The Next Pandemic: On the Front Lines Against Humankind's Gravest Dangers

May 31, 2016

TV Show


In over 20 years at the CDC, Dr. Ali Khan battled Ebola, SARS, and other deadly diseases. But, as he reveals in this fascinating talk, what really worries him is the effect that political and social factors can have on fighting these outbreaks. With Zika emerging as the newest threat, what can governments--and individuals--do to be better prepared?


JOANNE MYERS: Good morning, everyone. I'm Joanne Myers, and on behalf of the Carnegie Council, I would like to thank you all for beginning your morning with us.

We are delighted to welcome Dr. Ali Khan and C-SPAN Book TV to this breakfast program. Dr. Khan will be discussing his book, The Next Pandemic. As a former director of the Office of Public Health Preparedness and Response at the Centers for Disease Control and Prevention (CDC), Dr. Khan has been on the front lines in the fight to contain the world's deadliest diseases. But he is not the first to have done so.

Throughout history, humans have been fighting diseases, waging deadly and never-ending wars against rampant and violent contagions. In fact, there has never been a time when humans were not infected with microbes and fought against them.

During Dr. Khan's time as a self-described disease detective, our speaker has had his own brushes with viruses, infectious diseases, and contagion. For example, in 1995 he worked among Red Cross workers in Zaire for the first Ebola crisis. After 9/11, he was called to Washington to prevent the spread of anthrax spores in the Senate office building. And in 2003, he was called to Hong Kong to quarantine victims of SARS (severe acute respiratory syndrome). But these are just some of the stories Dr. Khan chronicles in The Next Pandemic. As an epidemic intelligence officer—a disease hunter, if you will—his mission for over two decades was to lead the U.S. government's efforts to prepare the public for disease outbreaks and health emergencies. He has seen it all.

While Dr. Khan tells us that rogue microbes will always be a problem, he also writes that not all epidemics and pandemics are inevitable. In fact, most outbreaks can be mitigated, if not prevented. But the question is, how? And do we have enough resources?

To help us separate the hype from the facts, what diseases pose the greatest risk, and what we need to do to prevent the next pandemic, please join me on a public health journey to the four corners of the Earth by welcoming Dr. Khan to the Carnegie Council this morning.

Thank you so much for coming.


ALI KHAN: Thank you very much. Good morning, everybody.

As you heard, I have spent a career in the preparedness business. Usually that meant for talks you are ready weeks in advance. Over time it became sort of getting ready just in time. At this point in my career, we are into the real-time speaking process, which is that I pretty much make it up as I go along.

One of the things I have been told is, "When you speak to an audience, put them at ease; start with a joke." But as you can tell, there is nothing about my career that starts with some levity. But I do promise sex, lots of sex. It will be mosquito sex, but, besides that, it will be lots of sex.

I'm really delighted to have this opportunity to share a whole bunch of stories with a broader audience on what it means to be a disease detective and hunting down these diseases. You hear about patient zero if you read the papers, the popular press, the movies, etc. But what is it from the perspective of somebody who has been doing it every day, with lots of other amazing public health practitioners? Also it's nice to give a talk when, if you read the paper this morning, you are either reading about Zika or Ebola or yellow fever going on in Angola. So it's topical. That makes it easy to start a discussion off about emerging infections.

So let's just start there—the idea of, why is this always in the paper and why are we always hearing about these types of diseases?

Our classical diseases—think about smallpox, think about measles—those all started pretty much around the agricultural revolution, when people came together, because you needed to have enough people to spread disease from person to person. That's when my story of infectious diseases starts. Everybody has their own story of when the world starts, but for me that's when the world starts, when some rodents that were carrying some version of smallpox moved into somebody's home, and that virus made this jump and started to cause smallpox in people. Same thing for measles, classic diseases.

Let me fast-forward to the Industrial Revolution, germ theory. We realized that infectious diseases weren't due to miasmas, but they are actually due to infectious agents that spread from person to person. A lot of enthusiasm occurred around the beginning of the 20th century with the sanitation revolution, vaccines, antibiotics, and people thought, "Okay, we're done with this whole infectious disease problem. All we have to do is pop a shot in somebody's arm, give them a couple of pills, and they will be all better."

Well, if that was true, we wouldn't be having this conversation today, right now. What is happening is that even though we have taken care of a lot of these classical scourges, we have these continued emerging infectious diseases. There are a lot of factors that drive this emergence and those diseases.

