I think that a sound effect was appropriate for the tension that might existtwe if there is the outbreak in the the need to learn what works to address that outbreak for one that is the merging and the need for learning it is quite acute. With that humanitarian need is so great . So are the leaders of the team recently published to implement Clinical Trials so i will turn over the podium the cochair of the team and is currently a professor at university and also managing als a very exciting institution to do research on dangerous diseases. He is working hard to try to bring that to fruition. David peters will be talking for a few minutes and then there will be a Panel Discussion from the humanitarian group that has saved more ebola lives than in the other group in those that supported the United States efforts to control the ebola epidemic as director of emergency the office said u. S. Foreign disaster assistance. My thanks as well for those who are watching remotely we are very grateful for your input for the National Academy of medicine to let get the issue of Clinical Researchs an e with those issues at the start of the outbreak. So actually there was very little known how to manage c the patience of ebola. There were no therapeutics or vaccines to human current Clinical Trials. So that is the genesis of where this committee began and i will tell you about that. Will were hoping todays to hear from you and your thoughts. Questi i dont think we need to go into those technical aspects but how do you integrate research of the epidemic response . Rigo clearly this has to happen. How you create that overall governance and structure with this type of issue and the criteria . I thought it was worthwhile how do you develop new drugs and vaccines . Except that issue of safety is not as significant so first you need the science to figure out the target for the viewer responds immune response for that pathogen and now you have to findo fund t that hour and d and that is the of Stream Research fromh, public money. The process that is done in this country in particular but determined ultimately whether these things work in humans and often they have applied where you have to show safety and efficacy in part because in response to a single drug or vaccineording depending on the species it works with to animals that it is safe for humans. So to get the Regulatory Approval to start phase one which is a small study looking for safety. If you can show that it is safe you can move on to a larger study with a Larger Population as well as the indication to perform as expected that it willte produce the immune response. And if that goes well so those phase three trials are larger scale as we begin to look at the efficacy of data. Most of the candidates thatnd enter into the process that is through phase three sow one of the questions that might be asked why is it different than other things in the past . So high mortality no proven treatment experimental human infection models are not possible. Even those of developing vaccines. So an outbreak is the only opportunity for human trial. Ria. With highly safe vaccine. And to shorten the clinical course. Not yet but it is not difficult to conduct trials as their large numbers of patients in generally summer not people. So why d you need research . To figure out how to care for the patience looking at the korean with two sides and those to we are inseparable that is part ofhe the model to be a health care professional. To invest that investigational drug back seat and efficacy because those the new models in general do not reliably predict a response. W to show that is working in its base and to ruth have a future outbreak and the fed has people who are said to have to be able to retrievee them effectively with fis standard of Clinical Care with survival and reduction. So this part of a dancing general knowledge isnt what the fda says and conditions dont know how or well if there are several of them in and what part of a treatment will work . You need that information to manufacture and distribute to and rapid the as possible expand access they say Clinical Research is not necessarily for the person involved in the Clinical Trial but it is potentially available to individuals that are suffering from the disease if they show that to be beneficial so withoutt Research Done during the outbreak definitively and because of that the National Academy was asked to assessmy the trial and recommend improvements sponsors with three parts to hhs the academy created from usa and europe with three public workshops, six closed Committee Meetings and Conference Calls and incredibly expensive internal and external review process basically in that context, is thought that patient zero as day to yearold became ill towards the end of december 2013 by the middle love jerry that some of january they were recognized as an unusual and of medical officer notified the ministry of health and sent the team but only because that was a part of that without breaks in the past the diarrhea was bloody they did not identify that an until that is to be Something Different doing something and the response was immediate and they said the society tragic fever and the diagnosis was made in march. Class to lunch at the point of the outbreak that was important because at thathat po Point Crossing borders and to those contiguous countries. And they quickly recognize it was different from anything they have done with ebola and they kept sayingth this is different. And with that contained outbreak could be you easily controlled but did not agree. And as a moderate event to be supported by the Regional Office with that Global Recognition that it needs and not until o august that publest level of concern then it was declared by debbie rate to zero. And then it started to kickto kk in and then with the possibility of Clinical Trials and now six months have gone by and that has never been seen before inha the Ebola Outbreak. So ultimately 28,000 