>> GOOD AFTERNOON, LADIES AND GENTLEMEN, AND WELCOME TO THED 2011 JOSEPH J. KINYOUN MEMORIAL LECTURE. ASOME OF YOU MAY KNOW -- OOPS, GOT TO GO FORWARD. DR. KINYOUN IS AN IMPORTANT FIGURE IN THE NATIONA INSTITUTES OF HALE. IN 1887 H HE ESTABLISHED THE LAB OF HYGIENE ON STA TON ISLAND AND THIS LOVED TO WASHINGTON D.C. IN 1991 AND BECAME THE FORERUNNER OF TODAY'S NIH. DR. KINYOUN'S ONE-ROOM LABORATORY BEGAN A NEWER WHERE OF FIGHTING INFECTIONISEASES THROUGH RIGOROUS SCIENTIFIC RESEARCH COMBINED WITH EPIDEMIOLOGICAL INVESTIGATION. HIS VISION CONTINUES TO INSPIRE OUR APPROACHES TO IMPROVING HEALTH. IN HIS HONOR T NATNAL INSTITUTE OF ALLERGY AND INFECION ESTABLISHED THE KINYOUN LECTURE SHI TO HIGHLIGHT A ADVANCES IN INFECTION AND IMMUNITY. NEXT SLIDE. I AM VERY PLEASED TO INTRODUCE OUR SPEAKER TODAY, DR. THOMAS FRIEDEN WHO HAS A LONG HISTORY OF APPLYING THE PUBLIC HEALTH STRATEGIESO EFFECTIVELY PREVENT AND CONTROL INFECTION DISEASES. HE'S THE DIRTOR FOR CENTERS FORKER DISEASE CONTROL AND ADMINISTRATION. DR. FRIEDEN RECEIVED HIS MEDICAL DEGREE FROM COLUMBIA COLLEGE OF PHYSICIANS AND SURGEONS ANDw3Ť A MASTERS FROM COLUMBIA SCHOOL OF PUBLIC HETH. HE COMPLETED AN INTERNAL TRAININGw3t( AND INFECTION DISEASE FELLOWSH AT YALE. HE BEGAN HIS CAREER WORKINGAS AN EP DECK MIK INTELLIGENCE OFFICE WITH THE NEW YORK CITY DEPARTMENT OF HEALTH AND TWO YELATER HE BECAME THE CITY'S DIRECTORER OF THE BUREAU OF TUBERCULOSIS. UNDER HIS LEADERERSHIP TB INCIDENCE WAS REDUCED BY HALF. FROM 1996-2001, HE WORD IN INDIAASSISTING WITH NATIONAL TB CONTROL EFFORTS AND AS A MEDICAL OFFICER FOR THE WORLD BANK. IN 2002, HE RETURNED TO NEW YORK CITY DEPARTMENT OF HEALTH AS ITS COMMISSIONER, A POSITION HE HELD UNTIL 2009. HISENURE AS COMMISSIONER OF HEALTH PVED TO BE ONE OF THE MOST SUCCEFUL IN MEMORY OF THE CITY. THERE, HE LED AGGRESSIVE PUBLIC HETH PPROACHES TO CITY'S HIV/AIDS PROBLEM, REALIZED MAJOR DECLINES IN TEEN SMOKING, TRACKED THE CITY'S GROWING DIABETES EPIDEMIC AND EMPTY THE FIRST U.S. CITY BAN ON THE USE OF ARTIFICIAL TRANS FATS IN HIS SINCE APPOINTMENT TWO YEARS AGO AS THE DIRECTOR OF THE CDC, TOM HAS WORKED TO IMPROVE HEALTH OUTCOMES AT THE LOW KALE, STATE, NATIONAL AND INTERNATIONAL LEVEL. HE'S WORKED TOENS HANS CDC'S- AND FOCUSED THEIR RESOURCES ON NUTRITION AND FOODSAFETY, HIV PREVENTION, TOBACCO CONTROL AND REDUCING THE RATES OF MOTOR VEHICLE PREVENTION AND TEEN PREGNANCY. ON OF HIS FIRST DUESŤ WAS TO LEAD THE RESPONSE TO H1N1 PANDEMIC FO HIS CONTRIBUTIONS RECEIVED A NU MBER OF HE HASŤV HONORS COOP MED. HE'S RECEIVED AN HONORARY DOCTORATE FROM TUFS FROM ME PERSONALLY AND FROM TH NIH, TOM HAS BEEN A CLOSE FRIEND AND VALUED AND RESPECTED COLLEAGUE WHO'S OPINION AND COUNCIL WE READY AND OFF SO PLEASJOIN ME IN WELCOMING DR. THOMAS FRIEDEN. [APPLAUSE] >> THANKS. THANKS VERY MUCH, TONY. IT'S ACTUALLY BEEN A DELIGHTFUL EXPERIENCE TO GET TO KNOW AND WORK WITH TONY MORE IF MY CURRENT JOB. I'M DELIGHTED TO BE HERE TO TALK TO YOU A BIT ABOUT INFECTION DISEASES, BOTH IN THIS COUNTRY AND GLOBALLY. IN PREPARING FOR THIS TALK IG PULLED A BIT ABOUT WHAT YOUR COLLABORATIONS HAVE BEEN AND AISLE MENTION THOSE AT THE END. THE STRIKING FACT -- REALLY THERE ARE TWO STRIKING FACTS ABOUT OUR COLLABORATIO. FIRST S IN THE AREAS WHEREE NLDZ COLLABORATE, WEFD Ö SUCCESS, SECOND IS WE HARDLY EVER COLLABORATE. [LAUGHTER] TREMENDOUS SUCCESS. I THOUGHT I WOULD TALK TO YOU A BIT ABOUT MY PATHWAY AND MY JOURNEY IN AND PUBLIC HEALTH GENERALLY AND THE PERSPECTIVE BRING TO BEAR ON WHERE I THINK WE NEED TO BE ING IN COMMUNICABLE DISEASE CONTRO I TINK OF THE FACTORS THAT INFLUENCE HEALTH AS AT THE BASIS SOCIO ECONOMIC, POVERTY, HOUSING, INEQUALITY. THESE ARE TNGS THAT DRIVE PROGRESS OR LACK OF PROGRESS IN HEALTH. ONE LEVEL ABO THAT ARE THE CLASSICAL PUBLIC HEALTH INTERVENTIONS OF CHANGING THE CONTEXT TO MAKE INDIVIDUAL DECISIONS, D THE HEALTHY DECISIONS; CLEAN AIR AND WATER, FOOD AND DRUG SAFE, FE ROADS. THESE ARE ALL THINGS THAT MAKE IT HARDER FOR US TO DO THE THING THAT'S GOING TO MAKE US SICKER. AT A LEVEL ABOVE THAT ARE LONG-LASTING PREVENTIVE INTERVENTIONS, MOST PROMINENTLY VACCINES BUT ALSO MASS DRUG ADMINISTRATIONS FOR TROPICAL DISEASES BED NETS AND NOW WE KNOW MALE MEDICAL CIRCUMSION. LEVBOVE THAT ARE THE CLINICAL INTERVENTIONS WHERE WE HAVE TO PROVIDE TREATMENT E SHALLY EVERY DAY OF THE YEAR, YEAR-ROUND IN HEALTH FACILITIES THROUGHOUT COMMUNITIES TO HAVE A POPULATION IMPACT, AND TREATMENT ŤHIV, AND NOW OF TUBERCULOSIS, OF Oo OF HEPATITIS FALL INTO THIS CATEGO. AT THE LEVEL ABOVE THAT, COUNSELING AND EDUCATION. EDUCATION ON INFANT CARE, WASHING YOUR HANDS ORŤ— USING CONDOMS. IN GENERAL, AT THE LOWER LEVELS OF THIS PYRAMID, YOU HAVE LARGER IMPACT; AT THE HIGHER LEVELS, LESS IMPACT. THAT DOES NOT MEAN YOU DO NOT WORK AT EVERY LEVEL. WE DO, BUT WE ALWAYS TRY TO DRIVE DOWN THAT LOWER LEVEL WHERE WE'RE GOING TO HAVE PRY MOD Y'ALL PREVENTION IMPACT. WE'RE ALL CONNECTED BY THE AIR WE BREATHE AND AS A TUBERCULOSIS DOCTOR FOR MORE THAN A DECADE, IF WE UNDERSTAND THE EPIDEMIOLOGY OF TB IN A SOCIETY,yM WE UNDERSTAND HOW THAT SOCIETY WORKS, AND IF WE UNDERSTAND HOW OUR GOVERNMENT IMPLEMENTS TB CONTROL, WE CAN UNDERSTAND HOW THAT GOVERNMENT WORKS. ONŤ THE LEFT, YOUR LEFT, IS A PICTURE. IT'S A PICTURE THAT I TOOK. IT'S A PICTURE THAT I TOOK IN THIS COUNTRY IN 1988. IT WAS IN A HOMELESS SHELTER IN NEW YORK SYMPATHY CITY WHERE I HAD WORK FOR A A YEAR PART-TIME SCREENING MENTALLY ILLŤ HOMELESS MEN FOR THEIR ONCE-A-YEAR PHYSICAL. ON MY LAST SESSION, FINISHING MEDICALN RESIDENCY, I TOOK THIS PICTURE AND THE GUARD THREATENED TO TAKE AWAY THE CAMERA AND EXPOSE ALL THE FILM BECAUSE HE SAID IT WOULD GIVE PEOPLE THE WRONG IMPRESSION. BUT THIS, IN FACT WAS T RHT IMPRESSION WAS THIS WAS WHAT WAS HAPPENING IN NEW YORK CITY. THERE WERE NINE HUNDRED MEN SLEEPING ON A GRILL w3FLOOR, HIGH HIV PRESENCE AND SIGNIFICANCE SPREAD OF TUBERCULOSIS. THIS IS AN YOU ARE BAN SLUM IN A DEVELOPING COUNTRY AND THESE KIND OF CONTEXTS ARE THE BREEDING GROUND FOR TUBERCULOSIS AND OTHER COMMUNICABLE DISEASES. AS AN EIS OFFICER EPIDEMIC NELGS OFFICER, I WAS ABLE TO DOCUMENT THE SPREAD OF MULTI-DRUG RESISTANT TUBERCULOSIS IN NEW YORK CITY AND BECAME THE DIRECTOR OF THE BUREAU OF TUBERCULOSIS CONTROL AND CAROL CAME TO VISIT. MOST PEOPLE HAVE NEVER HEARD OF CAR ROLL. IN FACT, EVEN MOST TUBERCULOSIS SPECIALISTS HAVE EVERY HEARD OF HIM. SO IF K I JUST HAVE A SHOW OF HANDS, HOW MANY HAVE HEARD CAROL? WOW. [LAUGHTER] OKAY. CAROL CREATED THE DOTS STRATEGY. HE WAS ABSOLUTELY BRILLIANT. I'LL TALK A LITTLE BIT ABOUT HIS ACCOMPLISHMENTS. IF YOU WANT TO LEARN ABOUT TB EPIDEMIOLOGY, HE HAS A COLLECTIVE BOOK OF PAPERS ON TUBERCULOSIS EPIDEMIOLOGY WHICH I DEFY ANYONE TO FULLY UNDERSTAND. THERE REALLY, REALLY DEEP THINKING ABOUT TB EPIDEMIOLOGY AND MODELLING AND THREE DIMENSIONAL GRAPHING ALL DONE