Some of the key factors are just around microbes. I'm somebody who thinks that they are smart collectively, and they evolve. They have multiple generations with a single day. Humans, if we are lucky, have a generation in, what, 35 years or something before we can swap out our genetic materials? Microbes, no problem at all. They swap genetic material all the time. They get smarter all the time. That's why you read about these drug-resistant microbes, because that's what they do; they sort of move around, they find a good set of genes, and they go, "Oh, this will protect me from this set of antibiotics," and, boom, you get your superbugs. So the microbes evolve.

Humans change their behavior. A hundred years ago, I can tell you, nobody had a kidney transplant. We change, and our risks to infections change.

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. With Zika, obviously it's with mosquitoes. With Ebola, it's bats, which are the original cause for where this virus lives. It infects somebody, and that is how you then spread out the chain of transmission in humans.

Seventy-five percent of the diseases that you hear about, the new diseases, these emerging diseases, are zoonotic. What that means is they have an animal connection. So if you move people out into the environment, into the jungle, they get infected. That disease has the potential, then, to cause person-to-person transmission, as we see with Ebola or, let's say, with MERS (Middle East respiratory syndrome), which we believe is from bats and camels. If you are having somehow contact with camels, that's how you get the disease.

So it's not a surprise, when we think about these emerging infections, that 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 their pigs, live very close to their birds, or fowl, chickens, and that is a great opportunity for these viruses to swap their genes and eventually infect humans and then become global pandemics.

So that is some set of environmental conditions that lead to these infections and why we keep hearing about them.

I want to do a special call-out to climate change as one of those environmental factors that lead to emerging infections. First, I want to say that often climate change is framed as either an economic issue or as an energy issue. I think over the last year or two we have been doing a better job of reframing this actually as a public health issue of what is happening with climate currently.

April was the hottest month on record since 1880. People ask me, "Ali, how do you know what was going on in 1880?" Believe it or not, if you are a farmer, it's 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. If you are out as a captain and you are doing your daily log, one of the things you would be logging is what water temperature looks like. So we have excellent records. Then, if you pass through that historical, documented record, you can look at all sorts of other information that looks at temperature thousands to millions of years ago.

But April was the hottest month on record and it is the 12th hottest year in a row. This isn't a coincidence, what is happening with climate. If you look at carbon dioxide, we should be about 200 parts per million, 238 parts per million, sort of pre-industrial level. We are now at 400 parts per million. So the thought that by 2100 we are going to only cap increases to 1.5 degrees is highly unlikely.

But let me tell this story in a different way. I got into the climate change business 20 years ago almost. It had to do with Rift Valley fever. This is a mosquito-borne disease in Africa. If you are in Africa, you don't have a 401(k). You have your cows. You have your goats. That is your 401(k). If a mosquito-borne virus comes around and your animals die and are aborting, that is bad news. That is Rift Valley fever. It's a biblical disease.

What we have recognized over the last couple of decades of studying this, besides the fact that it's moving out of sub-Saharan Africa into Northern Africa and into the Middle East, is that it actually depends on climate when this mosquito emerges. You have to have these great, heavy dry periods followed by wet periods to cause this to happen.

To protect your animals—and Rift Valley fever also causes bad disease in humans. It causes abortions in humans. It causes hemorrhagic fever and it causes brain inflammation and blindness in humans.

But the farmers don't have the money to vaccinate the animals every year. If you had some sort of tool, every 5 to 10 to 15 years, to say, "You know what? This is the bad year. Get vaccinated this year," that would really benefit them. So people have spent a lot of time trying to understand what happens with weather and climate so they help protect these farmers and protect their animals, and then, obviously, the community.

So that's how I got into climate change issues, understanding what the dynamics were. What became very clear is that when we talk about climate change, everybody is like, "What's going to happen in 2100?" Well, no. It's really what is happening today.

If we look at diseases, the biggest disease in the United States that is caused by arthropods, which are ticks and mosquitoes, is actually Lyme disease, which everybody in this audience knows very well if you live up here in the Northeast. If you look at where Lyme disease vectors are spreading, they actually, over the last 20 to 30 years, have continued to spread across the United States. They are almost in about half of the U.S. counties. So we are seeing that already today.

There is a tropical fungus up in Vancouver causing infections of humans and animals. It doesn't belong in Vancouver. It belongs in the tropics. We are getting infected oysters from the Northwest. Any oyster eaters here, like me? Oh, you don't pay attention to all the good public health messages about oysters, okay. I'm an oyster eater. You eat oysters in cold months. One of the reasons you eat oysters in months with "r" in them is to try to protect yourself from infected oysters, especially Gulf oysters. But that shouldn't be a problem if you are getting your oysters from the Northwestern United States or from the Alaska area, because those should be nice cold waters. But we have now started to see outbreaks reported from those oysters in cold waters because the waters aren't as cold anymore.

