Pandemic: From Cholera to Ebola and Beyond

SONIA SHAH Author

01/25/2017 Added

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Sonia Shah is an investigative science journalist and author of critically acclaimed and prize-winning books on science, human rights, and international politics. Her most recent book, “Pandemic: Tracking Contagions from Cholera to Ebola and Beyond,” was selected as a New York Times Book Review Editor’s Choice. Her critically acclaimed 2010 book, “The Fever: How Malaria Has Ruled Humankind for 500,000 Years,” was based on five years of original reportage in Cameroon, Malawi, and Panama and was called a “tour-de-force” by the New York Times.

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[00:00:09.576]NARRATOR: Today you are part of an important conversation
[00:00:12.445]about our shared future.
[00:00:14.614]The E.N. Thompson Forum on World Issues
[00:00:16.816]explores the diversity of view points on international
[00:00:19.919]and public policy issues to promote understanding
[00:00:23.490]and encourage debate across the University
[00:00:25.692]and the state of Nebraska.
[00:00:28.094]Since its inception in 1988,
[00:00:30.997]hundreds of distinguished speakers have challenged
[00:00:33.633]and inspired us making this forum
[00:00:36.736]one of the preeminent speaker series in higher education.
[00:00:42.342]It all started when E.N. Jack Thompson imagined
[00:00:46.346]a forum on global issues that would increase Nebraskans'
[00:00:49.582]understanding of cultures and events from around the world.
[00:00:53.620]Jack's perspective was influenced by his travels,
[00:00:56.990]his role in helping to found the United Nations
[00:00:59.826]and his work at the
[00:01:01.060]Carnegie Endowment for International Peace.
[00:01:04.931]As president of the Cooper Foundation in Lincoln
[00:01:07.767]Jack pledged substantial funding to the forum
[00:01:10.603]and the University of Nebraska
[00:01:12.806]Lied Center for Performing Arts agreed to cosponsor.
[00:01:17.510]Later Jack and his wife Kaity
[00:01:19.813]created the Thompson Family Fund
[00:01:22.048]to support the forum and all their programs.
[00:01:25.485]Today major support is provided
[00:01:28.321]by the Cooper Foundation, Lied Center for Performing Arts
[00:01:32.592]and University of Nebraska Lincoln.
[00:01:35.695]We hope these talks spark an exciting conversation
[00:01:38.998]among you.
[00:01:42.469]And now on with the show.
[00:01:50.376]HOST: With the University of Nebraska
[00:01:51.678]and it is my pleasure to welcome you this evening
[00:01:53.413]to the E.N Thompson Forum on World Issues.
[00:01:56.015]For more than a quarter century,
[00:01:57.550]the university has partnered with the Cooper Foundation
[00:01:59.919]and Lied Center for Performing Arts
[00:02:01.287]to make this forum possible.
[00:02:03.223]A special thanks this evening to our generous sponsors
[00:02:05.725]including the university's college of Journalism
[00:02:08.127]and Mass Communications and School of Biological Sciences
[00:02:11.364]and the Sigma PhI Epsilon fraternity.
[00:02:15.368](audience applauding)
[00:02:21.574]This season E.N. Thompson forum speakers
[00:02:23.276]have been addressing the theme Crossing Borders.
[00:02:26.012]Tonight our speaker will help us explore
[00:02:28.147]that which knows no borders.
[00:02:29.782]Infectious disease.
[00:02:31.551]Sonia Shah is an investigative science journalist
[00:02:34.554]and author of critically acclaimed and prize winning
[00:02:36.823]books on science, human rights, and international politics.
[00:02:40.860]Her more recent book Pandemic, Tracking
[00:02:43.196]Contagions from Cholera to Ebola and Beyond
[00:02:46.032]was selected as a New York Times Book Review
[00:02:48.234]Editor's Choice.
[00:02:49.869]Her critically acclaimed book in 2010,
[00:02:52.338]The Fever: How Malaria Has Ruined Humankind
[00:02:55.008]for 500,000 Years
[00:02:57.577]was based on five years of original research
[00:03:00.179]and reportage in Cameroon, Malawi, and Panama.
[00:03:03.783]The New York Times called it a Tour de Force.
[00:03:06.619]Her Ted Talk on malaria has been viewed
[00:03:08.321]more than a million times
[00:03:09.956]and Shah has lectured at many US universities.
[00:03:12.492]She served as the 2014 Ottaway Professor of Journalism
[00:03:15.929]at SUNY New Paltz
[00:03:17.230]and she's frequently been supported
[00:03:18.565]by the Pulitzer Center on Crisis Reporting.
[00:03:21.834]She holds a bachelors degree in journalism,
[00:03:23.636]philosophy and neuroscience from Oberlin College.
[00:03:27.240]This evening after her remarks,
[00:03:28.474]you'll have an opportunity to ask Sonia
[00:03:30.310]questions via Twitter.
[00:03:31.878]Please use the hashtag #enthompsonforum.
[00:03:34.847]Also ushers will be in the aisles
[00:03:36.516]to collect your written questions and will bring
[00:03:37.884]them to the stage.
[00:03:39.719]And following her talk this evening,
[00:03:41.254]Sonia will autograph books in the first floor lobby.
[00:03:44.891]The title of tonight's presentation is Pandemic,
[00:03:47.527]from Cholera to Ebola and beyond.
[00:03:50.763]Ladies and gentlemen, please
[00:03:51.798]join me in welcoming Sonia Shah.
[00:03:54.300](audience applauding)
[00:04:05.778]SONIA SHAH: Thank you all for coming.
[00:04:09.415]So over the past 50 years, we've seen over 300
[00:04:15.088]infectious diseases either newly emerge
[00:04:17.690]or reemerge into new places
[00:04:19.225]where they've never been seen before.
[00:04:21.628]We've had Zika in the Americas,
[00:04:23.630]never been seen before.
[00:04:25.999]We've had Ebola in West Africa.
[00:04:28.301]It had never been seen there before.
[00:04:30.670]We've had new kinds of Avian influenza,
[00:04:33.306]new kinds of tick borne illnesses,
[00:04:35.908]new kinds of extremely drug resistant
[00:04:38.711]bacterial pathogens.
[00:04:41.848]So there is this sense that a pandemic
[00:04:44.484]that is a wave of disease, an outbreak of diseases,
[00:04:47.286]starts in one part of the world
[00:04:49.088]and then spreads like a wave across global populations
[00:04:52.258]and continents.
[00:04:54.894]The sense that one of those is coming is growing.
[00:04:58.765]But that's not just the opinion of
[00:05:01.067]the worried well as they call people like me.
[00:05:04.537]It is also the opinion of experts.
[00:05:07.573]In a recent survey of epidemiologists,
[00:05:10.643]the majority said that pandemic
[00:05:13.046]that would sicken a billion people,
[00:05:15.415]kill a 165 million
[00:05:18.284]and cause the global economy three trillion dollars
[00:05:22.088]would occur sometime in the next two generations.
[00:05:27.694]So the question is which microbe is going to cause this
[00:05:31.864]destruction?
[00:05:34.033]And there are a lot of contenders.
[00:05:35.501]We have about 150,000 species of bacteria.
[00:05:39.072]Over a million kinds of viruses that can infect mammals.
[00:05:43.443]So figuring out which one of all of these contenders
[00:05:46.479]will cause the next pandemic is a very
[00:05:50.249]difficult if not impossible task.
[00:05:54.654]But while we can't know which one will cause the next
[00:05:57.590]pandemic, what we can potentially know is how.
[00:06:03.029]Because historically, only very few pathogens
[00:06:04.931]have been able to cause pandemics.
[00:06:07.133]We've had Yersinia pestis which causes plague pandemics.
[00:06:12.004]Influenza which causes seasonal flu pandemics.
[00:06:15.875]Variola viruses which cause the smallpox
[00:06:19.112]pandemics in the past.
[00:06:20.713]HIV which causes the ongoing AIDS pandemic
[00:06:24.450]and then we have the fifth one,
[00:06:26.085]which is the one that interests me the most,
[00:06:28.254]the Vibrio cholera.
[00:06:29.822]This is the pathogen that causes the disease
[00:06:31.824]we know as cholera.
[00:06:34.861]Cholera interests me not only because it's really deadly,
[00:06:37.330]it kills about 50% of the people who get it
[00:06:39.799]will die if they are not rapidly treated.
[00:06:42.401]So it's really deadly.
[00:06:44.604]but it's also one of our most successful pandemic causing
[00:06:47.507]pathogens.
[00:06:49.742]Cholera has caused not just one or two pandemics.
[00:06:53.446]It has caused seven.
[00:06:56.282]And the seventh one is going on right now
[00:06:58.050]just a few hundred miles off the coast of Florida in Haiti.
[00:07:02.955]Now we think of cholera as a poor person's disease
[00:07:06.559]and that is true today.
[00:07:09.662]But that wasn't true when cholera was new.
[00:07:11.597]When cholera was a brand-new disease,
[00:07:14.100]it hit some of the most advanced cities in the world.
[00:07:17.870]Cities like New York, which was repeatedly plagued by
[00:07:21.574]epidemics of cholera over the course of the 19th century.
[00:07:24.944]This image shows an outbreak that occurred in 1832.
[00:07:29.549]But it wasn't just New York,
[00:07:31.017]it was London, it was Paris, it was New Orleans,
[00:07:32.752]it was Hamburg.
[00:07:34.287]All of the great cities of the day fell prey to cholera
[00:07:38.791]and thousands and thousands of people died.
[00:07:42.195]But these epidemics were not just deadly,
[00:07:44.630]they were also really disruptive
[00:07:47.200]and this is a hallmark of new diseases.
