Pandemic Preparedness in the Next Administration: Keynote Address by Anthony S. Fauci

my name is alen while I'm editor-in chief of Health Affairs we're very pleased to be a partner in this event uh I want to uh add my thanks to you all for being here and particularly my appreciation to Ashish and John for the collegial way we've put this together uh we each bring great strengths to this topic and I think together we do something none of us could do individually and I want to Echo Aisha's comment at the beginning that we hope this is the beginning of more uh even if we have to leave the rarified air of Washington DC and Cambridge Massachusetts to do so uh it is truly my honor to be able to introduce our keynote speaker today it is often said just look at the bio uh there's so much there and indeed there is but I think it's important that you understand uh if you don't already U the uh great credibility and accomplishments of our speaker today uh Tony fouchi who's director of the National Institute of allergy and infectious diseases at the National Institutes of Health as you'll hear in his remarks he served under five presidents which I think is quite relevant to the conversation we've been having already this morning he was one of the principal architects of the creation of pepar uh he's a member of the National Academy of Sciences the National Academy of Medicine many uh Awards including the national medal of Science and the presidential medal of freedom uh Dr fouchy has 43 honorary doctoral degrees author co-edit author editor of more than 1290 scientific Publications he brings uh experience and credibility and perspective uh please join me in welcoming Dr fouchi thank you thank you very much it's a pleasure to be here with you today um I've spoken at after dinner U speeches and intra dinner speeches but I've never spoken to a line of people waiting to get their food so it's nice to have you um anyway it's um uh the idea that we are now uh a few days away from a new Administration I obviously prompted the really extraordinary very enjoyable and I had I'm really pleased I had the opportunity to uh listen to the panel both of Amy and Ron and as well as Bill and Dr Jafari uh which really I think set the stage for so many of the things that we are going to be dealing with uh over the coming years given as you heard from the introduction that I have been around for a while and have had the opportunity and and the privilege and the pleasure of serving in five administrations um I thought I would bring that perspective to the topic today is the issue of pandemic uh preparedness and if there's one message that I want to leave with you today based on my experience and you'll see that in a moment is that there is no question that there will be a challenge the coming Administration in the arena of infectious diseases both chronic infectious diseases in the sense of or already ongoing disease and we have certainly a large burden of that but also there will be a surprise outbreak and I hope by the end of my relatively short presentation you will understand why history the history of the last 32 years that I've been the director of niid will tell the next Administration that there's no doubt in anyone's mind that they will be faced with the challenges that their predecessors were faced with so for those who think that infectious diseases is gone there's so many people who have made fool hearty statements not knowing at the time that they made them I usually show a quote from an old Surgeon General or an old uh pundit in infectious disease so I thought I'd pull this one out from Sir mcfallen Bernett who was actually a uh Nobel prizewinning immunologist uh who made the statement as many did to write about infectious diseases is almost to write of something that has passed into history the most likely forecast about the future of infectious diseases is that it will be very dull uh which is really kind of interesting coming from a semi Genius Like McFall and Bernette and I think what he did in the mistake that so many people have made is something that several of our panelists have already referred to and that is a failure to look beyond our own borders in the issue of the globality of health issues not only things that are there that will come here but surprises that we have so when I think about infectious diseases I break it down into a few buckets the established infectious diseases that we know and when I say I know we mean that you could reasonably predict today what the disease burden of morbidity and mortality is going to be next year in my mind that's the Tony definition of an established infectious disease but there are also other issues that we're talking about now are diseases that are brand new that we've never seen them before or much more common diseases that reemerge so let's take a very quick look at established infectious disease and show you what I mean so there are diseases and disease burden and these are projected every year and they're almost always right for example lower respiratory infections and these are deaths there's going to be over 2.5 million deaths they're about 1.6 to 1.8 million deaths of tuberculosis Hepatitis B and hepatitis C diarrheal diseases it is of note that I have HIV AIDS here on an established infectious disease when I was giving this lecture and I'm going to get to it in a moment uh it was an emerging infectious disease and now after 32 35 years and six months it is an established infectious diseases so let's take a look at the burden and then we'll quickly go on to the emerging so by the last count of that article that came out in Lancet uh uh um just this past year if you look at the total of 56 million deaths worldwide each year about 15% of them are infectious diseases that used to be 27% when I first started giving this lecture and what that tells us is some of the advances we've made in vaccinations