To the stage, ACOM President, Dr. Robert Bourgeois. Thank you and good afternoon. I hope everyone's been enjoying this fabulous conference. This afternoon, I will be presenting the recipients of the 2022 Occupational and Environmental Medicine Media Awards, also known as the OEMs. We will then hear a few words from our UK counterpart, the Society of Occupational Medicine, or SOM, before we introduce our Patterson Memorial Lecturer. This is the second annual OEM award ceremony, established by the 2020 and 2021 Presidential Task Force on OEM Visibility and continued by the new Council on External Relations and Communications, or CERC. The OEMs are a series of awards which aim to recognize and honor the efforts of journalists who promote understanding of occupational and environmental medicine, increase public awareness of workplace health, and focus coverage on worker well-being. The OEM awards were developed to encourage and promote the visibility of OEM and ACOM to the public and to establish relationships with external media. This year, awards were given in five categories. Student Journalism, COVID-19 Specific Journalism, OEM Trade Specific Journalism, Written Journalism, and Multimedia Journalism. The winners were mailed their awards prior to the conference. The recipient of the 2022 Student Journalism Award for OEM is Lillian Polson from the University of Iowa for her article in the Daily Iowan from the COVID-19 Unit, What Iowa Healthcare Workers Want You to Know. The recipient of the 2022 COVID-19 Reporting OEM Award is Renetta DeGregorio of First Coast News WTLV WJXX in Jacksonville, Florida for her piece, Why Won't You Save Yourself? Healthcare Workers Frustrated, Overworked Due to Unvaccinated COVID-19 Patients. The recipient of the 2022 OEM Trade Specific Journalism OEME Award is Anne-Marie Mannion from Risk and Insurance Magazine for her article, Five States Are Getting $1 Million Each to Implement a Multi-Sector Return to Work Approach. Is your state one of them? The recipient of the 2022 Written Journalism OEME Award is Michael Hawthorne of the Chicago Tribune for his article, Mayor Lori Lightfoot Set a Goal to Replace 650 Toxic Leg Pipes in Chicago in 2021. So far, three have been removed. And finally, the 2022 Multimedia Journalism OEME Award goes to the NPR special series, Hot Days, Heat's Mounting Death Toll on Workers in the U.S., which consisted of five stories and 15 contributors. Heat is killing workers in the U.S. and there are no federal rules to protect them. Julia Shipley, Brian Edwards, David Nickerson, Robert Benincasa, Stella Chavez, and Cheryl W. Thompson. As the nation gets hotter, efforts to protect worker heat deaths accelerate, but fixes aren't as simple as they seem. Kim Chrisburg, California firefighters keep getting injured during training. Some have died. Higher temperatures and less oversight mean workers are at a growing risk in the climate emergency. Brian Edwards and Jacob Magolis. New investigation targets heat exposure deaths across Texas and the U.S. Rhonda Fanning and Wells Dunbar. And Texas workers are dying in the summer heat and companies aren't being held accountable. David Nickerson, Julia Shipley, Stella Chavez, and Sarah Ernst. Accepting the OEME Award for Multimedia Journalism on behalf of the entire special series team are Julia Shipley and David Nickerson who join us via video. Hello, I'm David Nickerson and I'm Julia Shipley and we are two of the reporters on the Hot Days series. On behalf of the team, thank you for recognizing our work with this amazing award. We are honored to receive it. These stories were a collaboration between Columbia Journalism Investigations, NPR, and Texas and California Newsrooms and Public Health Watch. I'd like to thank the reporters, producers, and editors who worked tirelessly to make them happen. I'd also like to thank the Fund for Investigative Journalism for supporting the project. The story began after we saw the disproportionate toll of worker heat deaths on communities of color throughout the country. Through our reporting, we learned that regulators were failing to protect workers even as scientists, occupational health experts, were warning top officials that climate change would exacerbate the problem. Our reporting took us to cornfields in Nebraska, athletic fields in Texas, and leek farms in California. We couldn't tell the story without the help of occupational health experts, workers, and worker families, especially the families of workers who died on the job. Shortly after we published our national investigation, the Biden administration kicked off the long regulatory process that could result in a rule to protect workers from heat illnesses. While that is a start, our reporting found that the prioritization of worker health at all regulatory levels is necessary for these protections to be effective. As the frequency of extreme heat days increases, it will require even more attention and diligence from regulators, occupational health experts, and journalists to ensure that workers are protected from this worsening lethal hazard. Again, thank you so much for recognizing our work and believing that this is worthy of this tremendous honor. Thank you. Now, I am pleased to introduce Dr. Jane Moore, the incoming president of the Society of Occupational Medicine in the UK. Dr. Moore has been a member of the SOM since 1988, first as a GP, and then throughout her occupational health specialty training. She's worked regularly in the National Health Service, the NHS, for the UK government, within several commercial organizations, and has also held several posts within the Faculty of Occupational Medicine. Her interests lie in attracting people into occupational health, supporting training, enabling access to this specialty for the UK working population. Please welcome Dr. Moore to the podium. Hello, and thank you very much for asking me to join your conference. It's wonderful to be at a conference that's in person. Zoom has sustained us during the pandemic, but face-to-face feels more nourishing. I'm here as the president of the Society of Occupational Medicine. The Society is the largest and oldest UK professional organization for people who are interested in occupational health. Membership is for anyone. We have a multi-professional base with doctors, nurses, psychologists, physiotherapists, anyone who has an interest in the subject. We have pulled together during the pandemic, producing guidance on many things, including managing COVID at work, long COVID, and mental health support. We've held webinars, as soon as information on the topics could be collated to keep members up to date in the fast-changing environment. Our membership numbers have increased during the pandemic, and it may be that the fast current information and resource availability could be the reason why. We are following your lead and planning a face-to-face conference in Edinburgh in June, so June 22nd to 24th, so if you want to join us, we'd be pleased to see you. We haven't confined our activities to focusing on COVID during the pandemic. We've been advocating for wider access to occupational health in the UK. The estimate is that only 35 to 40% of the UK workforce have access to occupational health services. To this end, we've held an online summit looking at universal access to occupational health. We've been speaking to MPs. We have been arranging for questions to be asked in Parliament, and working with other colleges and faculties to raise the profile of occupational health. You may be familiar with our yellow journal, the Journal of Occupational Medicine. We have a themed issue coming up, which is later this year. It's basically, it will be based on climate change, and we're looking for articles, which will include editorials, systematic reviews, narrative reviews, primary research, and small articles as fillers. So if anyone has anything that would like to submit, the deadline is the 31st of May. Some of these developments I have already mentioned, but we have recently produced a scholarship fund for people coming into occupational medicine, which can help to fund a primary qualification, may go partway towards that, help more people into the specialty. I have mentioned to Richard that he is doing a leadership series in autumn, so that will be available as a webinar if you want to hear him speak at that. We have a number of reports that we have published and that are available to be read, should you wish to do so. Alongside that, we have worked with Public Health England on fact sheets to help employers maintain and improve good health and work outcomes for communities in the pandemic. They're on a variety of topics, which can be found on our website, and although that sounded a bit like an advert for us, we are very grateful that you've asked us to help join in the conference, and I'd like to just say thank you again. Thank you, Dr. Moore. And I understand Dr. Doug Martin may be attending the Edinburgh conference, so if you could get a picture of him in a kilt, we can use that for an OEHF fundraiser. We'd appreciate that. Now I have the honor of introducing this year's Patterson Lecture. The Patterson Lecture honors the memory of the late William Patterson, M.D., FACOEM, and ACOM board member who was chair of the Committee on Ethical Practice in OEM. Dr. Patterson led the charge of revising ACOM's Code of Ethics. The AOHC 2022 Patterson Lecturer is Dr. John Dreisner. As the former director of the Center for Preparedness and Response at the Centers for Disease Control and Prevention, the CDC, and former Tennessee Commissioner of Health, Dr. Dreisner brings expertise in the preparedness for and response to widespread infectious disease. His lecture, There Will Be a Next Time, Can We Do Better?, calls into question the nation's preparedness for the next global health emergency and examines extenuating factors that stalled early efforts to squash the COVID-19 pandemic. Dr. Dreisner will discuss doing the right thing, the four rights, the three tiers of preparedness, and the art and science of ethical population-focused prevention in the context of humility. Ladies and gentlemen, please join me in welcoming Dr. John Dreisner to the stage. Good afternoon. I notice that I'm the only person on this stage recently that doesn't have a cool accent, so you'll have to bear with me. I want to take a moment to thank Mr. President, Bob Bourgeois, and the ACOM board, and all of you for the honor of this invitation to speak to you. Thank you all for being here. I know this is the last plenary, so congratulations for sticking it out. I never expected to be here on the stage. I also feel a desire to shout out to a few longtime ACOM friends and colleagues that have inspired me and kept me