Transcripts For CSPAN2 Health 20240705

Authors and others who are making things happen. Booknotes of visits is a weekly conversation that feature as they did authors of Nonfiction Books on a wide variety of topics. And the about books podcast takes you behind the scenes of the Nonfiction Book Publishing Industry with insider interviews come industry updates and bestsellers list. Find all of our podcast by downloading the free cspan now apple or wherever you get your podcasts. And on our website cspan. Org podcasts e here. Next to look at decision they the covid19 pandemic and how covid19 impacted health policy. Will hear from Infectious Disease scholars along with fda Principal Deputy commissioner Janet Woodcock and former commissioner mark mcclellan. This event was hosted by the American Enterprise institute. I am tony mills come soon affiliate the American Enterprise institute, i want to looking at all and thank your coming. Particularly those of you who braved the friday before the Holiday Weekend to be with us in person. But also thanks to those who are tuning in virtually. What i thought i would do is, before getting intoo our panel, we have a terrific life today, two excellent panels im really excited about the discussions which will cover a range of important and substantive issues related to the covid19 crisis. I wanted to to start missing a few words about why were having this event here now by way of background. I thinkk it would be uncontroversial to say that the covid19 crisis was, in fact, a crisis. However we think about it, its something well all be grappling with for some time to come. Certainly among the most important events of recent times. Of course it was a Public Health crisis, arguably the worst in 100 years, which resulted in an unspeakable amount of death and illness. But it also has resulted in a set of policy and political decisions which were unprecedented, the effects of which we are still grappling with and trying to understand, and the effects of covid could be measured not only in terms of the massive amount of carnage but also the secondary effects of the crisis, think in terms of learning l loss, Mental Health issues, other sort of medical problems that were exacerbated by the crisis. But also the effect of the crisis at on our social fabric and our political life. If you spend time reading the history of epidemics, which is a demoralizing exercise i dont necessarily recommend, youll find this is a very frequent pattern. One of the worst effects of epidemics and pandemics is to cause social conflict, political conflict and an erosion of social trust. I think we sit today and we will be grappling with that for a long time to come. All of that would be reason enough to have serious reflection on o what happened during theha covid crisis, whate did well, what we did badly, what lessons we can learn but theres another arguably more important reason m which is that covid is not the last Public Health crisis we will face. It is very likely not the last pandemic we will face. In the years to come. And so while recognizing with i think you mentally are certain deep patterns that can recur when crisis like a stasis, we are not helpless and we do have tools we canan use and drawn to think about how to grapple with crisis like this. One thing we could all agree on, regards the politics and blog think about covid is we did not handle covid very well. That response particularly in the United States is not an exemplar of Good Governance or r good policy, and the question that we have to think about today is how we can do better next time what kinds of lessons we can learn for policy, for thinking about how we use evidence for policymaking which is a subject of our first panel but also how we think about institutional reform and building resilience into our federal and other institutions which is what we will talk more about in the second panel. As the crisis recedes, the window which to learn the lessons risks is closing. Its for this reason i think we need have this conversation now. One might have expected a National Blue Ribbon Commission to look at the covid crisis and to think about what we did well and family so maybe i can do what happened after the 9 11 attacks in 2001. Demoralizing late we have seen surprisingly little action of that kind here in washington. Relatively little compared to the scale of the crisis and its importance for thinking about thee future. As it happens a group of experts did get together in 2021 with the purpose of trying to create a Commission Like the 9 11 commission, and had inadequate success among policymakers in putting Something Like that together. Fortunately for us they decide to press onward and formed the Covid Crisis Group which was an independent group of experts that triedgr to examine what we did well and badly during the crisis, put together a set of recommendations for how we might move forward. These recommendations came together in a report book called lessons from the covid war that was released this past spring. So part of what we want to do to do is highlight the work of that report and engage with its findings and recommendations, andd so were fortunate to have an member of the Covid Crisis Group on each of our panels today. We hope this will be the beginning of a set of conversations, only the start of more to come, and we are honored here at aei to convene this and contribute to that in a small way. It so without further ado i would like to introduce our first panel so we can hear lesson for me and more from the experts. So join us on a first panel today we have Marc Lipsitch who is a professor of epidemiology at the harvard chance go Public Health and director for senator to medical disease dynamics. During the pandemic he was named the founding codirector of the new center for forecasting and operate analytics within the center for Disease Control and prevention where he now serves as a senior advisor. We also have joined us emily ricotta whose independent Research Scholar in the division of Intramural Research at the National Institute of allergy and Infectious Diseases, one of the divisions within the National Institutes of health were invalid emily leade epidemiology and Data Management unit. Last but not least we have jonathan fuller who has the dubious