BY HANDkO BY HIM. HE CAME TO NEW YORK CITY IN JANUARY OF '93. I'D BEEN TB CONTROLLER FOR ABOUT SEVEN MONTHS AND HE SAID SOMETHING THAT REALLY MADE AN IMPACT. TB CONTROL IS SIMPLE. THERE'S ONLY RUN RULE, NO CHEATING. EVERY PATIENT YOU START ON TREATMENT, YOU ARE RESPONSIBLE FOR THEIR OCOME OUT COME AND HE ASKED ME A SINGLE QUESTION THAT CHANGED MY LIFE. HE LOOKED AT OUR DATA INFORMATION SUMMARY WHERE HE HAD ANALYZED THE THREE THOUSAND 881 PATIENTS WE HAD HAD THE PREVIOUS YEAR IN EVERY WAY YOU CAN SLICE AND DICE; lZ GEOGRAPHIC, CLINICAL. HE SAID DOCTOR -- AND THEN SHE SHOWED ME SEVERAL EPIDEMIOLOGY TRENDS I HAD MISSED AND I HAD WRITTEN IT SO I WAS MIFFED. HE SAID THIS DOESN'T TELL ME ONE THING -- IN FACT, IT DOESN'T TELL ME THE MOST IMPORTANT THING. YOU HAD 3881 PATIENTS LAST YEAR DIAGNOSED WITH TB, HOW MANY OF THEM DID YOU CURE? AND I DIDN'T KNOW. I WAS TERRIBLY ASHAMED, AND THE NEXT DAY I BEGAN A SYSTEM OF COHORT REVIEW TO REVIEW THE STATUS OF EVERY SINGLE PATIENT DIAGNOSISED IN THE PREVIOUS QUARTER IN EVERY REGION OF THE CITY EVERY QUARTER. FOR THE NEXT FIVE YEARS, I REVIEWED EVERY PATIENT IN NEW YORK CITY. IN DOING THAT, WE LEARNED ALL SORTS OF PROBLEMS. WE LEARNED WHAT THE DOCTORS WERE„/7q DOING WRONG, WE LEARN WHAT OUR STAFF WAS DOING WRONG, WE LEARNED PATIENT CHALLENGES. AND THAT KIND OF ACCOUNTABILITY IS THE UNDERLYING PRINCIPLE OF TUBERCULOSIS CONTROL. NOW TB DEATHS DECREASED IN NEW YORK CITY AND THROUGHOUT THE COUNTRY BY 99.9% IN THE 20th v: CENTURY. IN 1900, THE POPULATION OF NEW YORK CITY UNDER THE AGE OF 65 WAS 3.3 MILLION AND THERE WERE 61,000 DEATHS AND TUBERCULOSIS WAS THE LEADINGŤ SINGLE CAUSE OF DEATH. BY 2005 T POPULATION HAD DOUBLED, BUT THE NUMBER OF DEATHS WAS CUT BY A FACTOR OF FOUR, SO THE DEATH RATE WAS CUT BY EIGHT FOLD AND TUBERCULOSIS WENT OFF THE MAP. SO ONLY 13 DEATHS AND NOT ANYWHERE NEAR THE TOP 25 OR 50 CAUSES OF DEATH. HOWEVER, UM, FROM 1955 TO 2002, WE A DRAMATIC INCREASE IN [INDISCERNIBLE] RESISTANT TUBERCULOSIS IN NEW YORK CITY. WE THEN IMPLEMENTED THE DOTS STRATEGY WHICH I'LL TALK ABOUT AND OVER THE FOLLOWING YEARS, WE SAW A SUBSTANTIAL REDUCTION IN THIS IS IMPORTANT BECAUSE OF THE ESSENTIAL LESSON OF THE t( DIRECTLY-OBSERVED TREATMENT SHORT COURSE CMOTHERAPY STRATEGY, WHICH STEVE LOWE CREATED, WHICH IS THAT A POORLY-FUNCTIONING PROGRAM CAN CREATE DRUG RESISTANT TUBERCULOSIS FASTER THAN ANY PROGRAM CAN TREAT DRUG-RESISTANT TUBERCULOSIS NO MATTER HOW MANY RESOURCES YOU HAVE AVAILABLE. THIS IS A GRAPH OF THE NUMBER OF NEW TB CASES IN PURPLE, AND NEW MDRTB CASES IN ORANGE AND THE PERCENTAGE OF CASES WHO'S EVERY DOSE WAS OBSERVED, IDEALLY SHOULD GET TO 100% BUT GOT TO ABOUT 75% AND THERE'S A VERY TIGHT NEGATIVE CORRELATION. THIS IS A LITTLE FASZ LED BECAUSE WE WERE FORTUNATE IN A SENSE THAT WHEN TB WAS EPIDEMIC IN NEW YORK CITY HERE, A VERY HIGH PROPORTIONŤ OF CASES WERE ARISING FROM RECENT TRANSMISSION. AS YOU KNOW IN TUBERCULOSIS, IF YOU BECOME INFECTED, YOU'VE GOT ABOUT A 10% LIFETIME RISK OF GETTING ACTIVE TB AND ABOUT 80% OF THAT RISK IS IN THE FIrST FIVE YEARS, REALLY IN THE FIRST TWO YEARS AFTER INFECTION. SO, UM, I'M GOING TO TALK ABOUT THIS MORE A LITTLE BIT, BUT WHAT WE DIDN'T KNOW WHEN WE STARTED WAS THAT THIS HUGE INCREASE WAS NOT SIMPLY BECAUSE WE HAD A LOT OF AIDS PATIENTS WITH DEPRESSIONED IMMUNE SYSTEMS WHO WERE BREAKING DOWN WITH TB THAT THEY HAD BEEN INFECTED WITH DECADES EARLIER. WHAT THIS REFLECTED WAS AN ON GANG SPREAD OF TB WITHIN THE CONFINES OF NEW YORK CITY IN PLACES LIKE THAT HOMELESS SHELTER I SHOWED YOU EARLIER AND ESPECIALLY IN HOSPITALS BECAUSE GUESS WHAT? SICK PEOPLE GO TO HOSPITALS, AND THEREFORE, A LOT OF PEOPLE ARE COMING TO HOSPITAL WHO MAY SPREAD TB WIDELY TO OTHERS. WE DID A STUDY, THE FIRST STUDY ACTUALLY EVER DONE OF THE MOLECULAR EPIDEMIOLOGY OF TUBERCULOSIS WAS DONE WHEN I WAS IN THE IS OFFICER IN NEW YORK CITY AND WE FOUND THAT OF EVERY TB CASE IN NEW YORK CITY, AT LEAST 6% AROSE SPREAD IN HOSPITALS. THAT'S NOT AN INSIGNIFICANT NUMBER AND IT'S QUITE RELEVANT TO WHAT'S HAPPENING TODAY IN MANY PARTS OF AFRICA WHERE YOU HAVE THE COMBINATION OF HIV AND TB BOTH TOGETHER. TUBERCULOSIS CONTROL, I BELIEVE, IS A MODEL FOR PUBLIC HEALTH PRACTICE. WE HAVESA WHICH CRUCIALLY IMPORTANT. SURVEILLANCE I'M OFTEN REQUIRED TOb TO PUBLIC HEALTH. HOW DO YOU KNOW WHAT THE PROBLEMS ARE? HOW DO YOU KNOW WHERE TO TARGET YOUR ACTIVITIES? HOW DO YOU KNOW WHETHER YOUR PROGRAMS ARE WORKING? ALL BASED ON SURVEILLANCE AND I'VE BEEN IN SITUATIONS WHERE WE'VE HAD TO RETRENCH AND CUT BACK ON SERVICES, AND THE ONE THING I INSIST WE NOT CUT BACK ON IS SURVEILLANCE BECAUSE IN A STORM, YOU WANT TO KEEPŤ YOUR RUDDER. YOU WANT TO KNOW WHAT'S HAPPENING. SECOND IS STANDARDIZED TREATMENT. THE BRITISH MEDICAL RESEARCH COUNCIL DID PHENOMENAL STUDIES OVER DECADES TO RIGOROUSLY DOCUMENT OPTIMIZED TREATMENT, WHAT'S THE ROLE OF THESE?my CAN YOU GIVE IT TWICE OR THRICE WEEKLY THIS IS A FANTASTIC BODY OF EVIDENCE. THERE'S A WONDERFUL SUMMARY OF THIS IS AN ARTICLE THAT DANNY WROTE CALLED HAIL BRITAIN YEAH ABOUT THE WONDERFUL -- THERE IS NOTHING WE DO, I THINK IN PUBLIC HEALTH THAT HASHE LEVEL OF RIGOR THAT THESE RCT HAS PROVIDED. AND OF COURSE IT'S TUBERCULOSIS THAT PROVIDED THE WORLD'S FIRST RCT. PATIENT-CENTERED CARE. BECAUSE ULTIMATELY TUBERCULOSIS IS ABOUT BOTH HOW PEOPLE GET INFECTED BECAUSE OF THE CONNECTIONS BY THE AIR WE BREATHE BUT HOW C RECONNECT TO PEOPLE WHO HAVE BEEN ISOLATED FROM SOCIETY, MALNRISHED, POOR, MAYBE HIV, MAYBE HOMELESS, OR, UH, IN ANY CASE, EXPERIENCING STIGMA BECAUSE THEY HAVE A CONTAGIOUS DISEASE,ND I'LL TELL YOU, I HAD PATIENTS IN NEW YORK CITY WHO I CARED FOR WHO HAD HIV AND TB A AND THEY TOLD ME, YOU CAN TELL MY FAMILY I GOT HIV BUT PLEASE DON'T TELL THEM I'VE GOT TBxD BECAUSE KI GIVE THEM THE TB AND MY MOTHER AND FATHER, UH YOU KNOW, I DON'T MIND IF THEY KNOW I GOT HIV, BUT IF THEY FIND OUT I GOT TB, I MAY GET THROWN OUT. GETTING PATIENTS BACK INTO CARE AND HELPING THEM COMPLETE CARE IS REALLY A QUESTION OF A HUMAN BOND THAT ESTABLISHES AND BRINGS THEM BACK INTO SOCIETY. ACCOUNTABILITY FOR OUTCOMES, ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH AND STUS SUSTAINING POLITICAL COMMITMENT, WHICH IS SO CHALLENGING IN TB. THERE WAS AN ARTICLE CALLED THE "U H-SHAPED CURVE OF CONCERN." WHAT GENERALLY HAPPENS OF INFECTION DISEASES IS PEOPLE ARE WORRIED ABOUT IT BECAUSE IT'S IN THE HEADLINE, WE STOP FUNDING, IT COMES BACK ROARING EXPENSIVELY AS A RESURGENCE WITH RESISTANCE, OFTEN, AND THEN WE PAY ATTENTION AGAIN. SO WE HAVE TO FIGHT AGAINST THAT U-SHAPED CURVE OF CONCERN. I CALCULATED EARLY ON THAT NEW YORK CITY HAD TO BAY PAY NOT FOR CONTROL BUT JUST THE CARE FOR PEOPLE THE REJER SENSE OF TB THAT WAS LARGELY AFFORDABLE IN NEW YORK CITY, A BILLION DOLLARS. NOW EVIDENCE-BASED PUBLIC HEALTH ARE INTERVENTION HS THAT HAVE SUBSTANTIAL IMPACT THAT WORK. THE RCT IS GOLD-STANDARD IN CLINICAL CARE AND IT STARTED WITH TB, BUT PUBLIC HEALTH SEFD MUCH BROADER THAN RCT. NOT EVERYTHING CAN BE STUDIED BY AN RCT. THERE ARE COMMUNITYU INTERVENTION TRIAL WITH DEFINED OUTCOMES. THERE ARE RIGOROUSLY EVALUATED PILOT PROGRAMS. SCALING IS VERY IMPORTANT. IT'S ONE THING TO SAY THAT SOMETHING WORKS. IT'S ANOTHER THING TO SAY IT CAN BE DONE ON A POPULATION BASIS. THERE ARE THREE QUESTIONS: DOES IT WORKS? IS IT IMPORTANT? AND CAN IT BE SCALED UP?; IDEALLY YOU'D WANT THE DOCUMENTED EPIDEMIOLOGY BOOK BEFORE AND AFTER AN INTERVENTION. GLOBALLY, NEARLY NINE MILLION CASES OF TB, MORE THAN A MILLION DEATHS; HOWEVER, CASES ARE FALLING, INCIDENCE IS FALLING, AND DEATH RATES ARE FALLEN BY 1/3 SINCE 1990. IN CHINA WHERE THEY SCALED UP RELATIVELY RAPIDLY AND THEY'VE HAD ECONOMIC PROGRESS, IN A 20-YEAR PERIOD THE PREVALENCE WAS CUT IN HALF, MORTALITY FELL BY 80% AND INSURANCE DENSE FELL BY 3.