We are delighted to welcome dr. Ali khan. Dr. Khan will be discussing his book the next pandemic. As former director of the office of Public Health preparedness and response at the centers for Disease Control and prevention dr. Khan has been on the front lines in the fight to contain the worlds deadliest diseases. Hes not the first one to have done so. Throughout history humans have been fighting diseases, deadly wars against contagions and there has never been a time where humans were not affects with microbes and fought against him. During khans time our speaker has had with contagions. He worked among red cross for the first ebola crisis. After 911 called to washington to prevent the spread of anthrax in the Senate Office building. A disease hunter, if you will, mission was to read the governments efforts to prepare public for disease outbreaks and health emergencies. He has seen it all. He also writes that not all epidemics and pandemics are inevitable. Most can be mitigated if not prevented. The question is how and do we have enough resources. To help us separate hype from the facts what diseases pose greatest risk and what we need to do do to prevent next pandemic please join me in four corners of the earth by welcoming dr. Khan to the Carnegie Council this morning. [applause] thank you very much, good morning, everybody. Lets put this over here. There we go. So as you heard, ive spent career in the preparedness business and usually la meant for talks, weeks, over time it became get ready just in time and at this time in my point is the realtime process and i make it up as i go along. One of the things ive been told when you speak at audience, put them at ease, joke, as you can see nothing that starts with levity but i do promise sex, lots of sex. Itll be mosquito sex. [laughter] but besides that, lots of sex. So im really delighted to have this opportunity to share a whole bunch of stories with the broader audience of what it means to be a disease detective and hunting down diseases. You hear about patients, if you read the papers the popular press, movies, et cetera, what is it from perspective of somebody who has been doing it every day with lots of other amazing Public Health practitioners and also its nice to give a talk when if you read the paper this morning either reading about zika, ebola, yellow fever going on in angola. Its topical so makes it easy to start discussion about emerging infections. Lets just start there and the idea is why is this always on the paper and why are we always hearing about the types of diseases. Now our classical diseases, think about smallpox, measles, you know, those all started pretty much around the agricultural revolution when people sort of came together. You needed to have enough people to spread disease from person to person. And so thats when i start my story of Infectious Diseases start. Everybody has their story when the world start. Some rottens that were carrying smallpox and moved into somebodys home and the virus made jump and same thing for measles, classic diseases. Let me fastforward you to the industrial revolution, germ theory, we realize Infectious Diseases arent due to asthmas but infectant agents spread by person to person and a lot of enthusiasm that occurred around the beginning of the 20th century with sanitation revolution, vaccines, antibiotics and people thought, okay, we are done with this whole Infectious Disease problem, all we have to do is pop shots in somebodys arm, give them a couple of pills and theyll be all better. If that was true we wouldnt be having the conversation today right now, right . And what is happening is that even though weve taken care a lot of the classical birches and theres a lot of factors that drive emerging diseases. Collectively somebody who think that is they are smart collectively and they evolve, you know, they have multiple generations with a single day. Humans if we are lucky, you know, generation in 35 years or something before we can swap out our genetic materials. Microbes no problem at all. They swap genetic material all of the time. They get smarter all of the time. Its why you read about the drugresistant microbes because thats what they do, they move around, they find good set of genes and, boom, you get your super bugs, so the microbes evolve. Human change behavior. 1400 years ago i could tell you nobody had a kidney transplant and so we changed and our risks to infections changed. The other thing that happens is we change our environment. This is a big driver in why we have emerging Infectious Diseases. It should not be surprising that when i talk about zika, when i talk about ebola somehow very quickly the animal connection comes into play but zika obviously is mosquitoes with ebola its bats which are the original cause for where the virus sort of lives and spread out chain of transmission in humans. 75 of the diseases that you hear about, new diseases, emerging diseases are animal connection. If you move people out into the environment into the jungle, you know, they get infected and that disease has a potential then to cause person to person transmission, as we see with ebola or lets say with mers from bats and camels. They tend to come from africa or south america or parts of Southeast Asia where you have a lot of connection with animals, bird flu is another good example where you have people in china and other parts of Southeast Asia who live very close to pigs, live close to birds or chickens and great opportunity for viruses to swamp genes and infect humans and become global pandemics. These are the environmental, some set of environmental conditions that lead to infections and why we keep hearing about them. I want to do a special callout to