distinction of being a fellow philosopher like me. Hes currently serving as a visiting scholar at the department of bioethics at the National Institutes of health also a professor and that appropriate to share philosophy of sight of university of pittsburgh as well as a cofounder and Deputy Editor of the excellent journal which recommend philosophy of medicine. So with that i would like to pass it over to mark. Thanks, tony, thanks for the invitation to be here. Im glad this is happening. Its an opportune time to get that it gets less opportunity by the day so the sooner we discuss these things and reach some medicine at how we can move Forward Together the better your i should say that although i do hold a parttime to the cdc come on speaking in my personal and academic capacity, not as a representative of the cdc. I was would have people i was on the Covid Crisis Group which produced this book that many of you may have seen. And lessons from the covid war. And tony sp to set a couple words process of that. As tony mentioned the original idea was toth be the sort of groundwork layers for a fullscale Investigative Commission that might be set up by the government or in some other way. And that begin in 2021 through the efforts of philip who led the 9 11 commission as executive director and who worked with four foundations, the schmidt futures foundation, the rockefeller foundation, the School Foundation and stand together to try to get some diversity of funding and diversity of viewpoints on the planning, what was then thenn Covid Commission planning group. He began assemblingp that group through a snowball process of interviewing people who would been involved in the pandemic in variouss ways, asking some of u, after the interviews, to come and join the group that was doing these interviews. So we sort of assembled in that way. And as tony said the goal had been to put together documents and oral history and some fresh memories for the potential future commission. As we all saw, that was not adopted in more ferries piece of legislation that could have adopted it. And so the book was written really by philip, which is good because hes a great writer and some of us are not all as good writers, most of us are not as good writers as he. I wont go into the details of it. I do recommend one of the things thats good about it is its extremely readable because his ability to write well, even about kind of bureaucratic and institutional history, which weve all read books about those topics that are not well written and its a lot easier to write about personalities and individual stories. But the goal was to write about the systemic issues and what was decided, how it was decided and why it had to be dissent in certain ways that lead to less good outcomes then we wouldve liked. I think thats part of the value of the i book is that it does he individual characters. It does have stories but it really focuses on the structures in on the unfortunate fact that had we had the best leadership possible at that time and all parts of government we stillim wouldve had a really uphill battle. There were some clear failures of leadership, and those are discussed in the book, but the system really was not decide, talks about thee sort of Grover Cleveland area designed for Public Health system and the analogy between the way that we deliver Public Health and the state militias under the articles of confederation. So they keep you a taste of kind of level at which its written. And nonetheless its easily readable. I think i will leave it there. Well come back to l some of the topics that aref in the book during the course of the discussion. I think i will now sort of shift to a few perspectives of my own that iw think are consistent wih but probably not all in the book. Deep, seriously consistent with what the book triesy to lay ou. So the topic of her panel is the of science in pandemic decisionmaking. The perspectives i want to bring our to start i think about the kind of time evolution of that question. So the pandemic at all of its stasis phases was an exercise in Decision Making under uncertainty, and the uncertainty in many ways with greatest at the beginning and narrowed as it went on and as we learned more dirt but it persisted. I think its helpful to think about how you should act in relation to the signs scie science is minimal, when its somewhat more established, and when its more mature, which we could think of is kind of the beginning, the middle, and the later phases of the pandemic. So in the beginning there is a need to be precautionary and use shreds of evidence, even shreds of indirect evidence to make policies that will delay the bad outcome. And i think there was a process of education that happened atas the beginning of the pandemic where people started to understand what it means to have an exponentially growing threat which can be small today and large tomorrow, and where small is easier to l control than lar, and where delay is the name of the game. In the sense as we found in this pandemic, if you got covid in february, sorry, in april of 2020, you faced overloaded hospitals, and review of medical countermeasures, very little evidence about what countermeasures might work and so forth. If you v got it a year later, people knew how to treat the disease. There was not yet an antiviral that was specific and good but there were steroids, there were other procedures in the hospital. You are much better off. If it was, if it wasnt new york at the height of its first wave, you are also less likely to be an overcrowded hospital. So delay is valuable. Flattening the curve as hackneyed as the term became really does mean that fewer people get infected over the course of it, as well as those who do get infected, get infected later. So really you are trying your best as a society to delay the spread. We didnt do that as well as we could have. D that is, that was one of the biggest issues. Its important to mention the issue of the complementarity of following science in that environment. I was one of the few people among my friends who was in favor initially of border restrictions. It was not a popular view among many Public Healthg experts here but in retrospect i made an assumption that was wrong, which was that if we could do late entry by a month, or delay