 It's now my great pleasure to welcome you to the afternoon session and we have the honor of being joined by Jeremy Farah who is the director of the welcome trust. He has a long bio listing many accomplishments with nearly 500 contributions to research papers amongst many others and so with his involvement from the welcome trust and his past history in Involvement in research. He's very qualified to be tackling the difficult question around Ebola and research and humanitarian Organizations and I'd really like to welcome Jeremy to take the stage so thanks very much for the introduction and and I know everyone says this when they start to talk, but it is a real privilege to come and speak at this event and I'm only really going to say one thing today and so after I've said this you can Leave or go to sleep. I think there is a Unique is a big word, but I think there is a unique opportunity between what has been relatively siloed communities But who share a great deal of common Ethos and philosophy to come closer together and and if that's the single thing I say today we can stop now and go away what I want to extend is is how Coming over the coming days weeks and months and years the MSF Family if that's the right word for it with all its challenges within a family and the welcome trust Which has its own challenges within a family may seek to work more closely together So thanks very much so this was me Sorry, I think it is important. I think history is very important Sorry, I don't know if this is works or how I work at technical challenges. There we go. That's that's me some years ago 1960 X Giving any more details. I actually discovered the Acropolis, but but that's a different I was born in Asia and then it was dragged around as the youngest of six children with an English teaching father And an artist as a mother through through many countries which Have been through their own challenges and and the reason why I think that is important and important to the current discussion and important in the way I see I hope the way the welcome trust itself is going to go is That that that experience as a child I think leaves very very deep memories to you and and and growing up in places Like the Yemen and and in Libya and in other places about the world really leaves a very Profound influence on you and it's something that I certainly wish to bring to the welcome trust to see the welcome trust as an outward-looking global organization wanting to contribute to global health and not as just a UK based institution looking inward To a single country. I came to the UK when I was a teenager studied medicine at University College, London Then worked at most of my postgraduate training in Edinburgh and in Melbourne had a year in San Francisco As part of a PhD at Oxford and was destined to become a neurologist in the UK That's what I trained in Before in an audience very similar to this and I hope it hasn't the same effect on me In Norwich at the Association of British Neurology and about this stage in the talk looked up at the audience and thought I Don't want to work with you lot for the rest of my life Apologies to neurologists in the audience So I left neurology and in those days one could do this one could go between specialties sadly lost in global medical another training and Going back to actually talks for the next day and the fact that the lab I was working in was next door to the malaria lab and happened to have a coffee with somebody who said There's an opportunity coming up in Vietnam And they might be looking for somebody with some of some of your your skills and would you be interested in from that moment? Onwards moved to Vietnam with a thought that I would be there for about one or two years and come back to a migraine clinic in Edinburgh stayed for 18 years and came back for some reason about a year ago 18 months ago Everything I'm gonna say is therefore very influenced and colored by the experiences in Vietnam I was then became the head of clinical research unit based in what I think is the largest infectious disease hospital in the world the hospital Chop disease is Ho Chi Minh City somewhere between 600 and a thousand beds dedicated to infectious diseases government public hospital in the center of Saigon Ho Chi Minh City I Won't go through all the individuals But but just to pick out one a very young-looking professor here and here who is soon to retire actually But probably has been the most important mentor in in my life. I Swap that in October 2013 From the beauty of Hue in central Vietnam and the the beauty of a big Asian city Ho Chi Minh City For a wonderful commute On a daily basis from Oxford into Paddington station a pleasure a pleasure And I haven't stopped thinking what a pleasure that's been ever since So I came back to Britain after having been out of the UK for 18 years and actually having only spent Less certainly less than half my life here. So it's been a major cultural professional and personal Challenge moving back But the reason I did so And this is not meant to sound too hebristic But I think the Wellcome Trust actually is a very very important organization And I think if it can work with partners in collaboration and takes this global perspective I think we can contribute in a way that goes beyond what we've achieved today and that is my aim I'm a clinician. I trained as a neurologist said but but and never trained formally in infectious diseases And I'm sure many in the audience will notice that with some of my advice over the last year or so But but I did do and I did until September 2013 a ward round every day essentially around the more sort of intensive care of Severe of infectious diseases and this was the spectrum of diseases that was on the ward in the last few weeks that I left with patients with with these diseases And what perhaps one of the highlights of this for me is not necessarily the individual diseases But it's actually that the top one and it's something I'll come back to talk about in the moment And the truth is even in an extremely good hospital in a in a well-supported