closer to ACOM, to the college, than I might otherwise have been in my time in public health. This list is inevitably incomplete, but I want to say a special thanks to Dr. Jim Tocci, Dr. Ron Stout, Dr. Ron Lopkey, Dr. Warner Hudson, Mr. Pat O'Connor, who has been somebody I've spoken to a number of times over the last couple of decades, and Dr. Matthew Krebs. Also many of the other past ACOM presidents and boards that have inspired me since I was the chair of the residence and recent graduate section here at the college with their leadership and service. I also want to take a few minutes to recognize a few of the greats in my professional life whose shoulders I have stood on. I will never forget the first time I heard the quote from Isaac Newton. It was from Dr. Roy DeHart at the Rocky Mountain Center for Occupational and Environmental Health, where I did my residency, actually right here in Salt Lake City, where my wife and I lived here for a couple of years. These are people that have lifted me up at key moments in my professional life. I have stood on their shoulders, and I recognize that I'm like the turtle on the fence post, right? I didn't get here by myself. So two of these folks, and I won't go through everybody, but two of these folks I want to especially mention, Dr. Rod Van Der Beek in the corner there. He was an F-15, is an F-15, or rather, F-16 physician pilot who taught me a lot of leadership lessons when I was in the Air Force. And then some of you may know, there's a guy on that screen named Bill Haslam. He was the two-time mayor of Knoxville, two-time governor of Tennessee. Also a number of other folks, two of them were teachers. Three of them were actually colleagues and friends. And then the one, in addition to my family of origin, and my in-laws, and my kids, my wife, Jana Dreisner, has been foundational to my journey and in my career. She's here with me today. We celebrate 33 years on Friday, and she's put up with my preparations for this. There's a lot of other people I could mention, including many reverse mentors over the years. People who are younger than I am and have taught me a lot, but they are in my head and in my heart. I also want to thank Dr. Bill Patterson and his family and friends for his inspiration to devote time in our lives to the consideration of ethics in our profession. I knew Bill. Many years ago, I was considering joining a clinical enterprise that he was involved in leading. One thing he said to me has always stuck in my mind, and it's funny what sticks in your mind when people say to you, but he said, docs have to haul freight. And of course, he was referring to the importance that occupational medicine physicians had in his line of work for both profitability and credibility of the company. But I think in another sense, he was referring to what clinicians have to do to stay on track, to keep our ethical commitments front and center. He recognized the narrow gauge track occupational health clinicians ran on, in particular, to be trusted by both their patients and the workplaces and the employers who relied on their expertise and their advice. Because of him, we're here today. The truth is, when Bob honored me with this request to speak, I wanted to run the other way. I struggled with what to cover in my minutes that would be most beneficial to you. How to speak truthfully and not disdainfully. Like each of you, I've lived this pandemic in a variety of ways. It's vexed me, and inevitably, some of the things I think I know, those areas that I'm convinced about, will be wrong. Quick context. Bob already mentioned a couple of the roles I had. I started my health care life in the Air Force. I had a rapid opportunity to have some amazing leadership opportunities, leading organizations of various size. I also had some great opportunities to have some tremendous leadership failures very early on and took full advantage of those failures and the people that helped me figure out how to move out of those. But I liked doing that, and I found a calling in organizational leadership, and I've had an opportunity to lead organizations of increasing complexity and size over those years. I want to say that I was also, you might not know, a local public health official. So much of my thinking about preparedness response that didn't come out of the Air Force came from my lived experience as a local health official for a decade in Appalachia, including through the H1N1 pandemic and other issues. There's so much yet to learn and understand, but being here seemed like it passed our four rights test. The right thing at the right time, the right way for the right reasons. This is a framing that I and teams have used as a public official because we realized that just thinking you're doing the right thing, just that one thing, is not enough. We found that this four rights test and other kinds of tests like it help avoid self-deception and maintain humility. So because there's a lot of ground I want to cover, so please buckle up. If I haven't irritated a few people by the end of this talk, I really haven't done my job. I thought it would be best to give you the bottom lines up front and what I plan to present. You can nap after that, but if you do, I hope you'll miss some good stuff. So I believe we can do much better. We'll discuss why we must. We will look at some of the risks on the public health radar screen, the minds of global thinkers and a moral philosopher's perspective. COVID-19 is a gift of a terrible sort. We must not fail to learn and grow from it. So let me say right now that yes, we have to make difficult choices with incomplete information about how to balance competing priorities of our economy and our health. But there's morbidity and mortality on both sides of that. And at the end of the day, health and prosperity are two sides of the same coin. They require a holistic approach, more so than I think we've seen. My third point there, people are policy. People are policy. Substantial restructuring, reforms to ensure people who are making policy have accountability. In particular, I think federal civil service reform is essential, and I'll talk a little bit about that. The fourth point there, health and governmental enterprise culture needs a systems approach. Aviation style safety management and continuous improvement frameworks. I don't think that's a nice to do. I think that's essential. Humility and level five or servant leadership at all levels is essential, common, and ancient. Incentive alignment is a key feature of mission-oriented leadership. Application of ethical principles is essential. They set a kind of a vision for our art. We've seen too many failures to employ these principles, resulting in authority exceeded and the social contract broken. We'll briefly explore that. In my view, knowledge discovery throughout this pandemic has been, at best, suboptimal. The scientific method has been squelched, free and open debate cut off, harming us all. Mistakes were made. They're institutionalized. Nonpartisan political will is needed to address this. Money will not solve it. Preparedness and response, like health generally, needs an emphasis on primary prevention. I call it primary preparedness. Think of the cost of this pandemic. We can't tertiarily, as we're trying to do now, or even secondarily, prevent our way out of all the risks that we face. We'll look briefly at the importance of one health approaches and of the dual use and biosynthetic research and the very real catastrophic threat of an engineered pandemic. Then I'll invite your observations and conversation. So, a few thoughts up front about where we are in this current pandemic response. We continue to muddle through this latest pandemic. A lot went wrong. Some went right. The story is still playing out. The spinning began quickly. Analysis will take time. History is being written. When we will be able to trust that history, as we read it, is yet to be determined. Aren't we terribly polarized? I'm going to try and experiment. Masking. Mandatory vaccination. Ivermectin. CDC guidance. Just saying those words can prompt us to stop listening and start attacking or defending. We could spend this entire time running through any one of those issues without satisfying everybody in this room or those who are joining us online. Polarization gets in the way of knowledge acquisition and arriving at an interim theoretical consensus, because we don't know everything. Many clinicians and public health practitioners hold the bag in the meantime or flee to the false safety of dictates or inaction. Three years into this pandemic and there's still so much we don't know. We are absent a fully and open, a fully open and transparent, rather scientific debate and discovery. We, the people, don't know who to believe. Did COVID give us a strange and terrible gift? So, regardless of the true origins of SARS-Coronavirus-2, the world has seen far worse pandemics. We know that. The black death in Europe killed 25 to 50 percent of the European population and many others in continuous continents. The Americas weren't discovered at that point, but by the time we did, we had the the Columbia Exchange die-off that resulted probably in the loss of about 10 percent of the world's population. And H1N1 in 1918 was more severe than than we faced here. We will have naturally occurring pandemics again. We have a chance for cultural learning and adaptation and a window, I think, now to correct our failures. So, that's where I see the gift. The other four common cold coronaviruses, after all, were probably significant human pandemics of zoonotic origin in the past. Probably significant pandemics of zoonotic origin in the past. So, ever-present risk remains for natural pandemics, but as terrible as these are, so far they have not engendered a existential risk for humanity. There is, however, a plausible risk of an existential catastrophe from deliberately bioengineered microorganisms, whether they are well-intentioned or not. I arrived at the CDC in September of 2019 as the first permanent director of the Reorganized Center for Preparedness and Response. I was among a small group of people just before New Year's of 2020 who learned of a cluster of atypical SARS-like pneumonias that would appear to be a zoonotic outbreak in Wuhan, China. At the time, we hoped and kind of initially believed that there was no human-to-human transmission. We kind of bought that for a very brief period of time, even though most likely at that time there was transmission going on right in the continental United States. So, our CPR team was, and is, a dedicated and passionate team of about 600 souls. So, the CDC has 13 centers, institutes, and offices. I was privileged to head up one of them. It had three