infected there was no vaccines or treatments and then to think about Clinical Trials then they came out of though woodworking you talk about eliminating there were still potential candidates. This is a time line so those three lines were the three target countries your is when the International Concern was raided by who with the outbreak is sluggish and several months i later those trials that were done were all initiated with major implications and here are the results. None were conclusive that this works. But one of the trials suggests efficacy but it will not be sufficient for the Regulatory Agency that this is okay. The initial indication that they were not to intervene to mortality and not at that point. No evidence. Although it was publicized last december when it defective. The problem with that conclusion is the most appropriate Statistical Analysis the effective rate was 65 but to be around that estimate it could be coincidental. D be not so it looked promising but they still need to go through the necessary Clinical Research. The next outbreak will not likely be as big as this one that we have to be prepared. Poi so the of Clinical Trials of september or october to get that improved and or logistics if the rate to which this happened was remarkable. Enough. Net is a key lesson. The conditions on the ground were really a chaotic and because of that if you fixeded on those people who were at risk for dying, they were sitting right in front of you why do we get involved . Pa under those ambient conditions to havede investigators there there is a whole set of issues on the study in how to organize it. They really did not recognize ebola although that the virus was in west africa. It ended is how the messaging works into engaged the community in the process some of these experimental therapies were from west africa. They seem to do pretty well. Mortality was pretty low with a magic surround searle that was given but not to the africans. With say lack of trust in with a civil conflict. Es were in to be poorly coordinatedetit to get into west trial that is the most with dad that was controlled. So that search is necessary that is to be integrated into epidemic response. How do y so that is the challenge now. So to do randomized trials that analysis of the report is clear in did is proven to do those randomized trialsprep and to participate in this research will be useful at all it will be rigorous with useful information. So planning and organizing with International Coordination and collaboration in the of process is before the next epidemic happens. You cannot do the Research Without it soco excluding them makes that separate there was little capacity that we dont want to separate the research a first World Research agency to build a beautiful study ward in a decrepit hospital where the level of Clinical Care is awful but it has to be the response. And need to be linked together. So moving toward this process with the engagement and coordination and that is critical heidi get that off the old leadership . And his team is doing a clinical intervention. And a broader picture of what was going on. And now a share of the department of Global Health is great expertise will try to raise some of those t questions to create that collaboration. Thanks for inviting me. Invin i am happy to be here. Im happy to follow up on those points with of governance and leadership aspect. With the i h. R. Is a regulation the wingback to the 1850s. In it is about setting those conditions for those epidemic diseases. And the difficulty is notve working very well. But it does happen from time to time. And not just the inability to have a side 196 countries have the capacity in and of those west african countries are in the position. But still there is a long way to go. So it does have cleared governance structure so i can call and other experts using of the emergency communities. So hopefully it will be further revised in terms ofa making it work better. City but lack of enforcement and in fact, never has there been a mandate so research has not been a part of this but it needs to be part of as epidemic response in ways to bridge those practices. How to redo this Going Forward . So with say work in progress have we do with that governments gap . Has a social construct so the issue around Health Research is that these are broad multi stakeholder networksks with those capabilities andin mandates so we need to have that governance model so we need to learn how to do that. E thin sold to highlight those takeovers those National Governments with ministries of a and often they are critical but yet not talking to each other. Obviously who has a major role. And with those most prominent with those humanitarian ngos and those other groups with dating to Research Shows pharmaceuticals and diagnostic companies they are all critical stakeholders so what we did in the report with a set of functions and principles that are around inclusivee prinl autonomous organizations so with that epidemic and planning period, but between a major crisis we need to be better prepared to bring across these stakeholders with these occasional sets an io to involve those full sets with the Community Representatives and how do you prioritize the research that needs to be done . And to identify those standard types of research. All the things that slowdown the research and the key players without rapidti response workgroup when the outbreak is with people whogi have expertise specifically with those viruses you need to bring it in those to doth that regulatory work so we propose to that to have that roster so these are the two kinds of functions that we think need to be set up as a coalition so looking at what is happening in with that agenda and the coalition and a ban of them are perfect fits the we really like the approach with the full set of stakeholders. And then to move toward Something Like that. We have and to bring in the full set of stakeholders with those