so we were asked by the Global Fund to participate because they realized that we do have some relationships with many of the countries in the area and to help get them those military medical departments interested as well in this problem so they can come to the table with their counterparts in their Ministry of Health because in some instances that may not be something that occurs on an everyday basis so they asked me if I could make my, as I did with this Major General Bin to talk to him and he was very receptive to that concept as well as his Ministry of Health. So that was again a large basis of our involvement and also the realization as you mentioned as Dr. Miguel mentioned that these militaries as we know the endemic regions for the resistant strains is in the border regions and this is the areas where the militaries operate because they work in the border regions and as Dr. Miguel said, they travel back and forth and so that's a potential conduit for transmission of the disease from their borders perhaps to their larger cities so that's obviously a great concern but also as we have found out that the militaries also may be the only major source of healthcare in these regions and they also as we've discovered they also may take care of a significant proportion of the civilian population in these border regions and some of the numbers that we've discovered up to 30 to 50% of the healthcare could be provided by the military. So again, sort of emphasize the need for my opinion for the military to be part of the discussion and part of the solution. My personal belief is that to have a successful national strategy to eliminate malaria for the reason I just sort of cited that the militaries need to be involved in discussions and in developing the national strategies. So with that in mind over the past year we have had two conferences. There was first in Demang in June of last year hosted by the Global Fund and we were a participant and then in August, two months later, Paycom with the Armed Forces Health Surveillance Center also hosted a conference in Cambodia in which again we had representatives from both Ministry of Defense and Ministry of Health who came to the same table, came to the same venue and had a great discussion. Everyone shared what the challenges were, what their populations at risk were. So good initial sharing of information and the plan for the forward is to continue that effort again with our partners with the Global Fund, Presence Malaria Initiative, Bill Millen and the Gates Foundation and the World Health Organization. And then my final comment would be the other area that we have concern. You sort of heard that I think in the opening session is that our realization that many of the militaries in the Greater Bayconk Subregion also send peacekeeping forces to Africa. So obviously there's the potential transmission of this strain of malaria to Africa which I think would be a global catastrophe that I think we could prevent. So our interest is working with the militaries to find out more about how do they, what are their pre-deployment strategies? Do they, how do they pre-screen their service members before they deploy them and what are the treatments that they're given if again for malaria? And so we are starting in some initial private pilot projects to work that. So that's a very, very brief summary is our contribution to the effort. And again, I look forward to any questions that you have my way as we proceed with the panel. Thank you. Great, thank you Admiral Chen. Maybe our next turn to Colonel Fukuda to make some comments in his current role. Thank you, Ellen. Yeah, I'd like to echo many of the comments that Admiral Chen and you, Ellen, have articulated from my experience, both from having experience in our own military health system as well as now in the position of working with PMI is that I understand that malaria is, that our risk that we face in our own military is very common with the risks and the perceptions of how to address the issue in foreign militaries and that in fact there is more to be shared in the experience of in common between our military as well as between militaries in the region. Like our military, there's a job to do. They're on mission. Unit commanders have to be apprised of the importance for malaria prevention and control measures and that malaria, comprehensive malaria control has to spend beyond simply being viewed as a medical issue. Famously, every once in a while have unfortunate cases in the US military where we are on deployment and the simple preventable measures are not taken and then we have the unfortunate circumstance of either having deaths or what have you for a disease that could have been diagnosed with a $2 rapid diagnostic test. So in that regard I think to push the awareness, the diagnostics and treatment capabilities down to the lowest possible level that prevents that from occurring that takes the occupational force, the military out of its traditional mission role so they can be returned to duty is a common interest in our military and in our partner militaries. It is worthwhile to keep in mind that that's the way that we will make the best, I believe, progress with our partner militaries is to, in many of the same ways with private sector engagements, occupational plantation workers, for example, their interest is to stay on the job as long as possible. The plantation owner wants a healthy workforce. Our militaries want a healthy workforce and that's really the way to approach this problem. Thanks, Mark. Great comments. I'll just take this opportunity to note that one of the papers that was written for this meeting is actually written by Mark and it's about the contributions of the DOD, two malaria elimination in the MECONG and then also take note that Chris Plow also wrote a paper on Artemisthen resistance for this conference. Those will be available to you and I encourage you to read them. So let me turn to my left here and ask Major General Ben to make some comments on the perspective of Vietnam and the Vietnam People's Army. Thank you very much for your invitation. It's my second time in Washington. Now let me share some lessons we learned from the military civilian cooperation is the last time. For more understanding to the cooperation, it's good or not good. Let me first of all to present to you some reason from our military malaria prevention from the last time. Vietnam is in the last 20 years highly successful in history against malaria. So I can give you some data from this. Dramatic decrease in malaria, for example, 1990.8% mortality reduction from 1991 until now. For example, in 1991, there are more than 4,646 deaths per year, but last year in 2013, there are just only six deaths in the year. And the 97% case reduction from 1991 until now. In 2000, there are 270,910 cases. But in 2013, there