and antibiotics and what have you but if you look regionally it is still the number one cause of dieses which is disability adjusted life years which is death plus disability in the developing World in individuals from birth to 49 years old so it still is a major problem so that's established infectious diseases but now we're talking about what an Administration might face in regard to emerging diseases and I'm going to just put them together into newly and reemerging diseases and I'll get in a second to what I mean so from my own personal experiences why I can say with some confidence that history tells us that we will definitely get surprised in the next few years so it all started for me when I became director of niid and that was in 1984 and since and this is the NIH record showing this young immunologist who just took over as the Director of niid and over the years from then as you've heard in the introduction I've had the opportunity to serve five and advise five presidents and these are the five presidents and I'm going to go into the things that I had to advise them about but before I do that just to show you the importance of these diseases this is a picture of me in the very early 880s one of my first testimonies before a congressional committee now there are two aspects about the number I'm going to tell you uh and that is that we went back with my ledge office at the NIH and I've testified and this is not briefings these are official testifying before the Congress either the senate or the house since I became director approximately 250 times and every single one one of those was related one way or another to an emerging infectious disease uh it's started off with HIV and then it went up to the last few that we did that I had the opportunity to do with Tom freden and with Sylvia Burwell and others with zika and we did about 10 or 12 of those with that so when I first started and I began to testify uh it was right in because I became director in 198 84 in HIV we first found about it in 1981 so I wanted to testify before the Congress and make the point this is 32 years ago that there are emerging infectious diseases so I drew a map I I sketched it I'm not that good an artist and uh I had my uh uh graphics people do it a a sort of a a a map of the United States of America and I put on the map this new americ ing infectious disease which is HIV AIDS and I take that map and one way or another every single time I testify before the Congress particularly for my budget almost always for my budget and I talk about global health and emerging infectious diseases I add one sometimes two sometimes three either new diseases or reemerging diseases and the last time I did that was this past spring and this is what the map looked like uh this is the accumulation of things that have emerged sometimes there blips on the radar screen and sometimes they're profound so for me it started off with Ronald Reagan and the two that he had is one that was under the radar screen and only years later became but one that we should have paid more attention to at the time and I and I show you this because there is outbreaks that are very profound acute and dramatic like Ebola like what we've seen with zika and then there are outbreaks that may be really subtle they're happening and you're not necessarily noticing them and that's exactly what happened with the first outbreak that I had to deal with and that was the outbreak of HIV AIDS which we first became aware of in 1981 with the now very famous two uh mmws morbidity morality weekly reports from the CDC first of five gay men and then a month later of 26 gay men first in LA and then in La New York and San Francisco at the time we thought this was an American gay disease we did not know that as we were talking about these 2 mmws there were likely hundreds of thousands of people in subsaharan Africa who were already infected but nobody noticed it this was something that actually changed my career and I talk about it often because as an infectious disease immunologist at the time I said to myself this is going to be really really bad and I try to get people interested in it and very few people did with some exceptions the CDC certainly was we were up here so what I did is I tried to give um I I refer to it as my apia provita sua I could say that in Georgetown because you all take Latin right okay um which is really an an explanation for what you're doing with your life so I wrote an article and sent it into the New England Journal of Medicine they rejected it because they said it was too alarmist so then I sent it to the annals of internal medicine I wrote it in 1981 in December and it got published in June of 1982 and I said because we don't know the cause of this syndrome any assumption that it's going to remain restricted to a particular segment of our society is an assumption that is truly without scientific basis and unfortunately that was one of the more prophetic things that I have said because if you fast forward now 35 years when I said this there were about 125 reported cases of of HIV to the CDC and we didn't even know it was HIV then we were calling it grid fast forward and now we have about 80 million cases about 35 to 40 million deaths 36 million people living with HIV 1.1 million deaths a year 2.1 million new infections during the first Administration that I dealt with there was not the proper attention that was paid to it because of a number of reasons one of which nobody perceived that it was going to be particularly important but it was when George HW Bush was vice president running for president he came to the NIH and had the opportunity to show him around and really brief him very very intensively about this new emerging outbreak that people were now starting to pay attention to so George HW Bush really took on HIV AIDS and the budget of the NIH went very very very high and here's