divisions, Division of Select Agents and Toxins, Division of State and Local Readiness, and the EOC. So, the you see picture there, the EOC. Our team staffed that, we ran that, but we were not the drivers of the COVID-19 pandemic response. That fell to another to another CDC center, and it was zealously guarded. To continue the the driving analogy, the automotive analogy, from our center's perspective, we were kind of the engine of the response. But if we knocked hard enough on the window, occasionally the drivers would roll it down to see what we wanted. That's a laugh line, it's not a very good one, but I'm doing the best I can here. So, from a public health standpoint, we enumerated many risks, and this is a little CDC-centric, but it's also a lot of things that the public health officials think about on a regular basis. Bioterrorism, pandemics, disease outbreaks generally, chem, radnuke, natural disasters, we didn't account for them all. Keep in mind, at the state, local, federal level, there's always overlapping agency responsibilities. Some things you're on point for, some things you're back up for, depending on your organization. However, those risks were not considered equally, right? You'll be surprised to learn that I was repeatedly cautioned, I was the new guy, I was repeatedly cautioned that my efforts to bring radnuke issues to the fore, because in my assessment, they were both more dangerous than we thought at the time, remember this is 2019, and also I knew from my local and state experience how woefully underprepared we were for even something that would have been more superfluous than serious. In any event, I was advised to lay law on that, I did not take that advice. Similarly, things like looking at weather emergencies, the public health responses to hurricanes were kind of quietly derided because infectious diseases were of the greatest interest to that particular organization, to the CDC. It gets to the founding mission of the agency, what people knew and how they made their power bases and careers, I called it the infectious disease mafia. So you could do other stuff at the CDC, but you were not in the cool kids group. The competition for resources and attention from leadership is very real, priorities are entrenched, the budgets are quite set, and settling on the most familiar enemies in the last battles is a frequent default. So this is a quick results of a survey of 16,000 Millennials in 16 countries, about half in conflict, half not in conflict. This is 2019, so before the war in Ukraine, and 54% of those Millennials believed a nuclear war was likely in the next decade. 84% of them believed nuclear weapons use is never acceptable, and 74% believed war is avoidable, which means a lot of them believed that war wasn't avoidable, and a disturbing percentage believed that nuclear weapons use was acceptable. This is a survey by the World Economic Forum of thousands of global leaders. The environmental concerns are in green, societal are in kind of red, pink, the tech concerns are in purple, the economic are in blue, and the geopolitical risks are in yellow. 84% of these world leaders are concerned or worried about the world, so that's a good thing, but note that climate action, failure, and extreme weather is in the top three of all time frames, but concerningly, nuclear risk does not appear in any of the top ten. This is just before hostilities, the war broke out in Ukraine. Regarding opinions on mitigation effectiveness, international crime and weapons of mass destructions were risks that the surveyed felt were effectively prepared for. Let me say that again. International crime and weapons of mass destruction, to include nuclear weapons, were risks that those surveyed felt were effectively prepared for, but artificial intelligence, cross-border cyber attacks, and misinformation are areas that these global leaders thought we are less or unprotected against, so I'm very glad that they are concerned about artificial intelligence. I worry deeply about efforts to protect me from misinformation. Note that the social environmental issues, that graphic down there at the corner, so social and environmental issues were thought by these leaders to have been made most worse by COVID, global risks that had gotten worse by COVID, and interestingly, extreme weather. Societies and civilizations collapse, that is the rule, not the exception, we all know that. That has occurred, or at least in many instances, dramatic transformations of those societies have occurred in our historic past. We don't know about what happened prior to written history, and we don't know what risks may befall, but we do know that they will. We know for sure that our now planetary civilization, its continuation, and the amazing and unprecedented human flourishing it has brought about is not inevitable, not inevitable, inevitable. But we also know that uniquely, for the first time, our species has the ability to both assure and to end its own future. Winston Churchill, in his famous Iron Curtain speech in Fulton County, Missouri, said, what might now shower immeasurable material blessings upon mankind may even bring about its total destruction. So that brings me to a moral philosopher's perspective that I think it's very important, and one that I feel ethically bound to consider and to comment on here. A look at his dedication goes to the heart of what he's asking us to consider, dedication to the book, to the hundred billion people before us who fashioned our civilization, to the seven billion now alive whose actions may determine its fate, to the trillions to come whose existence lies in the balance. So this book, The Precipice, is about 250 pages long and another roughly 200 pages of appendices and notes. I recommend it to you. The Precipice is Toby Ord's analogy for where we as humanity found ourselves in 1945 when we had the ability to bring about, potentially, our own extinction, our own end. And he has a very, some very interesting perspectives on that as a moral philosopher. And he essentially says, if we succeed in navigating this precipice over the next several centuries, people will marvel at where we've come, because our technology and our capabilities currently exceed our wisdom, exceed our wisdom. And getting through this is not a given, not a given. So he, one of the things he says, I think, really brings his point home, is the other thing I'm going to quote, which is one of my principal aims in writing this book, is to end our neglect of existential risk, or to establish the pivotal importance of safeguarding humanity and place it among the pantheon of causes to which the world devotes substantial attention and resources. Exactly how substantial remains an open question. I suggest we start by spending more on protecting our future than we do on ice cream and decide where to go from there. So, building on the work of many others which he goes over, he categorizes existential risk, a risk that threatens the destruction of humanity's long-term potential, a risk, and an existential catastrophe, the destruction of humanity's long-term potential, which is unrecoverable. Either we become extinct, or we find ourselves in some type of unrecoverable dystopian future, an authoritarian future, or perhaps one controlled by unaligned artificial intelligence. Trillions of future lives hang in the balance. He provides us with a detailed analysis and estimates of existential catastrophic risks. You can only have one. His educated hypotheses on the probabilities of which he places in an order of magnitude range. I don't have time to do his quite fascinating analysis justice, but one of the things that I think is important is that when looked at it from a future of humanity standpoint, the natural risks are relatively low. It's the anthropogenic or the human-caused risks that are high, and you'll note there the two things that I highlighted. The naturally arising pandemics, he estimates about 1 in 10,000, but the engineered pandemics, about 1 in 30, and unaligned artificial intelligence, 1 in 10. So, his two highest estimates based on a lot of expert opinion that he goes through. Though I have not met him, I heard him speak, and he strikes me as a humble moral philosopher. In my view, humility is at the core of the most effective leadership. This is not a secret. What makes for great leadership is ancient knowledge. The Chinese philosopher, Lao Tzu, remarked on it 2,500 years ago. He says, to lead the people, walk beside them. As for the best leaders, the people do not notice their existence. The next best, people honor and praise. The next, people fear. The next, people hate. When the best leader's work is done, the people will say, we did it ourselves. So, Jiddan Collins, in his seminal book, Good to Great, also recognized what he called level five leadership, servant leadership, humble leadership. It's not typical of what gets popularized as leadership, but it's the kind of leadership that people want to work for. A leader who walks beside them, who makes it their idea. And the good news is, as Collins kind of repeatedly notes, that level five leadership is not uncommon. It's common. The best organizations have this at both the top and at all other levels of leadership. I always like to say, no one's more important than anybody else. Everybody has their role, and leadership at all levels really matters to the success of an organization. Think of Abraham Lincoln's team of rivals. You know, a president who would humble himself to hold the horse of his General McClellan, if only he would go and fight for victory. Or, a president who had the courage to quietly move that general on, if he would not. So, humility and humble leadership is not meek or weak. It is integral, it is kind, and it is self-aware. These level five leaders are strategists, not transactors. They have a method. They have a vision. They share it. They're mostly predictable. You don't have to, you know, you don't have to hear what they're gonna say next. You have to wait for them to tell you what to do next, if you're working with them. You pretty much know what they want you to do. They make it about the mission, about the service, not about them. I like to use this acronym, Mission, Organization, Person. That should be the order. When people get too focused on themselves or others, or even on the organization itself, it's time to get out the mop. Particularly for governmental, nonprofit, educational organizations, this is the order. A little bit different, I think, if you're, if you're a revenue-producing and profit-making organization, but I think the principle applies. Why would I talk about this guy? Nobel Laureate James Buchanan. Newsflash. Politicians are motivated by self-interest. That was a