So those are contemporary examples of today what we are already seeing because of climate change.

Let me shift you over from the United States to Europe. If you go to Sweden, they have this tick-borne disease called, very simply, tick-borne encephalitis.

We doctors, when we name stuff, what we do is we take whatever you tell us, we give it back to you as a medical term, and you think we're all smart. So you go, "Oh, my head hurts," and we go, "Oh, you have cephalagia," and you're like, "Oh, my gosh, you're so smart." Yes, exactly. We know what it says in Latin.

So it's called tick-borne brain inflammation. What we have seen in Sweden is that this disease has been spreading over the last couple of decades. There are a lot of factors for that spread, in addition to where the heck we are living. Climate is one of those.

Respiratory syncytial virus (RSV), for any of you who were kids, have kids or grandchildren—little kids get infected with RSV, which causes this severe little respiratory illness. Usually they are okay, but not always. What we are seeing is that those respiratory syncytial virus seasons in Europe are becoming shorter and shorter because there are fewer cold months. So those seasons are becoming shorter.

Again, these are contemporary examples right now that are only going to get worse when we think about heat waves.

What is happening in India right now? One hundred twenty-eight degrees or something like that, heat waves. And, yes, fewer people will die from cold, but proportionately more will die from heat.

When we think about heart and lung disease from all the air pollution, and then, obviously, all the infectious disease—anything that has to do with mosquitoes and ticks and where things are, climate plays a big role in those.

Then there are food-borne illnesses; there are water-borne illnesses that are an issue with this as we get flooding, obviously severe storms; and mental health illnesses.

So I want to make a quick shout-out 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 the microbes, what is happening to us, what is happening in the environment—is actually more political, social factors. If you look at these outbreaks, these diseases will continue to emerge, as I hope I have convinced you over the last five to ten minutes. But I think we play a role in keeping them from becoming epidemics and pandemics.

A good example would be the recent outbreak of Ebola in West Africa. It wasn't new. We have known about Ebola since 1976. We have known about the science of Ebola since 1976. I had the opportunity to help support that science in the mid-1990s when I did an Ebola outbreak in Zaire.

So what happens? You get infected with Ebola, usually probably with a bat, and if you are out in the bush, you die. Eighty-five to 95 percent of people die. Unfortunately, maybe a family member or two will die with you. But if you are out in the middle of the bush, you are done.

Let's say you change that dynamic and you decide to go seek health care in a hospital—unfortunately, in a hospital that doesn't have infection control. When you are infected with Ebola, you essentially become a virus factory. You get infected and, if your immune system doesn't kick in, you are just increasing the amount of virus you are producing every minute until you die. When do you have the most possible virus in your body? When you die—well, as you go to the hospital because you are sick. You don't have more than when you die. I can give you a 10 with lots of big numbers around it, meaning hundreds of millions or billions of virions that happen to be in a milliliter of your blood.

So here you are, sick, dying in a hospital, and somebody doesn't wash their hands as they go from patient to patient. What's going to happen? You are spreading Ebola from patient to patient. So hospitals have always served—and we have known this for many years—as a reservoir for how these diseases get amplified and spread within the community. If somebody is sick at home and you are the family member taking care of them, you are at risk—science; 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 this Ebola outbreak was they would wash the body and then they would use that water to allow little kids and other people to wash their hands to take on the attributes of this sainted person who had just died. This is not a good idea. Let's admit that.

But that's the science. We know the science. But the science isn't the issue.

When this outbreak occurred—I think this was the 24th, 25th, something like that, outbreak of Ebola we have seen since 1976—many people thought, "Oh, this is just going to be like what we have been seeing happening in East Africa. Uganda sees outbreaks all the time. They shut them down within a couple of days. They have a system in place to identify the case. Teams rush in. They don't even need international teams anymore. The locals know exactly what to do. They rush in, they test everybody, they follow everybody who is potentially sick, and they extinguish these outbreaks very quickly."

This outbreak occurred in West Africa, where it has never occurred before. Nobody had seen the disease before. It very quickly spread to urban areas, large, metropolitan, dense urban areas, with slums. The thinking was, "Oh, more of the same—rush in, take care of everything, and this Ebola outbreak will go away."

What happened? That is not what happened. Eleven thousand deaths. Each and every one was a needless death, I would say. An inadequate global response. An inadequate local response obviously, but an inadequate global response.

So politics in our public health systems play the biggest role in whether or not this goes from a handful of cases or a small outbreak to whether or not you have—what we had was essentially an epidemic across West Africa, with seeding of cases across the world, including—obviously, we know what happened here in the United States. One of the reasons we had that case in the United States is another sociopolitical factor that plays into infectious diseases that we didn't have in the 1800s.

