Fact there has never been a time when humans were not affected during his time as a selfdescribed disease detective he has had his own brushes with viruses and wnfectious disease in contagion in 1995 he worked in zaire for the first a bola after 9 11 he was called to washington to prevent the spread of anthrax and in 2003 called to hong kong to help quarantines ours. These are some of the stories he chronicles in the next pandemic as a disease hunter and has been trying to prepare the public for Health Emergencies and he has seen it all. Telling us microbes will always be a problem he also writes that in all all epidemics and pandemics are inevitable in fact most can be mitigated if not prevented. But how do we have enough resources . To help a separate the hype from the facts what poses the greatest risk of what we need to do please join me on a Public Health journey by welcoming doctor kohn to the Carnegie Council this morning. [applause] thank you very much. Good morning everybody. As you have heard i spent a career in the preparedness environment normally means and weeks over time getting ready just in time now in the realtime speaking process. So ive been told put them at ease but there is nothing about my career that has levity but a lot of sex although it is most sex. [laughter] one mosquito sex and trying to give you the idea of what it means to be a disease detective and if you read the papers or the press and from the perspective of somebody doing it every day with other practitioners reading the paper this morning reading about zika virus so it is topical its easy to start a topic of infections so why are we always hearing about these types of diseases . Think of smallpox and measles and it all started around the end of the culturalre revolution when people came to gather and then started spreading from person to person. That is when i start my story of Infectious Disease but thats when the world starts for me the rodents that were caring smallpox moved into somebodys home and that virus made the jump to cause smallpox even including measles now fastforward to the industrialal revolution germ theory we realize Infectious Disease is due to in texas one infectious agents for asthma and around the 20th century the sanitation and revolution and the vaccines and antibiotics. Now we are all done with this Infectious Disease now give him a shot and a pill and they will be better if thats true we wouldnt be having this conversation today right now. So even though we haveen taken care of a lot we have the continued emerging effects there is a lot of factors that drive these diseases. The key factors are microbes they are smart collectively they have multiple generations in ara single day may be a human is a generation and 35 years microbes no problem at all days swab all the time they get smarter from drugresistant microbes because that is what they do. They say this will protect me from the set of antibiotics and then you have the superbug. So microbes evolve and humans change behaviors so nobody had a kidney transplant so we change and the risks to infections change. This should not be surprising talking about ebola or zika virus very quickly the animal connection comeses into play like mosquitoes and ebola it is bats the original cause. Thats a spread the chain of transmission 75 percent of the diseases you hear about they are zoonotic that there is the animal cannot one connection. And that disease has the potential to go person to person and murders is from bats and camels so its not a surprise that they tend to come from africa or south america or Southeast Asia with connection with the animals. And those that are very close to the date on the pigs and birds andd foul. With the global pandemics. So in that subset to lead to these infections. So often Climate Change is framed as an economicco issue. Over the last year or two as a Public Health issue of what is happening with the climate currently. So april with the hottest record on one year on record since 1980 people ask me how do you know 191 1880 . Believe that are not if you are a farmer it is really important to you what the temperature is so there are excellent records about what temperature looks like at least the 100 years the same thing with marine temperatures if you are a captain doing your daily log he would be logging the water temperature. So we have excellent records but april was the hottest year on record and the 12th hottest year in a row. This is not a coincidence what is happening with climate. If you look at Carbon Dioxide not 400 parts per million so the thought to only tap increases at one. 5 degrees is highly unlikely. But you tell this from a different way i got into the Climate Change business 20 years ago this is us mosquito Borne Disease in africa you dont have 401 k but cows and goats that is the 401 k . If a mosquito borne virus comes around and the animals die, that is bad news. It is a biblical disease and what we recognize over the last couple of decades at Subsaharan Africa from Northern Africa and into the middle east actually depends on climate and when this mosquito emerges with these dry periods followed by wet periods. It also causes abortions in humans and brain inflammation in humans. But the farmers dont have the money to vaccinate the animal every years every five or ten or 15 years say this is a bad year if we got vaccinated that would benefit. And so help to protect the farmers and the animals in the community. Thats how i got into Climate Change issues. And what became very clear right now and 2100 but what is happening today. Into the arthropods and mosquitoes it is actually lyme disease. And to live up here in the northeast and then over the last 