Climate Change as one of those environmental factors that lead to emerging infections. First i want to say often Climate Change is framed as either an economic issue or has an energy somehow issues and i think over the last year or two we have been doing a better time reframing this actually as Public Health issue of whats happening with climate currently. So april was the hottest record on year hottest year on record since 1880. And people ask me, how do you know what was going on in 1880, believe it or not, if youre a farmer its really important to you what the temperature is. So there are excellent records about what temperature looked like at least for the last 100, 150 years, the same thing with marine temperatures because if youre out there as a captain your doing your daily log, one of the things that you will log is what does water temperature look like so we have excellent records and if you pass through the historical sort of documented records and look at all sorts of other information that looks at temperatures, thousands of millions of years ago, but april was the hottest record, hottest year on record and its the 12th hottest year in a row, okay. This isnt a coincidence whats happening with temperature whats happening with climate and if you look at carbon dioxide, we should be about 200 parts of million, 238 parts million preindustrial level. We are now 400 parts per million. But let me tell you the story in a different way. I got in the climate business almost 20 years ago and had to do with fever, mosquitoborne disease in africa. If you are in africa, you dont have 401 k , you have cows and goats, thats your 401 k . If a mosquitoborne virus comes and youre animals are dying, that is bad news and so thats fever and its a biblical disease, besides the fact that its moving out of Subsaharan Africa into Northern Africa and into the middle east is that its actually depends on climate on when the viruses sort of when this mosquito emerges and you sort of have to have the great heavy dry periods followed by wet periods to cause this to happen and to protect your animals and this virus, fever also causes bad disease in humans, abortions in humans, fever and causes brain inflammation and blindness in humans, but the farmers, they dont have the money to vaccinate the animal every year so if you catch some sort of tool every 5 to 10, 15 years, you know what, this is the bat year, that would benefit them. People spend a lot of time trying to understand what happens weather and climate to help protect farmers and protect their animals and then obviously the community. So thats how i got into Climate Change issues, understanding what the dynamics were and what became very clear right now is when we talk about Climate Change everybody is like, whats going to happen in 2100, well, what is happening today . If we look at diseases, the biggest decide diseases in the United States which are ticks, its lyme disease. If you look at where lyme disease sectors are spreading, they are actually over the last 20 to 30 years have continued to spread across the United States. Theyre almost in about half of u. S. County, fungus in vancouver, doesnt belong in vancouver, it belongs in forest. Im an oyster eater. Thats to try to protect yourself from infected oysters especially gulf oysters. That shouldnt be a problem if youre getting oysters up from the North WesternUnited States, up from the alaska area because those should be nice, cold waters but we have not seen outbreaks because the waters arent as cold anymore. If you go to sweden they have the tickborne disease. We doctors, when we name stuff, we take whatever you tell us, you think we are all smart, oh, my head hurts, you have we know what it says in latin. What we have seen in sweden that the disease has been spreading over the couple of decades. Theres a lot of factors but climate is one of those. Respiratory virus for those who have kids, grandkids, little kids get infected with rsd, usually they are okay but not always and what we are seeing the respiratory seasons in europe are becoming shorter are becoming shorter and shorter because theres less cold months and the seasons are becoming shorter. Contemporary examples that are only going to get worse when we think about heat waves. Whats happening in india right now, 128degrees or Something Like that. Heat waves and, yes, less people will die from cold but proportionately will die from heat when we think about heart and lung disease from all the air pollution and obviously all of the all the Infectious Diseases. Anything that has to do with the mosquitoes and ticks and where things are, climate plays a big role, waterborne illnesses that are an issue if we get flooding, so i want to make a quick shoutout to Climate Change as one of the factors to keep in mind as you think about emerging infections. The biggest factor of all of these and all of these are important, what is happening to microbes, what is happening to us, what is happening in the environment is more political social factors and if you look at the outbreaks, these diseases will continue to emerge as i hope ive convinced you over the last 5 to 10 minutes. I think we play a role in thinking of them becoming epidemics and pandemics. A good example the recent outbreak of ebola in west africa, so it wasnt new, right, we have known about ebola since 1976. Weve known about the science of ebola since 1976 and i had the opportunity to help support that science in 19 mid1990s when i did Ebola Outbreak in zair. What happens, you get infected probably with a bat. If youre out way in the bush you die 85 to 95 of people die. Unfortunately maybe a Family Member or two would die with you but youre out in the middle of the