How many people—I won't ask, because the answer will be yes—have read Around the World in 80 Days or have heard of Around the World in 80 Days? How quaint! Eighty days to get around the world.

For 22 years I wore a public health uniform, and on my public health uniform was an anchor. I would get asked about the anchor on the public health uniform. The public health uniform looks very much like a Navy uniform. The reason it looks like a Navy uniform is that we started about 200 years ago providing care to Merchant Marines. One of the chores of the Public Health Service, which we still have right now, was essentially to fly quarantine flags when a ship came into port and there was somebody with yellow fever or smallpox on it. Well, if it's going to take you 80 days to go from point A to point B, by the time you showed up in the port of New York City, we knew if you had smallpox, we knew if you had yellow fever, because the incubation period—the time it takes to get infected, to manifest your symptoms—was always shorter than the time it was going to take to go from point A to point B.

Well, we have turned that upside down now. You can now go to your mother's funeral in Liberia—so you fly to Liberia, go to your mother's funeral, engage in the usual acts that you would around a funeral—you are distraught; your mother has died; you are kissing her, you are hugging her—and then the next day you get on a plane, up through Amsterdam to New York City. So we have, what, 18, 24 hours, maybe 48 hours. An incubation of five to seven days? Well, it's three days after you show back up in New York before all of a sudden you go, "I've got a headache. I've got a fever. I'm not feeling quite well right now." You show up at a hospital. If it's a good hospital, their number-one diagnosis will be malaria—one, two, and three. If it's not malaria and they miss this, then it is very easy to see how you get hospitalized for something and you can spread disease within the community.

We saw this happen in Texas, the exact same scenario. Somebody showed up, came home, infected two local nurses.

I have spent a lot of time in places across the world to let you know that our health-care system is not better than what you saw in Toronto when they had the SARS outbreak, what you saw in Singapore when they had their SARS outbreak, or Hong Kong. I just spent some time in Seoul. Seoul had an outbreak due to MERS, which is a SARS relative. Again, an excellent health-care system, like ours. Excellent health-care systems, but they are not ready for these patients coming in with these high-hazard viruses.

So travel has played a big role in how these diseases emerge currently.

I think I have given you a sense of why you will always hear about this, but what we can try to do to make things better around the sociopolitical aspects of protecting people.

I do want to spend a couple of minutes to talk about you at the Carnegie Council, that says "Ethics Matters."

An observation which—I guess I have recognized it my whole life. If you think about HIV and who gets infected with HIV, it is often marginalized populations. But as I started to write the book, it sort of dawned on me how almost every chapter you could pull out the marginalized population that was at increased risk for emerging infection.

Think about hantaviruses. This is a disease that is due to rodents. It often occurs in the Southwestern United States. The most likely people to get infected, and where the original outbreak occurred, were amongst Native Americans. Some of you will remember that when this hantavirus outbreak occurred in the early 1990s, there was this group of young Navajo kids who had come to DC for a Capitol tour, and they were denied a tour of the Capitol, because "Oh, you happen to come from the Southwest. You could potentially be infected with hantavirus." There was nothing in anything we knew that said that these kids were at risk, and they weren't. They didn't pose any risk to us.

But often these diseases affect marginalized populations and that helps increase some of the prejudice against those marginalized populations. I have already talked about HIV. I have talked a little bit about Ebola and the poor, marginalized populations in West Africa.

In today's day and age, we are talking about Zika. The marginalized population there is poor pregnant women in Brazil. Brazil has about 1.1 million cases—I think that is what they are calculating now—of Zika virus and over 1,500 women who have been infected and their babies have gotten congenital Zika syndrome. This is a severe illness of babies where they get small brains, other developmental disabilities, including hearing loss and vision problems. What we have learned now is that Zika is essentially a laser-guided missile for neurons. It looks for your neuron cells and it kills your neuron cells. And it's not just true in babies. When Zika was first described, what we were told was, "Yeah, about 20 percent of people will get sick, and if they get sick, they will get a fever, they will get a little headache, they will get some itching, some red eyes, and they will get better."

Then, very quickly, it became clear that this was a problem for pregnant women. But now we know even for adults, because of this laser-like focus on neuronal cells, we have this disease called Guillain-Barré syndrome. This is a neurologic illness that causes weakness. We also know that even in a healthy person Zika virus can cause brain inflammation and inflammation of the coverings around your brain. So even in what we think of as otherwise normal, healthy adults who are not pregnant, this virus is a problem.