a picture of uh George H W bush and Barbara Bush in the salarium and those people who are dressed around him are my patients who got all dressed up to talk to the president of the United States and his wife Barbara Bush and here he is listening very intely and I'm sitting right next to him and one of my prize patients is between him and Bara Bush and he really did get it but he got it at a time when we remember we missed several years before of realizing how extraordinary this outbreak was going to be and the budget for the NIH comparably went up if you look at the time that George HW Bush became president uh and the time that he left the presidency we had a dramatic increase in the HIV aids budget which led to extraordinary advances in every one of the areas on these Yellow Boxes I could spend the entire 25 minutes half hour talking about each and every one of these individually but the one that was the most important and it gets to one of the things that was said during the panel with Ron and with Amy about the scientific aspects of the investments in science because it was the investment in science that led to treatments which completely turned around what was one of the most depressing things that we possibly could have faced a disease that was essentially 100% fatal so here again is a picture of me making rounds on a w in the early 80s and the reason I show it is because at that time we had no therapy this was 1982 883 and the only thing we were doing was putting Band-Aids on hemorrhages and people were dying but it was the scientific Endeavor the investment ultimately in billions of dollars that led to the drugs that we have now that have completely turned around the cost of an HIV infected individual such that the median survival in this picture was about a year to 15 months today in the same room that I see patients the median survival now is an additional 50 plus years which is one of the most extraordinary scientific advances that has been made in response to a new outbreak so one of the things we did back then and I did this with my my colleague Greg folus in my office we put together a commentary in jamas saying you know we've been quite successful with HIV AIDS perhaps there are impl implications for other infectious diseases of global Health importance and what are the lessons that we learned from HIV one you have to commit substantial financial and human resources these things don't get a uh a addressed spontaneously by themselves you have to enlist the best and the brightest investigators in both basic and clinical research you have to involve the community be it the gay community in the United States or the community in Africa and West Africa when we dealt with ebola or the people in South America when we're dealing with zika you have to have cross sector collaboration you can't do it alone the CDC can't do it alone the NIH can't do it alone you do it it with all of us with industry with global organizations with philanthropy and Nos and you got to get the leaders and the policy makers involved those are the principles we learned and we applied them so from an NIH perspective and I have to take that because that's where I'm coming from these are the things that we get involved with basic and clinical research genomics expansion of research capacity like we did in West Africa and Liberia the way the CDC did in Sierra Leon the way inserm did in Guinea ultimately to develop counter measures so let's get back to my map now and take a look at it I mentioned that there was also the trickling of Deni in the Americas course remember Deni is an Asian African disease and it came in under the radar screen but now we're really addressing it and so when you look at Deni right now we have our sites on Deni they're very much the same way as we're doing with zika and actually this is a release from just this spring in which we now have an experimental uh stage of phase three clinical trial we have an approved Deni vaccine that we need to do better on because it's only about 60 some odd percent effective so we really want to get one that's up in the 85 and 90% so that was George HW Bush then things started to heat up a bit when we got to President Clinton because he had a deal with HIV it wasn't going away but now we had some other things where West Nile h5n1 antibiotic resistance we go back to the same Paradigm of the things you need to do you need to do basic research the CDC does public health the wh does what they do and you wind up with counter measures and let me take a look with you at some of the things we had to deal with and some of the briefings of those 200 plus briefings that we had to do one was West Nile West Nile is reemerging it isn't new it was in Africa and the Middle East likely for hundreds of years then either a mosquito a bird or a person got on a plane in Israel and landed at Kennedy Airport and then boom we now have West Nile which is endemic in the United States so what are we going to do about it we're going to do to develop countermeasures such as vaccines now it's very interesting when we first started to develop a West Nile vaccine we had a an successful vaccine it was safe it induced a good immune response we couldn't find a company to partner with us to develop it in an advanced way that is not the case now with zika since there are a number of companies that are very interested in that then there's the issue of antimicrobial resistance which we have gotten very deeply involved with up to and including the current president who who gave an executive order so I don't want to jump ahead of myself but these are not things that just stay with one Administration they spill over into the other so we first in Earnest started to see it back then so we really addressed it as we've done in so many other things then came George W bush again HIV AIDS was still prominent but he had to deal with something that was