public hospital in Ho Chi Minh City The truth of the matter is that most things we haven't got a clue what's going on and and that I think is a huge huge problem Globally global health is changing hugely David used to look like this and David increasingly looks like that and that has implications for all of us the world is changing It's changing in all sorts of ways And infectious diseases and non-communicable diseases are starting to have an an overlap and an impact on each other Which we we have not really witnessed through the history of medicine So take dengue for example a disease I know a lot about dengue in somebody looking like that is Actually a very different disease to dengue in a disease looking like that the pharmacology of the anti-malarial drugs that we give the Pharmacology of the antifungal drugs we give to individual patients or at a population level looks looks very very different And one of the great challenges for health systems around the world which is a crucial area The challenge of health systems around the world is many low and middle-income countries are quite well set up Huge variability, but some of them quite well set up to deal with some of the challenges And I'll come back to West African a minute that some of the challenges of acute infections in relatively young individuals Where you come in very sick and in all honesty you go out with a treatment and you survive or you die And you die very quickly The world is changing such that those infections are going to be hugely influenced by the rest of the environment and the societies They're in and by the rise of the non-communicable diseases and the health systems that one needs to cope with the rise of the non-communical Diseases is actually quite a different system than one might need for dealing with the acute infectious diseases that many Low middle-income countries are challenged by and actually the so-called developed world that the relatively rich world or the rich world Has in the main not had to deal with that coming together So although it's not quite true, but the world did UK United States Western Europe's Exeter did manage to reduce their burdens of infectious diseases as the non-communicable diseases rights One of the huge challenges for low and middle-income countries is how you deal with those two challenges together Both at an individual patient level and also as a health systems Level and talk a little bit about emerging infections and it actually underpins The health systems comment I made earlier. The world is not equal in terms of where potential emerging infections may arise There are undoubtedly hot spots and you can map these as an old paper now But you can map these around the world where you may think that the emergence of major new issues Which will challenge the whole of society are more likely to emerge and this was actually a very very nice Paper from a few years ago now But it divided up the emergence of issues and trying to map them and give some idea of where the the complexities may arise Into zoonotic pathogens from wildlife From primates for instance zoonotic pathogens from non-wildlife poultry chickens, etc the vector-borne diseases Mosquito or tick etc and and then for me the most important emerging infectious disease of our time the arise and spread Of drug resistance, which which is going to have in my view the most profound impact on on global emerging infections What needs to happen to this sort of work is that one needs to overlay on top of this not just This descriptive and the nice maps that this demonstrates But also the environment in which it's happening and how that's changing the way societies are changing Societies in West Africa are not the same as societies in the the Democratic Republic of Congo in 1976 And therefore our response to events has got to change And overlaying the way that these These communities are into the interlinked with the rest of the world So the drivers of these emerging infections and again I put drug resistance as the most important emerging infectious issue of our time are multifaceted recent Terrible events in Kathmandu the recent events in in West Africa just demonstrate That these issues arise in on they do not arise in the absence of understanding the culture and the environment in which they're Rising so whether it be earthquakes or whether it be war or civil war or Or disconnects between the governed and the governing Put enormous challenges on the emergence of infections and the ability of the health systems to cope with it so on top of the Hot spots around the world of where environmental factors may lead to the emergence of new emerging infections or drug resistance, etc we have to overlay on top of that the ability and the Resilience of the systems that can cope with it if we don't put those together We won't understand where the risks and threats lie and we won't be able to address the underlying issues You cannot in my view separate these two Environmental and climate change will lead to many many changes some of them unpredictable But they will certainly have an impact for instance on on on mosquito population stick born Etc. Will change in the demo in the way they are spread around the world and society itself is changing We're going from rural to an increasingly urban society and the urban societies do act Anthropologically and interconnected where in ways that that is that is different In the ways that the rural communities act and and the drivers of this I think underpins many of the emergence and challenges We face with with with infections counterfeit drugs crucial crucial issue I think both in terms of individual patients and populations not getting the drugs they need but also in the emergence of drug resistance If you have a tablet an injection etc with no drug in it That's one thing the individual will suffer dreadfully if you have a Counterfeit drug with 20% of the ingredients of the antibiotic anti-malarial anti TB drug anti HIV drug That's a second issue if it's 50% if it's 70% if it's 90% then you will have profound implications For both