This virus shouldn't be a problem. The virus is spread by something called Aedes aegypti. It's a certain type of mosquito. This mosquito is not new to us. This is the exact same mosquito that spreads yellow fever, that causes about 30,000 deaths a year. This is the exact same mosquito that spreads dengue. If we were having this conversation about five years ago, we would be talking about this large dengue outbreak that is occurring in South America. Dengue causes, I think, about 30,000 deaths, something around that. This is the same exact mosquito that causes chikungunya virus. That was the big thing in the news two, three years ago. That one doesn't seem to cause any deaths.

But because of the failure since the 1970s to keep up with these efforts to decrease mosquitoes and kill mosquitoes, and not paying attention to the people dying from yellow fever, the people dying from dengue, now all of a sudden we are all up in arms that, "Oh, we have a disease due to Aedes aegypti that seems to be infecting pregnant women." So it is this lack of action over the last 40, 50 years against a known threat that has put us in this current position, at least if you happen to be in South America these days.

I heard yesterday that Zika now has not moved just throughout the Americas, but is now at Cape Verde. So it is essentially knocking on the door of Africa to say, "Hi, you're next." Think about what is going to happen as that virus then sweeps through Africa and the risk to pregnant women in Africa.

Margaret Chan, who is the head of WHO (World Health Organization)—a brilliant woman, did some amazing work in her time in Hong Kong—has admitted a major policy failure over the last 40 years in addressing this mosquito. Also she broadened it to talk about major policy failure as we think about protecting women and contraceptive rights for women, because this is a big issue in Brazil and other places where they don't have the same sort of contraceptive rights as you take for granted here in the United States and other parts of the Western world.

Why did it take all this time, people dying of dengue, people dying of yellow fever, which has a vaccine, to all of a sudden say, "Oh, you know what? We need to pay attention, because now we may get some cases in Europe and in North America of women who may have this disease."

We will see Zika in the United States. I will preempt that question. Hopefully we will not see a whole lot of cases, but we will likely see it.

You gave me a lovely comment the other day, "the ethics of a delayed response." I think this goes back to some of what you talk about here amongst your audience. If you think about these marginalized populations, why do we see these delayed responses? We are seeing it today. The stories in the last couple of days are this conversation—there are probably better terms for it than "conversation"—of "let's protect the United States against Zika," and nobody can decide whether they want to do it and how much they want to pay for it.

I often get asked, "Ali, should it be $500 million that Congress wants to give, the $1.9 billion that the president asked, or the $1.1 billion that the Senate wants to give, some version in there?"

I don't care what it is. Pick a number. But why are we having this conversation six months later? We know what's going to happen. We also know that mosquito control in the United States is not a federal function. It's not even a state function. It's a city and county and district function. You need to get the money out to these people so they can be doing what they should be doing, which is eliminating mosquitoes and making sure they are identifying cases. Do you have the money to think about—hopefully, a long-term strategy would be a vaccine strategy here to protect pregnant women? Do you have some sort of thoughts about are we funding a vaccine development for a long-term vaccine strategy? Why are we still having this conversation six months later? Why are we not already doing that? Why are we robbing Peter to pay Paul?

My old program at CDC was responsible for essentially keeping Americans safe from all public health threats, no matter what their nature—if it was pandemics, natural disasters, biological/chemical terrorism. As part of that program, my passion was for the Public Health Preparedness Program, which put money out into state and local health departments. To help pay for the Zika response, we essentially pulled back some of that money to help support some of the dire activities in other places, including Puerto Rico, where they have already had 1,100 cases, believe it or not. It's tragic enough.

My analogy is taking the bricks out of a foundation to build a second story of a building. If this is our preparedness infrastructure to support the United States, why are we taking money out of that to do something like Zika? We should be putting money into the preparedness infrastructure.

What I will leave you with is a number, because I'm all about observable measures—6.7. In the last three years, the Robert Wood Johnson Foundation has been doing some great work looking at how prepared the United States is for public health emergencies. Every year it gets a little bit better. I think we started at 6.3. But 6.7 out of 10—that's just not good enough for us here, if we really want to make sure Americans are protected against public health threats.

As far as I am concerned, the responsibility of government is to protect us against threats, and that includes public health and health threats. I'm old enough now to realize you can't completely strip politics out of policy decisions, and it is not always about the science. But maybe sometimes we need to be stripping a little bit more politics and thinking about what the health needs are of our population.

Thank you.


JOANNE MYERS: That was fascinating. You seem so calm, though. What keeps you up at night, if anything?

ALI KHAN: I think I'm calm because I decided 20 years ago that fear is not a public health strategy. I know it makes for great press—you know, "The sky is falling!" But really it is about education and good science.

