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Infectious diseases, especially those transmitted from person to person through the respiratory route, continue to pose a threat to the global community. Public health surveillance systems and the International Health Regulations are intended to facilitate the recognition of and rapid response to infectious diseases that pose the risk of developing into a pandemic, but the response to the 2009 H1N1 influenza pandemic illustrates the continuing challenges to implementing appropriate prevention and control measures. The response to the 2009 H1N1 influenza pandemic will be discussed and its implications examined.


Speaker biography:

Arthur Reingold, MD is Professor and Head of the Division of Epidemiology and Associate Dean for Research in the School of Public Health (SPH) at the University of California, Berkeley (UCB). He holds concurrent appointments in Medicine and in Epidemiology and Biostatistics at the University of California, San Francisco (UCSF). He completed his BA and MD degrees at the University of Chicago and then completed a residency in internal medicine at Mt. Auburn Hospital in Cambridge, Massachusetts. He is board certified in internal medicine and holds a current medical license in California, but has devoted the last 25 years to the study and prevention of infectious diseases in the U.S and in developing countries throughout the world.

He began his career as an infectious disease epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC), working there for eight years. While at CDC, he worked domestically on Toxic Shock Syndrome, Legionnaires’ disease, bacterial meningitis, fungal infections, and non-tuberculous mycobacterial infections and internationally on epidemic meningitis in West Africa and Nepal.

Since joining the faculty at UCB in 1987, he has worked on a variety of emerging and re-emerging infections in the U.S.; on acute rheumatic fever in New Zealand; and on AIDS, tuberculosis, malaria, and acute respiraatory infections in Brazil, Uganda, Ivory Coast, Zimbabwe, India and Indonesia. He has directed the National Institutes of Health (NIH) Fogarty AIDS International Training and Research Program at UCB/UCSF since its inception in 1988; co-directed (with Dr. Duc Vugia of the California Department of Health Services), the CDC-funded California Emerging Infections Program since its inception in 1994; and served as the Principal Investigator of the UCB Center for Infectious Disease Preparedness (CIDP) since its inception in 2002.

He also has ongoing research projects concerning malaria in Uganda; HIV/AIDS and related conditions in Brazil; and tuberculosis in India.  He regularly teaches courses on epidemiologic methods, outbreak investigation, and the application of epidemiologic methods in developing countries, among others. He also teaches annual short courses on similar topics in Hong Kong, Brazil, Switzerland, and other countries.

He has been elected to membership in the American Epidemiological Society; fellowship in the American Association for the Advancement of Science and the Infectious Diseases Society of America; and membership in the Institute of Medicine of the National Academy of Sciences. In Hong Kong, He has a close working relationship with Chinese University, particularly with its School of Public Health and its Centre for Emerging Infectious Diseases. Dr. Reingold gives short courses at the School of Public Health each year and he serves on the Advisory Board of the Centre for Emerging Infectious diseases.

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Arthur Reingold Professor of Epidemiology and Associate Dean of Research Speaker UC Berkeley School of Public Health
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Congratulations to Anand Habib, selected this weekend for a Rhodes Scholarship. Habib, 22, of Houston, Texas, is a 2011 graduate of Stanford, where he earned a bachelor's degree in biology, with honors in international security studies. He plans to pursue a master's degree in public policy and in medical anthropology at Oxford.

Habib is currently working on community health programs at St. Joseph's Clinic in Thomassique, Haiti, under a one-year global health fellowship awarded by Medical Missionaries. The nonprofit organization is a volunteer group of more than 200 doctors, nurses, dentists, and others who work to improve the health of the poorest of the poor in the United States and throughout the world.

In 2011, he won a Deans' Award for Academic Accomplishment which honors extraordinary undergraduate students for "exceptional, tangible" intellectual achievements. One of the professors who nominated him for the award described him as a "superb critical thinker" whose work is characterized by "creative genius" and "mature insights," adding that he "exemplifies exactly the kind of deeply informed, pragmatic and caring leadership that the world needs and Stanford enables."

As a Stanford student, Habib worked on behalf of politically and medically disenfranchised people in India, Mexico and Guatemala. On campus, he turned the Stanford tradition of the annual Dance Marathon into a vehicle dedicated to addressing the HIV/AIDS pandemic by engaging not only Stanford students but also local communities and corporations, raising more than $100,000. His exceptional work was recognized by his participation in the Clinton Global Initiative University Conference in April, 2011.

From Haiti, Habib discussed his current position, his plans in Oxford, and how his CISAC thesis relates to his work. 

What are you currently working on? 