treating individual patients the population in which they live and the emergence of drug resistance So we know to no sees obviously I won't go into any more details and lastly of course the interconnectivity The ability I first came to the UK. I got on a boat In Asia and I arrived in Southampton docks and I've supported Southampton ever since then actually Arrived at Southampton docks six and a half seven weeks later if I'd got on with a dreaded lurky in 1960 Whatever 1970 whatever it was. I would have either have got over it by the time I arrived now Of course you can be there in 12 hours and I would imagine those people in this room who yesterday were in some more distant distant place that is a Potential capacity for us to spread things around the world much more quickly than in previous eras The other thing is these emerging issues happen very very quickly 1918 was the thing we all are terrified by the pandemic of 1918 with 2040 50 million people killed in a world with about two billion people at that stage This is a very beautiful graph. This is Months of the year. This is October 1918 these are four cities New York London Paris and Berlin and the important thing here is this is Mortality and this is excess mortality and you can see that in individual cities the upswing of that epidemic and the Downswing there were further waves across here in individual places that that Peak of that epidemic went up and came down very very quickly The take-home message for me in that is if we're going to act we have to act in a speed which is heather to been unthought of We are now 15 16 17 months into the Ebola epidemic and our capacity to respond to it as MSF has led has just not in the time frame that's consistent with where we have to be if we're going to act More quickly and and again whilst I believe that surveillance is Absolutely critical and sharing of information and knowledge of what is and what is not happening is absolutely critical The truth is surveillance picked up Ebola in January or February at 2014 and apart from MSF The world did not act until August September October. So surveillance was in itself not the problem It was our ability to act if we don't add a response mode to our ability to gather the information Then we will continue to be there. I said stamp collecting around the data We have to add a component to it This is Mexico and the only reason for showing this of the pandemic is because it follows a very very similar pattern This is the center of Mexico in 19 in 2009 So when I look back and I deliberately have not chosen Ebola to frame this talk on and I've chosen something very different But which I think has the same implications and that's the pandemic of 2009 but actually and and and not deliberately but I have actually For reasons that escape me a little bit been very directly involved in in SARS Carlo Ibane who first raised the issue of SARS in 2004 and closed the hospital in Vietnam, which essentially saved the country from Desperately suffering from the SARS epidemic and lost his life in doing so Very involved through SARS actually started with NIPA 1998 H5M1 Entravirus 71 in Southeast Asia at the moment viral hemorrhagic fevers hemolytic uremic syndrome H7N9 in China at the moment cholera MERS CoV drug resistance in Ebola and I have in one way or another been involved in all of these I think in parts of the community We people have improved dramatically There is much better surveillance now than there was in the old days We would never have known H7N9 was appearing in China now We know of it and in fact in some ways we have too much information now You will know in 2015 if there is an HXNY influenza avian influenza in out of Mongolia You will you will know that will be picked up. I would imagine So I think the surveillance and actually the sharing of data can certainly be improved But compared to where it was a decade ago. We are in a much better position I actually think that international cooperation, but we can come back to that has been has been reasonably good And overall it looks easy to criticize I actually think the media have been involved in many of these in a in a in actually mostly a positive positive way I think the community which has failed to step up to the mark is my community And that is the patient-orientated research community And I think because of fragmented services and I believe a major component of stifling regulation and conservatism We have not Combined with collaborated with the individuals working in other sectors such that we can start to do the essential work in that very short Window one has to learn what one can do to make a difference. There are enormous practical There's huge ethical There's huge questions about subsequent access to information data and samples and huge access access to further treatment But the window of opportunity to change epidemics is early in their natural history And if we don't Learn have gained the ability to act at that time. I fear we keep will keep going through the mistakes of all of these Merz covee is a very good example The first case of Merz covee off top my head was was diagnosed actually in this city in September 2013 we are now in May 2015 we don't understand the epidemiology we don't understand the annual reservoir We don't understand the transmission dynamics We have not worked out how to treat individual patients or prevent secondary transmission and we do not have a vaccine That's true of every one of these So if you ask a very simple question, I just remind everyone I'm a clinician not an epidemiologist I'm a clinician, but if you ask for influenza arguably One of the infectious diseases which could cause global catastrophe if you ask the question for influenza How do you who do you treat with which drug or not? At what dose and for how long do we understand which drugs to use understanding the pharmacology the PKP day relationship the interventions that may work beyond Therapeutics to prevent secondary transmission. How does resistance to the drugs that we do have developed? Do we have vaccines which cross more than