What keeps me up at night is what the next pandemic is likely going to be. Zika is a pandemic, needless to say, but it is not causing hundreds of thousands of deaths.

What is likely to cause hundreds of thousands of deaths in the future is flu. We already know that from 1918. We get flu every year. I'm going to tell you right now my public health message of the day is get vaccinated. We get flu every year, and it changes a little bit, which is why we need a new vaccine every year. But unpredictably, flu just takes off its overcoat and all of a sudden you have no protection against it at all. If we repeated the same thing we saw in 1918 today, 7.5 million Americans would die, 2.5 percent. Think about the number of body bags. Think about how this would completely disrupt our society if within a couple of weeks to months we killed 7.5 million Americans. So flu keeps me up at night.

MERS and diseases like MERS keep me up at night. I do know—I have seen these health systems—our health systems are getting better. Our ability to respond to diseases is getting better. Part of my job at Nebraska with the National Ebola Training Center is to help hospitals get better. But we know the risk of health care-acquired infections here in the United States. So I worry about MERS as another example.

A third example—and I will stop at the third example—is the next HIV/AIDS. Nowadays you think of it in terms of sexual behaviors or IV drug abuse that get you HIV/AIDS. But let's remember, HIV/AIDS was another one of those zoonotic diseases. It came from non-human primates, probably multiple times, and one time it was the right version that made its way into humans. Then it spread from human to human. So I worry about another stealth virus like that that is spread through sexual transmission or some other mode, has a long incubation period before you get really sick, and by the time you discover it, it has already spread widely.

Those are some of the things that keep me up at night about what the next pandemic could be that would have really significant morbidity and mortality.

QUESTION: Susan Gitelson.

That was too fascinating, and especially in the morning. But we have to be concerned about what can be done. Here you are the most experienced person. So the question is, first of all, what is the CDC doing to educate people and control the diseases as soon as there is an indication that they might be serious?

On the other hand, you are now in Nebraska. What is the difference between control measures in an agricultural state with a relatively small population and Washington or New York, the large urban areas? How can the United States do more, and CDC do more, to prevent these outbreaks?

ALI KHAN: Thank you very much, Susan. That is an excellent question.

How we can do more starts, for me, at multiple levels. You always tell people they are more powerful than they think they really are. Let's start with something very simple, health care-acquired infections and drug-resistant microbes. A paper came out last week that suggested that one-third of all the antibiotics we are using are unnecessary. So as a patient, when you go in and talk to your doctor, you are powerful, to say, "Do I really need this antibiotic for my cold, Doc, or is it something we can work out for a couple of days, and then if it doesn't get better, I should take an antibiotic?" You have that power. You have that power when you walk into a health-care facility and a doctor or nurse or respiratory technician walks into the room, to say, "Did you remember to wash your hands?" You are powerful. Do not forget that.

You have the power within your community when you think about personal preparedness issues. Let's say a pandemic runs through your community or a natural disaster runs through your community. Are you prepared personally for that, not just in terms of having a kit in your home and being ready, but are your vaccines all up to date?

How many people in today's cell phone age actually know a physical phone number? The only one number I forced myself to memorize is my wife's number. If somebody asks for a phone number, what do I do? I pull out the cell phone. If my cell phone dies, not so good in terms of numbers.

Am I part of a response team within the community? Have I taken a CPR course so that if something bad happens, I don't need to call 911 for the little teeny things; I can take care of something small myself or help somebody else. Am I a blood donor?

There are all sorts of things we can personally do.

Then it's things that we should expect from our government. That's where we are powerful. If tomorrow morning in New York City we decided, "Let's lay off half the police force," my guess is you will tar and feather that mayor, because you think public safety is so important. But the same thing is happening invisibly to your public health/safety workforce here in the United States, where it is not fully funded, and nobody is tarring and feathering anybody when you get a score of 6.7 in how prepared your community is or how prepared your state is.

So demand the same things from your local representatives and demand the same things from your national representatives. We want a little less politics in what is happening in our health. Why are there still 28.6 million uninsured Americans in the United States right now, given the fact that we passed the Affordable Care Act? Nineteen states have not passed Medicaid expansion.

I think you are powerful and you need to expect more and ask for more at every level, including your own level.

When I was at CDC, I did a tongue-in-cheek thing about the zombie apocalypse to try to get people to be prepared for natural disasters. Somehow they weren't paying attention to the real natural disasters. But you mention zombies and everybody wants to know what to do for zombies. Don't ask me. We took a popular meme and converted it. One of the things I did use the meme for—I said, "You know what? The one thing you can do with zombies is outrun them. So please make sure you stay personally healthy so you can outrun those zombies." Again, something that you can personally do.