headline in 1986 when this, this economist from Tennessee shared the Nobel Prize with his collaborator, Gordon Tullock. Together they published in 1962, The Calculus of Consent, Logical Foundations of Constitutional Democracy. This work helped me understand the importance of incentive alignment, and also to deflate the dangerous, self-serving, and self-dealing notion of the supremacy, supremacy of public service. Hogwash. Hogwash. Haven't we all seen too many people in the governmental and nonprofit world deceive themselves, and attempt to deceive others in the arrogant belief that they are above reproach in their decision-making or motives, merely because they are public servants, or dot orgs, or dot edgies? In fact, can't they be the very worst kind of self-serving hypocrites? Putting their careers, their pay, their promotions, their power, their ease of work, their comforts, their privileges over the needs of people they serve. It does occasionally get them into trouble, but too often they get a pass. At least people who are in business, or working to make a profit, are clear and transparent in their aims. Buchanan said, politicians and bureaucrats are no different from the rest of us. They will maximize their incentives just like everybody else. He also said, the most efficient means of organizing human activities is that of leaving voluntary solutions free to emerge. So incentive alignment, the classic 1975 management paper by Stephen Kerr on the folly of rewarding A while helping for B, for me, adds a way of thinking through what is really being incentivized. As Kerr puts it, what behaviors are we paying off for? And for public servants to understand that as noble as they may be, and there's lots of noble, hardworking public servants, right? But we are all self-interested. We are all self-interested. And since we are all self-interested, if we can align our interests and those of our team with those of we, the people, the people we're serving, we have a shot. We have a shot at getting it right. And the people will say, we did it ourselves. One of the hard things about level five leadership, you don't often get credit for it. So what behaviors of public servants in this pandemic got paid off for? What do we need to rethink in our incentive system? Would service reform, with civil service reform, rather, help? So four principles of medical ethics. Some would say there are three. Ethics, I think, are a vision, a kind of vision of how to best live and practice our art. We may not always measure up, but without vision, the people perish. We need to have these principles to help us help our patients and humanity flourish. These medical ethical principles are rooted, and I think can be discerned in the classic Hippocratic oath, particularly beneficence and non-maleficence, or do no harm, or do good and don't do bad. The four principles popularized by Beauchamp and Childress, autonomy, beneficence, non-maleficence, and justice, have been extremely influential in the field of medical ethics, as you know, and have been fundamental to the current approach to ethical assessment in health. We also see these principles inspired the Physician's Charter of 2002, and our own ACOM Code of Ethics. We have seven ethical principles. That's a vision for the art of OM practice. The AMA, noting primacy of responsibility for the patient as paramount, has nine principles. Seven, nine, twelve. Public Health Leadership Society, also in 2002, like the Physician's Charter, articulated these principles, also speaking to beneficence and non-maleficence. They termed it preventing adverse health outcomes and respecting the rights of individuals, inspired by those same four principles, as I mentioned. These were looked at again a couple of decades later by the American Public Health Association. The modifications were substantial. The APHA's 2019 code seems to me less a vision and more of a specified standard. In reading it, I don't think it was much, if any, influence in the way our most recent public health crisis has played out. It would be difficult to do that, right? You know, six obligations, eight guidance for ethical analyses, twelve domains, and eighty-seven different ethical guidelines. If Janet gave me a list of eighty-seven things to get at the grocery store, I'd be good to get maybe thirty. I could get four. Let me just highlight a couple of things, right? Permissibility. Would the action being considered be ethically wrong, even if it were to have a good outcome? Should you experiment on a population even if you hope it will be helpful? I think about public health implementation of cannabis and its potential impact on child health. It was a big issue for me when I was in Tennessee. We actually issued a, as far as I know, the only warning a public health official has ever issued about cannabis, marijuana, and hemp, as a general warning, caution to the population. Proportionality. Would the proposed action demonstrate that public health practitioners are using their power and authority judiciously and with humility? Great, great analysis, but are mass, unsegmented mandates judicious? Public participation. In deciding on proposed action, have all potentially affected stakeholders had a meaningful opportunity to participate? If some are to be deliberately excluded from decision-making, is there an ethical justification for doing so? So I ask, is calling people names and quote-unquote taking them down because they have a scientific disagreement with you, providing a meaningful participation opportunity? So these were not followed. I think anybody can see that they weren't, even for those public health practitioners who might have been aware of them. This is the public health monoculture, okay? These are people that I love. I've been working with them for 20 years, 30 years, but we broke the social contract in this pandemic and I'm not sure how it recovers in this generation, but I hope it will. Some definitions. Autonomy is one of the core principles as we've seen. It and moral agencies are components of liberty and freedom. The point is we have to be very cautious with requirements and mandates. An ethical framework is essential to evaluating them. So is at least an interim scientific and medical theoretical framework in guiding their import. Expediency is dangerous. That's why the four rights tests or some other test. Finally, dehumanizing people who don't agree with you is unjust and harmful, further flying the face of our ethical vision. Another one of my favorite Nobel laureates, Richard Feynman, theoretical physicist. He said a lot of different things about science. He was a teacher of science and the scientific method, but one of the things he said was, science is the belief in the ignorance of experts. There's a great number of other scientists who understand that science is a culture of doubt, a culture of doubt rather than of faith, of uncertainty rather than certainty. A wise scientist approaches a subject with humility. The famous physician educator, William Ulzer said, medicine is a science of uncertainty and an art of probability. So whether we apply that to individuals, we apply that to populations, nothing about that has fundamentally changed. There were many failures in this pandemic, I think, but chief among them were missing the unknown knowns. Things that other people knew that people that were making decisions didn't. A failure to use the wisdom of the group, failure to use the wisdom of the group. That's why we are where we are today. That's why our civilization is where it is today. We are excellent at learning from people in the past. You look in this room, everything around us, everything around us is built by those hundred billion lives that came before us. We wouldn't be here, none of this stuff would be here without that collected technology. Not one of us could build a chair like that from materials we would find in the ground. Nobody could do it. There's some people out there that could upholster it, some people out there that could weld stuff, people out there that could staple stuff, but you couldn't make the staples. You couldn't do all the things it would take to make that chair. Sometimes with the great arrogance of self-interest, people sought to suppress not only the, they not only missed the unknown knowns, but they sought to suppress the known unknowns and sometimes the known knowns and we can do better. So should our failures in the United States be a surprise? Okay. Not if we'd been paying attention. So rather than, you know, talk about my anecdotes, these failures were and will remain unless we take serious substantial action, inevitable. Just look at this. This is a report from the Government Accountability Office, okay? For more than a decade, there's a quote, for more than a decade, we found persistent deficiencies in HHS's leadership role preparing for and responding to public health emergencies, including COVID-19 and other infectious diseases such as the H1N1 influenza pandemic, Zika, Ebola and extreme weather events, end quote. This is also from the GAO website directly. Significant improvements are needed in leadership and oversight. So they document having 115 recommendations made to HHS from 2007 to 2022 and they note the majority of them have not been fully implemented. They cite persistent deficiencies such as persistent deficiencies in preparedness and response efforts, establishing clear roles and responsibilities, collecting and analyzing complete and consistent data, providing clear, consistent communication, establishing transparency and accountability and understanding key partners' capabilities and limitations. One of the reasons I was recruited and brought it to the CDC is because I had a depth of knowledge in local and state capabilities. My guess is that these Government Accountability Office findings ring true with a good many of you who had to rely on HHS agencies through emergencies like H1N1, fungal meningitis, Ebola, Zika and COVID. So ask yourself why very smart people, these are very smart people, working very hard, they work very hard, with many years of experience and repeated opportunities to improve, would have their efforts so consistently fail to meet expectations. I submit it's because they are not truly incentivized to do better. They are in fact, as Nobel Laureate economist James Buchanan would say, maximizing their incentives just like everybody else. When you multiply these incentive maximizing decisions, whether such decisions are made on an individual, a small group or even an organizational basis, taken across time, these are the failings that we would expect. There's another critical piece to this. People are policy. You hire someone, not only hiring the individual, you're hiring