is only 35,406 cases. So inside of the military, in the last five years, there is no deaths inside our military. And several malaria cases, there is only one case per year. And malaria cases rate for 1,000 soldiers, less than 1.3. And until now, we have no malaria outbreak. So we learned from some lessons from this reason, or some factors resulting in our success. We established a very strong commitment of leadership and involvement of all levels of government and communities. For example, we have a national program again for malaria protection. And we have a steering committee from inside of military. And we have a Malaria Prevention Center in many levels, in the province. In each province, there is very one Malaria prevention center so they're looking for the malaria control inside of the province. And our military, we have a steering committee for malaria control. And we meet each other two times per year and we get a report from cases and follow-up and providing strategy against malaria. And now we have more than 25 military hospitals. We deploy countrywide and each hospital, they have a duty, a job to looking for the malaria cases, surrounding where the hospital is deployed. And we have, there are more than 400 military care health services, especially in the, along to the borders. So these forces belong to the border guards. So they're looking for the malaria cases in the population surrounding there. And very important is most of this, they deploy in the remote areas, in the island and some areas of poverty. So where the people living in poor education and poor environment, the military forces provide the health care service and provide the program for the malaria control and some we provide medication for free for the people living there. So the other point is that we have very good civilian and military cooperation. In the last time, the chief of military department take the same position like vice minister of health. So they have two functions, one is military and one is minister of health. So we have some, the military myself is the member of the national program for malaria prevention. And we have cooperation with military medical doctors with civil doctors in any areas where they deploy. So in the last time we have some cooperation with the international from the Global Fund and some with the Australian Defense Force for project for 10 years and now we are improving and establish the cooperation with the US Navy. So from this one for the next future we still have to face with some challenges for the malaria elimination. For example, in some region in Vietnam, in Central Highland and Southeast Vietnam is still prevalent some belong to the malaria epidemic. And immigration and malaria in Vietnam now is per year, nearly 2 million people, they belong to large mobile population. And more than 1,050,000, they move to the Southeast of Vietnam and in the Central Highland. And more than 85,000, they are living now in Africa, in the Middle East, and making progress. So all of them, they are on the rest of malaria. So we have some problem with malaria, drug resistance with after-machines and the rate between from 14 to 31% from some studies in these areas. So our strategy for the next future is we have keep our good lesson we have and we have more cooperation with the civilian and military and in our military the left cases, infected malaria cases, most of them is we cannot follow up the cases. So our next strategy is we develop our case follow-up system when we can improve this system so we can go closer, closer to malaria elimination. Thank you very much. Thank you. Very nice comments. Let me turn to my right here and Dr. Nipon Chinanawit, the director of the Thai Bureau of Vector of Born Diseases. Yes. In Thailand, the majority of treatment of malaria is not the military. But in the past, when do you have the social infection with malaria? We go to the public health hospital and now they have a unit from the military to treatment malaria in the military. And I will call themselves to support equipment sometimes or something when you request, not as usual. And when do I get to the goal of illuminate in Thailand in the last year? I will cooperate with the Army Medical Department to send and you have in the future we will cooperate with the military with the civilian to illuminate the goal in this. And when in the past, Thailand has a Medicaid of Myanmar Thai border has Medicaid and Thai Cambodia is a Medicaid. And in the last year have the Medicaid in the Thai Rao and Cambodia in the south of Rao and Cambodia and not eat from there to have the illegal cut wood and the infection from this outbreak has about 30% in this year it's from this area has the illegal cutting wood is not an infection. It's not live in the mid-air it's not in the genus care in this community in the last year. I think it's up to when in the future we will get and we got with the military to set up with the to clinical practice skylight to teach men Maria again and I think it's up to some area to have the resistance for artists in it to shoot to use the dream Maria. Now in Thailand to use the ACT to involve the artisan and and primary queen and coral queen is not used the H.A.P. Parakeet. The H.A.P. Parakeet in Thailand is to pilot to treat men is not used everything. And in the area have the resistance have to some area in the Thai Myanmar border and some area in the Thai Cambodia border there is no resistance in the Thai route it's not have evidence for the Thai route. In this year I will study for the resistance in Thai route it's a Ubon La Chathani province near Thai route in this year I will study for the resistance for artists in this year. I think it's a military is cooperate with the civilian in the future is a core important but it have the I think it's for supportive for the policymaker to decision for everything. In the past the budget for support Maria in the 10 years ago is a half is about the 7 700 baht in the past in the 2, 10 or 20 years ago. This year is a from the to Thailand is have to operate 10 or 20 baht a million baht in Thailand for a million but I think it's have to when you want to eliminate Maria you have the special project for to set up the eliminate Maria in Thailand every day of permanent secretary of public health you have a project you will to set up this project in this year and the 2 wrong in 10 years ago I think it's have to set up and to eliminate goal in the Thailand in the future and I think it's a million medical department it work with the and everyone too but I know everything you every man I give this coordinate with telling information and to try treatment and everything I think it's important to eliminate with my team in Thailand and I think it's have to to recommend for the policy and to everything to in your book to recommend I think it's important for me to