the than a few strains and whether and what works in the setting of a clinical setting? This is a disease which 16 to 20 percent of the world's population were infected by in 2009 And yet out of that period four years later. I don't believe we can answer With general agreement and consensus the answer to any of these questions and again I think that has been true of every single Epidemic and pandemic that that I refer to it to above such that in the end of 2013 The World Health Organization in their great wisdom were able to say overall the quality of the body of evidence was very low to low Leading to WHO global recommendations for the treatment of a hugely important infection a strong recommendation very low quality evidence. I Am a native English speaker And I could not tell you what that would mean As a clinician with a patient in front of me with flu and that's not WHO's fault in my view That's the my community's fault for not addressing that issue leading to guidelines leading sorry to headlines From from a very esteemed in some quarters journal British Medical Journal Stating very boldly the Osilt Hammer beer does not work I'll go on and Part of the reason is I believe that stifling Regulation and complexity and conservators and we bought to human what I call human subject research This is a patient with something quite badly wrong with them. This is a youngish clinician who's got a bright idea The pathway that that young clinician takes probably earlier in mid in their career when they're terrified of where their next job is Is to go and write a protocol? This is the previous drafts of the protocol. They're now on protocol version 563 They then and if any of you have not watched the YouTube video on teleconferences, please email me And I'll send it to you is one of the funniest YouTube videos ever They often then go to a teleconference when we were living in Asia that always included people in Europe and in North America And for some reason North Americans could never be out of bed in the middle of the night So this was always at 2 a.m. Asia time You never really understood what anyone was saying you couldn't hear what anyway They seem to be very very important in this whole process which led to version 896 and this young doctor clinician nurse whatever they are then goes back anyway by 6 day 611 it's improved a little bit since then It's now 609, but but this is the average time in 2011 that it took from bright idea to enrollment for first patient in a clinical study Trying to find out what was wrong with them or how best to treat them and their families or their communities We don't have 611 days in the in the emerging infectious disease world Bear in mind that 42 days six-week window when the epidemic curve often goes up and down and your greatest capacity to intervene is Is early on and then finally that's only to recruitment and of course To completion of the study writing it up getting all the kudos presenting at a meeting Polishing the paper moving on to your next job takes you into a doubt about day thousand Which no young clinician would dream of going into if they had any sense And that is one of the reasons why I think we're moving away from clinical research Which I think is so critical to the future. So I believe health research and in particularly my area Human subject research needs a new paradigm. Yes, we do have better surveillance now We will identify things in fact as I say we will identify potentially too many And we won't understand the biology to know whether hxny and out of Mongolia is going to cause a global pandemic or not We have to get smarter in our surveillance But we cannot think that surveillance on its own without the ability to act is going to sort out the problem I think we mean much more innovation in the design of research We haven't moved human subject clinical study design on in fact in the last 20 to 30 years And I think we even now even now in the events in West Africa We are still having in my view sterile arguments about designs of studies and how one might do things We can't do that in the context of an epidemic We have to have much much better Appreciation of the of the views and perspectives of the community that we're working with and that means very culturally sensitive times I'm going to move on very quickly because I don't want to talk about Ebola because I know you dealt with that very quickly 1947 was the setting up of the major global agencies whether they be the United Nations World Health Organization International Monetary Fund and others And I think there is a major question of what the role of all of these agencies in and their governance structure in a world That looks very different to when we had Yugoslavia As a member of that committee the world has moved on and we need to move on the governance structures of that We've tended to make things overly complicated This is the view from Geneva and yet on top of that over layering and partially because of our all of our concerns about the global governance of health We've invented new schemes and new systems and new infrastructures and new governance bodies Which looks to maybe supplant or take over from the World Health Organization But which in my view don't have the legitimacy of representing national governments with all of the issues that that comes from I think we could much much simplify This so yes We need better surveillance and we need to learn how to share that data in more real time and Critically and this is not often talked about we need to learn how to share the benefits of that research So that access to the to the benefits that accrue from this research becomes critically important We become much better at picking up things, but we must now learn how to act much more coherently and much more quickly and my last slide goes back to my first point and that is I think there is a unique opportunity and I appreciate the challenges of Bringing together your community who sees the world differently to others and and and the community I am in and I'm now in and looking at ways about how we can bring