the spread of the virus by a month, we would have time to prepare. In fact, that delay is only useful if your time to prepare, and because we were not doing much preparation in february and march, that delay was not as valuable as it couldve been. So i think i was right on the principle but wrong in the event. As you get, and the precautionary approach means you do a lot of interventions that should be marked very big, with a very big red asterisk as temper and based on our current level of ignorance. And School Closures which is included to later is a good example of that. It was actually the right thing to close schools initially because we didnt know what the role of children would be in spreadingch it, and it made a b, and made a lot of sense given our understanding of how many respiratory viruses are spread. But it should have had an asterisk saying this is based on what wee know, and were going o revisit these decisions. I think thats a general issue that i will mention in a second. As the pandemic wears on, evidence begins to accumulate but it often is not decisive, and so they need to integrate evidence from different sources, from social science, from economics, from biology, from randomized trials of particulard interventions becomes more necessary. As we try to figure out now to live with what turned out to be a very longterm threat. The goal really has to be to make sense of t different kindsf evidence, none of which is completely conclusive by itself, and to treat it as as a multe input decisionmaking problem. Later stages, what struck me s the importance of observational evidence as opposed to the demised trial evidence as opposed to minimized trial evidence. Most of what we know about vaccines are based on observational studies because we did not do trials with this variant. There are a lot of things we cannot do trials on. We have to understand the value of observational evidence and take steps to make it better. I want to finish i wonder finish by saying b a s couple of things we can learn from other responses and how to integrate. One of the most informal processes in major industrializeded countries on Public Health and putting it aside words formalized we have, there was no centralized group of experts filtered evidence to do policy making in the United Kingdom for the criticism, it provides decisionmakers with a sense of what the Scientific Community believes. Another lesson that i think happened informally but no structure, the governor because it was informal, it meant for several hours a week commitment and nobody have the time, we couldnt respond to formal request. Another thing the uk did very well was invest, to put in place structures to gather evidence and it made them understand what was going on at all times across jurisdictional we never had and then putting in place data structures for federal agencies to collect data from the state and structures reported to be more effective. From an epidemiologist of scholars Infectious Diseases. Here to give opinions, im here to talk about data. Having the uncertainty as we move across the pandemic, how we become more certain is gathering data and data is difficult to collect and manage but its more difficult in this situation so in who want to talk about the things we cannot from better during the pandemic in terms of research. There is a difference in why we collect data and where we collected from based on understanding disease spread in the community and would not want to know the questions of how well the vaccine works so we need to separate surveillance and research and data needsec because its not just onesizefitsall so my expertise is clinical studies as well as how and why and how we manage it so i had the opportunity to work at the state Health Departments in academia. I worked on surveillance is a unique opportunity to understand the variety of different areas so during the call pandemic, anybody who has done research, its difficult to collect large amounts of data so your collecting information on health, who is sick, demographic information in the. They have and people have various feelings about the and reasons why they may not like that and we are doing this in a sensitive manner and difficult to do a data systems across the platforms. Having data from three weeks ago to respond to pandemic, how many people are getting tested positive or negative and read this in real time. Understand how we can respond, otherwise where we investigating this . Is also economic consideration using this data totu inform how and where but in addition to realtime, just having a bunch of data is better than no data but it takes time to manage data. 70 of cleaning, those are surveillance as well so if you get data from state and local Health Departments and Healthcare Companies all over the place in one of these are meant to work with one another which is problematic, we need the data to be joined together so we can say we may not have one set of data but we have data covers what we need so we need to have a standardized and people who can analyze and utilize the Decision Makers and data andased on the responseal and United States has fallen short and we dont have oversight organizations and make it actionable. We could touch on that today, who may be responsible fors insights making them actionable. Weve got research in different places we can get. We can get data in in the u. S. , the program where the country reports data on certain diseases and the cdc collects information and reportable illnesses so we have the systems in place, Electronic Transfer to the cdc so one thing we talk about is the potential in the system to Pay Attention and invest as a way of helping fix the problem although there are many others. We also collect data and studies where you are not randomizing people in the randomized controlled trials but we cant always view them. You have to set them up standardization and protocols and it takes time and money and theres just no way to get enough people because cases flew through but theres not a reason to use the randomized controlled trial in turn is something else. The problem again is standardization so theres not much work standardizing observational studies not protocols and things we could spend time and prepare for and be ready when this emerges and collect