the way they think, you're hiring their biases, you're hiring them to do the things that you know that they'll probably do. And many people think that it's appointed officials that hold the policy cards, but that is not true. Most of the appointed officials, or the politicals as they're often called in federal government, have no choice but to rely on the career officials, the careers. The careers have the agency knowledge, the procedural expertise, the loyal staffs, the internal and external relationships to get things done. And they hold many, if not most of the cards. And some careers will say, we are the B team. We are the B team. That means we will be here after you, the political team, are gone. They are deeply burrowed in, and they have spent most of their careers in government and often in a single agency to get that level of essentially unaccountable power. They don't like to give it up. They don't like to have it challenged. Thus, civil service reform and restructuring is essential if we are to see progress. I'm not talking about across the board. There were some things that have been proposed by others, but just to make sure that people that are handling money, that are making policy decisions, that are making higher decisions, because very few people get moved on, are as accountable to we the people who put them in those positions as they should be. By the way, federal civil servants also have an ethical, a code of ethical conduct. It's not as pretty as ours. Public service is a public trust, requiring employees to place loyalty to the Constitution, the laws and ethical principles above private gain, although private gain is not always defined the way you and I might define it. And not everybody knows this, but all federal officials, people that take a federal role, take an oath of office just like you may have in the military if you served. This is the HHS org chart. I actually had to cut and paste this and then glue it back together if it looks a little funny, because it's so long it doesn't even fit on a web page, okay? So the size and complexity of this organization does not help matters. It has a $1.3 trillion budget. That's a trillion dollars. But put that in context, okay? $1.3 trillion is more than the gross domestic product of all but about 14 nations in the world, okay? And about 153,000 employees. This is a hard slide to read from probably where you're sitting, but federal layoffs and discharges have the lowest rate by a substantial margin, including local and state employees of any industry. The lowest rates of any industry. Do we think they are just that good? What about the World Health Organization? Okay, I really can't tell if it's the same, a bit better, or a bit worse than our own federal government agencies or HHS. I have my suspicions. Like us, they had a practice pandemic in 2009. They had SARS-CoV-1 in 2002. Note that their failures were found to have worsened this current pandemic. Worsened it by an independent panel that they, the World Health Organization, called for and chose. Now, you see in the World Health Assembly agrees to launch process to develop historic global accord on pandemic prevention, preparedness and response. Reading between the lines, I think they want more money and power. Giving failing organizations more money and power doesn't usually help. I could be wrong there, and I really truly hope I am. So preparedness and response. Why preparedness and response? So there's no greater calling than to show up for your community, preserving life and health in a crisis. They don't care what you know until they know that you care. And that's my obvious bias. I've been a preparedness and response guy really since the beginning, because I think it's at the heart of what we do in health. The best kind of response, of course, is the one that you don't have to have. The next best kind of response is the one that you're really prepared for. But when you show up, like a trusted family doc, when you show up that family doc in a crisis, when you show up for your community, or they know you're ready to show up for them, then they're more likely to take your advice on really important things that may be much more important to their life and health. But art is acute in the moment. So that's a part of trust. I think that I would always encourage folks, and personally when I was a local director and then later on, fight like you train and train like you fight. Find ways in your organizations to exercise the way it is you plan to respond when some response occurs. Find a stand and find a marker. I'm sure many of you do it. But when you don't do that, when you don't incentivize that kind of thinking, when the balloon goes up, you inevitably aren't very prepared for it. People are the net. I got to testify before Congress on this a few years ago. I didn't bring a prop with me today, but I actually brought a little net to kind of hold up so they'd remember it. Because a lot of times our leaders think they need to give us money for stuff. But it's people that are the net. People and the networks of trust that they create at the local level, that's where the rubber really meets the road. The vital services, information, and supplies come from these people. It's the people that we the people can benefit from because they can help translate for us what's needed or they can meet our needs because they know us. Materials and supplies, the stuff is needed, and there's a lot that goes into that. There's a lot that goes into that. But without the people and their networks built on trust at the pointy end of the response spear or the vaccination spear, most of the benefit is lost or the benefit gets delayed and lives hang in the balance. I like to think about primary, secondary, and tertiary preparedness. Okay, so primary preparedness, preventing the event from occurring or substantially impacting a person or population in the first place. And it goes on. So this is the analogous to what we all learned about in the types of prevention. So two, as in health and health care, the pyramid is inverted, right? Primary should be at the base, but how we put most of our resources into tertiary plans and activities, this is the dead wrong approach. But one we have been so far unable to graduate from. Our hierarchy of controls teaches us it is much better to eliminate the risk or engineer it away than it is to make laws to mitigate or regulate it or treat it or try to protect people from it once it's present. So two quick slides. Got to go from this to that. But says easy, does hard. I'd be remiss if I didn't mention One Health and our planet, right? Because this is where emerging infectious diseases and pandemic threats are coming from. We need to pay a lot more attention to this. That's the health world and the veterinary world and the horticultural world all working together. As a practical example, a very careful occupational health attention to people collecting bats for study, let's say, or other animals for food. Or a very careful occupational health attention to the vaccine status and the flu vaccine status of people who are culling birds with a highly pathogenic H5N1. I mentioned my three divisions when I was at the Center for Preparedness and Response. One of them was the Division of Select Agents and Toxins, a small group of mostly PhDs, super smart people who regulate roughly 250 labs in the United States that do work on select agents and toxins. Those are things that pose a very severe potential health threat. Their reach does not extend to foreign labs. They're top-notch folks, and they know that there are many holes in the Swiss cheese of this research and development enterprise, even as it's legitimately practiced in the United States and elsewhere. These holes can line up. They have lined up. If they do anywhere in the world, it's a threat to all of us. Remember Toby Ord's engineered pandemic risk assessment. For example, we have seen accidental lab releases or biosecurity incidents, and this is not classified, with SARS Coronavirus 1, with smallpox, with anthrax, with anthrax just less than 100 miles from where I'm standing, samples of live anthrax spores released to I think about 92 labs around the world, bubonic plague, potential pandemic strains of flu, foot and mouth disease in the UK. So this is not a theoretical risk. Was this SARS Coronavirus 2 pandemic the worst lab release so far? I can't prove it, but I believe it was. Can we do better? Of course. It's a decision. Can we do worse? Also yes, but let's not. Will more money help? Short answer, no. I put together three slides here. So as a percentage of GDP, as a total spend, and as a per capita, we spend the most money of any nation in the world on our health care system. Depending on the year, you look at $3.1, $3.3, $3.5 trillion latest figures. Again, let me put that in context. If the US health care system were an independent country, it would be the fifth largest gross domestic product producing country in the world. In the world. It would be behind only the US itself, China, Japan, and Germany, and the US health care system. So think about that from a global equality and a global health equity standard. How are we doing there? Not so hot. Not so hot. What do we get for that? We get one of the worst performing health care or sick care systems among the 11 most developed systems. That's according to the Common Health Fund. You can quibble with stuff, but there are a lot of reasons to understand that most of us, if you think about it, if you've personally been to a health care facility for any length of time, or you have a loved one who's been in a health care facility for any length of time, are you aware of an error-free stay, where nobody missed anything, or something didn't go right? Yeah, you laugh. You're right. Yeah. I mean, you just don't see it. It's very common. If health care were aviation, we'd have a plane crash every day. I should also note that our failing health care system is also a driver of our national debt, if anybody cares about that anymore. It's really rooted in chronic disease. We used to talk about, well, I won't go into that, but suffice to say that chronic disease, including substance use disorders, are a significant driver of our national debt, particularly among some of the highest risk populations that we have here in the country. So elements for doing better, elements for doing better. These are components that I have found helpful. Humility, ethics, knowledge acquisition, free, open, and continuous dialogue. See also the First Amendment. Incentive alignment, a commitment to improving the system rather than blaming individuals, an aviation safety model. So part of our challenge, and I'm sure I'm guilty of it myself