# PER YEAR. DOTS IS EVIDENCE-BASED PUBLIC HEALTH PRACTICE. IT'S A FIVE COMPONT TUBERCULOSIS CONTROL STRATEGY THAT STARTS WITH POLITICAL COMMITMENT, WHICH I HAVE STRAITED HERE WITH THE IMPLEMENT HERE WITH THE SIMPLEST INDICATOR. -- ONE OF THE THINGS WE'RE LEARNING NOW IS THAT MAY NOT BE SUFFICIENT IN AREAS OF HIGH HI OR LOW HIV. WE MAY NEED TO BE MORE AGGRESSIVE AT TRYING TO FIND TUBERCULOSIS BECAUSE WE DON'T DO A GREAT JOB, BUT HERE'S A QUIZ. ANYONE KNOW WHAT THIS IS AN IMAGE OF? CALL IT OUT. THESE ARE [INDISCERNIBLE] TUBERCULOSIS. ANYONE KNOW WHAT KIND OF STAIN THIS THIS IS?f‡ >> [INDISCERNIBLE]. >> KIN YAN. YOU MAY THINK OF KINYOUN AS A GREAT MAN BECAUSE OF HIS CREATION OF THIS WONDERFUL INSTITUTION, BUT TUBERCULOSIS SPECIALESTS, THE ABILITY TO CREATE A STAIN -- ANYONE KNOW HOW A KINYOUN STATE IS DIFFERENT FROM [INDISCERNIBLE] STAIN? DOESN'T REQUIRE HEATING. YOU'RE ABLE TO DO IT BY LETTING IT STAIN LONGER WITHOUT ACTUALLY HAVING A HEAT SOURCE. THE KINYOUN STAIN, ALTHOUGH w3Ť NON-STANDARD IS VERY IMPORTANT. I JUST WANTED TO MAKE THAT LINK TO THE LECTURE. [LAUGHTER] x ś< OBSERVED TREATMENT IS DIRECTLYhq ‚ WITH ANOTHER TO HELP THEM GET THROUGH TREATMENT AND ADEQUATE SUPPLY OF DRUGS WHICH REMAINS A HUGE PROBLEM AROUND THE WORLD. RECENTLY, WHO WORLD HEALTH ORGANIZATION HAS DONE AN EXCELLENT JOB IN TUBERCULOSIS CONTROL. THEY DON'T ALWAYS DO A GREAT JOB TO BE BLUNT, BUT THEY'VE DONE AN EXCELLENT JOB IN TB. THEY SAID, YOU KNOW SOMETHING, 80% OF THE WORLD'S TB CASES HAPPEN IN 22 COUNTRIES. LET'S FOCUS ON THEM AND GET THEM IN ORDER AROUND IF WE DO THAT, THE REST MAY WELL TAKE CARE OF THEMSELVES AND THEY'VE HAD TREMENDOUS PROGRESS IN DOING THAT, BUT EVEN AS LATE AS LAST YEAR, THERE WERE DRUG STOCKOUTS IN ABOUT HALF OF THOSE COUNTRIES DESPITE ALL OF THE EMPHASIS ON TUBERCULOSIS, AND THIS TB REGISTER, WHICH IS, I WILL NOT SPEND THE NEXT HALF HOUR GOING INTO WHY IT'S A WONDERFUL SYSTEM, BUT BELIEVE ME,ER IT IS. IT IS A SYSTEM THAT ALLOWS YOU TO TRACK THE PROGRESS OF EVERY SINGLE PATIENT AROUND THE WORLD 40 MILLION PATIENTS HAVE BEEN WRITTEN INTO REGISTERS LIKE THIS AND THEIR OUTCOME IS TRACKED INDIVIDUALLY AT EVERY LEVEL IN WAY THAT CAN BE EASY CHECKED AND VERIFIED AND FALSIFICATION EASILY FOUND. HI POCKTY SAID PATIENTS OFTEN LIE ABOUT THE TAKING OF MEDICINES PRESCRIBED. THIS IS AN ESSENTIAL INSIGHT OF THE TUBERCULOSIS WORLD. 1/3 OF PATIENT DOS NOT ADHERE TO MEDICATION REGIMENS, AND NON-ADHERENCE IS NOT RELATED TO ADVERSE EVENTS, DOSE OR PRIOR OBSERVED TREATMENTS. IT'S AS HIGH WITH PLACEBO AS IT IS WITH MEDICATIONS. IT'S IMPOSSIBLE TO PREDICT ADHERENCE. YOU MAY BE ABLE TO PREDICT NON-ADHERENCE A LITTLE BIT, BUT DOCTORS, LAWYERS, REALLY BAD AT TAKING MEDICATIONS. WE THOUGHT PEOPLE IN AFRICA WOULD BE BAD AT TAKING AIDS DRUGS, THEY'RE NOT. BUT EVERY STUDY DONE SHOWS THAT ABOUT A THIRD OF PATIENTS DON'T TAKE MEDICATIONS AS DESCRIBE PD. A A THIRD OF THE PRESCRIPTIONS WRITTEN IN MEDICARE, NEVER FILLED. SO ONE OF THE THINGS THAT TUBERCULOSIS TEACHES US IS A VERY CLEAR VIEW OF HUMAN NATURE AND HUMAN BEHAVIOR. WE HAVE A VERY SIMPLE BEHAVIORAL MOD UNTIL TUBERCULOSIS CONTROL. IF WE SEE YOU TAKE YOUR MEDICINE, WE BELIEVE YOU TOOK YOUR MEDICINE. IF WE DIDN'T SEE, WE DON'T BELIEVE. YOU CAN'T DO THAT IN ALLŤŤ SITUATIONS, BUT IT'S IMPORTANT TO UNDERSTAND HOW MUCH OF A LIMITATION ADHERENCE IS FOR OUR TREATMENT AND PATIENTS DON'T ACCURATELY REPORT ADHERENCE. SURPRISE HOME VISITS REVEAL A MUCH HIGHER DEGREE OF NON-ADHERENCE THAN PILL COUNTS OR YEARN TESTS. WE DID DIRECTLY OBSERVED TREATMENT IN NEW YORK CITY AS A CORE WAY OF DRIVING CASES DOWN. THIS IS AN OUTREACH WORKER ON THE STREET HELPING SOMEONE TAKE HIS MEDICINE. THIS ISw3@ WHICH WAS A A CRACK BIN AND WAS HOME TO AN ETENDED COMMUNITY FROM E QUESTION DOERsWHERE THERE WERE A LARGE CLUSTER OF TB CASES. OUR WORKERS WHEN TO THIS BUILDING EVERY DAY FOR TWO YEARS AND GOT PEOPLE THROUGH TREATMENT. WE WOULD HAVE RATHER GOTTEN PEOPLE HOME, BUT EVEN IF YOU CAN'T FIX SOCIETY, YOU CAN CURE TB. THIS IS HOW THE WORLD HEALTH ORGANIZATION HAS TRACKED PROGRESS, AND THIS IS A LITTLE BIT OF A COMPLICATED GRAPH IF YOU HAVEN'T SEEN IT BEFORE, BUT ON THIS X AXIS IS THE DETECTION RATE OVER AN ESTIMATED TOTAL. ON THE Y AXIS IS THE TREATMENT SUCCESS RATE. THE ANSWER TO THAT STEVE LOWE QUESTION, HOW MANY DID YOU CURE? THE COUNTRIES THAT ARE GOING IN THE WRONG DIRECTION, FOR EXAMPLE, ZIMBABWE, HAVE NOT ONLY IDENTIFIED FEWER PATIENTS, BUT CURED A LOWER OPORTION OF THEM. IDEALLY, YOU WANT TO START UP HERE, IDENTIFYING A FEW PATIENTS, AND TREATING THEM WELL, AND THEN EXPANDING YOUR CASE DETECTION TO THE TARGETS ZONE OF FINDING AND TREATING THE GREAT MAJORITY OF PATIENTS FINDING AND SUCCESSFUL SUCCESSFULLY TREATING THE GREAT MAJORITY OF PATIENTS. THERE'S NOTHING MAGICAL ABOUT THIS NUMBER, BUT CAROL STEVE LOWE ESTIMATED BASED ON MATHEMATICAL MODELS ESTIMATED THAT IF YOU MET THIS TARGET YOUR INCIDENCE RATE WOULD BE CUT IN HALF EVERY TEN YEARS. HE DID THAT BASED ON 40 YEARS OFŤ EPIDEMIOLOGIC RESEARCH IN EUROPE AND AFRICA BEFORE HIV CAME IN, AND IN THE ABSENCE OF HIV, HE IS EXACTLY RIGHT. HIV, UNFORTUNATELY, THROWS THINGS PRETTY FAR OFF. IN INDIA, WE WERE ABLE TO SUPPORT THE TUBERCULOSIS RESEARCH CENTER WHICH IS A PARTNER WITH NIAID AND IS A FANTASTIC INSTITUTION, AMAZING PLACE. I DON'T KNOW OF ANY PLACE LIKE IT ANYWHERE IN THE WORLD. YOU DON'T OVEN FIND PLACES WHERE THERE ARE TWO HUNDRED PEOPLE WHO DO NOTHING BUT WORK ON TUBERCULOSIS ALL YEAR ROUND AND WHO HAVE A COMMUNITY THAT'S BEEN UNDER CONTINUOUS SURVEILLANCE FOR TB INCLUDING WITH INPUT FROM THE U.S. PUBLIC HEALTH SERVICE SINCE 1969. THIS IS WHERE THE [INDISCERNIBLE] TRIAL WAS DONE. IT WAS A REMARKABLE TRIAL OF, I THINK, 450,000 PEOPLE, WHO WERE RANDOMIZED INTO PLACEBO, HIGH DOSE OR LOW DOSE BCG AND THEN FOLLOWED WITH X-RAYS EVERYI„ TWO-AND-A-HALF YEARS FOR 15 YEARS WITH MORE THAN 90-95% COMPLIANCE. ANYONE