[00:07:51.137]You know, new disease comes around
[00:07:53.506]nobody knows where it came from,
[00:07:55.641]nobody knows how it spreads
[00:07:57.910]nobody knows why it is plaguing us right now.
[00:08:01.814]And so in that vacuum of uncertainty,
[00:08:05.117]we start to blame each other.
[00:08:07.553]So in the 1830s, the cholera was blamed on the Irish.
[00:08:13.192]In 1840s, the cholera was the fault of the Muslims.
[00:08:18.130]By the 1890s, it was all the fault of the Eastern Europeans.
[00:08:23.903]And this wasn't just verbal scapegoating.
[00:08:25.738]This was violent too.
[00:08:29.175]In 2009, a stretch of railway track
[00:08:31.944]outside of Philadelphia was excavated by some archeologists.
[00:08:36.381]And what they found was a mass grave.
[00:08:39.552]And what had happened there we now know is back in 1832,
[00:08:43.054]a bunch of Irish immigrants had settled there to build the
[00:08:45.925]railway and there was a cholera outbreak
[00:08:49.562]and so the local community quarantined the valley.
[00:08:54.166]But what we now know is they then secretly went back
[00:08:57.603]and massacred all of the workers
[00:08:59.772]and buried them in a mass grave
[00:09:01.607]where their bullet ridden skulls have recently been found.
[00:09:06.879]But it is not just marginalized communities
[00:09:08.581]that suffered this scapegoating
[00:09:11.050]during the cholera epidemics.
[00:09:12.084]It was also health care workers,
[00:09:14.387]the very people who could actually maybe help,
[00:09:17.556]doctors were routinely stoned in the streets
[00:09:20.226]during cholera outbreaks in the 19th century.
[00:09:24.096]Cholera hospitals were surrounded by angry mobs
[00:09:26.565]and burnt down.
[00:09:29.035]So one of the questions I wanted to ask
[00:09:32.338]is how does a microbe,
[00:09:35.875]which is just this tiny little microscopic thing,
[00:09:38.711]it is invisible to the naked eye.
[00:09:41.147]Has no independent locomotion,
[00:09:42.548]it can't go anywhere on its own.
[00:09:45.051]How does a microbe cause all of this death and
[00:09:47.053]destruction?
[00:09:50.189]And the answer I found for cholera is it
[00:09:52.525]all starts in the environment.
[00:09:56.829]So the bacteria that causes cholera
[00:09:58.064]is actually a marine bacteria.
[00:10:00.766]It lives in the sea naturally,
[00:10:02.568]it lives in estuaries and coastal waters.
[00:10:05.371]And places like the Sundarbans
[00:10:06.605]which is pictured in this slide.
[00:10:09.442]This is where the major rivers of south Asia
[00:10:11.610]drain into the Bay of Bengal.
[00:10:14.947]The water there it's half salty,
[00:10:16.582]it's half fresh, it is quite warm
[00:10:18.818]and cholera bacteria is really rich in that water.
[00:10:22.588]And actually performs a useful
[00:10:23.823]ecological function there too.
[00:10:25.224]It helps to recycle nutrients.
[00:10:29.228]Now, people don't usually live
[00:10:30.463]in places like the Suburbans right?
[00:10:32.765]This is a place that's covered in mangrove swamps,
[00:10:35.568]there's crocodiles, there's tigers.
[00:10:38.004]It is actually flooded by the tides twice a day.
[00:10:41.941]So for a long time, people didn't live in places where
[00:10:44.210]there was a lot of cholera bacteria
[00:10:46.812]but that all changed in the 19th century
[00:10:49.415]when the British Raj decided
[00:10:51.183]they were going to go in and cut down the Sunderbans
[00:10:54.520]and turn them into rice farms.
[00:10:57.156]So over the course of the 19th century,
[00:10:59.358]90% of the Sundarbans was settled.
[00:11:02.495]So quite suddenly, people came into
[00:11:05.564]novel intimate contact with this bacteria rich water.
[00:11:11.404]And as they splashed their faces with the water
[00:11:13.839]and the water spilled over into their wells
[00:11:15.808]and into their drinking water,
[00:11:18.244]the bacteria started to adapt to the human body.
[00:11:22.915]And while in its natural marine environment
[00:11:24.683]it performs a useful ecological function,
[00:11:27.086]it did something very different inside the human body.
[00:11:31.290]So if you ingest a little bit of cholera bacteria
[00:11:33.259]say with a glass of water or something,
[00:11:35.461]that bacteria will line the interior of your gut
[00:11:40.032]and what it actually does is reverse the
[00:11:43.202]normal functioning of that organ.
[00:11:46.305]So that instead of replenishing the body with fluids,
[00:11:51.043]the cholera infected gut actually extracts fluids
[00:11:54.647]from the body and expels them in a massive torrent of
[00:11:59.051]watery diarrhea and vomiting.
[00:12:02.455]And that's what actually kills you.
[00:12:03.389]You actually dehydrate to death.
[00:12:06.692]You can lose up to 15 liters of fluid in a day
[00:12:10.830]when you're infected with cholera
[00:12:11.897]and that's how you die.
[00:12:13.065]You die of dehydration.
[00:12:16.068]Now this is a horrible thing for people
[00:12:19.004]but it is a great thing for the cholera bacteria
[00:12:21.574]because in every drop of that waste
[00:12:25.144]is teeming with cholera
[00:12:27.213]and if someone gets some on their hands and touches someone
[00:12:29.815]else or a little bit of that bacteria, that waste
[00:12:32.451]gets into your food or into your drinking water,
[00:12:36.956]well then it can pass on to the next person.
[00:12:40.059]And that's exactly what happened in 1817
[00:12:42.895]in the Sunderbans the first pandemic of cholera began.
[00:12:47.500]And then it traveled up into Russia,
[00:12:50.302]across into the cities of the old world.
[00:12:53.772]But of course to cause a pandemic,
[00:12:55.975]it would have to cross the ocean,
[00:12:57.610]it would have to get across the Atlantic
[00:12:59.912]and conquer the new world
[00:13:01.981]and that wasn't very easy to do.
[00:13:03.983]It took about eight weeks to cross the Atlantic.
[00:13:06.352]Not a lot of people did it.
[00:13:07.887]Sporadically attempted and then of course once
[00:13:10.956]you get to North America,
[00:13:12.491]it isn't like we had highways and roads back then.
[00:13:15.995]It was basically impenetrable.
[00:13:18.764]We had a few rivers, we had the Hudson and the Mississippi,
[00:13:21.300]great navigable rivers but you can go down, you can't go up.
[00:13:24.904]They're not connected.
[00:13:26.172]There's the Appalachian mountains in the middle.
[00:13:28.807]There is no sort of system of getting around.
[00:13:32.778]Well that all changed in the early 1900s,
[00:13:36.315]in the 19th century rather.
[00:13:40.853]In 1825, we opened the Erie Canal.
[00:13:43.856]We used steam engines to ram through a canal right through
[00:13:47.326]the Appalachian mountains,
[00:13:48.861]connected the Hudson river and the Atlantic Waterway
[00:13:52.064]with the Mississippi river valley.
[00:13:56.368]We used steam ships to go not just down the rivers
[00:13:58.137]but also up the rivers
[00:14:00.372]and we used steam ships and packet ships
[00:14:02.041]to cross the Atlantic.
[00:14:03.242]Now it would only take a week, not eight.
[00:14:06.812]So millions of people started coming over
[00:14:08.447]and when they did, they were able to penetrate the
[00:14:11.550]entire interior of North America,
[00:14:14.453]this watery highway we had created.
[00:14:18.557]And of course when cholera did that,
[00:14:20.192]what it found when it got to North America was these
[00:14:23.662]rapidly growing cities.
[00:14:26.832]This was the time of the factory age,
[00:14:28.767]industrialization was just setting in.
[00:14:30.436]People were leaving the farms
[00:14:31.670]and coming to the city in droves.
[00:14:35.107]This was happening across the western world.
[00:14:38.110]But there wasn't any you know subway systems
[00:14:40.412]or transit systems to you know, let people
[00:14:43.215]live sort of sprawled out away from work.
[00:14:46.752]Everyone had to live right near work
[00:14:49.922]or the possibility of work.
[00:14:52.191]They couldn't sprawl out.
[00:14:53.792]So these 19th century cities became incredibly crowded.
[00:14:57.563]Places like 19th century New York,
[00:15:00.299]there was about 77,000 people crammed
[00:15:03.035]into every square kilometer.
[00:15:06.805]That's six times more crowded than modern day Tokyo.
[00:15:10.809]It's a thousand times more crowded than anyone had ever
[00:15:12.978]lived before.
[00:15:15.114]When people are crowded that
[00:15:16.348]close together, it means that they are touching
[00:15:18.117]each other more, they are breathing on each other more.
[00:15:21.220]Their waste is more frequently contaminating
[00:15:24.323]their food and water
[00:15:25.791]and of course there was a huge sanitary crisis
[00:15:29.161]brought on by all this urbanization.
[00:15:32.331]When people moved from the country side into the city,
[00:15:34.233]they didn't change the way they managed human waste.
[00:15:38.337]You know, in the country side, people used
[00:15:40.172]outhouses and privies and cesspools.
[00:15:42.374]These were essentially kind of similar to what
[00:15:44.643]septic tanks do today.
[00:15:45.911]They just collect human waste in containers
[00:15:48.380]and let it decompose.
[00:15:50.816]Well that works okay out in the country
[00:15:52.418]when there is plenty of room
[00:15:55.087]but when you transplant that system into a city
[00:15:58.657]which is what they did, with no plumbing
[00:16:01.060]and in New York in the 19th century New York,
[00:16:03.562]there wasn't even any rules that you had
[00:16:05.798]to empty your privies or cesspools or outhouses.