capabilities. What are the key issues . So we have thought about the things. We need to have clarity to recognize and those ideologies and that each address these issues. And to have that david kaygo att so that entrenched opposition and with day favoritism with the who in the same room with these types of patterns. Bed the example i gave it is very hard for who to partner in particular but they also have difficultyil itll think it is entrenched opposition but i did think that is a barrier. With ebola you really need to have the engagement. Absolutely Community Engagement. In those processes that is legitimate it is say book of Justin Parker so now i do have questions better on the table now that things over neglected or should be addressed that includes welcome our who but this main thing to bring together Collaborative Research to save peoples lives andt there is some agreement. But what is that Research Agenda and scope . And what pathogens to include . Epidemiological so these kinds of issues and accountability and you should benefit and it should be made explicit as we develop government. L even t so to this kwh ago is claiming they have the of vested interest but ofma course, everybody does with certain ideologies and organizations for what it is evidence, the with the previous guidelines with a vested interest of that ideology and power is critical if we can implementgo that it means we can determine what gets done and recognize the agencies are a twoway accountability. Alth. And with a working principles yes with that global coordination mechanism there is a blueprint that a group of scientist at their behest that there are 39 passenger and pathogens but there are differences of buy you prior ties and there are other principles but there is a number of things of those stakeholders and how you get them to the table but cdc china this the biggest and held them for structure sold similarly to have bad infrastructure capacity to be very clumsy so a big issue hat you properly balance these . So with that delivered a of process, right now there is a default type of approach that governance is just like the International Health regulations. So high to avoid a conflict of interest so the other notion is really need to have a distributed approache ofe of those areas we dont arouly know how to do that the both of them will have issues so now even if you have the mandate to manage the research function but basically it is the full cycle out of you do research and development or other epidemic related research with that analysis thank communication and with intellectual Property Rights and access to a product as low as those that the mountain that translation with apple set of Research Functions and you want to have leadership in the idea is you should not do those things that are in conflict with those printers haitian efforts obviously that should have been done ahead of time and also it commissioned research and they were subject to ethical review. Analyzing the results so that is the trial they were devolved and involved in so i think the question and moving forward is how do you create this . This is a list of all those leadership functions the save list over here and what we should be asking is we have that capability and the right balance of accountability if you are funding and commissioning and for those who gets that to regulate that so this is Going Forward with the systematic approach in terms of capabilities so the red ones i have highlighted that are in conflict and played all of those roles. So how can we do better . Going back to the reports and we need to engage in coordination mechanism to develop those mechanisms of the Network Structure in those processes to move forward. And with that certain analysis and with that working group that you would have available with a Rapid Response for the next outbreak there is a lot we can do we are hoping their reports and the further discussion will help us move forward to be better prepared to respond to the next major threat of emerging infectious disease. Thanks very much. [applause] [inaudible conversations] were now entering that more interactive face. If youre watching the live t stream version you should use the hawks in now so now alaska ever to invited panelist to comment and this is been mentioned several times during the talk and i want to hear your reaction we share the fact we both had service in west africa so we were neighbors in that sense into developed countries and also a leading part of the Research Effort so i am wondering if you can respond . So those red squares talking about those potential conflicts that manifest during the Ebola Outbreak having who doing essentially everything. A ag for having us here today we are happy to be part of the discussion so that caveat very much speaking from my personal experience in the field of humanitarian madison so we have that internal capacity of that operational and Clinical Research in that humanitarian context in on a different scale and other institutions the with that humanitarian Aid Organization we also thinkatment fair treatment last to be there as well. H we thank you can have a critical Research Agenda and we applaud that effort from Public Health and Clinical Care delivering Critical Care by trying to do treat a patient on the ground. So the next epidemic there is is talk about that epidemic period but that you hear in 2017 than last year the guilty so for ss the humanitarian Aid Organization the realities are is an epidemic so of the scope of bad epidemic was unique in some sense l. A. s to recognize the problems that were extrapolated from Clinical Research which shows the need for flexibility and real also know that with the earlier parts of the presentation we would like to reaffirm the of legitimacy of the who and one to include that blueprint as a step in the right direction and the role in the value and to be able to do that work and so circulating back were of medical and humanitarian aidum organization