WITH ABNORMALZv X-RAY HAD TESTING DONE BY SMEAR CULTURE AND THEY SHOWED THAT BCG DIDN'T WORK. REMARKABLE TRIAL. WE THOUGHT WE WOULD DO THE -- IT WAS CALLED THE [INDISCERNIBLE] PREVENTION TRIAL. WE THOUGHT WE WOULD DO THE [INDISCERNIBLE] TREATMENT TRIAL AND WE STARTED DOT THERE IS. WE SAW DRAMATIC REDUCTIONS IN THE RATE OF INFECTION IN CHILDREN N THE PREVALENCE OF TB. UNFORTUNATELY T QUALITY OF THE PROGRAM WENT DOWN HILL. IT WASN'T A MODEL DOTS PROGRAM, IT WAS A A BELOW-AVERAGE DOTS PROGRAM. IN SUBSEQUENCE YEARS THE RESULTS HAVE BEEN HAVE NOT BEEN AS ENCOURAGE PG. WHAT'S HAPPENING IN INDIA OVER THE PAST 15 YEARS IS THAT INDIA HAD TREATED 14 MILLION TB PATIENTS AND PREVENTED TWO-AND-A-HALF MILLION DEATHS FROM TUBERCULOSIS. THERE'S A LOT WE CAN DO NO TB BUT SOME THINGS WE CAN'T. WE CAN REDUCE TB DEATHS. REMARKABLE SUCCESS FROM PA RUE, ALTHOUGH AGAIN, AFTER THIS SLIDE ENDS, THE QUALITY OF THE PROGRAM WENT DOWN SUBSTANTIALLY AND THE IMPACT WAS LESS. IN BEIJING WHERE IT STREKTLY DIRECTLY OBSERVED TREATMENT, YOU HAD DECLINE IN CASES. IN VIETNAM, YOU HAD A DRAMATIC REDUCTION INTY-DRUG RESISTANCE WITH IMPLEMENTATION OF DOTS, BUT WE SDROBT EFFECTIVE TOOLS TO CONTROL TB WHERE HIV PREVALENCE IS HIGH AND THIS IS AN ENORMOUS CHALLENGE. SO, WHY IS TB INCIDENCE FALLING ONLY GRADUALLY IN DEVELOPING COUNTRIES? THERE ARE BASICALLY THREE OPTIONS. THEY MAY ALL BE PART OF THE SOLUTION. ONE, BAD DOTS. TWO, TOO MUCH REACTIVATION DISEASE, WAVES CRASHING ON THE BEACH FROM A BOAT THAT'S ALREADY PASSED IN THE MEMORABLE–r RANDY SHOELTS ANALOGY. THREE, SOCIAL CHANGE. THERE'S GOOD EVIDENCE FOR ALL THREE OF THESE EXPLANATION. BAD DOTS, INSUFFICIENT CASE FINDING. WE'RE FINDING PEOPLE TOO LITTLE, TOO LATE, OR BOTH. IT MAY WELL BE THAT THOUGH WE THINK WE'RE FINDING 70 OR 80% OF PEOPLE, WE'VE MISCALCULATED HOW MANY THERE ARE AND WE'RE ONLY REALLY FINDING 50%. IT M BE THAT PEOPLE ARE SICK FOR SO LONG THAT IT DOESN'T REALLY MATTER THAT WE'VE TREATED THEM BECAUSE THEY'VE ALREADY INFECTED ALL THE PEOPLE AROUND THEM. YOU COULD HAVE TWO PROGRAMS BOTH OF WHICH DIAGNOSED AND CURE 85% OF THEIR TB PATIENTS. ONE OF THEM DOES I AFTER FOUR MONTHS WHEN PEOPLE HAVE ALREADY INFECTED ON AVERGE 20 PEOPLE, THE OTHER DOES IT AFTER A WEEK IN WHICH CASE THEY'VE ONLY INFECTED TWO PEOPLE AND THE IMPLICATIONS FOR THE EPIDEMIOLOGY WILL BE DRAMATICALLY–r DIFFERENT. NOT REGISTERING ALL DIAGNOSED PATIENTS, NOT ENSURING CONTINUOUSi] MEDICATION -- THESE ARE NOT JUST AN ACADEMIC QUESTION, IT'S A QUESTION OF MEDIATE [INDISCERNIBLE] FOR WHAT IS HAPPENING? WHAT'S GOING WRONG? IF IT'S THE CASE THAT IT'S BAD DOTS THEN WE IMPROVE TREATMENT AND INFECTION CONTROL. IF IT'S REACTIVATION, WAVES CRASHING ON THE BEACH, THEN WE WOULD HAVE TO PREVENT REACTION OF LATEENED TB OR DISEASE PREVIOUSLY CONSIDERED CURED AND THERE'S SOME EVIDENCE FOR THIS. IN–rŤ HONG KONG THE RISK OF DEVELOPING TB FROM REACTIVATION IS MUCH HIGHER THAN PRIMARY INFECTION. THE IMPLICATION IS MORE PREVENTION -- TO HAVE REACTIVATION. PERSISTENCE IS KEY FOR TUBERCULOSIS CONTROL. FOR AN INDIVIDUAL THE TEMPTATION IS AFTER COUPLE OF WEEKS OR A MONTH OR TWO, YOU FEEL GREAT, WHY SHOULD YOU TAKE THESE HORRIBLE MEDICATIONS. YOU STOP AND YOU REACTIVATE OR YOU DON'T CLEAT AND YOU MAY GET DRUG RESISTANCE. SAME IS TRUE FOR PROGRAMS. DOCTOR ALL TOO OFTEN FID WL THE REGIMEN.P,„ YOU JUST HAVE TO STICK WITH IT BECAUSE TB IS SLOW-GROWING AND IT'S GOING TAKE A WILE FOR IT TO GET CURED, AND, UM, PROGRAMS NEED TO CONTINUE WITH THE POLICIES THAT THEY HAVE EVEN IF IT'S JUST MORE OF THE SAME. SOMETIMES YOU JUST GOT TO DO THAT. MAYBE IT'S THE NEED FOR SOCIAL CHANGE; POVERTY, HOUSING, EDUCATION. INTERESTINGLY A RECENT ANALYSIS SUGGESTS THAT THERE'S A LOT OF EVIDENCE FOR THIS UNDERNUTRITION MAY ACCOUNT FOR MORE THAN A QUARTER OF TB CASES, INDOOR AIR POLLUTION, 16% P ALCOHOL AND DIABETES ABOUT 10% EACH. SIR JOHN KROFTON WHO CREATED MULTIDRUG TREATMENT FOR THE TUBERCULOSIS PASS AID WAY A COUPLE OF YEARS AGO, WONDERFUL HUMAN BEING, SAID THAT WITH TB THERE'S NEVER MUCH TIME TO REST ON ONE'S LAURELst AND THAT'S VERY FRA FE TICK [INDISCERNIBLE] WE HAVE A LOT OF GAPS IN TB KNOWLEDGE AND THINKING ABOUT WHATŤ WE DO, DO TOGETHER, WE COULD BENEFIT FROM FAST AND ACCURATE DIAGNOSES. THERE'S SOME REAL ADVANCES IN RECENT YEARS.jF WE COULD BENEFIT BETTER DRUGS FOR DRUG RESISTANCE AND LESS TOXIC DRUGS AND ABOVE ALL A VACCINE WHICH WOULD BE WITHOUT A DOUBT A NOBEL PRIZE-WORTHY DISCOVERY. ARGUE THAT IM PROVING THE I GO.1 TECHNOLOGY OF TREATING HEALTH TBI, IS MORE IMPORTANT THAN IMPROVING CURATIVE TREATMENT. WHY? BECAUSE AFFECTIVE IDENTIFY KAGS WILL DO A LOT. ONE OUT OF 20, ONE OUT OF 25 PEOPLE WITH TB INFECTION WILL PROGRESS TO ACTIVE TB. IF WE COULD IDENTIFY WHO THEY ARE AND TREAT THEM EFFECTIVELY, WE COULD DRASTICALLY REDUCE TB. WE'VE ALREADY GOT A GOOD TREATMENT FOR TB. IT'S VIRTUALLY 100%zV KOOURTIVE WITH SIMPLE LOW CT DRUGS. THAT'S ONLY TB SPECIALISTS THAT CALL SIX MONTHS OF TREATMENT SHORT COURSE, BUT STILL, IT'S POSSIBLE TOQ% DO. I PREDICTED IN 2000, THAT IT WOULD BE AT LEAST A DECADE BEFORE TB TREATMENT WOULD GET DOWN BELOW FOUR MONTHS. I THINK I CAN PROBABLY MAKE ABOUT THE SAME PREDICTION FOR LESS THAN THREE MONTHS NOW AND NOT HAVE TOO MUCH RISK OF BEING ONG, AND FRANKLY, A LOT OF PEOPLE, A LOT OF THE PATIENTS DROP OUT IN THE LAST FEW MONTHS OF TREATMENT ANYWAY. THE INCREMENTAL BENEFIT OF NEW DRUGS FOR ACTIVE TB IS SIGNIFICANT, WE SHOULD KEEP WORKING ON IT, BUTQ% GAME CHANGERS WOULD BE A VACCINE OR A WAY OF IDENTIFYING THOSE AT HIGH RISK WHO ARE INFECTED AND THEN TREATING THEMw3 EFFECTIVELY. WE CAN MAKE RAPID PROGRESS BY IMPLEMENTING EXISTING STRATEGIMS AND COMING UP WITH NEW ONES. THE GLOBAL TB STRATEGY IS JUST THAT, TO PURSUE HIGH-QUALITY DOTS EXPANSION. THAT BASIC DOTS IN THE FIRST PART OF THIS SLIDE TO ADDRESS HIV, MDR AND OTHER CHALLENGES, TO CONTRIBUTE IN STRENGTHENING HEALTH SYSTEMS AND ENGAGE ALL PROVIDERS TO EMPOWER PEOPLE WITH TB AND COMMUNITIES AND TO ENABLE AND PROMOTE REARCH. JUST TO MENTION PUBLIC/PRIVATE MIX. I WAS IN TANZANIA LAST YEAR AND I SAW THE PLACE WHERE STEVE LOWE ACTUALLY DESIGNED THE DOTS STRATEGY AND I -- DESPITE HAVING WORKED ON TB FOR 15 YEARS -- I DIDN'T REALIZE THAT STEVE LOWE GOT IT RIGHT FROM DAY ONE. HE SAID, TB REGISTER HAS TO BE EVERY PATIENT WITH TB IN A DISTRICT WHOEVER DIAGNOSES THEM; PUBLIC SECTOR OR PRIVATE SECTOR, AND THE PUBLIC SECTOR IS ACCOUNTABLE FOR THEIR OUTCOMES NO MATTER WHAT HAPPENS. WHEN HURER MAN BIGS WHO WAS LEADER OF THE NEW YORK CITY AND STATE HEALTH DEPARTMENTS A HUNDRED PLUS YEARS A AGO PROPOSED THAT T THE B BE MADE REPORTABLE IN NEW YORK CITY T MEDICAL SOCIETY OF NEW YORK REFERRED TO THAT AS MISTAKEN INTRUSIVE, MISGUIDED AND PROEP PROPOSED THE ELIMINATION OF THE CITY HEALTH GARMENT. FUNDAMENTALLY, THE CONCEPT IS THAT THE GOVERNMENT IS ACCOUNTABLE AND RESPONSIBLE