sometimes, is we look to the individual and say, you've done bad. We used to say, when there was an aircraft mishap, that pilot didn't get up that morning, strap on that jet and say, how can I kill myself and destroy a $100 million airplane today? That's just not, that wasn't what they thought about. We've got, aviation is so, aviation and transportation generally are so far ahead of us in the health field. There's some bright spots in the health field, but as an industry, we're far behind. So helpful components. We need an actionable paradigm or theory to guide a vision. Methodology to progress, perform, innovate, test theories continuously, get better. The Baldrige framework, the scientific method, PDCA cycles. I've already mentioned tests to avoid self-organizational self-deception. Recognize and reward success itself is a powerful incentive. So I had an eight-year journey as a commissioner of health in Tennessee. And basically, this is how we ran the department. Basically, two ideas. Primary prevention is what we do. We do a lot of other stuff, but primary prevention is what we do. Performance excellence, how we do it. We provided direct services. We touched one in five Tennesseans in the 95 county health departments annually. We provided primary prevention services everywhere. We regulated the entire health care system in Tennessee. Most of the food and hospitality industry. A number of other things. I was blessed to lead a team of 3,500 souls. And it was a lot of fun. I do want to give you one brag alert. In that eight years, because you're hearing me criticize HHS and their audit findings, in that eight years, we had two major audits. They were called sunset audits. That meant if we failed them, they sunset the agency. We went away. We had a lot of other audits, but two major audits from our GAO, our comptroller. In that time, we had five findings. All of them we addressed. Two of them, we told them, you need to give us these findings. This is the org chart. The green and blue boxes reported to me as commissioner. All those other boxes, though, and most of their direct reports, after we did civil service reform in Tennessee in 2012, served at the pleasure of the governor, vis-a-vis the pleasure of me, the commissioner. It was exceptionally rare to move anybody on. So civil service reform is not the whole thing, but it's really important. It's really important to get alignment, to get everybody pulling in the same direction. I used to say, I don't even care if you're just pulling on a tangent, but just don't pull on the opposite direction, and we can move forward. This was kind of the vision we used. This was a health paradigm we put together, built on the work of a lot of other people, but it just talks about education and meaningful work, being directly involved in health and prosperity, the importance of relationships, of place, of the genetic and developmental background, of good governance, and just the whole idea that health and prosperity are linked. Show me a healthy community. I'll show you a prosperous one. Show me a prosperous community, and I'll show you a healthy one. Did I reverse that? Show me a healthy community. I will show you a prosperous one. Show me a prosperous community, and I will show you a healthy one. So that's how we talked about health, and this is how we got folks moving towards primary prevention, because they recognized most of what we were after were behavioral issues, things that we can control. I'm a Baldrige guy. I have very good reasons for it. In particular, I find it consistent with the scientific method and intuitive for most people. It's not been hard to get people enthused about it. It's a framework. It's got a lot of room for tools like Six Sigma and Lean. It was actually developed in the Reagan administration by the Commerce Secretary for Ronald Reagan, Malcolm Baldrige, a colorful guy. He died in a rodeo accident. They named the framework after him. But he saw that the United States was getting its clock cleaned by foreign competitors because we didn't have a methodology to get better in business. We need a methodology to get better in government. We need a methodology to get better in education, methodology to get better in the health care sector. A lot of folks use this. I think this is a particularly good framework for that. There are other frameworks out there. The point is, pick one. What I like about this framework is it's a framework. It doesn't specify what to do. It makes you think about what your key factors for success are, asks you to develop an approach, a deployment, to learn from that deployment, PDCA, check new check-out cycles, and then integrate what you learn across your organization to continue that success. It's not a destination. There's an award for it, but it's not a destination. It's a journey. You can always get better, and you never get it entirely right. There's been several different versions of the Baldrige framework. They're all essentially the same. They just modeled them a little bit differently. Speaking of rewarding success, this is innovative incentive alignment. How many of you all have heard of the Ibrahim Prize? A few, probably not enough. It's not awarded every year. It's not awarded every year because they can't find good candidates for it, because this is a billionaire, a cell company billionaire who's used his resources to help his native country of Africa move needles towards good governments. So his prize rewards a democratically elected head of state who serves their constitutionally mandated term and demonstrates exceptional leadership. So he's hoping for good governance, and he's rewarding for good governance. $5 million prize at the end of their service, and $200,000 a year for life. Interestingly enough, one of the people on that chart there was one of the members of the World Health Organization's selected panel that looked at their performance in the pandemic that I mentioned just a few minutes ago. This may be hard to see, but what this shows is better governance equals more happiness. You've got governance as applied to a corruption perception. It's not one-to-one, but people are more happy. People are more fulfilled, more human flourishing in places where people can count on rules, the rules of law, and not the good graces of government officials. So the bluff, the bottom line up front is a common federal thing. Maybe I just made up a new word, the bottom line and back. Probably not. Again, I do believe we can do much better. I hope we can agree risks are clear and present, and the stakes are incalculably high. Next time is too close. We must learn from this pandemic and leverage our learnings to address other risks. As we know, we have to make difficult choices with incomplete information about how we balance competing priorities. But at the end of the day, health and prosperity are two sides of the same coin, and we have to have a more holistic and a more wisdom of the group-centered approach. COVID-19 is a gift of a terrible sort, and we must not fail to learn and grow from it. If we do fail, we betray the legacy of 100 billion souls that built our civilization to this point. Humanity could die in its cradle, and we end in this century or the next, failing trillions of our potential future progeny. People are policy. Substantial restructuring and reforms are needed, in particular, federal civil service reform. Good governance matters, and we can't rest on our laurels. Other states have led on this, and I think others would likely follow a federal example. We've talked about the health and government enterprise cultures needing a systems approach, a different approach to safety management, and continuous improvement frameworks. I think these are important foundations for future progress in governance, and I think they're foundations. I don't think they're nice to dos. Humility and level five servant leadership at all levels are ascension, common and ancient. We talked about mop it up, ethics, a decision test, creating a shared vision, because without vision, the people perish, and they like it when it's their idea. I just want to reemphasize what Nobel laureate James Buchanan reminds us of. We are all self-interested. We are all self-interested, not just those other people, but us. We have met the enemy, and it is us. No exceptions. We can all admit this without shame, right? We can all admit this without shame. It's hardwired. The only shame, in my view, is the self-deception of not recognizing our own self-interest. Each of us can also rise above pure self-interest, particularly if we work to align our incentives with those of the people we serve. Incentive alignment is a key feature of leadership. If we hope for A, we must reward for A. The other key feature is the golden rule. Thus, the application of ethics is essential. Too many public health decision makers and leaders failed to or were unable to grasp and employ these principles. They exceeded their authority. We exceeded our authority and broke the social contract with too many of those in our care. Recovery can occur. It will be hard. Knowledge discovery throughout this pandemic has been suboptimal. The scientific method has been squelched, and free and open debate cut off. Collection and sharing of data and information from our public servants has been terribly inadequate. Still is. Decision makers, often in their own arrogance, were plagued by unknown knowns and actively squelching known knowns that were inconvenient or might curtail their power, prestige, or influence, or budgets. Mistakes were made, many of them. They were predictable. Their institutionalized political will is needed to address this. In my view, Congress needs to hold HHS accountable. HHS can start by addressing Open Government Accountability Office recommendations. Money won't solve it. They also need to further investigate the National Institute of Health regarding their funding of research, indirectly or not. It could not be done on United States soil and demand further regulatory safeguards for biosynthetic dual-use gain-of-function research if it should be done at all. Preparedness and response, like health generally, needs far greater emphasis on primary prevention, primary preparedness, and more attention to the hierarchy of controls in our application of mitigation. We can't afford not to. One health approach is a re-examination of the R&D enterprise that I just mentioned are critical to the prevention of future zoonotic naturally occurring pandemics and the potential for a catastrophic engineered pandemic. We can do better. Again, says easy, does hard. Just like this incredible formation over the skies of Atlanta in 2020, the Thunderbirds and the Blue Angels. I'm not gonna note that the Thunderbirds are ahead of the Blue Angels, that wouldn't be fair. But, you know, they make it look easy. You know, nothing about what they did there is easy. Really tough stuff. But we know next time is coming. We just don't know precisely when or what it will look like. I know we can do better. It's just not a given. I hope that what I've offered here provides some insight and an approach that can be deployed. It is inevitably flawed and incomplete. Thus, our collective brains to share and learn from all are needed for continuous improvement. At root, freedom of speech is a necessity for civilization to survive and thrive. We are not the first to try and navigate a way forward before the nature of the problem is fully understood. The Sappingham Lecture and the Patterson Lecture both referenced the genius of John Snow, apprenticed at 14, dead by the age of 45, but the father of both anesthesiology and modern epidemiology. When he made that map in Soho in 1854, he didn't know that cholera was a microorganism. We see through a glass darkly, but I hope that as we go forward, the light will shine. Thanks. So observation and conversation is invited. Just don't expect me, if you ask me any questions, to have all the answers. Thanks. Thank you, Dr. Dreiser, for your incredibly insightful perspectives. At this time, Dr. Dreiser will take questions from the audience. Please raise your hand if you would like to ask a question. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. And if you would like to ask a question, please raise your hand. I'm with Vanderbilt Medical Center. I wanted to ask you, you talked about funding of foreign entities. Yes. And you put up a slide. Funding of foreign? Foreign entities. And you mentioned how... For the purposes of biosynthetic research. Oh, I see. For specific purposes. Okay. My question was how we could potentially address issues like Lassa and Ebola without sending funds to foreign entities. I'm not suggesting at all that we don't send funding to foreign entities for research into zoonoses we know are there and going to occur. What I'm very concerned about is biosynthesis and dual-use research and gain-of-function studies on very, very dangerous pathogens. If we engineer Ebola to be even more transmissible or to be able to evade the incredible vaccine work that's been done, we're in a potentially new world of hurt. And I have deep concerns that the potential for an existential catastrophe that is the extinction of humanity could come from that kind of research. And I know from personal regulatory experience in my role that there are a lot of holes in that Swiss cheese and they have lined up. So one of the things that I would be very concerned about is something that say some countries decide that it's too dangerous to do this work on our soil. So we will fund another lab somewhere else and say Wuhan, China to do that work. The problem is it's on the same planet. And a lab leak there is a lab leak everywhere. So we've already learned that lesson. Even if we're not sure that we've learned that lesson that way, I think we need to kind of think about, well, gosh, that could happen. And we need to reexamine that R&D enterprise. If we don't, like I say, I think we potentially betray the hundred billion lives that came before us and the billions and trillions that could come after. Thank you. Thank you. Hi. Thank you. Dr. Andrew Jeremijenko here. Look, I got the impression that you weren't that impressed with the US response. But in fairness, a lot of countries had a fairly bad response. And there are some countries who had actually quite a good response. I'm from Australia. I was in Qatar when it happened. But Australia's got a fairly low death rate per capita, 10 times lower than America. New Zealand is 20 times lower. So Qatar, I think, was 10 times lower as well. But UK and US and other very rich nations had very high death rates per capita, around about 3,000 per million. So there is that international perspective as well. I don't think Australia's that brilliant. My public health doctors aren't any smarter than your doctors. But obviously there was other factors that contributed. So I'd be interested to hear your view on that international perspective, on why some countries did better and some countries did worse. Obviously, the Eastern European countries did even worse than the US. So have you got any views on that? Yeah, well, great question. Thank you for that. Part of why I preface my comments with the history is still being written is because that history is still being written. I don't really think that we, I think we right now can look at some of that information and draw some conclusions. I don't think we can draw ultimate conclusions. And I think if you're just looking at death rates and you're just looking at the rates of disease, you will draw a different conclusion than if you look at happiness, at freedom, at people's ability to live their lives, at suicide rates, at rates of mental illness, excess mortality. There's a lot of things that we have to look at before we decide that country A did better than country B, because there are a world of factors, health and prosperity, two sides of the same coin. And I think we're actually years away from really being able to say this is the best approach. And I'm not 100% we'll ever be able to say that with complete honesty. When I look at the world meter right now, I see China has three deaths in a million. I don't believe it. I also have friends in Australia who had a very different experience of the pandemic than I did, but were very, very unhappy about the way things went with what they felt was a totalitarian approach to that pandemic. Even in America, we had a pan flu plan, remember, we had a pretty robust plan. There were a lot of things that we said we weren't going to do in the pandemic flu plan that we in fact did when coronavirus occurred. So that's why I really didn't want to get into kind of looking at all those stats, because I think it's premature at the end of the day. And I think that we could debate for a long time who had the correct approach without really satisfying anybody. Because if your number one thing is I want to live my life, I want my freedom and I want to be able to flourish, that's a different way of thinking about things. And you have a right to think that way because you're autonomous, right? That's the ethical principle versus I want to be alive at the end of this three years. The other thing I would say is that we don't know, we still don't know how things are ultimately really going to play out with us, okay? We just don't. We see what's happening in China right now with Shanghai. Unfortunately, you can't really believe anything that comes out of the country because there's so much slant to it. It's hard to know what to think. But I would just caution us all to withhold judgment as to who has come out of this best. I think we need to learn, but I think we need to withhold judgment. Sure. Thank you very much. Does that make sense? Yeah, it does. Okay. Thank you. Melanie Swift, Mayo Clinic. Thank you very much for coming to be with us today. You stated a couple of times that our public decision leaders and decision makers failed in their response by deliberately squelching known knowns. I'm curious about that and wonder if you could provide an example. I can provide a generally available example and then a personal example. We knew much earlier than we were ready to admit that there was significant aerosol spread of SARS coronavirus 2. It is still very difficult, I think, to get a full story on that. We have not done nearly adequate research. I think just if you look around this room, some of us are wearing masks and some of us are not. So the truth is we don't really know for sure. We the people are still confused on that point. Three years into it, we shouldn't be confused. I was on a very early call, carefully, I was on a very early call where these matters were discussed. And there was a really hard push to say, you know, we shouldn't go with this. We shouldn't go with masking. Over all these reasons and all the things we've said over all this time, and a simple comment kind of won the day. And here was the comment, well, yeah, but I'd rather have a piece of cloth between me and somebody sneezing on me. Now, you know, that makes sense, right? But that simple piece of cloth doesn't stop aerosols. And we also didn't account for the fact that the virus was going to change and mutate. And what does a virus do if you make it harder to transmit? You know, it changes. So it transmits, you know, these transmission, there's better transmitting viruses. They just muscled their way out there. They made more copies of themselves, you know, in our upper respiratory tract than the earlier versions did. So we're just putting, you know, instead of, you know, I don't give you numbers. I can't give you numbers. Instead of a few, they were putting out many. And so they were thwarting some of the very means that we were putting in place, social distancing and masking. And we haven't fully leveled with the American public about that. We just want to be right about masking. We haven't talked about what does it mean to put a mask on a two-year-old or a three-year-old? What does it mean to muzzle somebody who is deaf? My wife happens to be a sign language interpreter, takes care of a lot of people that are deaf children, adults. You do this, and they can no longer understand you. They can't hear you. So masking might have been a reasonable approach had we segmented it by population and by circumstance. But we just said, everybody put one on. Personal protective equipment, as we all know, is kind of the last bastion of scoundrels. You know, if we can't figure out a better way to do it, then that's what we go for. Other better things would have been much more attention to ventilation. We also made some fundamental errors in our understanding of particle physics because we weren't listening to the particle physicists who knew about aerosols and medical aerosols. So those are just some of the things that didn't happen. Personal example. I hesitate to talk about this because this is disdainful, but I spent 20 years at the state and local level doing all kinds of response on the ground. I did a school-located influenza vaccine since I was a local health director in Appalachia for years. I really get how things work on the local level. I was brought to the CDC partly because of that experience. The CDC director hired several people like me who had been agency heads before, I think because he was trying to do some cultural change himself. I never really got a chance to really see that to fruition because, you know, the pandemic was going within three months of my