really brand new here Anthrax the beginning of h5n1 and SARS now when you talk about presidents worrying that when they get into office off there's going to be something they have to deal with some health issue that's going to be very disconcerting well it was a double whammy for George W bush because not only did we have the terrible events of 911 but ju deposed in the fall in October right after the 9911 issues we had the anthrax attacks and then all of a sudden a new outbreak that a president and the Departments had a deal with was biot terrorism and in fact this is one of the articles that we wrote back then 15 years ago Cliff Lane and John lontine and I in nature medicine about biot terrorism and the kinds of things we need to do to prepare for biot terrorism the country took this very seriously there were strategic plans for the category a agents namely agents that we knew had been stockpiled by the Soviet Union before the fall of the Iron Curtain those were small poox Anthrax botulism so I had the opportunity of dealing very closely with President George W bush and his staff in dealing with how we're going to address biot terrorism and I had a very interesting experience which I'll always treasure we were going up to Pittsburgh uh together with the president uh with the da Henderson with secretary Thompson and others to look at a new facility for modeling the possibility of a biot terror attack so I had the privilege of being on Air Force One and the president called me up to his compartment and said Tony what scares you most about potential microbial attacks and he was talking about a terrorist and I told him I said Mr President I worry more about the natural occurrence of an influenza pandemic and the ongoing plague of HIV than I do about a bio terror attack that that doesn't mean you want to diminish a biot terror attack but it does mean that you have to pay attention to the natural causes and with regard to HIV in his presidency as we all know the president did something that is historic he established pepar in his uh State of the Union Address in January of 2003 and announced a program which initially was $15 billion to prevent 7 million HIV infections treat 2 million HIV infected individuals and care for 10 million which turns out now unequivocally to be the most important Global Health Endeavor that has ever been established in history with regard to any single disease now getting back to Nature being a biot terrorist all of a sudden everybody started to notice that and the first hint we got about that and this was still during the George W Bush Administration was bird flu h5n1 it emerged in four Asian countries it then jumped into humans in a very ineffective way Bill stiger up there he and I took a trip uh to Southeast Asia uh when the uh with secretary levit to take a look at what was going on there and the administration took this very seriously they invested over7 billion do to prep us for bird flu so just the way you had the biot terrorist strategic plan all of a sudden we had a pandemic influenza strategic plan which is actually in effect right now we still work through that plan the CDC the FDA the NIH we all use that plan and again getting back to the things that we did with the Diagnostics and Therapeutics we started to develop a vaccine and we preemptively made a vaccine for h5n1 and we put it in the Strategic National stockpile the same way as we have one for h7n9 we haven't had to use it yet but the idea of having something ready to go originated way back during the h5n1 days but we really decided we needed to do better with our technology so we Advanced from egg based to cell-based to finally recombinant DNA Technologies and we're contining to develop better vaccine platforms so if that wasn't enough then SARS came along now the thing about saws saws really scared us because it came on and it came on very fulminant it started off in China went to Hong Kong you all know the story it's an epidemiologist Delight I mean if you want to if you want to specialize in epidemiology you just got to read this and you'll if you have any children you want to go in epidemiology tell them the SAR story they'll all go into epidemiology and it was someone who went to a hotel in Hong Kong 19 people in that hotel got on planes and went to different parts of the world and then we had the SARS outbreak 8,000 cases almost 800 deaths Not only was it a public health issue it was an economic issue this is a picture of a near empty flight from Hong Kong to Beijing in May 2003 it really put everything to a halt econom ionically including in Canada because Canada had a big problem so what did we do right then again we jumped on with new technologies because now we have rapid sequencing you don't have to grow the virus you can rapidly sequence it and we wound up developing a SARS vaccine that we again never had to use and the reason we didn't have to use it because the public health measures completely put the lid on it so here's an example of Public Health measures that are Antiquated if want to call it that working perfectly in stopping an outbreak so then we get to the present time a lot of headaches for this Administration with regard to outbreaks I mean they had more than their share there was the H1N1 pandemic right soon after the president came in now remember I know everybody in this audience sophisticated about that you see his presidency 2009 to 2017 what happened in 2009 as soon as he walked in the office the H1N1 2009 pandemic flu that's the kind of thing that is very um uh intimidating as well as disruptive to an Administration and then we had the other things which will get to Ms chicken G Ebola zika AAR back again to this so right now the threat of bird flu isn't just H5 N1 H7 N9 even today we're starting to see things like H5 five and8 so it's all over the place so what's the answer to that what's the best way to address