the data to use in place of lacking surveillance and during the pandemic we had vaccine studies and we were able to include pregnant women and we have to learn observational studies to assess intervention and standardizing making sure people have the money and the people to view that work is something we should be discussing in this initiative. This is electronic healthe recd and reuse the Data Research and it could be opportunity for surveillance. In the United States will have centralized Healthcare System, i dont know if all of you knew that but healthcare relies on working with different systems and they are not easily assessable or required to send data to the cdc in the event of an emergency. It can be difficult and timeconsuming and delays our ability to respond in emergency so another opportunity, how could we work with corporations to collect realworld data and how could they help us respond and get the data we need . Theres a lot of opportunity to work with the data and having that will enable us to prepare and respond to situations more efficient about so im here to talk about today and im looking forward to this. Thank you. We heard about data and the related process for conclusionso or certain decisions and evidencebased policy around government and Public Health and evidencebased policy might be using some kind of data or rational but this comes from the 1990s, evidencebased that has a number of principles thinking about evidence some of which are quite useful especially trying to evaluate but some might be inappropriate and it boils down to a few, evidencebased medicine says it comes from randomized control files and randomized units for individuals, communities or groups to compare the effectiveness or policies and who might want to have a different way by systematic review where possible and similar trials to come up with a singular estimate of intervention left done with drug trials and they might have a similar effect on different kinds of people in which the effectiveness might not be in the social climate. Another one can be summarized by the phrase too much, a Movement Popular in the United Kingdom, here in United States and elsewhere the idea that medicine especially in recent decades have been prone to overdiagnosis, too much science like epidemiology served as an important check by making sure they are supported by the best evidence and its more of political cut. Like mark mentioned we need and Public Health to make it diversity and we will have the transmission and they play and they were not intervening intervention that means the Public Health as was and evolving Public Health emergency different basis in which we have different amounts of Data Available interests require evidence ofa data thats possibe certain assumptions and outcomes, possibly supports the use of these that we might collect more data on in the highest quality evidence that it might lead us not over catastrophe. The interdisciplinary field, need to avoid blind spots as a prime example in complex health problems. In this could have had or understandings of what studies we need and what is appropriate. Partly to deal with this challenge or need for interdisciplinary, different ways in decisionmaking and a call for Scientific Advisory group the independence of both freedom from clinical interference but also the purpose of being a political, influence so a group of people who shouldnt be there in between and the second thing is government institutions to lead the way on preparing for the research dedicated funding streams coming up with protocols to standardize research in multiple areas when it comes to collect relevant data and identify priorities and gaps in research and kick and partner with public and private groups to get studies done quickly when we need them. It shouldnt just be left to academia even though academia did a great job during the pandemic. Second thing i want to say is evidencebased policy for Public Health but we need to talk not just about evidence but also values. We hear phrases like follow the signs, im oftentimes invoked by a policy sometimes one might be doing more than data, there is evidence on this particular problem but only becomes evident to support a conclusion in the argument we are making is strong evidence, planning for reasonable work, we might just need evidence to make certain outcomes possible it might be the best way with uncertainty. On the other hand if we try to justify intervention, who might want to know specifically how they might prevent harm to third parties and stop the spread of infection one person to another and then harm benefit analysis tryingr. To way this, there is evidence that intervention has that might not be available early on so its not just evidence but also requires thinking about what it is we are trying to achieve here, they may have been made foldable because of a legacy of injustices brought on them during a pandemic. Because values and decisionmaking are necessary that when groups disagree over relevant values, it can sometimes look like they disagree over the evidence so it can be easier to say i disagree with the values of priority but i want to criticize the strength of evidence youre using to supportus and be more objective and politically controlled make sure youre not letting the decisionmaking masquerade over evidence so they might be on the data or evidence justifying Public Health decisions for public scrutiny and not just data or evidence the last thing, we need Public Health approaches, not just medical approaches. We need to think about for the according to what they are, we need to adopt certain tools in different ways tracking the spread of an epidemic and appoint intervention for different purposes, facemasks to protect individuals from becoming affected harm and certain evidence to help us n whether or not they are good and we might want to look at the ability of intervention to help spread. Another example, testing for infection on various purposes, the purpose of diagnosing individual patients without also individuals to think about how to rationally deploy things, think about what outcomes weo achieve in the mut include public outcomes directed at the unity and not exclusively individual so this is maybe one way of supporting the common refrain we need to