[00:16:10.202]So all this material was allowed to just sit there
[00:16:12.971]and collect and spill out into the streets, into the alleys,
[00:16:17.509]into people's basements and into their drinking water wells.
[00:16:21.547]Over 1/12 of the city of New York was covered in cesspools
[00:16:25.984]and privies in the 19th century.
[00:16:27.986]The typical 19th century New Yorker was ingesting
[00:16:32.558]two teaspoons of fecal matter every day.
[00:16:37.796]So, yeah, I'm sorry.
[00:16:40.165](all laughing)
[00:16:42.134]It's horrible.
[00:16:46.038]But you think about a disease like cholera,
[00:16:48.407]when it enters into a system like that
[00:16:50.843]can just explode.
[00:16:53.579]And it did again and again.
[00:16:55.981]Now, there are things we could have done even back then.
[00:17:00.052]So the way pathogens spread is always only half the story.
[00:17:03.489]Other half of the story of
[00:17:05.357]epidemics and pandemics is how we respond
[00:17:08.426]and there were things we could have done even back then
[00:17:10.529]but they were stymied
[00:17:12.231]because of the rise of private interests.
[00:17:15.666]This was the time of the robber barons,
[00:17:17.935]and private interests were becoming
[00:17:19.738]incredibly powerful
[00:17:21.906]and when they didn't want to implement
[00:17:24.943]the best public health strategies
[00:17:26.878]to protect people from cholera,
[00:17:28.580]those strategies were frustrated.
[00:17:30.849]One example is the way cholera came down the water ways.
[00:17:34.219]Now in 1832, the governor of New York
[00:17:38.724]sent some physicians out to collect this data that is mapped
[00:17:41.593]right here on what was happening with the cholera
[00:17:44.997]and was it going to threaten the city of New York
[00:17:46.865]and it shows a pretty clear picture to us today.
[00:17:50.436]Cholera is coming down the Erie canal,
[00:17:52.204]it is coming down the Hudson river,
[00:17:53.739]it is heading straight for New York city.
[00:17:57.276]So the obvious thing to do would have been to quarantine the
[00:18:00.312]water ways,
[00:18:01.780]to stop traffic on the waterways so cholera doesn't
[00:18:04.416]reach the city
[00:18:06.051]but private interests said that would be too
[00:18:08.287]disruptive to commerce and so it was never done
[00:18:12.157]and cholera was allowed to travel down those waterways
[00:18:14.860]into the city of New York again and again.
[00:18:19.832]There were actually companies that were making money selling
[00:18:23.235]cholera contaminated water.
[00:18:25.838]The center of the epidemics of cholera
[00:18:28.106]in 19th century New York was a slum called Five Points
[00:18:31.143]which is pictured here.
[00:18:33.178]If anyone has seen the Martin Scorcese movie
[00:18:36.248]Gangs of New York,
[00:18:37.449]then that was actually about Five Points.
[00:18:41.019]So this slum had actually been built in
[00:18:42.554]what was once a pond.
[00:18:44.556]And that pond had been filled up with garbage
[00:18:48.193]and the slum was built on top of it
[00:18:50.762]so the ground water underneath this slum
[00:18:52.965]was very easily contaminated by all those leaky outhouses
[00:18:56.401]and privies on top.
[00:18:59.371]Now the company that the state of New York chartered
[00:19:03.475]to deliver piped drinking water to the
[00:19:05.544]people of New York, they didn't want to spend
[00:19:07.346]a lot of money on the piping system
[00:19:09.448]so rather than sink their well upstream of the city
[00:19:13.852]where they knew the water would be cleaner and fresher
[00:19:16.755]and would taste better,
[00:19:18.257]they sank their well right in the middle of that slum.
[00:19:23.161]And they delivered that water to
[00:19:24.596]one third of the residents of New York.
[00:19:28.667]And they did that throughout, repeated outbreaks of cholera.
[00:19:31.904]The reason they did that is interesting.
[00:19:35.607]Sort of like the reason why this happened in Fint Michigan.
[00:19:38.944]Which is they wanted to save money.
[00:19:41.580]And they wanted to save money
[00:19:43.015]because they wanted to build a bank which they did.
[00:19:45.217]And it was called the Bank of the Manhattan Company
[00:19:47.686]and it survives to this day.
[00:19:49.221]Does anyone know what the Bank of Manhattan Company
[00:19:50.956]is called right now?
[00:19:53.058](talking in distance)
[00:19:54.660]No it's JP Morgan Chase.
[00:19:57.429]Chase is better yeah.
[00:19:58.830]Biggest bank in America.
[00:20:01.500]Now, there are things doctors could have done
[00:20:03.902]to help prevent and treat cholera at the time too.
[00:20:08.807]The cure for cholera is very simple.
[00:20:11.209]It's water with a few salts in it.
[00:20:15.380]Preventing cholera is easy too.
[00:20:16.915]Technically, you separate your waste
[00:20:18.850]from your food and water
[00:20:21.320]but the way cholera spread eluded
[00:20:24.423]19th century physicians for decades
[00:20:27.292]because they applied their old paradigms
[00:20:29.294]of how diseases work to the new disease.
[00:20:32.698]Now the old paradigm of how contagious spread
[00:20:36.802]diseases spread was this theory called miasmatism.
[00:20:38.904]This was based on Hippocratic theory
[00:20:40.739]dated back thousands of years.
[00:20:44.409]Miasmatism's idea was that you get sick
[00:20:47.746]from these contagious ideas by breathing in miasmas.
[00:20:53.085]Miasmas were these stinky airs that rose
[00:20:55.821]up from decomposing organic materials like
[00:20:58.924]wetlands and swamps and waste.
[00:21:02.828]So if you've inhaled those stinky airs,
[00:21:05.564]that's what would make you sick.
[00:21:07.299]Essentially bad smells is what they thought caused these
[00:21:11.269]contagious diseases.
[00:21:13.105]Now, that might have made a certain amount of sense for old
[00:21:16.642]diseases like say malaria.
[00:21:19.411]Malaria is not caused by stinky air
[00:21:22.214]but if you expose yourself to the airs
[00:21:25.217]around say wetlands and swampy areas
[00:21:28.320]where there is sulfurous odors,
[00:21:30.555]you also would expose yourself to the mosquitoes
[00:21:33.058]that carry malaria.
[00:21:35.227]Miasmatism made a certain amount of sense
[00:21:37.329]for old diseases like malaria.
[00:21:41.733]But when applied to the new disease of cholera,
[00:21:45.137]miasmatism made things much worse.
[00:21:48.640]For example, in the city of London,
[00:21:51.977]people started installing what we now call
[00:21:54.913]flush toilets but what they called water closets
[00:21:57.816]in the 18th century.
[00:21:59.951]And they did that because they
[00:22:01.720]thought it would make them healthier.
[00:22:04.156]So it would get rid of the miasmas,
[00:22:05.957]the stinky smells of human waste.
[00:22:08.794]They wanted to flush all that stuff away,
[00:22:10.429]out of their homes, out of their streets.
[00:22:12.130]They liked flushed toilets for that
[00:22:14.700]but since they only cared about the smell
[00:22:17.969]and not the contents,
[00:22:20.072]they didn't care that they were dumping
[00:22:21.940]all the material, all of that waste
[00:22:24.643]directly into their drinking water
[00:22:27.279]which was the river Thames.
[00:22:30.048]In fact, after every cholera outbreak in London,
[00:22:33.151]the people of London installed more flush toilets
[00:22:37.222]to dump more of their human waste into the river
[00:22:40.592]rather than less.
[00:22:43.295]So the second question I wanted to answer is
[00:22:44.930]could this happen again?
[00:22:48.133]And I spent some time going to places where
[00:22:50.936]new diseases are emerging.
[00:22:52.404]Places like Haiti and south China
[00:22:55.207]and New Delhi and parts of the United States
[00:22:58.076]and what I found is these same factors that
[00:23:01.580]allowed cholera to become a pandemic in the 19th century
[00:23:04.382]are being recreated today but on a global scale.
[00:23:09.855]So we see wild species are moving today in a new way
[00:23:13.558]and that's because of climate change.
[00:23:15.127]So this video shows where species are going to have to
[00:23:17.562]move in order to keep up with their
[00:23:20.232]climactically habitable zones.
[00:23:23.335]So species are on the move by the thousands right now
[00:23:27.005]but at the same time, we humans are invading
[00:23:30.242]wildlife habitat on a huge scale.
[00:23:33.178]That's as we expand our population and our cities
[00:23:35.714]and our towns grow, our industrial activities grow.
[00:23:38.450]And of course that means we're destroying a lot of wildlife
[00:23:41.419]habitat and we are losing a lot of wild species
[00:23:44.589]but the species that remain, well they have to crowd
[00:23:47.425]in ever closer you know, with our habitations
[00:23:51.229]and our cities and our towns and what that means is that the
[00:23:55.233]microbes that live inside of animals
[00:23:58.003]can more easily spill over into the bodies of humans
[00:24:02.207]and in fact 60% of our new pathogens today
[00:24:05.277]originate in the bodies of animals.
[00:24:08.547]Over 70% of them are coming from the bodies of wild animals
[00:24:12.684]and a good example of that is Ebola.
[00:24:16.822]So this huge swath of Sub Saharan Africa
[00:24:18.757]is being steadily deforested
[00:24:21.493]and that's not just because of
[00:24:23.728]the expansion of cities and towns and industrial activities.
[00:24:26.198]It is also because of things like civil conflict.