take activities I will care for my boss to take action from this in the future great thank you thank you very much next speaker is Dr. T and this is a Myanmar and Myanmar is up until maybe 10 years ago clearly had one of the highest burdens of falciparum malaria in the greater Mekong sub region still has a high burden but there's been remarkable progress in just the last three or four years and so please just thank you actually the Myanmar among the sub Mekong region this this malaria is decreasing but still the most prevalent country in this Mekong region around 70% of malaria is belong to Myanmar Myanmar and also now the Mekong region the GMS is aiming to get elimination by 2030 this somebody said there's two ambitious because we have a lot of malaria in compared with Thailand and other GMS countries and also in concern with the civilian and military cooperation you know in terms of elimination one of the assumptions is social and political stability is very much important but you know in Myanmar there's a long civil war is still present often sometimes they fight and sometimes they talk about peace and also the most of the like a ethnic group army they're fighting along the border China Myanmar border and also Thailand Myanmar border there's a little bit deep cut to control the malaria also and also the military percent are ricks getting malaria and also they are ricks because they are because our control program is emphasizing on this migrant population and also the military groups are also migrant and mobile frequently and also they are carrying infections to place to place that's why the military percent are also a ricks full sign for to target for the malaria elimination and also like the military their orientation mission and mission is the military operational orientation and that's why they are for the like a malaria operation and also data sharing they keep for security and the secret secret that's why we need to negotiate between the civilian society, civilian and military to to get the malaria elimination in the future and also as a like a national program because in Myanmar military we have a very good relation between the front service medical research unit making some study and research together with the support of global now but the difficulty is they have their own cream and policy because our national malaria control program are not practicing the chemo provenance but the military they are practicing chemo provenance this is one difference to negotiate and also they have their own strategy but we need to be think about that military also as a like a national we need to make we need to negotiate and discuss for the policy and also coordinated strategic plan and also strategic plan and also the action plan together with military and also civilian and also most of the border area are occupied by this this is a sensible and personnel cannot reach and also the outreach personnel are in the area or the military strategy area and also the border checkpoint also under the military that's why if we we discuss with the military to become a like good partner with same same or modifying coordinated strategy plan we can do faster for the like a checking and border checkpoint and also the outreach area cover by military and get that our malaria elimination plan operate by military that's why we need to develop coordinated strategic plan and action plan for the to what malaria elimination and also we need to think about not only the government military and also ethnic group army we call non-state attack they are also managing malaria control and control activities along the border area especially in the dynamic map border that's why we also think about the military and also other non-state attack do important as a partner with the same goal and coordinated strategy and action plan thank you thank you Dr.T the so just thinking a little bit about this there was some comments made earlier about the global fund and I'd be very curious to know so five years ago I would have thought it would be impossible to conceive the global fund would actually sponsor and host a meeting about talking about the military working with the militaries in the greater Mekong sub region what do you think helped contribute to that what seems to me a little bit of a shift of focus based on and I'm sure some of many of you were at that session how do you think the global fund is one of the biggest multilateral donors in malaria typically working only with the civilian population but now seeming to embrace the military as a population within these communities maybe Admiral Chen if you want to make a comment there or an observation I guess I can start that conversation so I wasn't there during the initial sort of invitation to Pekong but I was aware that this was new ground for the global fund and so and I also think in DOD that we're changing how we're operating because I've brought to my office sort of more collaborative approach in which not only are we trying to work with our component services within Pekong, the Army Navy, Air Force, Marine Corps but also to work more closely and coordinate better with the U.S. Inter-ADC and be more transparent on what we're doing so I think perhaps when we then came to the table at those initial meetings that the global fund hosted I think we surprised them with that approach perhaps and again I don't want to speak for just from the global fund but that was the approach that I came in there is we want to be partners we want to work as a coordinated effort with everyone and perhaps that approach has been well received Thank you Mark any observations you've been in that region for a long time Well I think it just has to do with the population at risk and the population at risk and military that is the population that has to be addressed in many ways parallel to the conversations this morning about the role of the private sector it's a different health system where you need to take a different approach in order to reach populations that seek care in the private sector there are different distribution mechanisms different motivations so that sector cannot be ignored and nor I think can the military be ignored it's all part of the drive to fine tuning approaches that we really are reaching end-of-the-mile populations that it's really demonstrating So one thing I'd be curious to hear from our colleagues from the region what exactly are some of the challenges we talk about MIL-SIV and SIV-MIL interactions but then reducing that to what exactly does that mean does it mean data sharing well that's sharing data from the military is always going to be problematic because of operational security concerns and other issues that's generally not what militaries do is broadcast their deployment postures around the world and is it best technical practices is it at-risk populations