bush, youre done. Lets say you change the dynamic and you decide to go seek health care in a hospital. Unfortunately on hospital that doesnt have infection control. So when youre infected with ebola you essentially become a virus factory and you get infected and if your immune system doesnt kick in youre kicking the virus and when do you have the most possible virus in your body . When you die, as you go to the hospital because youre sick and you dont have more than when you die, okay, i can give you a 10 with lots of big numbers around it meaning hundreds of millions of billions that happened to be in the middle of your blood. So here you are sick, dying in a hospital and somebody doesnt wash their hands as they go from patient to patient, whats going to happen . Youre spreading ebola from patient to patient and so hospitals have always served and weve known this for many years as a reservoir for thousand the diseases get amplified and spread within their community. Somebody sick at home and youre Family Member taking care of them, youre at risk, we know that. They die unfortunately and then you decide to wash the body, kiss the body, hug the body, invite all the loved ones, one of the practices we saw during Ebola Outbreak, they would wash body and use that water to allow little kids and other people to wash their hands to take on the attributes of the sainted person who had just died. This is not a good idea, okay. Lets admit that. [laughter] thats the science. We know the science, right . But the science isnt the issue, so when this outbreak occurred and i think this was some 24, 25th Something Like that outbreak of ebola we have seen since 1976, many people thought this is like what we have been seeing in east africa, uganda sees outbreaks all of the time, they have a system in place to identify the case, teams rush in. They dont need international teams. They rush in and test everybody, they follow everybody who is potentially sick and extinguish the outbreaks very quickly and the outbreak occurred in west africa where its never occurred before. Nobody had seen the disease before and it very quickly spread to urban areas, large metropolitan urban areas and the thinking was, oh, more of the same, you know, rush in, take care of this everything and the Ebola Outbreak will go away, what happened . Thats not what happened, right . So 11,000 deaths each and every was a needless death i would say and inadequate response, Global Response. Inadequate local response obviously but inadequate Global Response and so politics and our Public Health systems, play the biggest role in whether this goes to handful of cases to what we had was essentially a epidemic across west africa with cases across the world. We know what happened here in the United States. And one to have reasons we had the case in the United States is another factor, social political factor that plays into Infectious Diseases that we didnt have in the 1800s. How many people, i wont ask, have read around the world in 180 days . 80 to get around the world. For 22 years i worked Public Health uniform and on my Publishing Health uniform there was an anchor and i would get asked about the anchor in Public Health uniform. The public uniform looks like a navy uniform and the reason it looks like a navy uniform we started providing care to merchant marines and one of the shores of the Public Health service is we still have right now is essential through flag quarantine flag when ship came to port and somebody with yellow fever or smallpox on it. If its going to take you 80 days from point a to point b, by the time you show up in port of new york city we knew if you had smallpox or yellow fever because the incubation fever, shorter than the time from point a to point b. Well, we turned that upside down now. You could go to your mothers funeral in liberia, right, so you fly to line line liberia, engage in usual acts, your mother has died, kissing her, the next day you get on a plane to amsterdam to new york city. You have 48 hours incubation of 5 to 7 days. 3 days before you show up back to new york. Ive got a headache and fever and im not feeling quite well right now. You show up to a hospital, the number one diagnosis would be malaria, 1, 2 and 3 and if its not malaria and they miss this its easy to see how you get hospitalized for something and spread disease within the community. We saw this happened in texas. Exact same scenario, somebody showed up, came home and infected two local nurses. And i have spent a lot of times in places across the world to let you know the Healthcare System is not what they see in toronto when they had their sars outbreak or hong kong or i just spent time in seoul due to mers, Excellent Health care system. Like ours, Excellent Health care systems but they are not ready for patients to come in with highhazard viruses. Travel has played a big role in how the diseases emerge currently. So let me now so now i think i gave you a sense of why you will always hear about this but what we can try to do to make things better around the social political aspects of protecting people. I did want to spend a couple of minutes to talk about you at the Carnegie Council and this in observation and i recognized it my whole life and if you think about hiv and who gets infected with hiv its often marginalized populations. As i started writing the book, it dawned on me you can pull out the marginalized population and think about viruses, a disease that is due to rodents. Often occurs in the southwest of the United States and most likely people to get infected are amongst native americans and some will remember when the hana Virus Outbreak occurred in early 1990s, group of young navajo kids who had come to dc or capi