that I think most of you know what I'm going to say in the next slide is something that we really have to get successful and that is the development of a universal influenza vaccine namely a vaccine that is not only effective against seasonal flu changes but also pandemic so that you do not have any distinguishing features between how you prepare for one or the other and this is something that Gary nabal and I wrote about about six or seven years ago uh when we were talking about the work that we started and it's coming along pretty well we don't have it yet we're probably not going to have it for a few years but we're getting closer and closer to Universal flu vaccine so just as soon as we thought we got that under control then in 2013 came chicken Guna the reason what's important it came to the Caribbean including Puerto Rico which was our territories it had never been in the Western Hemisphere before and then all of a sudden this is what it looked like after a while again together with the CDC and the FDA we wound up developing a chicken gunia Phase 2 trial vaccine which we're doing now so by that time you would think that all of us involved that the CDC and the FDA and the secretaries were really kind of getting exhausted but it gets worse because then we wind up getting ebola as we all know Ebola which had 24 outbreaks in subsaharan Africa anywhere from two people to 200 people then came away in a new circumstance which I referred to as the perfect storm three countries geographically overlapping each other very poor disorganized no Health Care System crowded and being very very skeptical of authority made it extremely difficult but after 28,000 cases and 11,000 deaths we finally got our arms arounded good Public Health measures as well as the research again that we mentioned that that Ron and Amy and others mentioned we did a program in Liberia the CDC did a program in Sierra Leon the who did one in Guinea and we wound up after all was said and done with having a vaccine having a drug that looks promising we haven't nailed it down yet but also understanding a lot about the disease now the only thing that put a little bit of a monkey wrench into things was one of the things that Ron and Amy had mentioned and that is the fear associated with what happens when what's over there can come here the fear was totally inordinate about what the reality was namely when one person came landed in Dallas two nurses got infected but what we did is that we started then something that we had been working on for years just in case there would have been an accident where we would have to take care of somebody so what happened is that there were special Ebola units and the NIH was one of them the one was in Nebraska one was in Emory and we trained considerably for that and we had the opportunity right here to show that in the developed world when you have the capabilities of taking care of people the way we did the way they took care of some of the people in Nebraska and in Emory we at NIH had the opportunity to take care of Nina fam and here's one example of me discharging her publicly uh in front of the NIH when she was shipped to us right after she got infected uh in Dallas but even more importantly when we had the opportunity to really get involved in the care of a desperately ill patient and I can't tell you who this person is because he does not want to be identified but this is my team waiting for him outside of the NIH back entrance here we are getting ready to go on the elevator and the way we did it the training we have and I'm I'm telling you this because it contrasts in a way to show what the people that like Dan Lucy and others who went to West Africa and really got their boots on the ground and did it on the very difficult circumstances we had two teams one was an infectious disease and one is a is a critical care unit and we rotated every two hours with the two people always in the room with multiple nurses and others and here's an example of me and a guy named Dan chertow Dan is the uh ICU guy I'm the Infectious Disease guy here we are getting suited up ready to go and this patient was one of the sickest patients I've ever seen and I've taken care of thousands of very sick patients so the reason I show you this is that this is I'm on the left and Dan is on the right uh tending to this young man who no doubt would have died if he were out in the field in West Africa but import importantly taking care of somebody under those circumstances in intensive care even with an air conditioned room it gets very very uncomfortable after about an hour in there so I made a rule nobody stays in more than two hours so you could imagine what the people who were in West Africa went through when they were in 105 110 degree heat the good news about the story he left the NIH really well he walked out of the hospital I walked him over to the car where his mother and father were waiting for him and I gave him a brand new red NIH t-shirt finally zika we all know about zika zika in the Americas I wrote an article for the New England Journal uh in January of 2016 one year ago almost to the day talking about the fact that this is not new this is yet again another Aro virus but again for epidemiology should we have seen it coming we know it was discovered in 47 First cases in 52 and it worked its way across the Pacific so when it got to ypp island with an outbreak the outbreak essentially attenuated itself in 2013 an outbreak in French Polynesia and then it got to just like with Ebola in West Africa What I Call The Perfect Storm a completely immunologically naive country Brazil a very very populous country a country with an awful lot of 80s egyps mosquitoes and then you had what we saw was an outbreak which would have been inconsequential given the fact that relatively speaking in the big picture of diseases zika is not a big deal except thanks to the good