need different tools or strategies just so from your perspective maybe start with you General Ben when we say military-civilian cooperation or coordination what exactly does that mean to you and what do you need from the civilian sector and what do you think you can provide from the military sector back I don't know how about the other countries but I think in my countries the cooperation between military and SIV-MIL very smoothly for example now we have inpatient in military hospital and more than 80% capacity from hospital we open for civilian and now in my countries the people still trust very strong from military medical service so they come very often and they like to choose to come to the military hospital so in the remote areas it's the same and the means of defense they cannot touch in the area especially the remote areas so they would like to pass this task to military and medical service in these areas so in my countries the cooperation very I think it's just very easy to work each other very easy and you share a burden from the healthcare from the population in Thailand some areas have to coordinate with the military and SIV-MIL some areas I'm not sure in some areas it has to coordinate to work together the same the not near the seas or near the Thai Cambodia body it has to work with the military and civilian to teach men and to control in the area of the seas game and some areas near the Thai Myanmar body I'm not sure to coordinate with the military to coordinate with the civilian I'm not sure but I think it has to sample from the Vietnam to some areas to set the system coordinate with the victory control or the other to prevention and to civilian in the military I think they have the civilian in military I'm not sure it looks like the civilian civilian in Thailand civilian in Thailand is from the civilian with the military in the community to report and to set up the the way they have the outbreak or the other and sometime in have outbreak in military I'm not sure to have to I think it has to in the future Thailand to set up with the system to consult and to to check with the military in the future let me add something for example in the some very remote areas very difficult areas we established some we put a big name is civilian, military medical service so we bring all the people from the military and civilian working together so improving the power in the very poor areas in the very benefits of this distribution I think it's the last year it has an outbreak in the in the province I have to consult with the soldier in the area to protect the illegal to cut the national I will use the soldier to protect this and just in the again your observations from the the ability of the military and civilian malaria groups in Myanmar to work together what works well what can be improved in the past because of a political issue there is no funding for the military group only for civilian group by global bank our government changed for civilian type the global bank flexible to support military group to conduct malaria control and also for the containment for other resistance by military medical personnel and also they are expanding the medical coverage by like the military medical unit not only for the military personnel but also for the civilians especially for the very remote area hard to reach area cannot reach by ordinary civilians medical service now the domestic funding from the government also increasing to support the military and also civilian especially for the malaria control group trying to get to the face of malaria elimination and also another problem is like they have their own mission and their reasons and also we've got to get the data and all data sharing is one problem and also our civilian surveillance system for malaria control is not included our surveillance system not included military that's why we need to modify and also as I said coordinated strategy plan and SEM plan also coordinated SEM that's why we need to modify our surveillance system include all the partners and also to get all the data for the program management that's we need to strengthen our surveillance system and also modify SEM thank you it kind of strikes me hearing some of the comments that you could take this unpack this military civilian a little more in the sense that you know the first step is I call it as a malaria free military that's sort of the first step whether it's American military or Vietnam or the first step is that your military is free and then malaria free and then you say well what exactly is the boundary of that we all recognize that you have your quote active duty component which is the men and women in uniform but then often there's a surrounding dependent there are families and groups that depending on the country and the military can actually even deploy with the military members so really defining the boundary of what's malaria free that's the base and then you build up there's a certain level of just say coordination and cooperation which is data sharing where actually are you collecting cases what's happening sharing best practices is there a forum by which the Vietnam people's army and the Myanmar military and Thailand and Cambodia and Laos for example the militaries can get together and share best practices for years and I think we still do that and then our forces get together on a routine basis the militaries and we'll actually share we'll talk to our British and French and Italian German colleagues and we'll share best practices and also worst practices which happen sometimes amongst each other because we learn from each other and then I was struck by your comment General Ben about well what's that next level which is almost integration which is this combined civilian military intervention of both organizations to accomplish a shared goal and I was thinking of the you know this is again in a regional effort this often comes down to the border regions and the border regions in all the countries I think share certain features which are it's an area where ethnic minority groups tend to be higher in numbers and diversity and for various reasons maybe because they're ethnic minorities and often just the remoteness they tend to be underserved and that the military can often bring one of its greatest strengths which is logistics manpower, transportation all the things that are really sort of hard to do and yet the military can do them very well in combination with our civilian colleagues to help deliver care and I recall you know a few years ago when the tsunami hit Indonesia and there was a massive global response and part of the American response was actually deployment of the Navy ships the Mercy and the Comfort staffed by Army, Navy and Air Force doctors and legions of civilian doctors it really was a combined military civilian mission on the part of the United