FOR THE CONTROL OF COMMUNICABLE DISEASES AND THIS IS A VERY IMPORTANT CONCEPT. IN TAKING OVER CDC, I IDENTIFIED SIX KEY AREAS WHICH I CONSIDER WINNABLE BATTLES IN THE U.S. TOBACCO, WHICHf‡ REMAINED THE LEADING PREVENTABLE CAUSE OF, NUTRITION, FOOD SAFETY. HEALTH CARE-ASSOCIATED INFECTIONS, TEEN PREGNANCY, AND HIV INFECTION. THESE ARE ALL AREAS WE CAN DO A LOT WITH TOOLS WE TOAD. HEALTH CARE ASSOCIATED INFECTION, JUST TO TALK ABOUT ONE OF THESE. AT LEAST A THIRD ARE PREVENTABLE WITH SIMPLE EXISTING TOOL NAPS COST ABOUT $30 BILLION A YEAR AND AFFECT ONE OUT OF 20 HOSPITALIZED PATIENTS. DIALYSIS CENTERS ARE FILTHY. WE HAVE AS MANY MRSAs AS WE DO IN INTENSIVE CARE UNITS BECAUSE WE'VE MADE A LOT OF PROGRESS, BUT WE HAVEN'T LOOKED AT THE DIALYSIS CENTERS. AMBULATORY SURGICAL CENTERS ARE A BIG EXPANSION. WE'VE SEEN HEPATITIS B, C, VARIETY OF OTHER ALIGN INFECTIONS IN THE SURGICAL AMBULATORY SURGERY CENTERS. THERE'S A LOT MORE WE NEED TOŤ— DO. STATES ARE REQUIRING REPORTING OF HEALTH CARE ASSOCIATED INFECTIONS. CDC HAS THE NATIONAL HEALTH CARE SURVEILLANCE NETWORK. WE NOW HAVE FIVE THOUSAND HOSPITALS REPORTING INE THE INFORMATION TO HELP IMPROVE THEIR PRACTICES. THAT IS OUR FUNDAMENTAL CONCEPT, WHICH IS GIVE PEOPLE INFORMATION TO IMPROVE THEIR OWN PERFORMANCE. THIS IS WHAT'S HAPPENED IN RECENT YEARS. SIGNIFICANT REDUCTION IN ICU BLOOD STREAM INFECTIONS. WE'VE HAD SOME PROGRESS IN OTHER AREAS AS WELL.Ť—v: RECENTLY, WE CONCLUDED UNDER DR. KABAZA'S LEADERSHIP, A FRAMEWORK FOR PREVENTING INFECTION DISEASES, A ROAD MAP REALLY TO IMPROVE OUR ABILITY TO PREVENT THROUGH STRONGER ADAPTABLE MULTI-PURPOSE HEALTH SYSTEMS IN THISmy COUNTRY. IT'S A GUIDE TO COLLECTIVE PUBLIC HEALTH ACTION DESPITE THE RESOURCE CONSTRAINTS THAT WE FACE TO ADVANCE OPPORTUNITIES THUGNEW IDEAS, PARTNERSHIPS, INNOVATIONS, VALIDATED TOOLS AND EVIDENCE-BASED POLICIES WITH THREE OVERARCHING GOALS: TO STRENGTHENING PUBLIC HEALTH,i] LABORATORY -- STATE AND LOCAL HEALTH DEPARTMENTS IN THIS COUNTRY ARE IN CRISIS. BECAUSE OF BUDGET CUTS OVER TH PAST THREE YEARS THE NUMBER OF STAFF WORKING AT ST STATE AND LOCAL LEVEL IN PUBLIC HEALTH HAS DECREASED BY 50,000 PEOPLE, AND NOTHING THAT CDC DOES IS GOING TO BE AS BROAD OR AS DEEP AS THE HOLE THAT THAT HASŤ CREATED. WE NEED TO FIGURE OUT SMARTER, QUICKER, FASTER, CHEAPER WAYS TO DO TRADITIONAL THINGS AS WELL AS TO SUPPORT STATE AND LOCAL GOVERNMENTS WHENEVER WE CAN. MOST CDC RESOURCES GO TO STATE ANDi] LOCAL GOVERNMENTS. SECOND TO IDENTIFY AND IMPLEMENT HIGH-IMPACT PUBLIC HEALTH INTERVENTIONS, TO REDUCE INFECTION DISEASES, IMMUNIZATIONS I'LL TALK ABOUT LATER, AND THOIRD DEVELOP ADVANCED POLICIES TO PREVENT, DETECT AND CONTROL. POLICY MEASURES CAN BE ESSENTIAL. ISSUES OF CONCERN ARE FAMILIAR TO YOU HERE; ANTIMICROBE RAL RESISTANCE, FOOD SAFETY, HIV, RESPIRATORY INFECTIONS, SAFE WATER, VACCINE PREVENTABLE DISEASES. I WANT TO TALK ABOUT GLOBAL HEALTH FOR A BIT BECAUSE SUPPORTING GLOBAL HEALTH HELPS AMERICANS BY AFFECTING REEMERGING THREATS AND ESTABLISHING THE PEOPLE NEEDED TO SUSTAINABILITY. WE PROTECT AMERICANS BY PROMOTING STABILITY IN KEY COUNTRIES. WE HAD ANSWER ECONOMIC INTERESTS BY PROMOTES PRODUCTIVITY SO PEOPLE CAN BUY OUR GOODS IN MARKETS. WE APPROPRIATE AMERICAN INTEREST THROUGH SOFT OR SMART POWER. IT'S A LOT CHEAP TORE GIVE [INDISCERNIBLE]. A LOT OF WHAT WE DO AROUND THE WORLDŤ CREATES A TREMENDOUS GLOW OF GOOD WILL TOWARD AMERICANS THAT YOU CAN'T BUY WITH MONEY, BUT WE'RE BUYING IT BECAUSE WE'RE PUTTING OUR SCIENCE AND s NO-HOW TO STRENGTHEN SYSTEMS AND PROTECT PEOPLE'S LIVES AROUND THE WORLD AND PROTECT KNOWLEDGE. MOST IMPORTANTLY BECAUSE IT'S THE RIGHT THING TO DO AND IT'S WHAT TA A GREAT COUNTRY LIKE THE UNITED STATES OF AMERICA DOES. OUR APPROACH AT CDC IN GLOBAL HEALTH IS REALLY ANALOGOUS TO WHAT WE DO IN DOMESTIC HEALTH. THE FUNCTIONS I'VE LISTEDŤ HERE ARE FIRST, A GUIDANCE FUNCTION, WHERE WE PROVIDE TECHNICAL ASSISTANCE, DIRECT FUNDING. WE OFTEN IMBED PEOPLE IN STATE ANDw3 LOCAL HEALTH DEPARTMENTS. CONCERN I WAS IMBEDDED IN THE WORLD HEALTH ORGANIZATION IN INDIA TO HELP A MULTINATIONAL ORGANIZATION DO THAT. SO WORKING GUIDANCE TECHNICAL SUPPORT, APPLIED EPIDEMIOLOGY AND@ LABw3 CAPACITY DEVELOPMENT THROUGH FIELD EPIDEMIOLOGY TRAINING PROGRAMS AROUND THE WORLD, IMBEDDED STAFF, LABORATORY NETWORKS, LABORATORYŤ QUALITY. WE TAKE FOR GRANTED THAT ANY DOCTOR CAN SEND A TEST TO ANY LAB IN THIS COUNTRY AND PRETTY MUCH TRUST THAT THE ANSWER'S RIGHT. MOST OF THE WORLD DOES NOT HAVE THAT SAME CONFIDENCE AND THEREFORE, IN PART, IN MOST OF THE WORLD LABORATORY DIAGNOSIS IS THE RARE EXCEPTION RATHER THAN THE RULE AND WE'RE WORKING TO CHANGE THAT.Ť— AND HEALTH SECURITY BECAUSE WE ARE ALL CONNECT BID THE AIR WE BREATH AND WE HAVE REAL CHALLENGES IN ENSURING THAT WHETHER NATURAL OR MAN-MADE WE HAVE THE ABILITY TO DETECT AND RAPIDLY RESPOND TO HEALTH PROBLEMS. INFECTIONS DISEASES CAUSE ABOUT ONE OUT OF EVERY FOUR DEATHS WORLDWIDE. COULD BE HIGH FER YOU COUNT SOME OF THE MALNUTRITION DEATHS WHICH ARE DRIVEN BY THE NUTRITIONAL INSULT AND EVEN HIGHER STILL IF THAT NUTRITIONAL INSULT AND CHILDHOOD MALNUTRITION DOES RESULT IN THE HIE KIND OF HIGHER SUSCEPTIBLE TO CHRONIC DISEASE LATER IN LIFE THAT WE BELIEVE NOW IS THE CASE. Ť PRIORITIES IN GLOBAL HEALTH KEYV TODAY INCLUDE IMMUNIZATION, ESPECIALLY POLIO, REDUCING MOTHER-TO-CHILD HIV, DETRANSMISSION IN CONGENITAL SYPHILIS, [INDISCERNIBLE] PROMOTING KOE TOBACCO CONTROL AND PREVENTING MOTOR VEHICLE INJURIES WHICH ARE THE LEADING CAUSE OF DEATH AMONG AMERICANS TRAVELING OVERSEAS. INFECTION DISEASES, 1.8 MILLION DEATHS AYEAR FROM AIDSES, 1.3 FROM TB, NEARLY 800,000 FROM MALARIA, HALF A MALL FROM THE TROPICAL DISEASES. ECONOMIC IMPACT OF EPIDEMICS IS ENORMOUS. WHAT YOU SEE HERE BY YEAR ARE THE DIFFERENT BOVINE [INDISCERNIBLE] AVIAN FLU, FOOT AND MOUTH DISEASE, SARS AND THE ECONOMIC IMPACT IS IN THE TENS OF BILLIONS OF DOLLARS. SO IT'S PAY ME NOW OR PAY ME LATER IN TERMS OF COMMUNICABLE DISEASE PREVENTION AND CONTROL. I WANT TO TALK ABOUT WHAT WE'RE DOING AT CDC–r TO STRENGTHEN CAPACITY AROUND THE WORLD. SURVEILLANCE SYSTEMS ARE AN OPTIMAL TOOL FOR MONITORING AND EVALUATION. YOU CAN DO SURVEYS, BUT EVEN BETTER IS TO HAVE A DAY IN AND DAY OUT EVALUATION WHICH GIVES YOU AN ASSESSMENT OF HOW THINGS ARE GOING. TUBERCULOSIS REGISTER WHERE I MENTIONED 40 MILLION -- THIS IS ONE ENTRY, 40 MILLION ENTRIES LIKE THIS HAVE BEEN MADE IN A 150 PLUS COUNTRIES IN THE STANDARDIZED WAY THAT CAN BE CHECKED AND VALIDATED. THIS IS IMPORTANT FOR FOOD SAFETY TO IDENTIFY AND STOP OUTBREAKS, TO TRACK TRENDS, TO TRACK THE EFFECTIVENESS OF POLICIES. THE WISTERIA OUTBREAK IN CANTALOUPE WAS DETECTED RAPIDLY BECAUSE THE STATE OF COLORADO DID A GREAT JOB. THEY NOTICED NOT FROM LABORATORY TESTING BUT FROM OLD FASHIONED EPIDEMIOLOGY THAT NUMBER OF CASES WERE HIGHER THAN EXPECTED. THEY NOTICED THAT THE FRIDAY BEFORE LABORDAY WEEK END. THEY WORKED THROUGH THE WEEKEND CALLING PATIENTS, DOING A CASE CONTROL STUDY. WITHIN DAYS THEY HAD IT OFF THE SHELVES. IF IT HADN'T BEEN FOR THAT RAPID RESPONSE, THERE WOULD HAVE BEEN MANY MORE DEATHS. WE HAVE GLOBAL SURVEILLANCE NETWORKS THAT DO THE SAME THING ON FOOD BORN DISEASE. 