observation of the Brazilian Public Health officials what they did notice was the great catastrophe of zika namely the extraordinary spike in micropal cases where kids born with micral which is just the tip of the iceberg because we're now starting to see that the congenital zika syndrome goes well beyond microsil again we put into fullblown the same pattern the basic clinical research developing counter measures and now we have a situation where we have a series of of vaccines and this is a complicated slide just to tell you that two of them are already in Phase One trial the first one getting ready to go into to phas two trial in February of this year the first one is a DNA the second is a zika particle inactivated and a company that bter is collaborating with Mna just started their phase one literally yesterday or the day before so what are the two approaches to end up this discussion there are two approaches you do when you come to a situation with regard to vaccines and Diagnostics you preemptively develop pathogen specific countermeasures there is some Merit and I put in cesis parenthesis some but that's a dangerous thing if that's all you do because as as Ron said and as Amy said and as others have said if we made a list Ebola wouldn't have been on our list and zika wouldn't have been on a list so a pre-developed list has a place but it's not the total answer one of the things you do need to do is develop Universal platforms the way we are with vaccines the way we're doing with diagnostic so when you get a new microbe you get the sequence you insert the gene into whatever the platform is vsv DNA mRNA whatever it is it is much much quicker than having to worry about going from scratch in trying to grow a microbe what about the Lessons Learned I've already said about HIV they're about the same Global surveillance these are all things that Ron and Amy and and and and others uh mentioned to you during the panel transparency and communication infrastructure capacity building coordination and collaboration the platform technology that I mentioned and I am very much in favor of what everyone has said here today namely we do need a public health emergency fund uh it's tough to get it for the reasons that Ron mentioned but we need it because what we had to go through physika I mean it was very very painful when the president asked for the 1.9 billion in February and we didn't get it until September that was a very painful process examples to develop flexible vaccine capacity there are a lot of things going on out there the global fund for vaccine development the Coalition of epidemic preparedness Innovation sepy that you may have heard of GSK has built a facility to be able to hit the ground running and then we have B so I'm going to end with the last slide and that is the administration next to last Slide the administration that is going to come in in the next few days will there be a Resurgence of zika we're getting into the summer of the South America are we going to see a Resurgence or not what about influenza are we going to get a new pandemic and the third bullet is probably the most important what about things that we're not even thinking about but what is for sure that no matter what history has told us definitively that it will happen because CA infectious diseases as I said eight years ago in this article with David morrens and Greg fulus that it is a Perpetual challenge it is not going to go away so the thing we're extraordinarily confident about is that we are going to see this in the next few years thank you so I I know Dr fouchi only has a few minutes um I'm G to ask a coup questions and then depending on how willing you are to cut it close we'll keep going but um you mentioned the importance of not going at Al loan uh Bill stiger earlier talked about hostility sometimes with the private sector we're looking at a new Administration you've been through administrations of both parties it seems like an opportunity here uh a positive opportunity is a a new leader who maybe has a more positive association with private sector initiatives if you were to uh set a course for opportunities in that context what would you advise the new president to do in terms of Partnerships with sectors outside of government well I I mean I would say this to to an incoming Administration but I would also say it even if we were in the middle of an Administration that when you're dealing with the the need to develop counter measures partnering with the private sector is absolutely essential I mean we we wouldn't we do an awful lot in the fundamental basic res research and the early type of development but if you want a product that's going to be widely used you have to partner with and embrace the private sector there's no doubt about that that's an that's a c quanon of what we do and are there concrete steps you would recommend to make that uh you know we're all to be honest with you we're already doing a lot of it now so it becomes very clear that we are very uh industry friendly when it when it when you talk about getting a pharmaceutical partner we try to get it from the very begin beginning we do something that I've referred to as drisking namely pharmaceutical companies that have a reluctance to Jump Right In in the development because they're not sure whether this is going to be a economically viable uh product they tend to hold back but if you do the basic research the early clinical studies and bring up the process closer and closer to the endgame they are much more enthusiastic about coming in and we do a lot of that in fact we've done it right now we're doing it with DNA we have a DNA product we don't yet nail down a final pharmaceutical partner but we're getting a lot of nibbles now because we're well into the phase one going into the phase two and that takes away a lot of the risk of the company great um others have referenced the