That changes whether I happen to be in Nebraska, an agricultural state, or whether I happen to be in Washington, DC, with greater risk of importation of diseases from international travel. The local public health entity needs to take the appropriate things into account, including, for example, for climate change. We are not coastal. You are coastal. What is that implication going to be for flooded water supplies and stuff like that?

QUESTION: Mike Koenig, Long Island University, a longtime inveterate New Scientist reader.

I remember an opinion piece some years ago to the effect that if only Silent Spring's publication had been delayed for about three years and if DDT use had continued for another two or three years, we wouldn't have malaria. You stressed mosquito control. I was wondering what your take on that thesis is.

ALI KHAN: We need to use every tool available to us when we think about mosquito control.

CDC is the only, or one of the only, federal agencies outside of Washington, DC. It took me a while to figure out why that is. The reason is malaria.

Malaria used to be in the Southern United States. There was a Malaria in War Areas program. What was happening was we were sending our troops down to be trained in the South and they were getting infected with malaria. We didn't need our young men and women getting ready to go to war to be infected with malaria. So this program was set up, and that program became the CDC, and malaria was very quickly eradicated in 1945-1946.

Let's look at dengue right now. We see dengue on the Texas border due to mosquitoes. We see it in Mexico. We don't see it in the United States. It is not due to DDT. It is due to screens and air conditioning, actually, which is one of the things that will protect us against Zika.

So you are right. When we think about what it takes to protect us, we need to use every tool available for us.

For mosquitoes, it's about killing the baby mosquitoes, which is called larvicide. It's about killing the adult mosquitoes, which is called insecticide. And then it's about source reduction, which means finding all the little sources of water out there and get rid of them. We need to be thinking about every tool that is available to us, I think including DDT and others. People are thinking that way. What is the right tool for the right area? What are mosquitoes resistant to? What are they not resistant to?

QUESTION: I'm Krishen Mehta. Thank you for this presentation.

Dr. Khan, as you know, a number of societies have had prohibitions against consumption of certain animal proteins. In the faith I grew up in beef and pork were forbidden. You made the connection that there is a lot of connection with these kinds of viruses that come from animals.

I wonder if any studies have been done to show that in societies where the consumption of animal protein is limited, or not at all, the ability to resist some of these illnesses, the ability to be able to take antibiotics and have them be effective—if there is a connection between our consumption and the likelihood of our continued ability to cope with the consequences of these illnesses. I wonder if you can comment on that.

ALI KHAN: That is actually an excellent and extremely complex question. Let me break it down into these two quick pieces.

One is, we do know that people who have a predominantly vegetarian diet live longer and do better. That has pretty much been well established at this point. That may get to this beef and animal consumption.

The other issue is around the zoonotic infections. The zoonotic infections really have to do more with the close contact we have with animals, not necessarily their consumption. When you think about it—and I say this all the time, because I get challenged about that since I don't eat pork either—if you just heat it to the right temperature, there is no risk. You hear this about your burgers; you shouldn't be eating burgers that are rare anymore, eating them medium-rare. So the risk comes not from the consumption, because all you have to do is just heat it to the right temperature.

The risk comes from the daily interaction you have with these animals, touching them, the routine set of interactions. Even if you are not eating them, if you are milking them, if you are keeping them in your houses, that risk is there.

The same thing with the fowl. A well-cooked chicken burger or filet of chicken isn't going to kill you, but handling these chickens that have chicken flu will potentially kill you.

QUESTION: Marlin Mattson from Weill Cornell Medical College.

I appreciate the clarity of your presentation and the impressive work you are doing.

One of the things that came to mind was the delay in identification and response to Ebola. My question really is, what does the CDC do to try to increase collaboration with health departments in countries around the world to begin to do something about early identification and response? And then, something maybe about the World Health Organization in terms of whether it plays a part in this area.

ALI KHAN: That's a great question, which links back to the earlier question about what can you do.

The U.S. government has embraced something called the Global Health Security Agenda, and so should we. That is a way for us to work with countries internationally to make sure that they have the right tools and systems in place for the early diagnosis. You want to find the first set of cases.

There are a number of countries that have bought into this, including WHO. And remember, CDC is a technical agency that does this work, and CDC has people all over the world to help with this. But WHO has a global mandate to do this. They are the world health agency. They have been very introspective and have recognized the failures of Ebola and what happened in Ebola, especially not just the failure from the early detection, but it took six to nine months until they called it a public health event of international concern, a PHEIC, which is their official term to say, "Oh, my gosh, this is a problem."