States in that area so you can see this spectrum across from a malaria free military which is a start and where it makes sense to have the joint military civilian integration maybe just to pick on the Americans a little bit I'll just throw this out to Mark how does military civilian coordination work in the U.S. between the military and the civilian and the CDC what works well what can be improved our CDC colleagues are here but they're not on the stage so we'll let them go well Alan it's perfect you know no deficiencies what's the right answer well I think this idea of data sharing between I was at the Armed Forces Health Surveillance Center which is the DOD's CDC equivalent at that time one of the early activities that we tried to do is to integrate the military data for cases that came through the military health system on an annual basis so they were not double counted and that they were integrated as part of the domestic branch CDC's domestic branch annual numbers that are reported every year in their MMWR I am humbled to say that that did not happen until approximately 2010 where there was a formal agreement in place so that we would provide data but that's the half glass full approach would say now that practice occurs there's always an opportunity to refine the way data are shared to deduplicate those data but that practice is there and is occurring so I would say maybe better late than never that's only about 75 years after the establishment of the two organizations but that's okay so I think I just highlight the fact that yes in the United States we have our own challenges about integrating and working in military civilian and they're not because the two organizations don't share the same goals and same missions it's just the typical bureaucracies of organizations is they grow up you have your own reporting systems and such and it does take a little bit of a conscious effort to reach out and share in that common goal also I think one point and then we'll open it up for some questions from the floor is this concept and you know for most of the years I was in the military the driver was very much protect the warfighter right that's that's what the military mission was protect the warfighter makes total sense right and that's why the military mission was distinct and separate from the civilian mission or the global health mission what I've seen in the last maybe five to ten years maybe much more so in just the last few is this concept that the military as we say protect the warfighter I mentioned this morning the best way to protect the warfighter is to eradicate malaria if there is no malaria then that's one more issue in force health protection that the military just doesn't have to deal with and I certainly believe and I sense from many of my colleagues that there's a growing awareness that that actually should be the ultimate goal of all militaries whether it's Vietnam or the Americans or Myanmar or whatever is actually the shared goal of eradication because that benefits everyone so maybe I'll start with you Admiral Chen is this how was your thinking on this evolved over the last few years from maybe say when you were 10 or 15 years ago until now and how do you see this eradication is actually a truly shared goal for all the militaries and our civilian community so I would say I would share with you that this is definitely something in evolution my first started 30 years ago it was clearly all about like you said it was force health protection that is our mission from a military medical perspective and that's what we do and we don't go beyond that I now come into my position at paycom 30 years later and that still my number one mission however it has expanded tremendously and so like I said while that force health protection piece is my number one mission what I spend most of my time on however is global health engagement working with my partners such as Ajay Albin in Vietnam as well as the counterparts in Thailand throughout Asia I spend a lot of time because that's what Admiral Locklear is asking me to do to execute his theater campaign security cooperation plan so I think you're seeing an evolution in the thinking within the Department of Defense and I was last week I was at the there's an Ampsis conference over at the Washington Convention Center and Dr. Woodson is now talking about his new pillars of focus of emphasis for the military health system and one of the major pillars now is global health which again I don't think we saw that in the past so so I think that's that's the new direction I could totally concur with this direction it could totally ties into again the national or the international global health security agenda effort I think Ebola has been very helpful and really raising the global awareness that this is something we do need to do we do need to help as a global community achieve the international health regulations and I can't think all these things I say tie into that and I get back here to this malaria effort again is tying in to that whole effort and I'm very happy to be a part of it maybe Mark from you have a unique perspective in that you're a long-term active duty army officer you've served at AFRMS in the region for many years and a operational research and clinical trial setting now you have this sort of new role in the CDC Presidents Malarian Initiative this broader concept of does eradication as the ultimate goal for the military does this make sense to you and Resonator and how do you relate that to maybe your past view 10 years ago well certainly I do think it makes sense for the reasons you've stated ultimately as Admiral should pointing out we're concerned about protecting the warfighter you know we make no bones about that being our primary mission and I think to say anything else would be disingenuous I think that we share with that as I said the opening of this session is that our forward military partners have the same interest in preserving their operational capability now I do think that the DOD has a great number of tools that have been used traditionally in the setting of as you're pointing out operational research those tools and that expertise I think can be used towards the purpose of public health towards malaria elimination ultimately to the mutual benefit of our partner militaries current new tools that are being deployed and piloted now in the setting in the Mekong setting one of them is targeted mass treatment of TMT but that's the same thing as chemopropyl axis which we've already heard is being widely practiced it's been common practice in our military so what are the drivers of compliance or non-compliance what's the best way to pilot these what populations in which they will work the military is in a position to study these things they're already being used in militaries and perhaps in a position to be a learning