[00:24:29.301]The three countries on the Western most Coast
[00:24:32.671]of West Africa, Sierra Leone, Liberia
[00:24:35.273]and Guinea, over the course of the '90s had a very
[00:24:38.810]complicated civil conflict.
[00:24:42.247]One result of that was over 600,000 refugees
[00:24:46.618]fled the fighting, and went into a forest
[00:24:50.222]that once covered the area
[00:24:51.857]where the those three countries meet.
[00:24:54.526]It was once one of the most biodiverse forests in the world.
[00:24:57.329]It was called the Guinea Forest Region
[00:24:58.930]and what happened to it is visible from space.
[00:25:02.701]In that inset picture is a satellite image
[00:25:05.470]of the area where those three countries meet
[00:25:07.172]the Guinea Forest Region.
[00:25:08.440]You can see it's almost all green.
[00:25:12.711]The larger image is from 1999
[00:25:16.548]and you can where see those three countries meet
[00:25:18.383]it is mostly brown.
[00:25:20.118]Because only 15% of that original forest remained.
[00:25:24.990]Those refugees they had to knock down the trees to,
[00:25:28.026]for their farms and their homes and for truckle.
[00:25:31.196]What we now know is when you destroy all of that
[00:25:34.132]wildlife habitat, a lot of it,
[00:25:36.635]what was being destroyed was habitat of fruit bats.
[00:25:39.671]It overlaps pretty well
[00:25:40.906]with the habitat of these fruit bats.
[00:25:43.508]So when we cut down the forests where the fruit bats live,
[00:25:47.412]they don't go extinct.
[00:25:48.847]They actually come and live in our farms
[00:25:50.448]and in our gardens and in our backyards.
[00:25:53.385]And what that means is that people and bats come into
[00:25:55.687]new kinds of intimate contact
[00:25:58.023]and the microbes that live in the bat's bodies
[00:26:01.259]can spill over into human bodies
[00:26:04.129]and one of those microbes is Ebola.
[00:26:08.500]So if you have a mango tree in your backyard for example,
[00:26:11.903]the way fruit bats, if you chop down
[00:26:14.639]all the forests that are far away
[00:26:16.408]and the fruit bats come and live in your back garden,
[00:26:19.411]what they do is they pick fruit off the tree,
[00:26:23.715]they pierce it with their teeth
[00:26:25.583]and they suck out all the juice
[00:26:27.452]and then they through throw the fruit on the ground.
[00:26:30.522]So these fruit trees are littered with half eaten fruits
[00:26:34.559]that are covered in bat saliva
[00:26:38.363]and in the bat saliva are all
[00:26:39.597]the bat microbes.
[00:26:41.666]So say you have a little kid who plays outside and picks up
[00:26:44.302]one of these fruits with their hand
[00:26:45.637]and gets some bat saliva on their hand
[00:26:47.806]and puts their hand in their mouth.
[00:26:49.941]That's it.
[00:26:51.242]You've created a bridge from the bat body
[00:26:53.044]into the human body
[00:26:54.279]and this is exactly what happened in late 2013.
[00:26:58.383]A 2-year-old child who was playing in a village
[00:27:01.152]near the Guinea Forest Region,
[00:27:03.688]playing near a tree that was known to be a place
[00:27:05.757]where bats were roosting
[00:27:08.126]he was the first one who came down with the Ebola virus
[00:27:11.730]and before he died, he infected his parents, his family
[00:27:17.202]and before they died, they infected their
[00:27:19.004]healthcare workers who infected their family members
[00:27:22.474]who infected their healthcare workers
[00:27:24.042]and on and on until we had the biggest Ebola epidemic
[00:27:27.178]in history, bigger than all previous outbreaks
[00:27:30.348]of Ebola combined.
[00:27:33.551]Over 11,000 people died.
[00:27:37.789]But this kind of spillover from wild animals
[00:27:40.091]into human bodies is not happening only in far off places.
[00:27:44.362]It's also happening here in the United States.
[00:27:46.965]One example is West Nile virus.
[00:27:50.735]The West Nile virus is a virus of migratory birds
[00:27:52.771]from Africa.
[00:27:54.406]They land here by the millions every year.
[00:27:55.940]They've been doing that forever
[00:27:58.109]but we never had West Nile virus in this country until 1999
[00:28:02.914]because we were protected by the diversity of bird species
[00:28:05.984]in our domestic bird flocks.
[00:28:08.053]We had birds like woodpeckers and rails.
[00:28:11.456]These are birds that actually repel West Nile virus.
[00:28:15.226]They're not good carriers of it.
[00:28:17.762]So as long as you have a lot of woodpeckers and rails
[00:28:19.264]and lots of diverse birds around, you don't have a lot of
[00:28:21.466]West Nile virus in your domestic bird flocks
[00:28:24.969]but what's happened over the past 25 years is
[00:28:26.738]we've actually lost a lot of that bird habitat.
[00:28:29.607]We've destroyed it.
[00:28:31.309]We've lost a lot of that biodiversity in our bird species.
[00:28:34.379]So woodpeckers and rails are pretty rare now
[00:28:37.482]but what we do have a lot of are birds like
[00:28:40.385]robins and crows.
[00:28:42.620]These are birds that can live in any kind of disturbed
[00:28:44.989]environment.
[00:28:47.525]Now, while woodpeckers and rails repel West Nile virus,
[00:28:51.996]robins and crows are excellent carriers of West Nile virus.
[00:28:58.236]So the fewer woodpeckers and rails you have around
[00:29:00.572]and the more robins and crows you have around,
[00:29:03.241]the more West Nile virus you have around in your domestic
[00:29:05.844]bird flocks and the more likely it becomes
[00:29:08.446]that a mosquito will bite an infected bird
[00:29:11.149]and then bite a person
[00:29:13.251]and give that person West Nile virus
[00:29:14.752]and that's exactly what happened in 1999.
[00:29:17.021]The first outbreak of West Nile virus in United States
[00:29:19.324]happened in New York City
[00:29:21.359]and since then it has steadily spread across the nation.
[00:29:25.430]This picture shows all the counties where West Nile virus
[00:29:29.134]infected the birds have been found.
[00:29:32.504]Similarly, in the Northeastern Forest
[00:29:35.640]we once had a diversity of woodland species.
[00:29:41.312]We had species like opossum and chipmunk
[00:29:45.817]and these are creatures that actually control
[00:29:48.052]tick populations.
[00:29:49.654]The typical opossum will destroy
[00:29:52.090]about 6,000 ticks a week through grooming.
[00:29:57.829]Now, what we've done over the past decades
[00:29:59.364]is we've expanded our suburbs into the Northeastern Forest
[00:30:02.567]so we've broken up the forest into these little patchwork
[00:30:07.172]quilts of pieces of forest,
[00:30:09.007]fragments of forest.
[00:30:12.076]Well the opossum and the chipmunks, they've all left.
[00:30:14.846]They're very rare in these suburbanized forests now
[00:30:18.650]but what we do have a lot of are creatures like
[00:30:21.486]white footed mice and deer.
[00:30:25.156]While the typical opossum destroys 6,000 ticks a week,
[00:30:29.394]the typical white footed mouse destroys about 50
[00:30:33.965]ticks a week.
[00:30:36.334]So the fewer opossum you have around
[00:30:38.636]and the more white footed mice you have around,
[00:30:41.606]the more ticks you have around
[00:30:43.708]and the more likely an outbreak of tick borne disease
[00:30:45.944]becomes in people.
[00:30:47.212]And that's exactly what happened in the 1970s,
[00:30:50.148]with first outbreak of what we now know as lyme disease
[00:30:53.751]which has since spread into what can only be called
[00:30:57.188]a national epidemic.
[00:30:58.489]We have about 300,000 people in this country
[00:31:02.260]diagnosed with lyme disease every year.
[00:31:06.864]Now of course we're driving, so we are driving
[00:31:08.366]pathogens into the human populations through these
[00:31:10.101]various mechanisms and then we are offering
[00:31:11.769]them these great amplification opportunities.
[00:31:15.039]Just like in the 19th century but on a global scale
[00:31:17.442]by 2030, majority of humans are going to live in cities.
[00:31:23.014]It will be the first time ever we'll be an urban species.
[00:31:26.985]But they're not going to be beautiful cities like
[00:31:29.020]Washington, DC and San Francisco.
[00:31:31.923]They're going to be cities more like Monrovia and Freetown
[00:31:35.326]in West Africa.
[00:31:36.561]There's lots of ad hoc development,
[00:31:38.696]not a lot of infrastructure and a lot of slums.
[00:31:42.200]But two billion of us will be living in slums by 2030
[00:31:48.573]and new pathogens are taking advantage of this
[00:31:51.109]opportunity already.
[00:31:52.277]Ebola is a good example of this as well.
[00:31:55.179]So we've had Ebola outbreaks since the 1970s
[00:31:59.417]but they were always kind of small and self-contained.
[00:32:02.887]In part because Ebola had never infected any place with
[00:32:06.758]more than a few hundred thousand inhabitants.
[00:32:11.062]Now, within weeks of emerging out of
[00:32:13.097]the Guinea Forest Region in 2013,
[00:32:16.034]Ebola reached three capital cities with a combined
[00:32:20.138]population of nearly three million.
[00:32:24.409]There's an important reason why it was such a huge
[00:32:27.679]conflagration, bigger than all previous Ebola epidemics
[00:32:31.182]in the past combined.
[00:32:33.718]Zika similarly, we had that since the 1940s,
[00:32:36.287]but it was carried in equatorial Asia and equatorial Africa
[00:32:41.225]by a forest mosquito that only bit forest animals,
[00:32:44.729]hardly ever bit people
[00:32:46.097]but by the time it got to Brazil
[00:32:47.965]it was being carried by an urban mosquito
[00:32:49.767]that only bit people.