to ensure it is beneficial that the tools cannot be used in contextext ma and that gives us to our example more recently it isnt a thermostable liess vaccine but then putting aside that large separate discussion we could not usedn that even if we were able to from a regulatory standpoint of those vaccines to that context so looking and not the report with some key message that should be amplified with those priorities setting standards and also with those issues of flexibility and it is difficult to forecast and even with the vaccine ebola trials. And with that preset protocol that could have been more constraining. However thinking those protocols of natural guidelines and should be put in place beforehand but also excess ability to ensure that technology is affecting therapeutics what is appropriate and those areur the key messages. Ng eff and talk about effecteds communities as well with national and local governments not only to be and part of the discussion with those changes of the heaters and practices and that it isnt something that we should ignore. So at the peak of the epidemic in our Ebola Treatment Centers and there were over 4300 so even though youre the International HumanitarianAid Organization that is c part of the community so that does it close to home and takes on the conversation. You really spoke to the issue. Now lets go to jeremyarge pr directing a large part of the United States from its position at usaid at the time and as i understand it a l was a large portion of the financing and also about germany could orchestrate with that coordination between those agents and for those that are working in supported by france. And how to get that outt there but as you probably saw to do research at theit command at the same time and if it had been available in with that Ebola Outbreak with the Emergency Response been very Close Partnership not and on and as it operational side. And also in humanitarian Field Operation with theat panel the who established to supervise the implementation and this is extremely important because we are very fortunate in a way to have the tools at the outset we came very close to do the point is hard to imagine it there without doing dramatically more damage. So with these Research Products in order to contain the outbreak. And it is very easy to imagine that sometime in the next 50 years to see an outbreak in the world thato the tools available to west cannot contain it we will need real medical innovation and then to defeat the pathogen. So one of those big challenges with that band with. And give it is interesting. And what this report identifies and but we see as success factors and that is where bandwidth becomes really important. Ckeyin as they all jockey in the same space so choose to talk about the importance with the host government and those that are charged with 1 million other things. But in the case of west africa of this is a real issue of as usaid had a response on the ground. T. This kind of report is important in highlighting to an ambassador say this is why it is really important so they can come in and do research. One problem we had on the outset of the transit outbreak is with that the Health Specialists and medical specialists and we do really not have much of a common language. Msf has that because it is the nature of the organization. The Us Government did not have the and more bradley the most humanitarians did not have that. So that, one of the important aspect of what theyre proposing here, they begin to establish those points. The connective tissue between the emergency operators and Public Health specialists and specialists. So when it is goat time there are relationships that need to be in place and we did not have much interoperability at that time on the onset. With that sort of context in mind a few things that i would highlight that the report talked about and one thing that i did not see a lot of but i think is quite important, the First Community engagement. Obviously an important issue. An important issue for doing research. A fundamental issue, the fundamental issue. There will inevitably be challenges doing specific Community Engagements on research amidst a much Larger Community engagement. That is fundamental to the success. And those things will be mapped very closely. They were problems in the early days of a sponsored massive confusion about what the disease was. What do you do . Getting a clear and consistent message and establishing a clear and consistent authority, a trusted authority transmitting the messages is very important. The interesting differences across the three countries in the level of Community Awareness and the level of the types of Community Behavior that he saw and some of that had to do with the government and how effective the government was. We saw interestingly, a much better uptake of the key message at a Community Level and lazier is always the and the avenues with they were engaged. Dropping another element into that, can disrupt some of the balance and it can affect the credibility. So it needs to be carefully handled. sare dropping a Research Element is that you want to really hammer on the core messages of how you prevent this from spreading in the community, how do you protect yourself . Part of the messaging is if you, the only way to protect yourself and the community where the best way is that you have to have people isolated. Talk about what treatment entails the research is not generally unknown with that. We will treat some of you with this we will not treat others, how do you explain, how do you map the explanation of the process into that core mobilization messaging . I think it is essentially pretty delicate and it needs to be carefully handled. You think it is impossible . It is not possible. It is proven to be possible. It is very difficult and again, i think my point is it needs to be mapped very closely with in that outreach because it is done separately which is create transport also