126 LABS IN 67 COUNTRIES TRAINED. WE HAVE EFFORTS TO STRENGTHEN GLOBAL LAB CAPACITY TO ESTABLISH GOOD QUALITY SERVICES. FIELD EPIDEMIOLOGY TRAINING PROGRAM WHICH IS THE EQUIVALENT OF THE EP MIK INTELLIGENCE SERVICE. IN THIS COUNTRY WE'VE HELPED MORE THAN 40 OF THEM START. 80% STAY IN THE COUNTRIES WHERE THEY'RE TRAINED. WE'RE CURRENTLY SUPPORTING ABOUT 24 OF THEM. JUST LAST YEAR WE HAD MORE THAN 300 TRAINEES WHO DID MANY OUTBREAK INVESTIGATIONS BUT WE REACHED LESS THAN 1% OF THE NEED THAT WE NEED TO, TO DEVELOP THE GENERATION OF THEŤ FUTURE AND THIS IS JUST A GREAT EXAMPLE. THESE ARE FOUR RECENT EIS OR FETP PROGRAMS AND WA SOME OF THEIR GRADUATES ARE DOING. THEY'RE RUNNING MALARIA OR VACCINE PROGRAMS OR LABORATORY QUALITY OR PREVENTIVE HEALTH OR THE NATIONAL LAB OR THE EPI PROGRAM. SO THESE ARE PEOPLE WHO COME LEADERS IN THEIR COUNTRIES. WE ALSO HAVE SEVEN GLOBAL DISEASE DETECTION CENTER WHICH IS MONITOR, DETECT AND CONTAIN EMERGING HEALTH THREATS AN WE DEPLOY PEOPLE 24/7 AT THE COUNTRY'S REQUEST. AN AMBASSADOR DPROR AFRICA SAID CDC IS THE 911 TO THE WORLD. WE RESPOND TO EMERGENCIES AND OVER THE PAST FIVE YEARS WE'VE PROVIDED THROUGH THESE CENTERS RAPID RESPONSE TO 600 PLUS OUTBREAKS IN 39 COUNTRIES. WE DO POPULATION BASED SURVEYS TO HELP TARGET WHERE THE RESEARCH NEEDS TO BE AND WHERE THE PROGRAM NEEDS TO BE. ONE AREA LIKE THIS IS A DEMOGRAPHIC SURVEILLANCE SYSTEM. WE HAVE SEVERAL DIFFERENTŤ AREAS. THE ONE IN KENYA COVERED TWO HUNDRED THOUSAND PEOPLE, IN PATIENT AND OUTPATIENT. THEIR STUDIES HAVE BEEN IMPORTANT FOR VACCINE, TRIALS, DISEASET DELIVERY, A LOT OF COMMUNITY INVOLVEMENT AND IMPORTANT IN TRANSLATING DATA TO POLICY AND PROGRAM. WE'VE EXPANDED TO URBAN SLUMS AND RURALg# KENYA WITH ABOUT 25,000 PEOPLE PER SITE WITH WEEKLY HOME VISITS SO WE CAN FIND THE DISEASES AND FIND THE RESPONSE TO TREATMENT. THIS IS A ROE TA VIRUS SURVEILLANCE NETWORK AROUND THE WORLD. GLOBAL POLIO LABORATORY NETWORK IN NEARLY A HUNDRED COUNTRIES. NEEDLES AND ROEf‡ BELLA LABS IN DOZENS OF PLACES AROUND THE WORLD. GLOBAL VACCINE PREVENTIBLE DISEASE LABS IN MORE THAN 700 LABS. WANT TO TALK FORŤ— A MINUTE ABOUT MALARIA AND ABOUT HIV. I KNOW THAT TONY'S HERE SO I DON'T HAVE TO TELL YOU MUCH ABOUT HIV. TONY HAS BEEN A FANTASTIC LEADER FROM–xTHE START OF THE EP DEEM MIK. WE KNOW WHAT A TERRIBLE, TERRIBLE TRAGEDY HIV CONTINUES TO BE. MORE AMERICANS HAVE BEEN KILLED BY AIDS THAN HAVE DIED IN EVERY WAR SINCE THE CIVIL WAR. 25 MILLION PEOPLE HAVE DIED AROUND THE WORLD AND WE NOW HAVE STILL MORE THAN 30 MILLION PEOPLE INFECTS. HOWEVER, NUMBER OF DEATHS PER YEAR HAS FALLEN BY A THIRD. NUMBER OF NEW INFECTIONS HAS FALLEN BY HALF. WE'RE MAKING PROGRESS. WE DON'T HAVE A CURE, WE'RE RELYING ON YOU FOR THAT. WE DON'T HAVE A VACCINE, WE'REg# RELYING ON YOU AND YOER OTHERS FOR THAT, BUT WE HAVE THINGS THAT WORK WELL. ART FOR THE PARTNER, CIRCUMCISION. WHAT CAN BE SCALED UP OF THIS? CIRCUMCISION. 60 PLUS PERCENT REDUCTIONś PREVENTING FOUR MILLION INFECTIONS WITH A SUBSTANTIAL NET SAVINGS. REACHING 80% COVERAGE IN FIVE YEARS, FOUR MILLION INFECTIONS PREVENTED BUT WE'RE NOT MAKING THE PROGRESS WE NEED TO MAKE. KENYA AND TANZANIA ARE DOING A GREAT JOB. NO OTHER COUNTRY IS VERY FAR ALONG. MOTHER-TO-CHILD TRANSMISSION. WE'VE PREVENTED 114,000 BABIES FROM BECOMING INFECTED LAST YEAR. WE HAVE A LOT FURTHER TO GO. MALARIA. STILL TWO HUNDRED MILLION CASES A YEAR. 80% IN AFRICA, ESPECIALLY YOUNG CHILDREN, LOTS OF DEATHS, LOTS–x OF HEALTH CARE COSTS AND DIRECT AND INDIRECT COSTS, BUT ALSO REAL PROGRESS. AN INCREASED ACCESS TO–r INSECTICIDE-TREATED BED NETS. A THIRD OF THE CHILDREN SLEPT ON THEM. I'LL SHOW YOU WHAT THAT A THIRD FULL CAN DO ON A COMMUNITY BASIS. MOREŤ RESIDUAL SPRING, BETTER -- I WAS IN A REMOTE COMMUNITY IN ET YOEP YEAH WITH THE HEALTH AUKS SIL YEAR AND SHE WAS DOING TESTS ON EVERYONE WITH FEVER. THEY HAD A HUNDRED CASES A YEAR. IN THE PAST FIVE YEARS WITH BED NETS AND STANDING WATER CONTROLS, NOT A SINGLE CASE OF MALARIA AND SHE HAD TESTED WELL EVERYONE THERE. INCREASED TREATMENT, BETTER QUALITY TREATMENT. THIS IS FROM THAT DEMOGRAPHIC SURVEILLANCE SYSTEM SHOWING THAT THERE HAD BEEN A SUBSTANTIAL REDUCTION IN THE BURDEN OF [INDISCERNIBLE] RELATED TO A VERY SUBSTANTIAL REDUCTION IN OVERALL DEATH RATES. WE'RE TALKING ABOUT A 30% REDUCTION IN THE NUMBER OF KIDS WHO DIE OVER A FIVE-YEAR PERIOD OVER THE AGE OF FIVE FROM THIS SINGLE INTERVENTION AND FREEING UP OF BLOOD SUPPLIES WHICH IS VERY IMPORTANT AS WELL. VACCINES. VACCINES ARE ONE OF THE TRULY GREAT SUCCESS STORIES OF PUBLIC HEALTH. BASICŤ IMMUNIZATIONS PREVENTED 2.5 MILLION DEATHS GLOBALLY LAST YEAR, AND WE'RE PROUD TO BE A LEAD PARTNER IN POLIO, MEASLES AND MENINGITISXd PROGRAMS. KEY IS THE STRENGTH IN ROUTINE COVERAGE, HELP COUNTRIES INTRODUCE NEW VACCINES AND BUILD ON SURVEILLANCE NETWORKS. FOR EVERY BIRTHŤ COHORT IN THIS COUNTRY, EVERY YEAR IT DOES COST US ABOUT $7 BILLION TO DO THAT VACCINATION, BUT IT PREVENT 20 MILLION CASES OF DISEASE, SAVES 40,000 LIVES AND NET SAVES $14 BILLION IN HEALTH CARE COSTS, $70 BILLION IN SIGH TALL COST. FOR EVERYŤ DOLLAR INVESTED WE HAVE RETURN ON INVESTS OF $3 IN MEDICAL COSTS AND $10 IN MEDICAL SAVINGS. WE HAVE BOTH PROGRESS AND CHALLENGES. POLIO, 99% REDUCTION BUT STILL WAY TOO MUCH POLIO. MEASLES, 12.7 MILLION PEOPLE DIDN'T DIE FROM MEASLES IN THE PAST DECADE BECAUSE OF CAMPAIGNS BUT WE'VE HAD A RESURGENCE IN THE PAST TWO YEARS IN AMP CAN COUNTRIES. HEPATITIS B, DECREASED BY MORE THAN 90%u!q DEATHS A YEAR. POLIO DISTRIBUTION 1998-2001, A LOT OF PROGRESS. BUT 2006, ONLY FOUR COUNTRIES STILL HAD POLIO AND THEN ON GOING SPREAD. SO, THE INDIA HAS NOT HAD A CASE SINCE JANUARY 13TH, BUT PAKISTAN AND NIGERIA ARE STILL RIPE WITH POLIO AND UNLESS WE'RE ABLE TO CONTROL THAT, WE WILL NOT BE ABLE TO ERADICATE POLIO AND WE'LL BE STUCK HAVING TO DO THE SAME THING ON AND ON AND ON. IN THE LAST SIX MONTHS WE'VE CONTINUED TO SEE REIMPORTATIONS ELLIS WHERE. OUT OF CONTROL IN CHAD AND DEPORTATION AS WELL. LOTS OF ROOM TO GO STILL. MEASLES, STILL A LEADING CAUSE OF CHILDHOOD DEATH AND DOESN'T NEED TO BE. WE HAVE A GREAT VACCINE FOR IT. MENINGITIS, REAL EXCITING SUCCESS STORY. OVER FOUR HUNDRED PEOPLE PEOPLE ARE AT RISK FOR MENINGITIS IN AFRICA. THE VACCINE WAS LAUNCHED THROUGH MASS VACCINATION. IN TEN DAYS 11 MILLION PEOPLE VACCINATED. ONLY FOUR CONFIRMED CASES AMONG RESIDENTS. 