support Public Health and not just medicine in the regulation, policy guidance and scientific advice as well. Thank you all. A lot of topics i want to get back to, i thought wed begin before getting into the weeds, one thing we can start with, something i think everyone agrees as the pandemic unfolded, they were controversial and polarization resulting from mass and vaccines and so forth, one of the ironies that upfront be more precise and camera type interventions but we didnt have a clear picture so i was that . What was it that we lacked the didnt give us a picture we need to have Early Intervention to avoid what we ended up with . Data, we didnt have the data. Ha also the case in u. S. In 2020 when it turns out we probably had people come in earlier than that, once you turn on the tap, water is running, you cant put it back in the top so not knowing people had come and infected, where they were, who they might have affected, that led to compounding cases where we have no idea so if you dont know, how do you intervene . Contract tracy works better when you have one person and they have contacts, everything increases exponentially so the earlier you have data the earlier you can respond so the lack of data but also wanting to believe this was going to be a problem in america for us i think contributed. This is one of the first times a pandemic impacted americans directly we had to worry about yes we have the flu but this isu one where people want to not have the data or evidence and say they dont have anything to say its here and allow the ignorance without knowing who would have known better quick to respond. I agree with all g that and s partly willful decision to not respond. And it will affect the majority it will be a big thing in dozens of countries. And its spreading anywhere the risk even if china to control it at the source, it is the weakest link in the chance etiquettes back in the bottle, we didnt gear up as much as we could have and that the better data and there was institutional things about the inability to use blue can detect covid but we could have had more flexible abilities for what was going on and how preplanned our approval for the emergency need and i agree it was lack of data and the ability to respond what was here too many people. One of the other things i talked about in the report is i feel agencies whose responsibility it was responding to these things, everyone assumes thees cdc but thats not the case. The cdc can make recommendations but if its a imparted case, they have jurisdiction over this so theres confusion who should be doing got responding and collecting thefu data and its something i dont know if it ever got cured up, covid emissions didnt seem to help things so a lot of confusion of the on. One think we need to get the relevant data is the ability to rapidly contribute to the test so we can get and i and where it is and eventually allow us to return which took americans a long time to do partly perhaps because we didnt have certain groups working on developing and left to think carefully, it wasnt a National Strategy what we would need to do and how to surveilled covid effectively and the various environments and having the Production Capacity to manufacture the tests once we have this and are able to produce. Another thing is the industrial policy, non suspicious relationship between government and because of their example, they have established relationships and set up the infrastructure, not Production Capacity to my knowledge but the agreement and relationships and knowledge when the virus came, they scale up the manufacture test, at least the supply of tests in the development of the test but a complementary strategy is to have the capacity to build. I want to get into evidence and data, something you alluded to in opening remarks and youve written about one of the difficulties you have multiple kinds of expertise that require you have conflicts among experts and standards of good methods and one of the cultural clashes youve writtenut about his domas in medicine and Public Health that rely on randomized controlled trials and domains a that rely on modeling and i wonder if you could save more about those two approaches and particularly how it shaped the things around covid as part of what happened is public controversy but if you lift the hood you find that this was the onlys clearly identified and muddy the water in some cases. One thing i want to start off by saying is there is an Important Role for medical trials and randomized Clinical Trials and need them to understand the effectiveness and integrate example and critical trail where they delivered highquality results in about somebody we simply dont need these trials but there can be more different because of evidence and it is one in which just a few months ago among different sectors and whether or not we should be using to protect others and a few individuals in the community pointing out from previous reviews from evidence including randomized studies and other pathogens and facemasks were lower certain quality and didnt give clear direction whether orn nott it was for the pandemic so arguing from lack of evidence deploying facemasks they might be a drug that has theoretical possibility that turned out not to be effective. So one of the harms and there is some uncertainty whether or not, is there a different way we can ask ourselves, is a high quality rather on possible benefits and recommend rain facemasks specifically for Community Among the asymptomatic the question whether facemasks the guidance was more clear and a good thing to do. Fast forward three years when we have more data in looking at different regions to implement policies and using facemasks for slope transmissions help despite the fact that we have the pandemic and the wealth of different evidence from before the pandemic brought ability to stop these, presymptomatic andth asymptomatic spread in Community Transmission and evidence demonstrating airborne transmission respiratory particles and it remains for scientists and evidence and evidencebased medicine is an update of the literature on facemasks focusing only on randomized controlled trials in which facemasks during the pandemic dating back before the pandemic and other viruses whether or not Community Transmission