importance of agility you you mentioned it as well um in in addition to a fund which provides resources that can be used flexibly what other other aspects of either what we've done or what we need to do would provide us with the kind of agility that uh that we need to respond to threats that are at this point unknown okay well those are good questions one of them is to regulatory flexibility and I have to say I really want to tip my hat to the FDA because over the last several years without cutting any Corners they have worked with us right from the very beginning in the sense of usually you start on a on a project you go towards a product early then you get a product you to bring the FDA in for a final approval right now whenever we do anything we get them involved right from the very beginning to make sure we're right on the right track you know they don't design the pathway for us because they can't do that but we always go with them very very early on I think that's one of the things we need to do great um we learned a lot of lessons from HIV and AIDS uh we also made a lot of investments in infrastructure that are still there you mentioned the persistent burden of infectious disease but the majority of deaths globally from non-communal diseases uh in a resource constrainted environment how do we look at the infrastructure we've built the infrastructure we're building around other diseases to leverage that uh to uh expedite our response to emerging infectious diseases okay I think the the classic example among a few that really is a success story is pepar so for example the the countries that have benefited and the organizations that have benefited globally from pepar when other challenges came along the pepar countries inevitably did better than the non- pepar countries because they already had that infrastructure in place so pepar is a good example then there are individual uh capacity building events that have occurred so when we went into West Africa we concentrated on Liberia because of the traditional USA involvement in Liberia and we made it a point that when we started the vaccine and the treatment and the and the Survivor trials that we said we would do that in the context of building a sustainable infrastructure so we have rules now that we don't go into a country unless we're going to leave something there that they could continue it isn't in and out that was not the mindset years ago so I know you're on the Infectious Disease side but are there lessons we can learn from uh Investments around non-communal diseases oh yeah I mean obviously when when you look at the some of the clinics that got set up with pepar you Maternal Child Health is benefiting greatly from that uh cancer screening with HPV and others is benefiting greatly by that and that all is emanating from pepar I know you have limited time I uh don't know if we can convince you to take a we'll follow the same rules as earlier quick introduction and quick question and we have time for a few more before our closing but I I see a hand right here hi I'm Cavita burger from Griffin scientific I have a question that uh you refer to very uh nicely in your presentation and also Ron Clan had referred to in his presentation which is really leveraging the scientific information to be able to understand what's going on and then respond in an appropriate way um and as you obviously know yesterday the federal guidance came out on how uh agencies and departments should Implement dual use research of concerned with pandemic potential we've this is an ongoing thing for five years or more how do you balance those types of um uh policy in regulatory sort of uh issues with wanting to have and build a robust scientific capability to address some of these real problems well I mean obviously the answer is going to sound somewhat simplistic but it is that you always guide by the science as long as you stay within the general rules and regulations that are made by Society I don't see the P3 Co is what they're calling it right the pandemic mic potential pathogens of something concern and and and oversight oversight and something or other um we've been dealing as you know we've been dealing with that for years it has not interfered with our ability to do the kinds of research that we want to do on pathogens of concern it just hasn't and if you look at the big picture of what's been done the good news about that is that it sets up now a evidencebased Bas scientific system to evaluate experiments as you're thinking of planning them so rather than saying do it and then see if it worked out or not it says this is what you want to do these are the guidelines if you go by the guidelines then you know we know what you're doing uh I haven't seen this interfere in any way with anything that I think is scientifically important looking out okay then I'm G to ask one last qu yeah unless I'm just Blinded By the Light which is a possibility um let me just ask uh one last question there was a lot of reference to the uh earlier today about the linkage between the security communities and health communities and again you've had experience through this I'm thinking of this both as sort of a a political messaging where uh reference was made earlier on I think you were in the room to how effective a a messenger you've been on these issues so there's both both a public messaging role as well as an infrastructure and response role I just wondered you talked a lot about the science side if you could give us some of your thoughts on how to uh improve that linkage in terms of response between the science and the security the the security and the health communities yeah well you know that really worked extraordinarily well um both with ebola and we got even better with zika because when we have our um uh discussions as a whole of government response um we did it in a way we really got it down well that in the room