[00:32:51.969]That's an important reason why it suddenly became
[00:32:54.005]this huge problem.
[00:32:56.908]But it is not just people that are crowding together today.
[00:32:59.310]It's also our animals.
[00:33:02.780]We have more animals under domestication right now
[00:33:05.983]than in the last 10,000 years of domestication
[00:33:09.087]until 1960 combined.
[00:33:12.890]It's a huge, huge number of livestock we're keeping
[00:33:15.026]right now.
[00:33:16.394]And a greater proportion of them live in
[00:33:19.597]the animal equivalent of slums.
[00:33:22.700]That is factory farms where there's thousands and sometimes
[00:33:26.838]millions of individuals crowded really closely together.
[00:33:31.275]When they're that close together, they're touching each
[00:33:33.111]other more, they are breathing each other more,
[00:33:35.847]and they are being exposed to each other's waste
[00:33:38.816]and new pathogens are taking advantage of this too.
[00:33:41.919]One example is avian influenza.
[00:33:44.522]Avian influenza is a virus of wild waterfowl.
[00:33:48.726]It doesn't really make them sick
[00:33:51.129]but if those viruses can get into a factory farm full of
[00:33:53.731]captive chickens, then it starts to replicate really
[00:33:57.735]rapidly, amplify and evolve and it becomes more virulent.
[00:34:02.540]In fact this is such a predictable process
[00:34:05.476]that scientists can replicate it in a lab.
[00:34:08.312]You take an avian influenza virus from a wild waterfowl,
[00:34:11.916]that doesn't really make any one very sick,
[00:34:13.918]pass it through a few generations of chickens
[00:34:16.554]and presto you have this highly virulent form
[00:34:19.123]of avian influenza.
[00:34:20.391]And this is one reason why we have
[00:34:22.659]an increasing frequency of the emergence of these new kinds
[00:34:26.030]of avian influenza including some like H5N1
[00:34:30.868]that can infect humans although luckily it
[00:34:33.571]can't spread that well between us yet.
[00:34:38.176]Now, all of this crowding of course creates
[00:34:39.643]a secondary problem, which is a sanitary problem.
[00:34:42.847]We still have our old sanitary problem
[00:34:45.550]that is 2.6 billion people around the world have no access
[00:34:49.821]to modern sanitation at all
[00:34:52.290]and that is a standing catastrophe that pathogens
[00:34:55.259]have been taking advantage of for decades.
[00:34:58.930]But on top of that, we also now have a new sanitary crisis
[00:35:03.468]which is a sanitary crisis of our livestock waste.
[00:35:06.971]Around the world our livestock create
[00:35:08.806]seven billion tons of excreta every year.
[00:35:13.744]Now the old way of managing a livestock waste was to
[00:35:16.280]use it as fertilizer.
[00:35:17.715]You spread it on the crop lands.
[00:35:19.917]Well seven billion tons is far more
[00:35:21.986]than the world's crop lands could possibly absorb.
[00:35:26.624]So what farmers are doing now
[00:35:28.125]is simply collecting them in what is pictured here as a
[00:35:30.561]manure lagoon.
[00:35:32.430]It is basically an unlined, untreated
[00:35:36.534]open pit full of waste.
[00:35:39.904]And so when it rains or when there are storms,
[00:35:41.806]this material can get into the environment.
[00:35:45.476]And new pathogens are taking advantage of this too.
[00:35:48.813]About one half of all cattle on American feed lots
[00:35:52.283]is infected with a pathogen called Shiga toxin producing
[00:35:57.121]E. coli.
[00:35:58.589]Now it doesn't really make the cows sick at all
[00:36:01.392]but because cattle waste so frequently
[00:36:04.161]contaminates our food and water now,
[00:36:06.898]about 70,000 Americans are falling ill with
[00:36:09.133]Shiga toxin producing E. coli every year.
[00:36:11.536]You've probably heard of like the killer hamburger bug
[00:36:14.138]that's what I'm talking about.
[00:36:17.808]So when these pathogens emerge,
[00:36:19.677]we're now disseminating them around the globe
[00:36:22.246]on the most efficient network ever,
[00:36:25.316]which is our flight network.
[00:36:26.751]We don't just have a couple of airports in
[00:36:29.387]capital cities.
[00:36:30.321]We have hundreds of airports in
[00:36:32.423]every regional town and city,
[00:36:34.392]tens of thousands of connections between them,
[00:36:37.428]so when a pathogen emerges in one part of the world
[00:36:41.632]as this simulation of a flu pandemic shows,
[00:36:45.369]it can very rapidly spread across the globe.
[00:36:49.273]And in fact our flight network is so influential in shaping
[00:36:54.612]epidemics that you can actually predict
[00:36:56.914]where and when an outbreak will hit next
[00:37:00.384]simply by measuring the number of direct flights
[00:37:04.455]between infected and uninfected cities.
[00:37:07.425]If you take a map like this one,
[00:37:09.060]which is all the cities as connected
[00:37:12.330]by their direct flights
[00:37:13.564]and you run that same flu pandemic simulation
[00:37:16.200]I showed you in the last slide,
[00:37:18.069]you can see it results in this perfect series of waves.
[00:37:23.874]Now of course there's a ton of stuff we can do
[00:37:25.776]to reduce the risk of pandemics,
[00:37:30.047]but first we're going to have to overcome
[00:37:32.516]the obstacles that are standing in our way
[00:37:35.152]and there's a few of those.
[00:37:36.921]The biggest I think right now is probably
[00:37:38.789]xenophobia and scapegoating.
[00:37:40.825]We are seeing as these new pathogens are emerging
[00:37:43.361]in parallel a rise in xenophobia and scapegoating
[00:37:46.797]around the globe.
[00:37:48.599]We've seen anti-immigrant politicians rise to power here
[00:37:52.370]in the United States, in Europe.
[00:37:54.538]New border walls going up,
[00:37:56.140]refugees being denied their rights to asylum
[00:38:00.611]and this doesn't just violate their human rights.
[00:38:03.314]It actually will really complicate our
[00:38:05.149]efforts to control pathogens and epidemics.
[00:38:07.852]We saw a little bit of this with the Ebola outbreak
[00:38:10.154]in West Africa a few years ago
[00:38:12.390]when our fear of these diseased others led to calls to
[00:38:19.296]cancel flights to the affected area,
[00:38:21.832]to scapegoat and quarantine people who looked
[00:38:25.302]like they were from Africa or
[00:38:26.704]who had gone anywhere near Africa or
[00:38:29.106]even threatened to go to Africa, conferences
[00:38:30.975]or scientists who had been to the affected areas
[00:38:33.878]were canceled.
[00:38:35.446]These are all forms of scapegoating and xenophobia
[00:38:37.281]because of our fears of these diseased other people
[00:38:41.519]and they materially affected our ability
[00:38:43.854]to control that epidemic.
[00:38:45.456]Aid workers couldn't get on flights
[00:38:47.558]to go help out during the crisis.
[00:38:49.927]We saw in West Africa itself, healthcare workers
[00:38:53.831]were blamed for the Ebola
[00:38:56.233]and some of them were even assaulted.
[00:38:58.235]There was a couple that were even murdered.
[00:39:00.771]During the cholera outbreak in Haiti,
[00:39:02.740]similarly, healthcare workers were blamed
[00:39:04.542]for bringing the cholera.
[00:39:05.776]Red cross clinics were burnt down.
[00:39:08.045]This is going to be a major problem
[00:39:10.347]that we're all going to have to face in the future
[00:39:12.783]is tackling xenophobia at it's roots.
[00:39:15.686]Not just during epidemics but all the time
[00:39:17.521]because this now endangers our health too.
[00:39:23.728](audience applauding)
[00:39:29.166]On top of that, we also have the rise of private interests.
[00:39:32.369]This is the same problem we had back in the 19th century
[00:39:35.005]but writ large.
[00:39:37.675]Of the 100 largest economies in the world today,
[00:39:40.911]only 49 are governments.
[00:39:43.214]51 are corporations.
[00:39:46.283]So when our public health strategies sometimes conflict
[00:39:50.020]with what private interests want to do,
[00:39:52.223]they can get frustrated
[00:39:53.958]and this is happening not just in far off places
[00:39:56.127]where there's weak states and poor governance,
[00:39:58.028]it's happening right here in the United States
[00:40:00.464]and a good example is antibiotic resistant bacteria.
[00:40:04.735]We've known since the 1940s that if you use
[00:40:08.405]antibiotics in a way that is not medically necessary,
[00:40:11.909]you will trigger the evolution of antibiotic resistant bugs.
[00:40:16.380]But to this day, in the United States,
[00:40:18.315]80% of the antibiotics we use are
[00:40:21.819]used for commercial reasons.
[00:40:24.488]That is they're used by farmers
[00:40:25.923]to help promote the growth of their livestock
[00:40:28.759]so they can get them to market faster.
[00:40:30.761]That is 80%.
[00:40:33.564]Now, our public health agencies have tried to regulate this
[00:40:36.467]practice since the 1970s
[00:40:38.402]but they have been stymied again and again
[00:40:40.938]by the farm lobby.
[00:40:42.907]And one result of that is 23,000 Americans die
[00:40:46.477]every year of antibiotic resistant pathogens.
[00:40:50.815]Now, doctors can do a lot more today
[00:40:52.883]than they did in the 19th century of course,
[00:40:54.852]but I would argue we have a mismatch here too.