I am currently working on a global health fellowship with an NGO that operates a clinic in Haiti's Central Plateau. As part of the fellowship I am helping to manage a number of community and public health projects including fortified salt (to counter iodine deficiency and filariasis), a point-of-use potable water system, a malnutrition intervention program, and a small system of community health committees and community health workers. For the past two months, I've taken on a number of administrative functions along with my co-fellow, who is also a recent college graduate. I started the fellowship shortly after graduation at the end of June 2011 and I am slated to be in Haiti until the end of June 2012.

What will you do at Oxford?

I proposed two one-year Masters programs: a masters in public policy from Oxford's new Blavatnik School of Government, and an M.Sc. in medical anthropology. As of now, I'm thinking of sticking with my proposed programs -- probably pursuing the medical anthropology degree first as it is a bit more theoretical. I think it would be better to have the more "academic" experience first before gaining the practical tools that an MPP will hopefully afford me. After a short send-off in Washington, D.C., at the end of September 2012, I will fly with the other American Rhodes Scholars-elect to Oxford the first week of October with term beginning shortly thereafter.

How does your work in the CISAC Honors program relate to what you are currently doing, your plans for Oxford, or what you'll be doing afterward? 

My honors thesis has allowed me to contextualize my experiences in Haiti in some fairly amazing ways. Two very persistent issues in Haiti are that of poor governance -- e.g. lack of strong regulatory structures, lack of government effectiveness, etc. -- and ineffective aid modalities, or the ways in which aid is delivered. My thesis was situated exactly at this nexus: how to deliver aid more effectively in order to improve governance. Ninety-nine percent of relief aid after the 2010 earthquake in Haiti was funneled to non-state organizations and only 12 percent of recovery aid went toward supporting government activities. In Haiti, I've witnessed how detrimental a patchwork system of NGO activity can be with little coordination between NGOs and little harmonization of NGO activities with government objectives. It becomes very frustrating at times, because, if my thesis is any indication, things need not be this way if both NGOs and states were engaged in collaborative partnerships -- along the lines of what Dr. Paul Farmer, deputy U.N. special envoy to Haiti, calls "accompaniment."

My initial interest in the topic of global health financing was spurred by work out of Oxford's Global Economic Governance Project. The director of the project, Dr. Ngaire Woods, was actually named the Dean of the Blavatnik School of Government through which the MPP is offered. I'd love to continue exploring the issues broached in my thesis at Oxford -- especially issues of aid effectiveness and sustainable systems of delivering development aid for health. In the future, I hope to become a physician-policymaker, helping to not only deliver care to individuals in difficult conditions around the world, but also in fostering more robust global health governance.

- Interview by Michael Freedman

 

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Martin Family University Fellow in Undergraduate Education
Faculty Co-Director of Degree Programs, Hasso Plattner Institute of Design
Faculty of Bioengineering, Stanford University
Core Faculty, Center for International Security and Cooperation
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Drew Endy is a bioengineer at Stanford University who studies and teaches synthetic biology. His goals are civilization-scale flourishing and a renewal of liberal democracy. Prof. Endy helped launch new undergraduate majors in bioengineering at both MIT and Stanford and also the iGEM — a global genetic-engineering “Olympics” enabling thousands of students annually. His past students lead companies like Ginkgo Bioworks and Octant. He is married to Christina Smolke CEO of Antheia the essential medicine company. Endy served on the US National Science Advisory Board for Biosecurity (NSABB) the Committee on Science Technology & Law (CSTL) the International Union for the Conservation of Nature’s (IUCN) Synthetic Biology Task Force and, briefly, the Pentagon’s Defense Innovation Board (DIB). He currently serves on the World Health Organization’s (WHO) Advisory Committee on Variola Virus Research. Esquire magazine recognized Drew as one of the 75 most influential people of the 21st century.

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Stanford University
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Senior Fellow at the Freeman Spogli Institute for International Studies
Thomas C. and Joan M. Merigan Professor
Professor of Medicine
Professor of Microbiology and Immunology
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David A. Relman, M.D., is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine, and of Microbiology and Immunology at Stanford University, and Chief of Infectious Diseases at the Veterans Affairs Palo Alto Health Care System in Palo Alto, California. He is also Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford, and served as science co-director at the Center for International Security and Cooperation at Stanford from 2013-2017. He is currently director of a new Biosecurity Initiative at FSI.

Relman was an early pioneer in the modern study of the human indigenous microbiota. Most recently, his work has focused on human microbial community assembly, and community stability and resilience in the face of disturbance. Ecological theory and predictions are tested in clinical studies with multiple approaches for characterizing the human microbiome. Previous work included the development of molecular methods for identifying novel microbial pathogens, and the subsequent identification of several historically important microbial disease agents. One of his papers was selected as “one of the 50 most important publications of the past century” by the American Society for Microbiology.