stressed in the report on patient data and their difficulty. It was a huge problem. The data was terrible. At the onset. People at one time, there was a case when first identified and cannot be the second time of the case when theyre admitted to the clinic and potentially one third time transferred to another clinic or one third time when they were, if they passed away. So you can have one case. Because initially it was impossible to track people consistently across the different avenues. It made the numbers very difficult to track and in turn it made the response difficult because it moves so quickly and fluidly need to have realtime information and understanding with realtime visibility and how the disease is moving so you not to orient your response resources appropriately. We did not have that of the onset. And youre projecting out what this disease might do. Based on what you think it is doing now. But if you do not have a good picture of what it is doing now it is hard to predict what it is going to do. Huge issue for the operation response. So interesting to see how it is manifesting in this issue. The challenge is how do you get a good Data Management architecture and a very low tech, very difficult operating environment, complicated logistics. Unreliable Power Sources and so on. Just spit upon, there is some fascinating work that has been done. With biometrics and other humanitarian context. So using Biometric Registration for this can be done in a certain environment. It might have some whether that is a solution we need a lot of progress and innovation. It was such a handicap in the early days. And it was not until we went out and took a few volunteers and us military personnel for data entry. And the soldiers and several liberian counterparts set in a office and scrubbed the data and restart to get much more accurate picture of what the outbreak actually look like. Lets move now to the general discussion. I want to give a chance to say one or two sentences only please. In response to the comments. I think we are in general agreement to the points that i made. And as i said, lets go from words and taking action. It is true that outbreaks and epidemics are going on all the time. I do not have much to add except that we are in agreement. Really this is about the next steps and i think the point about needing to have flexibility is critical. I think you highlighted also the importance of what is the research . It is really access and also some of the other epidemic related systems that have really been behind. I think often sometimes i want to emphasize something jeremy said. It resonates with me because of my long experience now in looking at the economics of the hivaids response. That is identifiers. One of the Biggest Challenges in managing the hivaids response is of course on a much different timeframe, years or decades rather than only weeks as it was for ebola. One of the biggest problems is the same patient got captive multiple times and then they got missed in other instances. So we dont actually have as good information as we would like. With respect to whether patients are successfully making it through the entire treatment cascade. Answer the issue of the patient identifier stressed me as a common theme with this. And i am wondering if they waited a great to the technical effects that can be done now as we prepare for the next epidemic. With having patient identifier systems encounter is a necessary foundational step in order to prepare for the next outbreak. Had you feel about that . I think is absolutely essential. How do you feel about it . I think the answer for us is yes. Except i think it is a little on the biometric identification of the humanitarian Aid Organization. We need to step away from it a little bit and buy a little bit i mean a lot. So you mean it would help you in tracking patients and you are worried about some of the exactly. Patients can be effectively addressed then you would feel more comfortable. Yes you can mitigate that end of it i think you can which is why need to engage with community leaders. I am not sure exactly how much time we have but lets start to take some questions from the audience and also roxanne, if you questions on twitter please let us know. The lady in the front. My name is deirdre, i am an anthropologist converted to a Public Health practitioner. I did my degree in the department of International Health at johns hopkins. In the days before it underwent what i would call the social awareness revolution and became the Bloomberg School so i am happy to hear so much discussion about the importance of community, social awareness etc. There is one role i did not hear mentioned by anyone. And a fascinating visitation and that is the role of the anthropologist. I was an anthropologist with a capital a because that would be a key role in the area of prevention, a key role in the area and engagement the key role in mediation between Different Actors and also between the researchers and the community to make the research possible. So i would hope to see at some point that the anthropologist becomes a key player in the process. Lets collect two more questions than turn it over to the panel. Can we get two more questions . Lets, and curious myself. Given the importance of this. We have one more. And then i will give it. My question is about Us Government funding for research with seems to be on the decline and would be do you think it will be an appetite for this kind of work . Please introduce yourself. My name is i used to sit on several bodies of research coalitions. Global research coalitions. And we have this very ambitious program, could you maybe give us a glimpse on some of the Lessons Learned . It is not for the first time, right . Skepticism. Well, you can hear the tone of my voice, right . [laughter] the role of anthropologist i really am curious. None of you did nor did i mention that word. The possibilities Going Forward for funding and some skepticism about