In the spring of 2014 they misread the epi data to think that things were getting better when they really were just in a lull before they got worse. So they are in the midst of a complete reform process right now to be able to better respond to these emerging infections, including, for the first time, putting some teeth into their International Health Regulations to actually go and do country-level assessments, if they are ready.

Joanne showed me a lovely article from the World Bank today. The World Bank is setting up a brand-new pandemic response fund.

I have a story in my book from a really good friend of mine who was asked to come to respond to the Ebola outbreak in Sierra Leone, and he had no resources to do so. He just wanted a handful of cars and some dollars to do some work, and there was no ready sense of resources.

We cannot afford for an outbreak to get out of control because somebody can't get their hands on a couple of hundred thousand dollars to go do some surveillance and put some systems in place in hospitals.

QUESTION: I'm Helen Thurston with the Bryn Mawr Club of New York City.

The city sent out mosquito inspections and they put traps out. So New York City is actually looking for mosquitoes.

You mentioned the political aspect of the health situation. We have two candidates that are, I think, diametrically opposed on a number of health issues—more insurance care for many people, and also on the issue of women's reproductive rights, which are really, in my opinion, not women's, but all people's rights. Everything that happens to a family happens to everybody in the family. Could you comment a little bit on that and how this issue can be brought up in a way that affects the political outcome?

ALI KHAN: You know I'm the health person and not the politics person, right?

QUESTIONER: You raised politics. You opened the door.

ALI KHAN: I opened the door. I'm going to look for the expertise in this audience maybe for that answer.

Mosquitoes in New York. New York is my home. I grew up in Brooklyn. I actually went to PS 130 down the street, went to college and med school down there, before I realized I could leave Brooklyn. I actually have aunts and uncles who have never gone to the city, because "Why would you go to the city? Everything you want is in Brooklyn?" So I know a little bit about the city from having grown up here.

Mosquitoes—you are very fortunate in having some of the best public health practitioners in the world here. I will do a shout-out to Marci Layton and Annie Fine. In 1999 West Nile started where? Right here. So you know a lot about mosquitoes. West Nile is another good example. West Nile belongs in the West Nile; it doesn't belong in New York. Another example of a disease somewhere else that sort of came and decided America was home.

We need, as individuals, as we make choices about who we elect and who we support and the op-eds we write, to find people who say that health is an important factor.

You are much more eloquent than I can ever be about reproductive rights. You're right, it is an everybody right, it's not just pregnant women, and we need to make sure that women have their appropriate reproductive rights. We talk about Brazil, but let's not forget the United States. There are a lot of things going on across the United States where we need to make sure that women really do have a full set of rights.

QUESTION: Ron Berenbeim.

I want to ask a question about a developing global problem and also a potential developing response to that problem. The problem, of course, is refugees. I will just leave it at that.

As far as the global response is concerned, I think one of the things that has been overlooked has been the role of pharma and the lack of incentives in the pharmaceutical business for responding to these kinds of emergencies, and to make a really wild suggestion that perhaps it's time for pharmaceuticals to be considered pretty much as a public utility, a public good, like the military, like the water system, and like all the other things we have that we take for granted and that are not incentivized by profit.

ALI KHAN: Thank you. I assume the refugees were an issue to the infectious disease issues.

QUESTIONER: Yes, absolutely.

ALI KHAN: My comment to that always is: I know people often frame it in terms of "What risks do I have because of refugees?" I like to reframe that in terms of "How do we protect the refugees?" I don't want them getting measles. Measles is a horrific disease. What are we doing to help make sure that the refugees are protected themselves? We don't want people to have TB (tuberculosis). How do we make sure that they are protected, and in any screening and other processes we do to make sure that these people are protected.

Pharma—people have recognized this problem for a very long time. I will bring it to you from some of the stories I tell about anthrax. There is zero incentive for anybody to build a medical countermeasure against anthrax due to bioterrorism, or against smallpox, which is something else that I worked on.

The U.S. government actually established BARDA, the Biomedical Advanced Research and Development Authority, for that specific purpose, in the Department of Health and Human Services, to make sure that somebody understood how to work with big pharma and make sure we have these excellent products that now are available to us against things like anthrax. We have enough smallpox vaccine for everybody in the United States if somebody decides to re-engineer smallpox and make it in a lab. So we do have some mechanisms that are available to us.

But you're right, it's a challenge. Drug-resistant antimicrobes—how do you make sure that you continue to have new drugs available for these bugs that just get smarter and smarter all the time?

JOANNE MYERS: You addressed the biological threat issue just now. I was going to ask you about that.

I would just like to thank you for a really exciting journey that you took us on this morning. It was a wonderful talk.

The book is available for you to purchase. Thank you.

ALI KHAN: Thank you, everybody.

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