those together Because ultimately actually our underpinning philosophies and thinking are actually incredibly similar and this huge overlap I don't know how to do that. It won't happen today But that is my dream for the the coming months and years How can we work these two communities more closely together because we're actually both after the same things and I'll finish that Thank You Jeremy We're gonna have time for three questions if you can't say your question in one sentence Don't put your hand up for the microphone Please we're gonna go to the online audience first if you can put your hands up and I'll pick out the other two now a microphone here Please and anyone else? Thank you very much. I share your concern for bringing together communities that need to work together and have shared interests I wonder if you might have a comment about the Complexity of that process and the balance between critical and friend in that cliche I'm thinking I think your organization is under a little bit of pressure on fossil fuels right now for instance Which one do you want me to ask fossil fuels or collaborative ventures? Comments on how to collaborate constructively across silos Getting the right balance between Criticism and pushing people more and being supportive and friendly so firstly I think all organizations MSF welcome trust whoever you are has to be thick-skinned enough to take criticism and And appreciate and listen to it and whether you change or not is is for you to determine as you're listening But I think you have to be thick-skinned enough to take criticism Secondly, I think you will not build collaborations and and harmony if that's the right word By a top-down approach. I think the way to do it is to get a greater understanding At a depth within organizations such that actually this is driven by Individuals and actually to a different extent both these also of the organization and the and the individual chemistry between Players across the organization I think that is the best way of building Collaborations because at the moment the language of both not not saying our organizations But many organizations not used to working together the language is so different It's actually quite difficult sometimes for those communities to come together So I would not suggest a massive top-down approach that says A and B must work together in some ways I would suggest we build this Organically by by increasing the number of interactions between our organizations such that that embeds it much bigger better in both Vicky thank you very much. Jeremy. I'm Vicky from MSF UK in terms of calling outbreaks earlier and Therefore galvanizing a faster response. I think MSF's experience is that it's actually Governments who are the impediment to that so they are the ones who are reluctant to recognize this nature and scale Of an outbreak for whatever reason but at the same time they are the members if you like of the Global health architecture WHO etc. You as you refer to how do we unpick that? How do we? How do we yeah? How do we prevent governments or or avoid them actually being the ones that are the obstacle? Yeah to recognizing the outbreak in the first place obviously a huge issue And I don't want to give it sort of glib very short answer because I don't want to underestimate the complexity of it But I think the bottom line comes to the word incentive. I think at the moment there are massive massive disincentives for countries to do what you've described even to the point that Spanish flu is how it was called Spain was almost for a hundred years has now been blamed with that Epidemic the only reason was of course because the press in Spain were free They were able to report it German British American press was censored Spain has forever left with that sense that this was all Spain's fault Talk to anybody in Indonesia and they will tell you they have the same with bird flu I personally would like to get away from naming new viruses under the river or the country from which they come We've got to change the discourse from one of disincentive Your economy is gonna collapse You're gonna have airplanes that are gonna stop flying to you your tourist industry has gone to one where there's some incentives Built into the system such that transparency and honesty is rewarded rather than rather than trashed Right up the back Jeremy. Hi, Mary and Turner from nature You said right at the end that sharing the results of research is really important How do you see that that's best done? Do you see that through peer-reviewed publication? Do you see that through? online reports It's a huge world out there. Yeah And obviously open access which I'm sure nature is very committed to Um You should hear what I say if you weren't here Please say it. Say it. Say it. I'll pass it back. Trust me. I'm reporting back to Phil after this meeting What I meant actually was not about research sharing although that is a critical component It's actually beyond the research It's sharing in the benefits of contributing to that research the Indonesia Minister of Health who I would not Condone in terms of she was arguing ten years ago Why should we share each 5m1 viruses with you when all you'll do is sell us back the vaccine? Probably quite expensive No, but we have still not even through IHR and everything else We have not addressed that fundamental issue at the heart of her argument And I think we have to people need to appreciate comes back to the incentive point that if one is willing to contribute share Etc. There has to be Subsequent sharing of the benefits of contributing to that work including yes research, but more fundamentally Sharing the benefits of access to the bent to the research and where that leads whether that be to better access to the diagnostics The drugs the vaccines the community Interventions that are going to make a difference So I don't think you if we just leave the conversation at sharing data We will miss the bigger issue which is sharing the benefits of the data I'd like to ask you to join with me in thanking Jeremy for a challenging talk