laboratory to see what kinds of motivators are there so that troops ultimately comply with their chemopropyl axis regimens and what is the transformation of that information product to the rubber tree plantation worker or other populations at risk so yes of benefit those the chemopropyl axis is an analogy for the benefit to our forces but then there is also the benefit of how those packages interventions can be used for the benefit of other at-risk populations maybe general bin is the military representative here how does this sort of resonate with you or how does this fit your thinking of elimination in this case of initially F but ultimately PV bivax malaria elimination of malaria in the entire region as literally a strategic goal for the vietnamese people's army because that removes one more detriment to 4th health protection that's about we try to have a military free from malaria I think it's a good change for our military because now we have very limitation from the malaria infection cases and most of them belong to the border guards they deploy in the border and we now in the last time we cannot go further for elimination from these forces because we have no not enough capacity to follow up the cases so this for the vietnamese people's army free malaria for the next future we are looking for improving the capacity for the case for all when we can do this so we can have army military free malaria before I open up to broad questions from the audience I'd like to call on a couple of colleagues to make some comments or observations and this wasn't prescriptive so you'll be surprised so Pascal Ringwald my colleague from WHO you've been working tirelessly in the greater Mekong region for a decade plus what has changed in the last few years about military and civilian and how do you see this change yes thank you no first of all we welcome this new collaboration yes you're right I mean this has changed I would say the last 5-6 years I mean we started we started to work a lot more with the military especially that the military were involved in doing therapeutic efficacy testing and if I can give the example of Myanmar for instance to penetrate was a very good way of getting information on the efficacy of the drugs in this area then what was striking when you had the military and the civilian around the same table is that in fact they were talking about the same thing but not in the same language one of the problem is that they all agreed that you must use the most effective drug to treat the patient but they did not use the same drugs and they did not have the same channel of procurement they did not have the same etc etc so I think that now that they are reconciled and now sitting around the same table around the same table they can now coordinate and have the same goal in the same way having the same drug having the same policy using the same tools etc and collaborating better so in fact this discrepancy that in the past is now resolved and this is thanks to everything that is ongoing especially also with the Global Fund this Global Fund initiative calling these two meetings I guess was a very good initiative and clearly showed that they need to collaborate closer and to have the same goal Thank you Pascal next I'd like to ask Tom Kanyak who's one of my colleagues works with me at the foundation Tom's also been engaged in the work in the greater MECON for a long time a long time and with Pascal as well for a long time and I think that you know Alan you must have intercepted my text that I sent to Pascal before you called on him because I asked him to mention actually WHO's involvement in all this and we've been involved in supporting the WHO with the therapy to see surveillance studies and also working with AFRAMS with the Royal Cambodian Armed Forces I will state what my boss's goal is which is yours which is that we engage more broadly with the military at the Gates Foundation as we can under US law we see that also WHO and the Global Fund have been very open to now civilian military interaction we saw this in the Denang meeting which Admiral Chin mentioned which I attended and also then the follow on meeting the PECOM sponsored in Cambodia as well and that the idea is that actually in speaking with both Walter Kazati of the WHO era hub and with the Global Fund I don't want to put words in their mouth but there could be ways to get international funding for civilian run programs with the militaries and so I think this is something really that WHO has been a leader in exploring through their work in mobile and migrant populations and something that all of us should think about there are of course maybe an elephant in the room is that we can't the American military we can't work with all militaries out of the region but I do like your question that you did ask about the militaries of the region working with each other and how the civilians both in the ministries of health of the greater Mekong subregion and then from organizations such as ours and other donors can look to have under civilian control military programs to interact and I think that Pascal really hit the nail on the head when talking about that sometimes there's a difference it's either the uniform or the dress or the language or the culture that we use but really we are talking about a common language and we are sharing a common goal and I truly believe that if we don't eliminate malaria from the militaries of the greater Mekong subregion and elsewhere we aren't going to ultimately achieve our goal of eradication so thank you Alan we also worked with the UN in regarding we talked about the problem of the UN peacekeepers and especially the risk of of peacekeepers either transporting resistance parasites to Africa or coming back with parasites and we worked with the UN we drafted a recommendation to the UN in order to take measures of the troops before they leave South Asia in order to be free of all parasites especially the anti-musinine or the multi-drug resistance parasite in the area in order to go back to Africa without any risk of transmitting parasite and of course there are also recommendations that because these people are going in an area which is a high transmission area compared to the area they are coming all necessary recommendations when they come back to be screened and to be treated if they develop fever and if they develop malaria after return thanks Pascal maybe just a couple more I see Colin back there from a colleague of mine at the Walter Reed Army Institute of Research he's now living in Hanoi and actively engaged working with several partners in Vietnam and working in his new position at the University of California San Francisco and Colin you're sort of at the front lines and both working in malaria and with our partners any thoughts on how this has evolved in your last five years thanks