20 or 30 years continuing to spread across theve United Statesy so were seeing that already today and then to cause infections in humans and animals that does not belong in vancouver but in the itropics we are getting infected oysters from the northwest. So we all know if any oyster eaters are here like me to listen to all the good Health Messages about oysters. [laughter] eat oysters in the cold month eat them with a month of our to protect yourself from the infected oyster. But it shouldnt be a problem if you are getting them from the northwest United States were alaska with nice cold waters but we have not have these outbreaks reported because they are not as cold anymore so these contemporary examples already working from the us to europe. And encephalitis. And we give it back to as a medical term. And then my head hurts you yave encephalitis you are so smart. [laughter] its called brain inflammation. But that this has been spreading over the last couple of decades there are some factors of where that is spreading the climate is one. Respiratory those that have kids or grandchildren and then we see those seasons in europe are becoming shorter and shorter so those contemporary examples so what is happening in india 128 degrees heat wave and yes less people die from coal but proportionally more will die from heat and then heart and lung disease from all the air pollution with all this Infectious Disease anything that has to do with mosquitoes or checks and then the foodborne illnesses. That is an issue as we get flooding. I want to make a quick shout out to Climate Change think about emerging infections the biggest factor of what is happening to microbes and in the environment if you look at the outbreaks these will continue to emerge. But we play a role to keep them from becoming epidemics like f the recent outbreak of ebola and west africa. And know about the science and i had the opportunity in the mid 19 nineties working with the Ebola Outbreak in zaire. You are infected probably from a bat if you are in the bush you died 95 percent of the people die unfortunately a Family Member or two but then you change that dynamic and its in a hospital. And those that do not have infection control. So then you are a virus magnet and then to increase until you die so when you have the most possible virus in your body . As you go to the hospital because you are sick you dont have more than when you die. And then if the immune system then you increase the virus you produce so when you have the most possible virus in your body . As you go to the hospital and you dont have more than when you die. I could give you a ten with a lot of big numbers so here you are sick and dying in the hospital and somebody doesnt wash their hands going from patient to patient what will happen you spread ebola. We have known this for many years as a reservoir that spreads and then a Family Member taking care of them and we know that. And then they die unfortunately and then you wash the body and kiss the body and hug the body what are the practices we saw and then the sainted person that just died. This is not a good idea. [laughter] but that is the science. That is in the issue. So this is the 24th on outbreak and then you think this just like east africa we see these all the time then we shut them down. But they dont even need International Teams anymore they know exactly what to do they follow everybody who is potentially sick. But nobody had ever seen the disease before and it verym quickly spread to urban areas. And the thinking was more of the same then the outbreak will go away. What happened that is not what happened 11000 death each and every one of inadequate response so politics and the Public Health system play the biggest role in whether or not this goes from a handful of cases are small outbreak and with these cases across the world for what happened here in the United States. And i want to ask because the answer is yes how many have read around the world in 80 days . How quaint. Eighty days to get around the world. For 20 years or where the Public Health uniform and on that it looks very much like the navy uniform. Thats because we started as the merchant marines. So now that is the purpose is to fly quarantine but if it takes 80 days to go from point a to point b we knew if you had smallpox or yellow fever because the incubation period to manifest your symptoms is always shorter than the time it would take to go from point a to pointg b but now we have turned that upside down. You could go to your mothers funeral in liberia and engage in the usual ask around the funeral you are distraught you are kissing and hugging and then the next day you get on the plane go to amsterdam to new york city 1824 hours maybe 48 out incubation. Three days after you show back up in new york now i have a headache and a fever im not feeling quite well you show up at a hospital the number one diagnosis will be malaria and if it is not an they missed it and its easy to see him get hospitalizedit and then you spread disease in the community we saw this in texas with the exact same scenario and then infected to local nurses i have spent a lot of time in places across the world to let you know our Healthcare System is not better than what you see in toronto and they had sars or singapore when they had sars or hong kong i just spent some time in seoul korea they had an outbreak. And again Excellent Health ours. Ystem like but they are not ready for the patients coming in. So travel has played a big role how these diseases emerge. So now i have given youou a sense why you hear about this and what we can do around social and political aspects. I do want to spend a couple of minutes to talk about