arrival. But folks there weren't interested in our on-the-ground experience. When it came to Operation Warp Speed, which was a great effort in a lot of ways, we said But whatever you do, don't just throw this vaccine at them and expect them to make plans to get this stuff out there. Vaccine motor memory is maybe six months a year long, right? If you're not doing that every day, it's like saying, hey, let's take a road trip to San Antonio. Well, if you road trip all the time and your bags are packed and you've got a car, you know, okay, great. What are we going to do when we get there, you know? But most of the people that we were relying on to get vaccines and arms when the vaccine was available, they didn't have a car. They were concerned with what to pack. You know, they didn't know, you know, what's that trip going to be like? We tried to get them to you, tried to get folks to use influenza vaccine in the summer of 2020. Yeah, I think I'm right about my date. We tried to get them to use that in the summer before we knew Warp Speed vaccine was going to be available. But there was just not interest in that. We said, look, we actually were wrong about three things, right? We said three, triple A. We said, reduce the incidence of flu, reduce the incidence of co-infection and practice getting vaccine out there, right? So flu didn't show up. Co-infection was a thing, but it wasn't a big thing. But what we didn't do is use that opportunity to get people to practice, to get vaccine out there. So what did we do? We released vaccine over Christmas to a bunch of public health folks who are already exhausted. And consequently, I think we decreased the credibility of that program. There were a lot of people that wanted it, that couldn't get it early on. And we probably could have saved some people, the morbidity and mortality from COVID itself, had we prepared our workforce better and more thoroughly to get that vaccine out there. So there's a couple of examples of why I think those unknown knowns are so important. Thank you. Sir, I'm an epidemiologist and infectious disease trained by Tony... So I defer to you. No. Trained by Tony Fauci. I have my own thoughts, but the particular question that I have, and then I'm occupational medicine, but the particular question I have is the response to the Great Barrington Declaration. I mean, these were epidemiologists like I was, though Tony Fauci says he's an epidemiologist. He isn't. I know that for a fact. I just want your opinion on that response, because it seemed like it was more personal attacks on the three epidemiologists. I mean, if you saw the email, it didn't seem like it. It said, take them down. But as in your position in CDC, what was the climate? I mean, these are all epidemiologists. So there were people like me and others that thought, gosh, this is interesting. They have some important points. Let's talk about this. And I'll tell you what happens. Your name comes off emails. You stop getting invited to meetings. You don't hear about the phone calls. And if you're leading a group of 600 people who are hot and heavy in the response, good things stop happening for them. Now, I don't play games, and I won't play that game. But that's what happened. Now, to be truthful, I didn't know if they were right, the Great Barrington Declaration folks were right. I kept hearing from people that I respected and looked up to from an epidemiology and infectious disease standpoint that, no, that's crazy. But I kept saying, well, fine, then let's hear them out. Let's bring folks together in a room, at least, and give them the opportunity that they wanted to have the conversations with people who should be able to answer for it, right? People that are getting up and speaking to this every day that are becoming celebrities because of their positions, well, get those folks in a room. Make sure that the people that are putting forward the ideas that were found in the Great Barrington Declaration can have that conversation with them. That's what I did as commissioner of health in Tennessee, right? I frequently didn't know the right answer. But as my governor used to say, not my answer, but the best answer. You can't get to the best answer without having a free and open conversation. And it was shut down in so many different ways, and still is. It's still considered, I think, by a lot of people as a fringe idea. And I don't think it is. So I hope that's helpful. There was one question entered online in the chat. It says, not devastating the population economy, et cetera. Could some of the offered cures be worse than the disease? I'm sorry? Could some of the offered cures be worse than the disease? Well, sure. It's a question from online. Yeah. I mean, that's a, you know, whether we like it or not, we've got several natural experiments going on right now. And I think I'm disappointed in the way we dealt with therapeutics. I know that there was a lot of frustration among some of my ASPR colleagues. They were pushing therapeutics, I think, in a reasonable way. But they were frustrated with the lack of attention to some ways of thinking about therapeutics. The studies that were done were not necessarily done in ways that would give you the answers that you sought. If you're trying to look at the impact of a therapeutic on a mildly symptomatic individual before they're symptomatic enough to be hospitalized, versus giving that same therapeutic to somebody who's already very sick and in a hospital, and trying to draw conclusions about its value in that population, you haven't segmented those studies correctly. You might be able to point to a result and say, we're done. But you might be very wrong. I would also say, from the standpoint of vaccines, there are still unknown unknowns about mRNA technology. And, you know, anybody who can't openly admit that isn't really being truthful. Could it be, you know, a great thing? Yeah. Is it necessarily a great thing for all segments of society? Not necessarily. All segments of the population, all age groups. Point is, I don't know. I don't know. You know, I'm just at the mercy of the R&D community, of the epidemiologists, of people that are supposed to know a lot, as anybody else. It bothers me a lot that the FDA ignored some of the opinions of its own advisory group. Why would they do that? That's very strange. Why would a pharmaceutical company want its records to be sealed for 100 years? That's very strange. So, you know, does that mean that there's something, you know, problematic there? I don't know. But that's not the full open and transparent conversation that I want to have if I'm trying to make a, you know, if somebody says, well, you know, should I get my three-year-old vaccinated? I don't know. Not sure. I'm not sure I can really trust. One last question. Hi. Todd Hamill from Houston. So AOHC in Washington, D.C. had the opportunity to go on a worksite visit in Frederick, Maryland and tour USAMRIID. And they had a BL-4 lab that was just built and hadn't gone hot yet. And so it was both fascinating and frightening to be there and, you know, to talk with the medical director and who couldn't fully talk about what was going on there. But you know, hinted towards, yeah, we have some really scary stuff. So you know, China, other nations have BL-4 labs. We have them. You mentioned yourself modifying Ebola and Ebola vaccine. And you also mentioned extinction, which had Jim and I kind of frightened. So could you just comment on the countries that are doing this and how are we protecting the world? We are not adequately protecting the world. And that's my concern. I will say that in my, you know, less than two-year stint as the director of a division that did that regulatory work, I learned a lot. And my bias at that time, and I'm going to say it was a self-interested bias, right? Well, you know, the line was this work is really important to help us better understand these diseases, how they may mutate, how they may impact different populations. We need to understand some of the mechanisms so we can develop therapeutics and vaccines against these things, right? At the same time, we now have the capacity, you know, be careful what I say because even information can be not a good thing, right? But there are genomes that are out there on the World Wide Web that it doesn't take much of, more than mine, but there are 20-somethings that can synthesize some viruses that wouldn't be good, right? And we don't really have an adequate framework, in my view, for dealing with that reality and for the reality of people that are doing work that they think is good work to do on highly pathogenic H5N1, for example, but they don't have the safeguards in place to make sure it doesn't get leaked. And there's all kinds of, you know, what's a leak? Typically it's not, you break the vial and it leaks, although that happened, you know, the foot and mouth disease actually ended up in the water in Great Britain, groundwater. But it's, you know, a person gets infected, right, and they walk outside and they infect others like the shampoo commercial. And when that happens, it's a threat to all of us. So I think we really, I am now questioning whether doing that kind of research is a really stupid thing to do, or if it is a reasonable thing to do in some very limited circumstances. You know, I think we need to think about it the same way we think about nuclear testing. And you know, with that same level of important control, actually with more, right? You know, a nuclear test, right, exactly, I mean, so we are, you know, Mary Shelley warned us about this in her book called Frankenstein's Monster, right? If we don't have the wisdom to deal with the consequences, we probably shouldn't do the, we probably shouldn't do the work to begin with. I'm still open-minded about that, but I'm deeply concerned because I do now understand that that's probably one of the biggest threats to the future of humanity. Not just human beings, not just individuals in this room and the billions that are currently on this planet, but all those other lives that deserve to live, that deserve to be born, that, you know, who knows what can happen, you know, in our future. And that is, and we are, and what right do we have, what moral right do we have to mortgage or end that potential human flourishing 500 years from now? I don't think we have the right. Well, thank you all for sticking around. So, Dr. Dreiser, on behalf of the AECOM Board of Directors, I'm pleased to present you with this plaque reflecting our appreciation. We were talking, sorry. Don't smile, though. Thanks. Okay. This concludes today's programming. Enjoy your evening in Salt Lake City. See you all in the morning. Thank you.

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