davids very very ambitious plans. The anthropologist i think is a critical plan affecting the outbreak that it proves itself to be very useful and as a leading part of what as part of the Community Engagement. I would say that having that standing at the herbology platform, not just anthropologists but i would say that it is one of the questions in terms of the broader, what is the Research Agenda . Because i think there are huge questions on the applied research that it plays. And as well as the actual programming. It is not just strictly research. There is an important part of the Community Engagement. And the anthropologist approach and the response. That is what liberia did early on. I think its important also some groups are working on anthropology and accountability i think some of the research is particularly needed in terms of looking at some possibility, mapping accountability ecosystem that would help us as we move forward organizational. It is really crossing disciplines but i think some of the methods and tools would be useful both at the global level as well as research in response. Quickly, i want to make one point. As you can imagine, for these kinds of Clinical Trials, therapeutics and vaccines. This was coming outside of africa at High Research organizations. It was interesting at the beginning they really hadnt heard about social mobilization and Community Engagement and why they really need to make those connections . And once it started to happen, things began to move and in fact, we say in the course of the presentation that in fact randomized controlled trials can be done. But only when the community was engaged and understood what the rationale was. So this connection is as intimate as could be. And it has to be done better. Would you say that a key requirement is the community understand the depth of the ignorance in the medical community about what really works . There is lots of therapeutic misconceptions. Ms in the community itself has misconceptions. I would think that for the community to endorse the concept they need to be convinced actually that there is no cure. Currently there is no cure. If they understand that that the best people in the world, that might be the first step. Do you want to talk about the early messaging . Goahead that is rather important. I think will be difficult to assume that because what we found was a lot of the early messaging that did not work was around a bullet kills, it developed a sense of hopelessness and undermine both the response and the research. It is really around hope and understanding and so that is the approach i think that is one of the issues that lead families there is a very telling moment that we have one of our open meetings in monrovia. And one of the senior clerics in liberia got engaged in this late in the fall of 2014. When they discovered Community Engagement, so he said that in addressing his congregation, talking talking about all the things that expose people. You know when he talks about the laying of hands he does not mean skin to skin. And you can lay on hands at a safe distance. Its only the acceptance of the safer burial practices turned around. And it is those kinds of insights and messages that need to be there for the very beginning. Is hard to get the conversation going. Some of the leading researchers in the field said, we never heard about social mobilization. A new concept to us. Now is the time to make that connection happen. It is fact is that i have never heard of ecosystem before today. I can just mention that but i mustve conducted a lot of operational and applied research during the epidemic. Both in the beginning when we heard deafening silence from our colleagues national, international and across the board. But when we were in the field and when others doing this as well and including most certainly with anthropologists helped deliver some of the Key Community messages at Core Research which enabled us to do treatment. I think the role in anthropology is really well organized and recognized. You are talking about a role for executive function and the reinforcement. I know that amongst that who is now building the edge of the Emergency Response section. Quickly on the funding. It remains to be seen yet what will actually happen. I have been cuts that have been proposed by the white house that are incredibly irresponsible and incredibly damaging. Im not a Us Government so i can say that. I mean really deeply irresponsible. What is encouraging is those cuts have not gotten a lot of traction in congress and of Course Congress with the budget. I think there is some reasonable hope to hold out that some of the more damaging of that proposed will not make it through the probations process. It is hard to have a level of confidence in Congress Based on past performance. But i think there been some strong signals in fact when the president s budget proposed reducing, this fiscal year for the remainder of the fiscal year by 1 billion, congress increased that by 2 billion. And that increase is the set point that there is a continuing resolution for next to the budget is not 2 billion more than it was a little while ago. One of the things that we are trying to do, raising issues and constituencies in the public, to respond to and challenge Us Government policy being proposed sometimes also implement it. We need to raise the alarm. We need to get the Larger Community and agreement that our health is tied to the people elsewhere. And Global Health is relevant to us. And that is part of what we are doing and disseminating the issues around this important and activities at the National Academies can do. It is not implementing an organization. It is not going to be in the field with you and taking care of patients. But it has some substance and try to get that out there in this response agenda. The cost benefit on that is so incredibly compelling. Because if you look again at ebola, by having a slow response that did not have much in the