[00:40:59.390]Now the old way of dealing with infectious diseases
[00:41:01.425]is a paradigm I would call microbial xenophobia
[00:41:04.395]where we isolate the germ and we target it
[00:41:08.065]with military precision.
[00:41:09.934]We think of it as solely a biomedical problem
[00:41:13.804]but what we are seeing today with a lot of these
[00:41:16.173]epidemics is that pathogens are coming out of wildlife.
[00:41:20.444]They are being driven through human populations
[00:41:22.279]through social and political factors.
[00:41:25.316]So really the best way to counter the entire
[00:41:27.418]infectious disease process is
[00:41:30.254]through a multidisciplinary effort.
[00:41:32.056]We need the veterinarians and the wildlife experts
[00:41:35.025]and the biologists alongside the anthropologists
[00:41:38.395]and the engineers and the architects
[00:41:39.663]and the biomedical experts
[00:41:41.966]but that's not what we do.
[00:41:44.201]what we do when outbreaks occur
[00:41:46.871]is we treat them as solely
[00:41:48.405]a biomedical problem.
[00:41:49.940]And one example of that is the dengue outbreak in Florida.
[00:41:53.744]This happened in 2009.
[00:41:55.846]Dengue is a mosquito borne virus.
[00:41:57.615]It hadn't been seen in Florida for over 70 years.
[00:42:01.352]So it seemed unprecedented
[00:42:03.420]and it was immediately attacked as an invasion
[00:42:06.924]of these foreign mosquitoes and germs that we
[00:42:10.761]needed to direct our killing chemicals towards.
[00:42:13.797]We brought out our drones and we coated the countryside
[00:42:16.767]with insecticide to try to fight this disease.
[00:42:20.504]Well in fact, Florida has been
[00:42:23.774]surrounded by countries where dengue is endemic
[00:42:26.710]for a long time.
[00:42:29.346]And the mosquitoes that carry dengue
[00:42:31.916]have been present in Florida for a long time too.
[00:42:35.486]So there hadn't actually been any invasion.
[00:42:39.957]So what had happened?
[00:42:41.225]Well in 2008 we had had the housing crisis.
[00:42:45.095]We had a lot of foreclosed homes
[00:42:48.332]and that meant they were empty and abandoned
[00:42:50.367]and because this is Florida, that meant there was a
[00:42:52.136]lot of empty swimming pools.
[00:42:55.773]And so when the rains came,
[00:42:58.108]these empty swimming peoples filled up with standing water
[00:43:01.645]and with no one home to notice or to let the
[00:43:03.747]mosquito inspectors in,
[00:43:05.449]they became giant mosquito hatcheries.
[00:43:08.552]And lo and behold, a year later,
[00:43:10.120]we had this unprecedented outbreak of dengue.
[00:43:13.958]Similarly with the recent Zika outbreak in Miami,
[00:43:17.628]the counties where Zika first took hold,
[00:43:21.332]had five times higher foreclosure rates
[00:43:24.501]than the rest of the city.
[00:43:27.271]Now, would have addressing the housing crisis have helped
[00:43:32.710]contain or maybe even prevent outbreaks
[00:43:36.080]of mosquito borne disease?
[00:43:38.349]I don't know because nobody tried that.
[00:43:42.987]What we do know is arguably the biomedical approach
[00:43:45.422]has failed in the sense that dengue is now
[00:43:49.126]considered a permanent part of the Florida landscape.
[00:43:53.130]Now, all of this is not to say
[00:43:55.099]that this is definitely what is going to happen, right,
[00:43:57.668]this prediction.
[00:43:59.036]It is not Nostradamus.
[00:44:00.738]It's not a crystal ball.
[00:44:04.108]This is a warning of what will happen if we don't change
[00:44:07.511]and there is so much we can do.
[00:44:10.781]So, right now, this is a typical epidemic curve.
[00:44:13.684]It shows cases over time during an outbreak of disease
[00:44:17.755]that is if you do nothing at all,
[00:44:19.023]it will be a curve like this.
[00:44:20.557]You see in the beginning, a few people get infected,
[00:44:23.894]they're kind of isolated
[00:44:25.262]and then each of those infected people start to
[00:44:27.031]infect the people around them, two or three people
[00:44:29.533]and then you have this exponential growth,
[00:44:31.735]the steep upward line.
[00:44:34.972]Then you get to the plateau when most of the people
[00:44:37.074]who were gonna get infected who have already been infected
[00:44:39.810]so everyone is either immune or
[00:44:42.012]they've already recovered or they are dead.
[00:44:44.415]And then the epidemic starts to collapse on its own.
[00:44:47.751]This is what happens if you do nothing at all.
[00:44:50.487]Now, right now, the way our public health system works is
[00:44:54.658]we first start dealing with an epidemic.
[00:44:57.094]We first even have knowledge that an epidemic
[00:44:59.363]is happening around there.
[00:45:02.399]That's the earliest
[00:45:04.134]because that is when you have clusters of cases,
[00:45:06.103]you have families getting sick,
[00:45:07.504]or groups of students getting sick
[00:45:09.306]and so our public health agencies now they know
[00:45:12.009]when these clusters happen that an epidemic is underway
[00:45:15.479]and so that is when we start our control efforts,
[00:45:19.149]our containment efforts
[00:45:20.284]but of course by then,
[00:45:22.119]the pathogen is already spreading exponentially.
[00:45:25.856]and our response proceeds in a linear fashion at best.
[00:45:31.462]So we have this mismatch
[00:45:33.330]but what if we could push that back just a little to there?
[00:45:37.968]What if we could detect epidemics before they start
[00:45:41.872]to spread exponentially?
[00:45:44.241]And that is now technically possible.
[00:45:46.977]So we don't know which microbe is going to cause the
[00:45:50.247]next pandemic.
[00:45:51.982]But we do know how it happens.
[00:45:54.251]Which means we can predict
[00:45:56.787]where it is most likely to happen.
[00:45:59.389]Now, this map shows what are called disease hot spots.
[00:46:02.960]These are places where there's a lot of invasion of wildlife
[00:46:06.296]habitat or intensification of livestock agriculture,
[00:46:10.267]lot of slums, lot of flight connections
[00:46:12.069]or some combination of all of those things.
[00:46:15.739]We can't surveil microbes all over the globe
[00:46:18.208]but we can in these hot spots actively look for microbes
[00:46:22.045]that might be crossing over into people
[00:46:24.448]and become pathogens
[00:46:25.749]and then we can target them and control them
[00:46:29.853]and stamp them out before they start to spread.
[00:46:33.290]And there are NGOS and government agencies are starting to
[00:46:36.093]do this very important work.
[00:46:38.228]We can do even more than that.
[00:46:39.463]We can walk this back further even further
[00:46:40.497]and do primary prevention
[00:46:42.833]that is we can prevent the conditions
[00:46:45.569]that allow pandemics to happen in the first place.
[00:46:49.339]We can do things like restore wildlife habitats
[00:46:52.643]so that the microbes and animals stay in animals
[00:46:56.747]and don't spill over into people.
[00:46:59.583]We can do things like protect the health of the most
[00:47:01.818]vulnerable among us, refugees, people living in slums,
[00:47:06.957]animals in factory farms.
[00:47:08.192]These are the people who are on the front lines
[00:47:09.893]of new epidemics
[00:47:12.429]and our health depends on their good health.
[00:47:15.899]And finally, this all really begins with all of us
[00:47:18.769]becoming responsible citizens in this new age of pandemics.
[00:47:24.775]And that means a lot of things but in part I think it means
[00:47:27.444]being good consumers, using antibiotics sporadically,
[00:47:30.781]only when necessary, keeping up with our vaccines
[00:47:32.916]being good neighbors, cleaning up our neighborhood
[00:47:35.919]so that we don't have standing water around and
[00:47:39.556]garbage that becomes mosquito breeding grounds.
[00:47:42.292]Knowing our neighbor so that when there are outbreaks
[00:47:44.528]of disease, we know who to go to first,
[00:47:46.663]who we need to help first
[00:47:48.265]and more than anything I think today,
[00:47:51.201]we need to become responsible citizens
[00:47:53.804]and stand up for our public health agencies,
[00:47:57.908]the people and agencies that every day
[00:48:01.044]are making sure that our food is safe,
[00:48:03.380]that our water is clean,
[00:48:05.315]that our air is pure,
[00:48:06.717]that our medicines work.
[00:48:08.085]These are the people and agencies
[00:48:09.553]that are protecting us from epidemics and pandemics
[00:48:11.989]every day and we need to support their work too.
[00:48:15.292]So we can't live in a world
[00:48:17.694]without infectious disease.
[00:48:19.463]That is part of being human and is part of
[00:48:21.331]living on this planet
[00:48:22.866]but there's a lot we can do to prevent another pandemic.
[00:48:27.237]Thank you so much for listening.
[00:48:29.406](audience applauding)
[00:48:47.524]HOST: Thank you very much Sonia
[00:48:48.525]for enlightening us this evening
[00:48:50.193]and maybe frightening us a bit too.
[00:48:52.229](audience laughing)
[00:48:53.297]UNL was one of 10 institutions
[00:48:54.831]selected by the Argentina Fulbright Commission
[00:48:57.000]to host undergraduate Fulbright scholars
[00:48:58.935]on the campus.
[00:49:00.637]And our question or two first comes from our
[00:49:03.407]Argentinian Fulbright students this evening.
[00:49:06.043]Sonia many conspiracy theories suggest that pharmaceutical
[00:49:08.979]companies acted the behind the scenes
[00:49:10.747]to spread viruses that cause complicated diseases
[00:49:13.250]such as HIV.
[00:49:14.918]What do you think?