Alan I've actually been dreaming about this for the last 23 years when I was working on the Thai-Cambodian border and then in Cambodia I saw that malaria could be eliminated and I saw that malaria were part of the problem and part of the solution so now I am back in Asia, in Vietnam where I'm hoping to have this dream come true and Major General Bing I would actually like to turn this to some questions to you the first one is is I heard that you have 400 units working with Americans on the border with Cambodia and Lao given resources could you and the VPA actually expand this with financial resources maybe you should go ahead and then I'll ask you one more question expand yes until now we sometimes because now we improve we require men from the government to to setting the national strategy military, civilian program so from this program we can take some financing from this one but the lab we have take from our Ministry of Defense fund with additional funding could you do more now it's it's not easy to do more but something you know already our military forces normally they're very healthy we use what they have for the people living there for free so the second question is and first of all it is really wonderful that you've implemented the prevention practices you have in the VPA but I know that some of the surrounding countries don't use those same practices do you think you could help with Laos in particular or potentially Cambodia or Myanmar to change the practices to be more like Vietnam's yes it's a little difficult because I don't know how about the mechanism from the other countries but I think it's our lesson I found this lesson is good lesson so I share lesson so we can could be not all of the lesson you can take part of the lesson I think we try our best to connect with the people our countries clothing to us and to share experiences if they adapted or not I can say okay thank you very much sir so I look very much forward to working with the Vietnamese people's army and the other militaries in the region to help achieve the goal of global eradication thank you so one comment I think it's interesting to follow up and I've noticed this a bit when and this is just the nature of life in the politics when NATO decides to call a meeting and you can get the Americans and the Brits and the Germans and Italians they can talk about malaria eradication and shared best practices and such because it is part of a formal alliance and such when I lived in Peru it was shall we say somewhat challenging to get the Peruvians and the Ecuadorians to sit in the same room and share that because they've had a bit of a history over the century or so and it took a third party it took somebody like Paho or someone a neutral party to sort of hold the convening and then people can attend and I think there's a lot of ways to achieve that shared best practice whether it's the foundation, the global fund paycom there's a variety of mechanisms by which you can create these neutral forums until there's a more of a built up period of trust and I'd like to call on is my friend Miang because she's unique of course that she was born in Myanmar just a few short years ago and has a perspective maybe on the changes that occurred in her own country and the ability to work with the military so Miang? Thanks Helen so we have been talking about how much has changed in terms of military involvement in public health in general in malaria in particular I think in I can talk only about Myanmar of course the change is huge now I can go into the country I was blacklisted now I can go into the country freely almost freely and I can work with anyone really including our military colleagues but I think the relationships and collaboration that we do in the name of malaria it's good enough to do the scientific work but we're not just doing scientific work anymore and I think that we need a lot more than scientific collaboration and that is why everyone is talking about political will you know half of my grant that you gave us is on that but the political will is has to come from multiple direction coming it has to be built in very low level of health workers and midwives and doctors all the way up to you know to the top leadership level in case of Myanmar for sure and it has to be beyond health you know Ministry of Health alone is not enough to take this great task of next 20, 30 years so in my perspective is that malaria work that we're doing is really not malaria work it's very much a diplomacy and a lot of political negotiation and building trust among many different factions and with some adversary history for many many years decades and also there's something that I wanted to bring up and I have had this conversation with Tom is that not only within the country but the US Myanmar relationship I talked a little bit about with Steve Morrison earlier and there's a lot of concerns a lot of anxieties over what's going to happen in 2015 and I think that we as a scientific community be proactive in that to protect our baby of malaria elimination from what will can happen and that the complex relationship between Myanmar and other countries including of course the US can kill it that can kill our effort to eliminate malaria and this conversation has been going on many times now it has become reality and so this is something that I want to the question that I want to raise for everyone in this room and particularly the US federal institutions who want to work very actively in Myanmar I don't know if I answer your question it's a very nice sort of elevation of this from as you're right I think the scientific and technical relationships now are pretty solid in most cases in building and growing but it really has to go to this higher level of trust which takes time and the best way to generate trust is through shared projects and shared goals and shared experiences that develop so I think we have a little time not much but a little time questions from the audience we have three right in front of me so we'll start there we'll take a couple of questions thank you first of all this is a wonderful panel and I am Andre Svazel and I am a director for Vietnam Southeast Asia and Washington DC for the interstate travel company in Detroit Michigan and also on the political note question I know very well what the wonderful work that the I mean the people in Vietnam but what I want to ask is really based on your question and also maybe to the army colonel my question is this you raised the question of the first priority mission of protecting the warrior with 27 years in the army I'm very aware of that and appreciate it but my question is this this is a hilarious eradication and the cooperation that you raised sir is the is another barrier to achieving better US military and civilian cooperation the fact that we got rid of conscription in favor