way of therapeutic transfer the Us Government needed to prepare for and respond, prepare on the homefront and respondent south africa to this crisis. That is an awful lot of money. That is a very small amount of money compared to what the nation would have to send in case of a true, truly deadly pandemic that probably will emerge at some point. Research pales in comparison to what we have to spend in a crisis scenario and helps. We in the reports simply im going to pay a lot more later. To do that is not just the treasuries money but it is death and morbidity and economic consequences that have huge implications. I wanted to respond as well. About the research consortium. I do not. And that is a different set of players. We have not done this before. Not at the global level. What makes a collaboration, a network work is the same kind of principles around how do you add value or connect commonality and the kinds of things we talked about in terms of recognizing different interests and accountabilities. Once you lose that you need to legitimacy, you lose the trust, you lose the ability to add value. I think that is what we are trying to be more explicit with what other things that you really have to take care of, understand and going with your eyes open rather than saying that it will take care of itself or that you know let them do certain things it will combat on the other side with government giving it a new kind of approach. We need to go in her eyes open looking for data around how do we add value. Let me make this last point. With the who system with Single Institution responsible for the entire chain they identified. We at least know who screwed up. What worries me with respect to proposal is that your accountability system may not allow us to even know that. I am wondering and i just it would allow us to know that if the accountability part really works. It looks to me as if what theyre proposing is a more inclusive system. One which involves multiple entities and a more peer to peer network sort of arrangement. And peer to pit networks and information a thousand there are systems that hold you accountable. How would you have a Network System with accountability . I think it is a balance making them explicit. The problem with having a single hierarchy is that we havent adjusted and dont have the capability to have the capacity and to do it this conflicts you do not want the funder, the commissioner being the one telling you what the results are. And doing the ethical clearance. It is just not, you get confused messages and you get the wrong messages. So you lose that trust. I am not talking about in this market. There needs to be real accountability who is actually going to develop the new product and who is going to ensure this . How do you track what happens to the prophets and who actually gets access to the new vaccines and drugs. You can do that through transparency. It does not happen on his own. If you have those seven functions i would do it around responsibility for functions. You should still have who and the response and in terms of the epidemic response i think it is clear we have not nearly invested enough in making that work. But i think just by the International Health regulation there is a core responsibility for government and they have failed terribly. So is not like there is ever a single responsibility. It is just that we need to be more creative and inclusive in terms of how we bring this together and what we have left is actually balancing independence. So by putting it all in one you know the same soccer player, the referee, this president and stand in the commissioner. You get a blowing game doesnt work very well. [laughter] i think unfortunately it is time to wrap up. I would like to thank all of our participants for coming in. We are glad to be able to help in the dissemination of this important National Academy report. We hope that pandemic preparedness is going to be a continuing priority for the International Community and for this administration here in washington d. C. We think that this report is pointed to some of the, point out some of the reasons why we need to prepare now and not wait for the next ebola epidemic and also gives us some pathways, directions in which we can move and we need to do that fast. Thanks to all of you. [applause] [inaudible conversations] [inaudible conversations] zeez that has been on the road meeting with winners of this years student cam video documentary competition. At Laramie High School in laramie wyoming they gathered with family and School Officials to accept the firstplace prize of 3000 for the documentary on wyomings dependence on fossil fuels. In golden colorado, ethan cranston, all of your classic academy accepted secondplace president 1500 rated documentary and cybersecurity. Also in denver, the thirdplace award of 750 went to 10th graders. And for their documentary about digital hacking. St. Thomas Moore High School in south dakota is where audrey, grace and carolyn won third place prizes for the documentary on racial inequality in america. In sioux falls south dakota seventh grader received a thirdplace prize of 750 rated documentary on the national debt. And a classmate got Honorable Mention for a documentary on marijuana. And a number of students one Honorable Mention and 250 per group. Lauren, haley and won Honorable Mention on global warming. Thank you to all of this is a took part in the competition. You watch any of the videos, go to student cam. Org. And student cam 2018 starts for the theme the constitution and you. Whereas his distant today provision of the u. S. Constitution and create a video of why it is important. You are watching booktv on cspan2. Television for serious readers. We are in prime time all this month while congress is in recess. Next, a look at manufacturing and labor with others deepak singh, we will start with mr. Deepak singh on his experiences working in the us service sector. His book is titled how may i help