[00:49:15.919]And before I let you answer that,
[00:49:17.387]I want to remind everyone please tweet your questions to
[00:49:18.889]#enthompson forum or write your questions on the cards
[00:49:21.625]and the ushers will get them up to
[00:49:23.126]us as quickly as possible.
[00:49:24.094]Sonia?
[00:49:25.595]SONIA SHAH: So what we see during epidemics of new diseases,
[00:49:28.098]conspiracy theories come up almost right away
[00:49:30.901]and rather than attack the conspiracy theorists,
[00:49:33.870]I think what we need to do is strengthen our
[00:49:35.272]public health institutions.
[00:49:37.307]So the reason we have conspiracy theories
[00:49:39.176]and the reason they spread so much is that
[00:49:41.178]people don't trust our biomedical establishment
[00:49:44.247]and our public health agencies
[00:49:45.849]and that's because of our own history of transgressions
[00:49:48.885]and own failures to do the outreach
[00:49:51.455]we need to make populations trust the public health
[00:49:54.624]establishment.
[00:49:55.859]I think that's really the key to ending those
[00:49:58.428]kinds of conspiracy theories is to really reach out
[00:49:59.830]and rebuild that trust.
[00:50:03.333]HOST: Okay to what extent do you think data mining
[00:50:05.535]is an effective tool in the prediction of pandemics?
[00:50:08.905]Are there any other innovative areas of research
[00:50:10.841]maybe big science related to the prediction of pandemics?
[00:50:13.343]SHAH: Yeah that's a great question.
[00:50:14.511]I actually gave a talk at Google
[00:50:15.779]and they asked me the same question.
[00:50:17.614]There is so much that can be done now with social media
[00:50:21.318]and with cell phone data because
[00:50:24.187]and we saw this during the cholera outbreak in Haiti
[00:50:27.491]where because there were so many NGOs already on the
[00:50:30.494]ground in Haiti in 2010 because of the earthquake
[00:50:33.697]when cholera broke out,
[00:50:34.998]they were able to really track
[00:50:36.533]where it was spreading just by using cell phone data
[00:50:41.037]and so they were able to map out exactly
[00:50:42.973]okay the cholera is coming down the highway,
[00:50:45.075]it is coming down this road, it is going to
[00:50:46.810]reach this village and hopefully then move resources
[00:50:49.579]to the right areas.
[00:50:50.847]We've seen this with trying to predict
[00:50:53.950]flu outbreaks and other outbreaks
[00:50:55.685]by mining social media information.
[00:51:00.023]It is still something that needs to be tweaked.
[00:51:01.792]It is not perfect yet,
[00:51:05.095]but as we do this more and more, I think it is gonna
[00:51:06.229]be an important tool.
[00:51:07.431]HOST: Okay thank you.
[00:51:08.832]If we could guarantee improvement in rural living by
[00:51:11.134]investing in the quality of life programs
[00:51:13.804]could we prevent the migration of populations to large
[00:51:16.239]cities without access to basic services?
[00:51:18.575]SHAH: I think we could do a lot
[00:51:19.776]and I think it is interesting to look at
[00:51:22.546]the history of how we conquered
[00:51:23.847]some of our old diseases like malaria for example
[00:51:26.650]which hung on in the United States until the 1940s.
[00:51:29.252]The way we got rid of it is by doing
[00:51:32.088]rural uplift, economic development in rural areas
[00:51:35.225]that were particularly plagued by malaria.
[00:51:38.195]We got the Tennessee Valley Authority
[00:51:40.397]that electrified a lot of these migrant farm
[00:51:44.634]workers and sharecroppers, shacks and things like that,
[00:51:48.839]and we created better roads, better drainage,
[00:51:51.174]better infrastructure in our rural areas
[00:51:53.143]which is really the solution.
[00:51:54.978]It ended malaria in the United States
[00:51:56.546]and we can do that in a lot of places around the world,
[00:51:58.915]absolutely.
[00:52:00.116]HOST: Thanks Sonia.
[00:52:01.351]From our twitter feed this evening,
[00:52:02.586]a UNL freshman who is from out of state
[00:52:05.055]asks as an aspiring biomedical engineer,
[00:52:08.658]is there anything I could do to improve our situation?
[00:52:13.063]SHAH: There's a ton we can do.
[00:52:14.331]There's a ton he can do.
[00:52:15.265]There's a ton all of us can do.
[00:52:16.800]Certainly in biomedical engineering
[00:52:18.768]there is so much need for better diagnostics,
[00:52:21.271]better tests, better drugs and vaccines that work in places
[00:52:25.709]around the world.
[00:52:27.143]Right now our industry creates a lot of great vaccines
[00:52:29.813]but sometimes they need to be refrigerated.
[00:52:32.315]We need a cold chain that exists from the lab
[00:52:35.385]to the warehouse to the trucks, to the clinics on the ground
[00:52:39.089]and here are these places where a lot of these
[00:52:41.291]outbreaks are happening, they don't have any of that.
[00:52:43.260]They don't have the electricity,
[00:52:44.928]they don't have the staff,
[00:52:46.162]they don't have any of that infrastructure.
[00:52:47.697]There's lots of places where innovation
[00:52:51.101]in biomedicine can really help reach those populations.
[00:52:55.505]HOST: All right now let's go to biology.
[00:52:57.207]What are your thoughts on fecal transplants
[00:52:58.975]and beneficial gut bacteria?
[00:53:01.611]SHAH: This is a great question.
[00:53:03.480]Fecal transplants if anyone hasn't heard about this is,
[00:53:05.882]there are microbes that live in your gut
[00:53:07.884]that actually appear to interact with your immune system.
[00:53:12.289]So you can actually re-jigger your immune system by changing
[00:53:16.793]your gut microbes and
[00:53:18.228]you can change your gut microbes through diet changes
[00:53:20.297]and things like that
[00:53:21.698]but also more radically through these fecal transplants.
[00:53:23.733]And from what I've read and what I understand
[00:53:26.369]it actually really works
[00:53:27.704]but only for a few things.
[00:53:30.006]So like anything,
[00:53:31.975]there's going to be this huge sort of you know,
[00:53:34.344]explosion of interest and sort of publicity
[00:53:37.647]and hype about the microbiome
[00:53:39.916]and all the things we can do with it
[00:53:41.151]but when you look at the evidence,
[00:53:42.519]it does really work for a few things.
[00:53:45.722]It is not gonna work for everything
[00:53:47.324]but there're some things it's gonna really work for.
[00:53:49.593]HOST: Thank you.
[00:53:50.860]One of our audience members tonight here
[00:53:52.362]at the Lied Center asks how do we educate without
[00:53:53.597]scaring or seeming like a radical?
[00:53:57.500]SHAH: (Laughs) I don't know if you want to ask me
[00:53:59.703]did I get that right?
[00:54:00.770]I'm not sure.
[00:54:02.272](all laughing)
[00:54:03.840]But you know, I think it's interesting to me this whole
[00:54:07.377]idea that we shouldn't alarm anybody right?
[00:54:10.981]I think in a way, that's true.
[00:54:12.616]We saw during the Ebola outbreak,
[00:54:15.218]we had this outbreak of paranoia.
[00:54:17.387]We had what people call it Ebolanoia.
[00:54:20.156]Where we thought people are saying
[00:54:22.559]Ebola is gonna take over.
[00:54:23.827]We shouldn't have any of these patients come
[00:54:25.629]into our country.
[00:54:27.030]Anyone who goes to Africa, should stay there.
[00:54:28.365]We should never let them in.
[00:54:29.532]All of these things
[00:54:31.167]and it was absolutely hysterical, alarmist and wrong headed,
[00:54:35.205]not based on the evidence.
[00:54:37.073]On the other hand, we have major epidemic going on
[00:54:40.310]and no alarm.
[00:54:42.646]So we have the rise of antibiotic resistant bacteria
[00:54:45.081]that's been steadily going up since at least the 1980s
[00:54:48.351]and maybe before that
[00:54:49.819]and more and more people are dying of that.
[00:54:51.655]There is no alarm.
[00:54:53.056]Where is the alarm?
[00:54:54.057]Where is panic?
[00:54:55.625]When Lyme diseases spread and I actually taught a class
[00:54:58.461]up in the epicenter of the lyme disease epidemic
[00:55:02.766]in upstate New York
[00:55:04.367]and the people there were just completely blase
[00:55:06.936]about ticks and tick bites.
[00:55:09.706]They hardly took any precautions whatsoever.
[00:55:13.643]Similarly during the dengue outbreak in Florida,
[00:55:15.412]there were parades in the street
[00:55:17.447]where people dressed up like mosquitoes
[00:55:19.516]and called themselves like Dengue Night Fever.
[00:55:22.485]It's a big joke, it was a big joke
[00:55:24.688]so yes, sometimes we get panicky and alarmed
[00:55:28.191]about these epidemics and sometimes we just
[00:55:32.228]treat them with a yawn and a laugh
[00:55:34.631]and if I had to choose between those two things, to me,
[00:55:38.334]being a little bit alarmed is good
[00:55:40.804]because it makes us do stuff.
[00:55:42.572]If we just dismiss and reject these true risks among us,
[00:55:46.710]that is never going to provoke us to act.
[00:55:50.313]HOST: Thanks Sonia.
[00:55:51.781]In your book, you talk about your family struggle
[00:55:52.682]with MRSA.
[00:55:53.983]Is that still ongoing
[00:55:55.185]and has it changed how you approach life?
[00:55:57.921]SHAH: My son came down with MRSA,
[00:56:00.423]which is methicillin-resistant staphylococcus aureus,
[00:56:03.426]in I don't know 2007 or so.