are you know the National Security uh Council I mean Lisa Monaco when when we when we really get up to a big decision we have Lisa there we have Amy there we have the people from the security there and we have all the health people there we have the CDC the FDA myself and the secretary and it it really works well in fact I was I wouldn't say surprised but I was gratified by seeing how when you get really smart security people who always to their credit when it comes to a scientific issue listen to The Scientist but when it comes to the potential impact in a security way they have an incredible amount of experience and it's worked very well I mean it's been one of those things where you come out of the meeting saying why that was really worthwhile well uh given you your commitments before I turn over to Ashish to say uh some closing remarks for the day I just want to say Not only was it a a very interesting informative uh presentation but like some of the other uh comments we heard this morning it's uh it's important I think for people in this room to thank you for your service in our Safety and Security in addition to appreciating uh the presentation you gave so thank you very much sorry guys um I'm try to hold this so it doesn't fall off um so I we're we're finishing up and there's still some food in the back for those who didn't get a chance to get it um I want to wrap up by just making a couple of remarks and and John had to uh run off actually to Chicago to listen to the president's uh farewell speech that he's going to be giving and and uh and so I I promised him that I would close up for us um I I think we've learned a lot this morning um and and as we've headed into the afternoon and it has I think been a remarkable morning of of people people who have been deeply engaged on these issues who've really been the national leaders uh certainly uh in the two panels people who've been deeply engaged in the last 10 15 years and then uh there really is nobody that the country owes greater gratitude for uh to for his extraordinary work on infectious disease on health security than Tony fouchy and so to listen to him give that history uh I think was pretty extraordinary and a privilege I'm going to make a couple of remarks of things that I learned some things we knew coming in U but some things that I think um are worth noting pandemic prevention and preparedness is going to end up being whether the administration likes it or not a priority a top priority one of the things I think we heard was um there is only one thing we can predict with uh with confidence there is going to be something unpredictable that the administration is going to have to deal with um and so this is not something where boy maybe it'll come up they may have to deal with it the second is we artificially and we knew we were doing this artificially set up a domestic panel and a global panel and we knew it was artificial and you heard it from the first moment that Amy Pope started speaking that there that there really is no distinction that to protect the American people we have to deeply engage with the global Community right there are no walls there are no barriers um we are in a hyperconnected world hyper dependent interdependent World um that is no longer if it ever was a a feasible strategy um the third is because we cannot predict we have to rely on some tools we have developed and one of the things that we saw in Dr fouche's talk consistently was that slide of the countermeasures that no matter what the world throws at us we have a set of countermeasures and they are science and they are basic public health and we cannot get away from those we have nothing better and we that's what we have have to uh stick with couple of other uh comments one of the slides that Dr fouchi had um which I thought was very important something we learned from Ebola something we got better with with zika was that fear spreads faster than diseases and that is something that we in the Public Health Community and the global Health Community have to get much much better at acknowledging understanding and dealing with these are scientific issues but they are also issues of communication uh of of uh engagement couple of last points I think you heard a a consensus among a people with a wide range of political views that we really cannot do this without a public health emergency fund as much as that is a political tough cell that is something we are going to need um second is we're not going to be able to do this without deep engagement with the public uh with the private sector and last but not least one of the things that I took away was this idea that when we make the kinds of Investments that we do in public health and in global Health they have effects and payoffs that go far beyond the intended consequences right we did pepar to deal with HIV and AIDS but it has paid off it paid off uh in uh in Nigeria when Ebola went to Nigeria it pays off in things like improving maternal and child health and so we have to begin to connect the dots in global health and pandemic preparedness and say these things are far more interl uh than we think they are all right all of you probably had other lessons but those are some comments that that I wanted to quickly uh highlight because those are things that I think were some of the highlights of the day um let me finish off by once again thanking uh Rebecca Katz who was really our intellectual leader of the day uh Andy and other members of her team who pull this whole thing off uh it looks easy it's incredibly hard um and so I'm incredibly grateful to Rebecca members of our team lyanna wasi Sarah braner uh Margaret s from uh Health Affairs this really was a truly collaborative effort uh first of many to come so you're going to be hearing more from us uh thank you all for participating engaging uh and have a good rest of the day and thank you all for coming