you at the Carnegie Council and the observation which i guess i recognize my whole life if you think of hiv and who was infected it is marginalized populations. But as i started to write the book it dawned on me how almost every chapter it was increased risk the disease due to rodents in the southwestern United States people get infected with the original outbreak occurred was with native americans some of you will remember when it occurred in the early 19 nineties there was a group of young navajo kids who came to dc for the capital tour and were denied aib tour because you came from the southwest you could potentially be infected so theres nothing that anything that we knew that said they were at our risk. But often they affect marginalized populations i already talked about hiv i talked about ebola and the poor marginalized populations in west africa and in todays day and age we talk about sica there are poor pregnant women in brazil that has one. 1 million cases think thats what they are calculating now in over 1500 infected and the babies have congenital zika virus illness with small brains other Developmental Disabilities including hearing loss and vision problems it is a laser guided missile for neurons it kills the neuron sales one cells and not just a with babies when first described was 20 percent of people will get sick then a little headache with some itching and red eyes and they will get better than very quickly it became clear this was a problem for pregnant women but now we knowh even adults because of the laser focus we have the is a one a disease that is neurological causing weakness and even in a healthy virus to cause brain inflammation of the coverings aroundto your brain even what you think is a normal healthy adult this virus is a problem. It should not be aes problem. It is spread by a certain type of mosquito it is not new to us it is the exact thing that spreads yellow fever causing 30000 deaths per year. The exact same mosquito that spreads dengue outbreak that causes about 30000 deaths per year. The same exact mosquito that has chicken gonyea virus that was in the news a couple years ago. That doesnt seem to cause any death but the cause of the failure since the seventies with the efforts to decrease mosquitoes and not Pay Attention to the people dying from yellow fever, people dying from dengue are now all up in arms we have the disease that is affecting pregnant women so there is a lack of action over the last 40 or 50 years against a known threat that has put us in the current position so i heard yesterday that zika virus didnt only move through the americas now in cape verde knocking on africa to say you are next so think when it sweeps through to pregnant women there in africa. The head of who a brilliant woman k doing amazing work admitted a major policy failure over the last 40 years to address this mosquito. Also talked about a major policy failure this is a big issue in brazil and other places where they dont have the same contraceptive rights that you take for granted here in the United States or other parts of the western world. So why did it take all this time people dying of yellow fever and dengue to say we need to Pay Attention because now in north america women may have this disease . We will see zika virus. Hopefully not a lot of cases but we will likely see it. Ethics of a delayed response goes back to what you talk about amongst your audience , think about these marginalized populations why we see these delayed responses and we see it today with the conversation there are better terms so lets protect the United States against zika virus and how much they want to pay for it and i often get asked should be 500 million that Congress Wants to give or one. One the senate wants to give . I dont care. Pick a number where we having this conversation six months later . Me know what will happen. We also know Mosquito Control in the United States is not a federal function. Is not even a state function by the city and county and district function and you need to get the money out to these people so they couldld be doing what they should be doing to eliminate mosquitoes and then think about a longterm strategy to protect pregnant women and then have a vaccine strategy why are we still having this conversation six months later . Why are we robbing peter to pay paul so this was essentially for keeping america safe from all Public Health threats no matter their nature whether a mak pandemic, terrorism and as part of that my passion was for the Public HealthPreparedness Program to putut money into state and local Health Departments and then we pulled back some of that money to support those cases. So why are we take in my analogy so if this is a preparedness infrastructure why are we taking money out of that but we should be putting that into preparedness i will leave you with a number because im all about observable measures. Six. Seven. In the last three years the foundation has been doing great work looking at how prepared the United States is for Public Health emergencies. Every year it gets a little bit better six. Seven out of ten just is not good enough if we want to make sure americans are protected. As far as i am a concerned the responsibility is to protect us against threats and that includes Public Health and Health Threats and how do we make sure im old enough to realize you cant completely pull the politics out but maybe we need to strip politics to think the health needs of the population. Thank you. [applause] that was fascinating you seem so calm. S [laughter] i am call because i decided 20 years ago that fear is not a Public Health strategy i know it makes for great press the sky is falling and good science now it keeps me up at night is the next pandemic zika virus is pandemic butte is not causing hundreds of thousands of deaths what is we already know from 1918 if we did a repeat we get the flu every year i will tell you right now and it changes a little bit which is why we need a new vaccine everyry year but the flu takes off the overcoat and i have no protection if we repeat the same thing from today seven. 