of a all volunteer force and Joseph Conafano a former director and each secretary of health education welfare Conafano printed a column a dumb rating a increasingly bifurcated society as a result of that and that certainly has proven out in a lot of ways but my question is on malaria cooperation on malaria is this a barrier sir next Michael then Steve so just to follow up a little bit about conservation we certainly appreciate what what after what captain beaver or personal protection application etc but I think the Mekong region is a unique ecological situation and you have such very restricted transmission zones because of the nature of anopheles dyrus and anopheles minimus and if there's one thing that the military is famous for is geographic reconnaissance and so we talked about change in the area I think the biggest change has been the ecological change I mean pay Lynn looks like Iowa now with the with the corn fields so is the military in a position to help the national malaria control programs with the delineation of the most at risk locations as Mark would say the delineation of the transmission zones so that we can concentrate there and not worry about cesophon or some of the other non-transmission areas but again thinking specifically of collaboration for targeting and geographic reconnaissance great Steve alright in front of you thanks one comment another way of working with the military we're working with the Indonesian military to actually do a vaccine trial of forces deployed from Java to Papua which is sort of an ideal setting for doing it but I had a question for Admiral Chin you talked and there was talk about the meetings and the discussions and we talked about disaster relief and we have public relations with the ships going around to different countries and so on but if I look at the budgets that were put up earlier about how much money is actually being invested and I don't know what the exact numbers are in the DoD but as far as I can tell the percentage that's being invested in things like malaria as compared to 10, 20 years ago has actually gone down so and I'm not sure that's true but I would ask you about that and I realize you're not in the R&D component but what is that do you see your interest your involvement with global health actually being translated into investment by the DoD monetarily and actually helping to solve the problem so maybe actually Admiral Chin if you want to just take that question directly we'll go 3, 2, 1 and you want to try to respond to Steve there so I can actually let me answer question number 2 first and I can actually answer the question but I also have one of my experts in my office in the audience who's got all the details but the answer is yes we can do and I think we are doing that geographical zone or any one else who's involved in that so we have experts we have 2 units that can do that we have the Navy Expeditionary Preventive Medicine Unit 6 which is based in Hawaii and then the Army has their Army Public Health Center Station in Japan they have experts that if the demands are out there we can ask them to do exactly what you're asking so that capability is out there and we're also doing that because that actually ties back that's the type of mission that they need to do and ties right back into that force health protection that ties back into helping protect US service members and the answer again Alan's question about is illumination becoming a priority a malaria illumination becoming a priority a DOD I think the answer if you've been here from the beginning of this seminar you're hearing it multiple times from multiple different sources it is becoming a theme that's out there and then now the answer to the question again yes I'm not an R&D expert that's a great question great challenge especially in these fiscally challenged times you know we're looking at 2016 you know another you know sequestration bogey's going to come out there and how's that going to hit us you've heard me mention that yes it's become one of Dr. Woodson's pillars for global health engagement but yes it's to be seen whether or not that is then going to translate into dollars in a future palm and so I'm not in a position I'm not in those discussions I'm not in a meeting obviously I'd love to see that happen but again I'm not in the part of the budget I can put in requests from paycom and I'm in the current budget cycle I have input into those sources of funding that paycom has oversight over that can be directed toward global health engagement activities and getting that type of funding towards these type of efforts we will see whether or not in the next couple of years that's going to be able to continue I have had to adjust some of our projects that we can support based on the budget sort of the best that I can answer your question without not being totally in the process here in DC I guess the question for this lobbying and so on and so forth right the question there from Steve was how can those of us in the audience who are no longer in the employee of the U.S. federal government help our colleagues because as we know all of our colleagues in the federal government completely support our President's budget as requested and I just sort of answer your question I'll just because I know we're running out of time just say that I don't actually think that the current and this is a personal view this is the conscript army actually makes a difference and in fact in many ways I think it actually is it actually makes things better in some ways because if you look at you know polls and surveys across the U.S. population today there aren't many aspects of governments particularly the federal government that get approval marks anything north of 50% except the U.S. military continues to get extremely high marks across the board it's perceived as actually does a good job pretty expensive but does their job and does it well and does it with pride and I think that carries over to all the missions that the U.S. military would take forward and I think it would add great credibility if the military as a U.S. government agency did its role it's not to say that as you say force health protection of the active force is key but as I would say really the long-term goal here there's only one way to protect the force and that's to eradicate malaria Steve I think we're probably running out of time yep so let me stop and I want to thank all of our panel members but in particular General Ben, Dr. T and Dr. Chinoway these individuals have flown from across the ocean if you will they're jet lagged and they're here speaking in a foreign language so if I were in Hanoi or Nipidau or Bangkok trying to speak in their language let's say how well would that go so a big thank you to all of our speakers and their comments and thanks to Steve and CISS for having us here thank you