[00:56:06.896]And then it spread to his brother and to me.
[00:56:09.566]So we all have it
[00:56:11.534]and it was a really eye opening experience
[00:56:14.571]because here was this extremely drug resistant
[00:56:17.340]bacterial pathogen.
[00:56:18.875]We went to doctors
[00:56:20.343]and they basically didn't have anything for us.
[00:56:22.045]They didn't really know what to do with this problem.
[00:56:25.782]It has become sort of a chronic issue
[00:56:27.617]and yes, it changes your life to some extent
[00:56:30.787]but it also made me realize that even more so that
[00:56:34.357]we live in a world of microbes.
[00:56:36.626]And there is no sort of escaping that.
[00:56:39.763]They were here first, actually.
[00:56:41.231]Microbes colonized this planet for billions of years
[00:56:43.767]before our first ancestors came around
[00:56:47.137]and so they are a lot better at surviving around here.
[00:56:50.206]We're the guests really.
[00:56:52.108]They own the place.
[00:56:55.111]I guess it has been a humbling experience I would say.
[00:56:57.647]HOST: Thank you.
[00:56:59.015]Natural pandemics are mappable, but bioterrorism is a
[00:57:01.017]real threat.
[00:57:02.152]How can we be prepared for that?
[00:57:04.587]SHAH: So if you look at the history of bioterrorism,
[00:57:08.258]there has been a lot more fears about bioterrorisms
[00:57:11.294]than actual bioterrorism and I think that's because
[00:57:14.197]it's actually really hard to turn a biological pathogen
[00:57:18.835]into a weapon.
[00:57:20.537]They do that on their own naturally a lot better than we
[00:57:24.407]have every been been able to do it.
[00:57:25.909]So there's only a handful of cases
[00:57:27.477]in which actual terrorists have been able to use bioweapons,
[00:57:30.680]and they haven't been able to really wreck
[00:57:33.483]that much destruction.
[00:57:35.318]So to me the natural threats of pathogens
[00:57:39.055]if you look at history and what has actually happened
[00:57:41.758]are far, far greater than bioterrorism bioweapons
[00:57:46.162]have ever been.
[00:57:47.730]HOST: You mentioned near the end of your speech
[00:57:49.232]the importance of working with public health organizations
[00:57:52.402]as part of the solution.
[00:57:54.771]what suggestions specifically do you have to improve those
[00:57:57.240]government public health organizations?
[00:57:59.409]SHAH: I think the problem with public health is
[00:58:01.878]you know, when they do their best work
[00:58:04.881]it's invisible.
[00:58:06.349]So we don't see the fact that we're not getting sick
[00:58:09.419]from our drinking water.
[00:58:11.154]We don't see the fact that we can trust the food that we get
[00:58:15.225]at our farmers markets and our grocery stores.
[00:58:17.894]We don't see the fact that when we go out
[00:58:19.963]into a baseball field, we can breathe the air freely
[00:58:23.633]and we don't have to wear a mask.
[00:58:24.868]These are things that we don't notice.
[00:58:27.937]It's an absence of evidence that proves that public health
[00:58:30.840]is working.
[00:58:32.308]I think that makes it incumbent upon us as citizens to bring
[00:58:36.379]those to the fore and recognize that the people and agencies
[00:58:39.482]that are doing that work for us every day
[00:58:41.851]behind the scenes, that was really hard won.
[00:58:44.954]When we had cholera epidemics in this country
[00:58:46.623]for over 80 years and the way we ended
[00:58:50.293]cholera for good is we created safe drinking water supplies
[00:58:54.030]and we created an infrastructure to deliver safe
[00:58:56.699]drinking water to the people of this country
[00:58:58.935]and that was a huge public health victory
[00:59:00.703]and every single one of us is alive today
[00:59:04.340]because of it.
[00:59:05.875]We really are, it's a huge victory that we just take
[00:59:09.445]for granted and you go to a different country where you
[00:59:11.314]don't have clean water and then you notice.
[00:59:13.216]So I think it is incumbent upon us to
[00:59:15.018]remember the public health legacy that allows us to live
[00:59:18.855]the healthy long lives that we do enjoy today.
[00:59:23.493](audience applauding)
[00:59:30.500]HOST: All right a couple more questions Sonia.
[00:59:32.168]How do we speed up the process of a cure
[00:59:33.770]with the CDC and FDA through the process of clinical
[00:59:35.872]trials?
[00:59:38.541]SHAH: Well, my second book was actually about clinical trials
[00:59:41.678]and what I was looking at is how
[00:59:44.480]drug companies were so eager to
[00:59:46.182]get the clinical trials done faster
[00:59:48.051]that they were starting to take their experiments overseas
[00:59:50.420]to Africa and Asia where they could
[00:59:53.790]do experiments more easily and
[00:59:56.092]recruit patients quicker because there was less regulation
[00:59:59.295]and what I learned from doing that
[01:00:04.000]research is that speed is not necessarily
[01:00:06.869]what we want in this process.
[01:00:09.038]We want drug development to proceed with the best evidence
[01:00:12.809]and I think one problem here in the United States
[01:00:15.778]is while the typical American brings home
[01:00:18.181]about 10 prescriptions every year,
[01:00:21.050]only one in dozens is willing to volunteer for a
[01:00:24.754]clinical trial.
[01:00:26.155]So we want the drugs that work but we don't
[01:00:28.558]want to do the dirty work of being the guinea pig
[01:00:32.195]and that creates a contradiction.
[01:00:33.997]So if we want to speed it up,
[01:00:35.431]there has been a lot of talk about
[01:00:37.166]speeding up clinical trials by
[01:00:38.701]reducing some of the regulations on informed consent
[01:00:42.271]or on ethical oversight or any of those things.
[01:00:44.474]I think that is a terrible idea.
[01:00:46.109]I think what we really need to do is
[01:00:47.543]to encourage more people to participate.
[01:00:49.445]If we want the benefits of great drugs that work,
[01:00:52.682]let's do the work of being experimental subjects as well
[01:00:56.152]and volunteering for some of that work.
[01:00:58.021]HOST: Okay thanks Sonia, how important are
[01:00:59.589]federal funds and grants for universities for responses
[01:01:02.425]to pandemics in the formal research and training?
[01:01:06.029]SHAH: Well I think it is hugely important to me.
[01:01:07.830]I think our whole research establishment really relies on
[01:01:10.233]federal funding.
[01:01:12.835]You know, I think it's a very sort of scary time
[01:01:15.738]time right now when we have
[01:01:16.973]some of our new leadership talking
[01:01:18.574]about slashing that kind of funding.
[01:01:21.044]I think we all need to kind of
[01:01:22.779]stand up and come together and say we need this.
[01:01:25.648](audience applauding)
[01:01:31.120]HOST: I'd like to follow up on that
[01:01:32.588]with one of our questions from the twitter feed
[01:01:34.090]asks how might the federal executive order stopping
[01:01:36.626]agencies from communicating with the public affect
[01:01:39.762]the infectious disease war?
[01:01:42.832]SHAH: I think this is such an alarming thing
[01:01:44.300]and this just happened today that
[01:01:47.403]there has been word that the federal agencies
[01:01:50.139]have been basically given a gag order where they're
[01:01:53.176]not supposed to communicate to the public
[01:01:54.811]on social media or they're not supposed to I think update
[01:01:57.447]their websites or something like that.
[01:02:00.049]Now it is important for the government
[01:02:01.284]to control the message.
[01:02:03.119]I think that is all fine and that is good
[01:02:05.822]but what all of our agencies need is to build more
[01:02:09.792]trust, more connection with the public, not less.
[01:02:13.496]You know, so whatever we do, we need to make sure that that
[01:02:17.200]trust is getting stronger, not being eroded
[01:02:20.103]and I think silence is exactly what makes us think
[01:02:23.206]they don't know, they don't know us,
[01:02:24.740]they're not reaching out to us.
[01:02:26.409]I think it really could have the opposite effect.
[01:02:28.711]If what they want is to control the message,
[01:02:31.714]we don't hear the message if we don't trust the messenger.
[01:02:36.452]HOST: Thank you.
[01:02:37.920]Ladies and gentlemen, before Sonia takes her final question,
[01:02:39.755]I'd like to thank each of you
[01:02:40.990]for joining us tonight here in the Lied Center
[01:02:42.492]and also online.
[01:02:44.026]We look forward to seeing you at
[01:02:45.528]the E.N. Thompson Forum on World Issues next fall.
[01:02:48.564]Sonia our last question this evening,
[01:02:49.899]what is your opinion on epidemics helping end
[01:02:52.735]overpopulation?
[01:02:55.438](all laughing)
[01:02:58.374]SHAH: I don't believe in overpopulation.
[01:03:00.409]I think that was an idea that has been sort of, you know,
[01:03:05.715]we've overcome it with evidence that it is not,
[01:03:08.651]the question is not overpopulation.
[01:03:09.952]It is really how do we distribute our goods and
[01:03:12.588]resources so that we have enough for everybody
[01:03:15.091]and I think we do have, we could have enough for everybody
[01:03:17.560]and one of the best ways that we've seen
[01:03:20.830]to actually protect populations is women's literacy.
[01:03:24.600]So if women become more empowered and learn to read they,
[01:03:28.171](audience applauding)
[01:03:30.072]we know this works.
[01:03:33.976]HOST: All right thank you so much ladies and gentlemen.
[01:03:35.211]SHAH: Thank you all so much.
[01:03:36.679]HOST: Sonia will sign books afterwards.
[01:03:38.047](audience applauding)
[01:03:44.287]HOST: Fantastic, thank you.

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Pandemic: From Cholera to Ebola and Beyond

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