20 MILLION PEOPLE VACCINATEDED TO DATE. WE'RE GOING TO GO TO OTHER COUNTRIES BY THE END OF THIS YEAR AND THINK WE CAN SAVE MORE THAN A HUNDRED THOUSAND LIVES IN A DECADE. IN THIS MENINGITIS BELT, PEOPLE ARE VERY AWARE OF IT. DOESN'T TAKE MUCH TO ENCOURAGE PEOPLE TO TAKE THE VACCINE. PNEUMOCOCC PNEUMOCOCCALzV–r VACCINE, ROE TOE VIRUS INTRODUCTION IN MEXICO. TREMENDOUS PROGRESS AT REDUCING THE NUMBER OF CASES AMONG KIDS. IN ENDING, I WOULD REMIND US GOING TO TAKE US SO FAR. FOR THE FIRST TIME IN HUMAN HISTORY, MORE PEOPLE LIVE IN URBAN THAN IN RURM RURAL AREAS. THERE ARE MORE PEOPLE OVERWEIGHT THAN UNDERWAIT. THERE ARE MORE DEATHS AMONG ADULTS THAN CHARN. THERE ARE HIGHER RATES OF NON-COMMUNICABLE DISEASES IN DEVELOPING COUNTRIES THAN DEVELOPED COUNTRIES. LOOK AT WHAT'S HAPPENING TO TOBACCO, HIV, TB AND MALARIA. ALREADY MORE PEOPLEv: ARE KILL BID TOBACCO THAN BY HIV, TB AND MALARIA COMBINED. OVER THE NEXT TWO DECADES, WE WILL CONTINUE TO REDUCE NUMBER OF PEOPLE WHO DIED FROMyM HIV, TB AND MALARIA, BUT TOBACCO DEATHS WITH INCREASE TO 10 MILLION AND IF WE DON'T TAKE URGENT ACTION AGAINST TOBACCO NOW, IN THISLP CENTURY, 1 BILLION PEOPLE WILL BE KILLED BY TOBACCO. TOBACCO IS NOW THE WORLD'S SINGLE LEADING AGENT OF DEATH. MORE PEOPLE THAN myAIDS, TB AND MALARIA COMBINED, AND I WAS -- I GOT INTO TROUBLE BY SAYING THAT, UM, THAT THE -- WELL MAR GREAT GRET CHAN SAID THAT TOBACCO EP DEM SMIK SPREAD BY A VECTOR, AND THAT VECTOR IS THE TOBACCO INDUSTRY. I WILL TELL YOU THAT HAVING FOUGHT TESH IN MANY COUNTRIES FOR MANY YEARS, TUBERCULOSIS, IT'S A TOUGH INDUSTRY BECAUSE IT AFFECTS MOSTLY THE BOOR, BUT THERE'S SOME THINGS THAT TUBERCULOSIS DOES NOT DO. IT DOES NOT BRIBE POLITICIANS. IT DOES NOT REBRAND ITSELF AS LIGHT TUBERCULOSIS, AND IT DOES NOT PAY CELEBRITIES TO CONVINCE PEOPLE THAT IT'S COOL AND SEXY TO GETŤ— TUBERCULOSIS. TOBACCO CONTROL IS A BIG CHALLENGE. WE HAVE A LOT OF COLLABORATIO„ BETWEEN CDC AND NIH, AND TUBERCULOSIS AND VIRAL DISEASES, BUT I DO HOPEU THAT WE CAN WORK TOGETHER TO IDENTITY FIVE EVEN MORE WAYS THAT WE CAN WORK TOGETHER TO HELP PEOPLE LIVE HEALTH YEAR, SAFER, AND MORE PRODUCTIVE LIVES BOTH IN THIS COUNTRY AND AROUND THE WORLD. THANK YOU ALL VERY MUCH. [APPLAUSE] >> THANK YOU VERY MUCH SH TOM, FOR THAT TERRIFIC LECTURE. QUESTIONS OR COMMENTS? DON'T BE SHY. I'LL START OFF. >> SO, UM, THE TB -- WE ALWAYS TALK ABOUT CONTROL ELIMINATION, ERADICATION. IF YOU TAKE TB AND THE REASON THE–r INCIDENCE IS NOT GOING DOWN, YOU SAID BAD DOTS, REEMERGENCE AND SOCIAL ISSUES. DO YOU THINK WITH THE RESOURCES THAT WE HAVE ARE PUT INTO DISEASES LIKE HIV, IF WE DID THE SAME THING WITH TB, WE COULD ACTUALLY ELIMINATE OR PERHAPS ERADICATE TB OR IS THE NATURE OF TB, DO YOU THINK THAT'S FEASIBLE GOAL? >> SO I THINK YOU HAVE TO IDENTIFY WHAT YOUR TARGET IS. IF YOUR TARGET IS TUBERCULOSIS DEATHS, YOU CAN BRING THEM DOWN VERY SUBSTANTIALLY. IF YOUR TARGET IS TUBERCULOSIS PREVALENCE, YOU CAN BRING IT DOWN 80% IN TEN YEARS OR MORE. IF YOUR TARGET THOUGH IS TB INCIDENCE, THEN I THINK WE REALLY NEED BETTER TOOLS, NOW, ESPECIALLY WHERE THERE'S TB AND HIV. WHERE THERE'S0–#TB AND NOT A LOT OF HIV, WE JUST NEED PATIENCE BECAUSE A WHOLE GENERATION IS INFECTED WITH THE BACTERIA AND THEY'RE GOING TO BREAK DOWN WITH ACTIVE DISEASE, SO WE NEED PERSISTENCE IN THE AREAS WITHOUT HIV AND WE NEED NEW TOOLS IN THE AREAS WITH HIV, BUT WITH CURRENT TOOLS, I DON'T THINK WE CANŤ DRASTICALLY REDUCE INCIDENCE, BUT WE CAN REDUCE DEATHS AND SPREAD, NEW INFECTIONS AND PREVALENCE QUITE DRAMATICALLY. >> BY TOOLS YOU NEED DIAGNOSTICS, HERE TO PEW TICKS AND VACCINES? >> YES. NOT JUST THE TECHNICAL TOOLS BUT HOW TO USE THEM. WE MAY NEED TO DEFINE -- MAYBE WE GO TO EVERY HIV POSITIVE PERSON AND TREAT THEM AGGRESSIVELY. >> PETER GREEN WALD AT NCI, I STARTED AS AN EIS OFFICE AND WORKED IN NEW YORK STATE [INDISCERNIBLE]. I WANT TO ASK YOU SOMETHING ABOUT TRAINING. MY IMPRESSION AND YOU CAN CORRECT ME IF I'M WRONG, IS THAT THE UNIVERSITY PUBLIC HEALTH DEPARTMENTS WHO DO A LOTŤ OF TRAINING HAVE TURNED AWAY FROM TRAINING PEOPLE TO WORK IN STATE AND LOCAL HEALTH AGENCIES. THEY EITHER TURN TOWARD LIKE GETTING NIHÖ GRANTS OR MAYBE GLOBAL. THE EIS PROGRAM IS WONDERFUL BUT IT DOESN'T MAKE UP FOR THAT, AND I JUST WONDERED WHAT YOUR VIEW IS OF HOW WE PREPARE PEOPLE TO DEAL WITH THIS KIND OF PROBLEM IN THE FUTURE. >> THANK YOU. UM, I THINK WE'VE TRIED TO ENGAGE WITH PUBLIC HEALTH SCHOOLS TO TRY TO IMPROVE THE PRACTICAL NATURE OF THE TRAINING THAT THEY DO. I GOT MY MPH AS COLUMBIA, AND I GAVE AN EPIDEMIOLOGYu! SEMINAR TO AN AUDIENCE ABOUT THIS SIZE OF THE ENTIRE EPIDEMIOLOGY DEPARTMENT WHEN I WAS AN EIS OFFICER. I TOOK THEM THROUGH AN '6zOUTBREAK INVESTIGATION, AND I DESCRIBED HOW IT STARTED WITH A TYPHOID OUTBREAK IN BROOK LYNN AND I ASKED THEM, WHAT'S THE FIRST THING YOU DO AND NOT A SINGLE PERSON SAID A CASE DEFINITION. I ASKED THEM AFTER TELLING THEM, WHAT'S THE NEXT THING YOU DO? IT WAS JUST STRIKING, BUT ONE OF THE THINGS WE'RE DOING THAT I'M EXCITEDED ABOUT IS CREATING SOMETHINGŤ CALLED THE PUBLIC HEALTH ASSOCIATES PROGRAM WHERE WE'RE HIRING PEOPLE WHO CAN HAVE A BACHELORS OR MASTERS AND STARTING THEM AT THE GROUND LEVEL WITH STATE AND LOCAL GARMENT AND TWO-YEAR PROGRAM WHERE THEY'RE TRAINED AND LEARN WHAT IT IS TO DO INVESTIGATION OUTBREAK CONTROL BECAUSE THE SECRET SAUCE OF CDC ISN'T JUST THE EIS PROGRAM, IT'S THE MARRIAGE OF THE EIS PROGRAM WITH THE PUBLIC HEALTH ADVISORY PROGRAM. SOMEONE WHO KNOWS HOW TO GET STUFF DONE WITH SOMEONE WHO CAN ANALYZE IT. THAT COMBINATION IS CRUCIAL AND WE'RE REBILLING THAT. WE HAVE 115 ASSOCIATES IN THE FIELD NOW FOR THE FIRST TIME. >> [LOW AUDIO]. >> BCG, BECAUSE OF THE WE KNOW DOES NOT REDUCE THE SEVERITY OR INCIDENCE OFISEASE ONG ADULTS, HOWEVER IN CHILDREN IT REDUCES TB MENINGITIS AND OTHER BACTERIA FORMS OF TB AND THEREFORE IN AREAS OF HIG TB PREVALENCE IT'S RECOMMENDED AT BIRTH AND ACTUALLY THE HIGHEST USED VACCINE OF ANY. IT'S CHEAP, EFFECTIVE AND IT WILL ALSO MAKE GETTING A GOOD VACCINE HARDER BECAUSE YOU'VE ALREADY GOT UNTHAT KINDyM OF WORKS SO YOU'RE NOT WORKING AGAINST NOTHING, YOU'RE WORKING AGAINST SOMETHING THAT IS PREVENTING A HORRIBLE DISEASE IN KIDS. >> [LOW AUDIO]. >> UM, ACCESS IS EXTREMELY IMPORTANT BOTH BECAUSE LACK OF ACCESS CONTRIBUTES PO POVERTY AND ALSO BECAUSE ITok MAKES A HUGE RESISTANCE. ONE OF THE GREAT SUCCESS STORIES OF PUBLIC HEALTH IN THIS DOWN INDUSTRY VACCINES FOR CHILDREN PROGRAM. THE VACCINES FOR CHILDREN PROGRAM PROVIDES 50% OF ALL THE CHILDHOOD VACCINES IN THIS COUNTRY, AND IT HAS ELIMINATED, ELIMINATED RACIAL AND ETHNIC DISPARITIES IN VACCINE UPTAKE EVEN IN FLU VACCINE. IT'S ALSO BENEFITTED ALL OF SOCIETY BECAUSE WE ALL BENEFIT WHEN PEOPLE GET VACCINATED. THERE ARE PROBLEMS WHAT WE'RE DOING IN THE VACCINES FOR CHILDREN PROGRAM ISb GUARANTEEING A MARKET, WE'RE DOING ALL OF THE PROFESSIONAL EDUCATION, WE'RE DOING ALL OF THE PUBLIC EDUCATION. WE'RE DOING AUTOOF THE LOGISTICS, ENDEM NE FIEING