and concluded it probably has little to no affect based on the review of uncertain quality and it was highly on variable in which it was highly variable ranging from providers in Healthcare Settings for Community Members living in villages so use the evidencebased approach bringing together studies to come up with an estimate for facemasks and some studies comparing Face Covering respirators so that is a medicine approach but if you look to the numbers of the Public Health community, they are looking at diversity of evidence not asking the question, what isev facemasks on respiratoryy pathogen asking how we understand the different studies and the mechanism by which it might have been a role in so looking at the evidence in trying to explain the results holistically rather than coming up with this range of studies that are being looked at and they are being studied and the outcomes and so on so singular effects of respiratory pathogens to be found. Its the scientific culture clash where people were used to interventions and w venison tryg to apply those in which those have limitations. Spaces to have these debates and the state of science and the policy recommendations and its contributed to polarization and trustly issues. I want to make sure we have time for questions but please feel free. The areas that existed in the area, where we are doing testing using transmission, did that filter up and would we make that same mistake again or do you think current policies will allow information to inform policy earlier on . I certainly dont know the details timeline where the information. The part that are trying to say, it was inconsistent in with their approval so the study was reviewed and not allowed to test it for other things. There is ahe delay in being able to do that in due to limitations on how they are written so once the case is reported, it made National News and was our problem of getting the information out. In Public Health agencies they have a problem they like the data, they dont like to speculate and they need to do controlled speculation and this is not data, it is an important opinion andth with seattle out f thatd way there cases in multipe countries, it is stupid to think there are not cases in the United States. The fact that we havent seen them but the story should not be the case in seattle, it should be the case in seattle and one role of bulimia recently we have reason tohe believe there casese need to prepare for that but we are in conversation with themselves thinking early on all. The evidence that comes from this, i think so. Elon musk cant get into this industry and theres a lot of garbage in the system and false positive and this shouldnt have and they got in trouble so we need to balance between invading and the standardized groups who made those and allowing them verdigris clinical standards because there are implications for having this data for putting region so that probably there will be more conversation and how we can incorporate academic institutions, new Genome Technology but i do think we need to make sure there are standards and regulations because it could go back, theres a lot of damage they could do and say its more data, more information. Thinking about technology coming online and garbage in, garbage out, i would like to ask briefly about wastewater approach which were essentially new technologies deployed as the pandemic was unfolding and theres interesting predictive forecasting information and the large language model in the contexte to predict future evolution of the spike protein and these are new approaches historically outside the Public Health medical arenas but as a result of the pandemic deployed and are being deployed and they dont fit the mode of randomized controlled trials if they represent where technology and curiosity based science to be deployed to yield positive outcomes in any of you can respond to that. Its been done for polio. Weve used it as a mechanism for Public Health in the past so as long as it is done in Ethical Fashion and able to answer the questions, why not . Why not have the data . Think it is great and the need for that situation, and go into areas where theres not access to healthcare and using it wastewater and could be good gettingan information in because of other issues we can talk about. And it is a gray area and i am an ep urologist and usually a proponent of making sure we are coming through things like mutation and vaccines, we can utilize a. I. , we have good quality data and different proteins but its not good quality they data and model things that will impact their wellbeing so here are some different targets and we can design studies through traditional observation studies if we need to so those are instances of these technologies we can use in this situation and an environment where its not going to it could contribute to the knowledge adding moread conflicting knowledge or more lowquality evidence so i wouldnt say lets apply to everything, you have to be mindful on how you are building them but there is room for newer technologies given people are thinking through the riskbenefit using them in an Ethical Fashion. We have time for one more question. When we think about the fact that our Healthcare System is universal, be opportunity to make it better the next time, how much is policy . Structural versus policy, how does that play out in your mind . The federal structure of the Public Healthhe system is the biggest constraint because its probably not going to go away meaning decentralized, policies can improve decisionmaking empowering units of government to use data and information and it is one thing we are focused on, working with state and local to spread the best approaches. The hedge against federal and ability to respond, its good to have capacity at multiple levels there and we need to redundantly find better to get Healthcare System data inasmuch as it should but to make it timely and collaborate rather than the Data Transfer eight which of the old and build arrangements in Public Health to do analysis and the structure is a constraint of the policycy and a lot we can improe for those. Unfortunately we are out of time and want too make sure we have time to think the panels and prepare for our next panel. Stick around and join meor in think that