5 million americans would die. Two. 5 percent think of how this would completely disrupt our society within a couple of weeks or months so the flu keeps me up at night. Mers and diseases like mers keep me up i have seen the Health Systems they are Getting Better with our ability to respond are Getting Better part of my job in Nebraska National ybor Training Center helps hospitals get better but we know that hospitals acquire infection so i worry about mers as another example the next is the hivaids. Nowadays you think of it in terms of sexual behavior or iv drug abuse but remember that was another zoonotic disease that came from nonhuman primates probably multiple times that it was the right version making its way to humans then spread from human to human. I worry about that spreading through sexual transmission with a long incubation. And by the time you discover it it has spread widely. Those are the things that keep me up at night with the next pandemic with more significant mortality. I would like to open the floor for discussion please introduce yourself. That was too fascinating especially in the morning. [laughter] but we have to be concerned about what could be done in your the most experience person so the question is first of allh all, what is the cdc doing to educate people to control the diseases cracks as soon as there is an indication . On the other hand you are now in nebraska. What is the difference between control measures with the agricultural state with a relatively small population and washington or new york with a large urban areas . How can the us do more to prevent these outbreaks . That is an excellent question. How we can do more starts at multiple levels. There more powerful than they think they are. Start with something very simple like healthcare acquired infections. A paper came out last week that suggested one third of all antibioticsal are unnecessary. One third. So as a patient you go in and talk to your doctor you are powerful to say do i reallye, need this antibiotic . If it doesnt get better than i can take that you have the power. You have the power to walk into a healthcare facility the doctor or nurse or respiratory technician says and then say did you wash your hands. You are powerful have the power within your community alth personal preparedness issues. If the pandemic runs through your community or a Natural Disaster runs to the community are you prepared personally for that . Ics not just in terms to have a kid in your home but are your vaccines up to date how many people today and a cell phone age know a phone number i force myself to memorize my wifes number what do i do i pull out the cell phone if that dies not so good. Not in terms of numbers. My part of our Response Team for the community . I took a cpr course i dont have to call 911 for the littleth things in my a blood donor. And then its things we should expect from our government so if tomorrow morning new york city we decided lets lay off half of the police force, my guess is you will tar and feather the mayor because Public Safety is so important but the same thing is happening to your Public Health and safety workforce in the United States where it is not fully funded nobody tires and feathers anybody with a score of six. Seven so to demand the same from your local representatives to have a little less politics why are there still uninsured americans in the United States right now given the fact we passed the Affordable Care act . So you are powerful you need to expect more and ask for more at every level including your own level. At cdc i did a tongue in cheek about the Zombie Apocalypse to get people prepared for Natural Disasters because they were not paying attention to the real Natural Disasters but everybody wants knew about zombies. Dontt ask. We took a popular meme and converted it. One of the things i did use the mean for that you cannot out run them so stay personally healthy to out run the zombies. And that changes whether nebraska agricultural state or washington dc with greater risk of importation from International Travel the Health Entity needs to take that into control like and to plan for flooded water supplies. I remember in the article some years ago to the effect only silent springs publication had been delayed three years and if ddt use continued another two or three years we would not have malaria. You stressed Mosquito Control so what is your take on that thesi thesis . We need to use every tool available to us thinking about Mosquito Control. We were fortunate here in the United States with actually cdc it is one of the only federal agencies outside of washington dc. It took me a while to figure that out because of malaria. Malaria used to be in the southwestern United States and what was happening we were sending troops to be trained in the south they were being infected with malaria we dont need the young men and women getting ready to go to war to be infected with malaria so the program was set up and it became cdc and it was quicklyy eradicated around 45 or 46. But look at dengue right now we see that on the texashe border due to mosquitoes we see it in mexico but not in the United States not do to ddt but screens and airconditioning. That also protects us against zika virus tonti think about wht takes to protect