THE COMPANIES AGAINST SUITS AND PAYING WHATEVER THE COMPANIES CHARGE. THERE'S A PROBLEM THERE. I DON'T KNOW THE SOLUTION. AT A MINIMUM I THINK THE COMPANIES NEED TO BE TRANSPARENT ABOUT WHAT THEIR COSTS AND PROFITS ARE. TEN YEARS A AGO YOU COUNT GET PEOPLE TO MAKE VACCINES, NOW SUDDENLY VACCINES ARE BLOCK BUSTER DRUGS. WE NEED TO THINK HARD ABOUT WHAT THE BEST WAY TO DEAL WITH THAT IS, BUT ACCESSf‡Ť AND ABSENCE OF COPAYMENTS FOR THINGS THAT PROVIDE SOCIETAL BENEFITS ARE IMPORTANT AND THE FACT THAT WE'LL HAVE MILLIONS MORE PEOPLE [JUPTt COVERED BY HEALTH CARE IN THIS COUNTRY IS VERY IMPORTANT. ONE OF THE THINGS WE KNOW VERY STRONGLY FROM TB IS THAT ANY USER CHARGE WHATSOEVER WILL DETER USE, AND SO ENSURING THAT WHAT WE WANT TO ENCOURAGE HAVE HAPPEN AND ONE OF THE THINGS THIS AFFORDABLE CARE ACT DID IS IT ELIMINATED COPAYMENTS THAT ARA B RECOMMENDATIONS OF THEŤ CLINICAL GUIDE. THAT'S VERY IMPORTANT BECAUSE EVEN A 5 OR $10 CO-PAY WILL MAKE A WIDE VARIETY OF PEOPLE LESS LIKELY TO TAKE UP SERVICES. Q >> [LOW AUDIO].X >> WELL, UM, A LOT]I„ OF THINGS ARE WORTH WHAT YOU PAY FOR, BUT, UM, IT'S ALSO TRUE THAT VOLUNTEERS CAN HAVE A CIT CLOOEICALLY IMPORTANT IMPACT. FOR EXAMPLE, WE AND AS PER AT HHS SUPPORT STATE AND LOCAL GOVERNMENTS TO DO MEDICAL RESERVE CORE, WHICH CAN BE CALLED ON RETIRED DOCTORS, DENTISTS OR STUDENTS AND OTHERS CAN BE CALLED ON TO HELP RUN SERVICES IN AN EMERGENCY. THEY WERE USED IN H1N1 TO GET VACCINE PROGRAMS DONE. I THINK ULTIMATELY PHILANTHROPY, VOLUNTEERISM, BUSINESS WHICH HAS SKIN IN THE GAME AND AN INTEREST IN PROMOTING HEALTH CAN ALL BE CRITICALLY IMPORTANT, BUT THEY CAN'T FILL THE HOLE LEFT BY WHAT GOVERNMENT IS OR ISN'T DOING. THEY CAN ENCOURAGE GOVERNMENT TO DO THE RIGHT THING AND THAT MAY BE THE MOST IMPORTANT ROLE THEY PLAY, THEY CAN FILL GAPS, START PROGRAMS AND SEE IF THEY WORK BUT ULTIMATELY IT'S A GOVERNMENT RESPONSIBILITY TO BOTH PROTECT YOU FROM OTHERS AND TO PROMOTE THE GENERAL WELFARE. >> [LOW AUDIO]. ALONG THOSE LINES WHEN YOU TALKED ABOUT THE U-SHAPED CURVE, IT SEEMS LIKE ONE OF THE GREATEST THREATS REALLY TO PUBLIC HEALTH IS THE COMPLACENCY IN THE FACE OF SUCCESS WHICH SEEMS PARTICULARLY ACUTE IN THIS ERA OF VERY STRONG GROIN ANTIGOVERNMENTokd8 SENTIMENT, SO I'M CURIOUS CHA YOUR THOUGHTS ARE ON THAT AND PERHAPS HOW TO MAKE MORE VIZ TBL PUBLIC HEALTH SUCCESS ANDj K Ž—!—h yŤg COMMONd8 GOOD IN A CLIMATE WHICH IS REALLY NOT SO MUCH ABOUT THE COME ON GOOD. >> NOBODY EVER HAD A RALLY ON THE STEPS OF CONGRESS OR CITY HALL ANYWAY ADVOCATING FOR THE COMMON GOOD. ONE OF THE UNFOJ NATE CHARACTERISTIC OF PUBLIC HEALTH IS THAT WE END TO BE GOOD FOR EVERYBODY A BIT AND BAD FOR INDIVIDUAL GROUPS A LOT. SO WHETHER IT'S ANTIVACCINATION OR PEOPLE WHO ARE OPPOSED TO HIV REPORTING, THE VOCAL MINORITY HAS THE RISK OF HIJACKING THE PUBLIC GOOD PIP MET WITH A A VERY POWERFUL SENATOR EARLY ON IN MY TENURE AND I ASKED HIM HOW WE COULD PRESERVE DOLLARS OR INCREASE DOLLARS -- THAT SEEMS LIKE A LONG TIME AGO -- [LAUGHTER] -- WHAT HE SAID TO ME WAS VERY TELLING. r HE SAID DON'T TELL US THE GOODko THINGS THAT ARE GOING TO HAPPEN IF WE GIVE YOU MONEY, TELL US THE BAD THINGS THAT ARE GOING TO HAPPEN TO US IF WE DON'T GIVE YOU MONEY. ONE OF THE CHALLENGES OF PUBLIC HEALTH IS THE CHALLENGE OF THE DOG NOT–r BARKING IN THE NIGHT. WHEN WE'RE SUCCESSFUL, NOTHING HAPPENS. NOBODY EVER BUILT A WING OF A HOSPITAL IN THEIR NAME BECAUSE -- LET ME PUT IT THIS WAY. THERE'S PLENTY OF WINGS OF HOSPITALS THAT ARE BUILT IN THE NAME OF SOMEONE WHO'S STROKE OR HEART ATTACK WAS CARED FOR IN THAT HOSPITAL. THERE IS NO WING ANYWHERE IN THE WORLD TO THE HEALTH DEPARTMENT THAT PREVENTED SOMEONE'S HEART ATTACK OR STROKE. [LAUGHTER] >> [LOW AUDIO]. >> WELL, I THINK THERE'S A LOT OF GREAT ROLES. GATES HAS DONE FANTASTIC WORK. THEY'VE CHANGED THE DEBATE ON VACCINES AND IMMUNIZATIONS IN PARTICULAR, AND THEY'VE PROMOTED OTHER ACTIVES VERY EFFECTIVELY. THE BLOOMBERG INITIATIVE WHICH IS NOT WELL KNOWN BUT ACTUALLY THE THE SECOND LARGEST GLOBAL HEALTH PLAN IN THE COUNTRY HAS CREATED A HALF A BILLION DOLLARS KOE TOW BAA KOE CONTROL PROGRAM THAT'S OPERATING IN DOZENS OF COUNTRIES AND HAVING LOTS OF PROGRESS DESPITE THE ACTIVITY OF TOBACCO INDUSTRY. THERE ARE A LOT OF THINGS THAT, UM, FI LAST LAN THROE PIS CAN DO TO EITHER SUPPORT NEW DEVELOPMENTS OR SUPPORT NEW WAYS TO APPLY EXISTING DEVELOPMENTS, AND ONE OF THE THINGS THAT WE FOUND IS CIVIL SOCIETY HAS A CRITICALLY IMPORTANT ROLE IN ENCOURAGING GOVERNMENT TO DO THE RIGHT THING. GOVERNMENT WILL GENERALLY NOT DO THE RIGHT THING UNLESS THEY'RE PUSHED TO TO DO IT BY CIVIL SOCIETY AND THAT'S INCREDIBLY IMPORTANT. SINCE TONY LIKED MY LINE ABOUT THE WING, I'LL TELL YOU, A LOT OF WHAT WE DO IN PUBLIC HEALTH JUST ISN'T EASY TO GET SUPPORT FOR. SO WHEN I WAS THE COMMISSIONER IN NEW YORK CITY, OUR STD CLINICS WERE FALLING APART AND USED TO SAY, IF SOMEONE GIVES US A MILLION DOLLARS, WE'LL NAME OUR STD CLINIC AFTER THEM. [LAUGHTER] IF THEY GIVE $5 MILON, WE WON'T. AND IF THEY GIVE US $10 BILLION, WE'LL MAIM IT AFTER THE PERSON OF THEIR CHOICE. [LAUGHTER] >> [LOW AUDIO]. >> WELL, I DO THINK WE DO THAT. I THINK WE PUSH THE SCIENTIFIC AGENDA WELL AND HARD, AND WE HAVE IMBEDDED STAFF AT WHO WHO ARE CRITICALLY IMPORTANT IN THAT. I THINK THEd8 SPECIFIC ISSUE YOU RAISED IS ONE OF THE MOST IMPORTANT ISSUES OF THE DAY, AND AS YOU MAY KNOW, UH, BILL, FORMER CDC DIRECTOR PUSHED FOR ICD USE 20 YEARS ÖO, SO I THINK ICD IS A BIG ISSUE FOR GLOBAL HEALTH AND I THINK IT MAY BE AN IMPORTANT PART OF TH END-GAME IN GETTING RID OF POLIO. WE NEED, THOUGH, ABOVE ALL WES, WE NEED TO BE WILLING TO LOOK AT THE DATA. TRY THINGS, RIGOROUSLY EVALUATE THEM AND THEN CHANGE OUR PRACTICES BASED ON WHAT HAPPENS. WHEN I WAS IN INDIA FOR FIVE YEARS, I WAS HELPING THE GOVERNOR OF INDIA TO IMPLEMENT THE PROGRAM AND I HIRED A FEW DOZEN CONSULTANTS WHO WERE PEOPLE WHO WE SENT OUT -- THEY WERE DOCTORS, RIGOROUSLY SELECTED, AND I TRAINED THEM KIND OF LIKE THE EIS PROGRAM WITH VERY INTENSIVE TRAINING AND SUPERVISION. AT THE END OF THEIR TRAINING, I ASKED THEM ALL ONE QUESTION; WHAT'S THE MOST IMPORTANT THING YOU D K DO IN THE DISTRICT OR STATE YOU'RE SENT TO? THEY WOULD SAY GOOD ANSWERS LIKE MAKE SURE THAT DOTDS IS PATIENT-FRIENDLY, MAKE SURE DATA IS ACCURATE, GETi] IT DONE QUICKLY, ALL GREAT ANSWER BUT NOT THE RIGHT ANSWER. THE RIGHT ANSWER WAS, I CAN HELP PEOPLE THERE USE DATA TO IMPROVE PERFORMANCE BECAUSE IF THAT'S IN PLACE, THEN THERE'S A SYSTEM THAT THAT HAS POTENTIAL TO BE SELF-CORRECTING. ANY PROGRAM NO MATTER HOW GOOD IS GOING TO GET OFF BASE, BUT IF YOUxD HAVE A FEEDBACK LOOP, THEN YOU CAN CONTINUOUSLY IMPROVE IT AND MAKE PROGRESS. >> OKAY. IF NO MORE QUESTIONS, THANK YOU VERY MUCH, TONY. THANK YOU VERY MUCH. [APPLAUSE] KINYOUN STATUE WHICH HE'LL BRING BACK WITH HIM OR SEND IT TO YOU, WHATEVER YOU LIKE.