us we have to use every tool available so for mosquitoes killing baby mosquitoes and adult mosquitoe mosquitoes, insecticide, and then source reduction which means find the little sources of water out there and get rid of it. So think about every tool like ddt and others. What is the right tool for the right area what are they resistant to and not resistant to . Thank you for this presentation number of societies had prohibition against certain animal proteins like beef and pork and you made the connection between these kinds of viruses coming from animals and have any studies been done to show societies with protein is limited or not at all, the ability to resist these illnesses to take the antibiotics and have that effective if that is a connection between consumption and the likelihood of other continued ability to cope with the consequences of these illnesses. Comment on that. That is an excellent and complex question. Let me break it down. We do know predominantly vegetarian diet live longer and do better. I will get to the beef and animal consumption the rest is the zoonotic infections that have to do more with close contact with animals not necessarily their consumption because if we think about it and i say this all the time because i dont eat pork that if you just heed it to the right temperature there is no risksk you hear this about your burgers so the risk comes not from the consumption but the daily interaction you have with these animals the routine set of interactions if you are milking them or keeping them in your houses. Or a well cooked chicken burger or filet of chicken will not kill you but handling these chickens will eventually carry one kill you. And have recognize the failures of ebola and what happened especially not just from the Early Detection but between six and nine months and then to say oh my gosh this is a problem and then that things were Getting Better. So in the midst of that process to better respond to these infections and not to do country level assessments. And then the world bank is setting up a brandnew pandemic response. I have a story in my book from a really good friend of mine and he had no resources he just had some dollars to do some work so we cannot afford for the outbreak that you cannot get your hands on a couple hundred thousand dollars to put something in place for the hospitals. One of my clients has mosquito inspections putting out traps of actually look for mosquitoes but you mentioned the political aspect. Where two candidates were diametrically opposed and also on reproductive rights that in my opinion but all peoples rights because everything that happens to a family happens to everyone. Could you comment on that and how this issue could be brought up in a way that affects the political outcome . Im the Health Person and thats a politics question. [laughter] i open the door . I will look for the expertise in this audience new york is my home i grew up in brooklyn when i went to ps 130. So actually have aunts and uncles who have never gone to the city because why would you go to the city . Everything you want is in brooklyn. [laughter] so i know little bit about the city but mosquitoes. You are very fortunate to have the best Public Health practitioners in the world here. Giving a shout out in 1999 west nile it started right here. West nile is another good example. It doesnt belong in new york its another example of the disease somewhere else decided america was home. We need to have individuals as we make choices and the opeds that we write to say health is an important factor it is everybody rights not just pregnant women we need to make sure they have their rights we can talk about brazil but dont forget about the United States theres a lot of things going on across the United States. I want to ask a question about our developing global problem in a developing response to that problem and that of course is refugees. I will leave it at that. As far as the Global Response is concerned one of the things that has been overlooked is the role of pharma and the lack of incentives in the pharmaceutical business for responding to these type of emergencies and to make a really wild suggestion that perhaps its time for pharmaceuticals to be considered as a public utility like the military or the water system and like all the other things that we have that we take for granted and that are not incentivized by profit. So i assume of Infectious Disease . People say what risk do i have but how i make sure . Measles is a horrific disease so what are we doing to help make sure that the refugees are protected themselves . How do we make sure they are protected with any screening or any other process that we do. So people have recognize this problem for a long time. Talking about anthrax there is zero incentive for anybody to build the medical countermeasure against anthrax or smallpox the Us Government establish the Research Agency with the department of youth and one dash hhs that somebody understood how to work with big pharma that we have these excellent products that are available to us that we have enough smallpox vaccines everybody in the United States if they decide to reengineer that and make it in our lab. We do have some mechanisms available but its a challenge so how do you make sure you have new drugs available but just get smarter and smarter all the tim time. I was going to ask about the biological issue thank you for this journey you took us on. [applause] thank you. [inaudible conversations] last november remarked the centennial and in november 1918 people thought relief the years of warfare and death were over. So the influenza pandemic of 1918 killed more people worldwide and was killed in