Dr. Relman received an S.B. (Biology) from MIT, M.D. from Harvard Medical School, and joined the faculty at Stanford in 1994. He served as vice-chair of the NAS Committee that reviewed the science performed as part of the FBI investigation of the 2001 Anthrax Letters, as a member of the National Science Advisory Board on Biosecurity, and as President of the Infectious Diseases Society of America. He is currently a member of the Intelligence Community Studies Board and the Committee on Science, Technology and the Law, both at the National Academies of Science. He has received an NIH Pioneer Award, an NIH Transformative Research Award, and was elected a member of the National Academy of Medicine in 2011.

Stanford Health Policy Affiliate
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Russia has had a long history of opposing US missile defense activities. Most recently, Russian concern focused on the alleged capability of the "third site" to intercept Russian ICBMs. The "third site" was a plan to place 10 ground-based interceptors in Poland and a large X-band radar in the Czech Republic proposed by the Bush Administration prior to its cancellation in 2009 by the Obama Administration. Now this same Russian concern has arisen regarding phases III and IV of the Phased Adaptive Approach to European missile defense proposed by the Obama Administration. This talk will assess the extent to which Russian concerns are valid in military/technical terms.


Speaker Biography:

Dean Wilkening is a Senior Research Scientist at the Center for International Security and Cooperation at Stanford University. He holds a Ph.D. in physics from Harvard University and worked at the RAND Corporation prior to coming to Stanford. His major research interests include nuclear strategy and policy, arms control, the proliferation of nuclear and biological weapons, bioterrorism, ballistic missile defense, and energy and security. His most recent research focuses on the broad strategic and political implications of ballistic missile defense deployments in Northeast Asia, South Asia and Europe. Prior work focused on the technical feasibility of boost-phase ballistic missile defense interceptors. His recent work on bioterrorism focuses on understanding the scientific and technical uncertainties associated with predicting the outcome of hypothetical airborne biological attacks and the human effects of inhalation anthrax, with the aim of devising more effective civil defenses. He has participated in, and briefed, several US National Academy of Science committees on biological terrorism and consults for several US national laboratories and government agencies.

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Dean Wilkening Senior Research Scientist Speaker CISAC
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Antibiotics have represented the primary line of defense for treating bacterial infections since 1935 when the first sulfur-containing compounds were introduced. Many antibiotic compounds are produced naturally by microorganisms while some more recently developed antibiotics are chemically designed based on a knowledge of susceptible biochemical pathways or physiological processes in pathogenic bacteria. Ciprofloxacin (“cipro”), a synthetic broad-spectrum antibiotic, functions by interfering with DNA replication.

Increased use and mis-use of antibiotics has led to increased numbers of pathogenic bacteria that are resistant to one or more antibiotics. Some resistant microbes possess mechanisms that allow continued growth in the presence of multiple antibiotics. These multiply drug-resistant pathogenic bacteria may also possess pathogenic properties that result in significantly more severe disease than their drug-sensitive cousins. Medical misuse of antibiotics – prescribing antibiotics for viral infections, failure of patients to complete treatment with the full regiment of antibiotics, or application of antibiotics based on inaccurate or incomplete tests can lead to selection of antibiotic resistant bacteria that can then cause infections that cannot be treated with the antibiotic(s) to which they are resistant. Multiple drug resistance can quickly reduce or eliminate all antibiotic-based treatment options. Infections caused by antibiotic resistant bacteria are very difficult to treat and can sometimes lead to death of the patient.

Antibiotic resistance can also result from selection based on exposure to antibiotics present in the environment. More than 70% of the antibiotics sold in the U.S. are used as supplements to animal feed. The intestinal bacteria in the animals provided with such feed often show resistance to the antibiotics in the feed and, in some documented cases, have transferred this resistance to pathogenic microbes with which they share the environment.

A brief of history of antibiotic use and the medical and public policy factors that are, in part, responsible for increased antibiotic resistance in pathogenic microbes and for a decrease in the development of new antibiotics will be presented. An introduction to new directions that are being taken to develop a next generation of antibiotic compounds will also be provided.


Speaker Biography:

Paul Jackson received his Bachelor's of Science degree from the University of Washington in Cellular Biology and his Ph.D. from the University of Utah in Molecular Biology. He became a CISAC Visiting Scholar in September 2011. He was previously a CISAC affiliate.

For the past 18 years he has been studying bacterial pathogens, first working to develop DNA-based methods of detecting these microbes and their remnants in environmental and laboratory samples, then developing methods to differentiate among different strains of the same pathogenic species. Research interests include the study of different methods of interrogating biological samples for detection and characterization of content, and development of bioforensic tools that provide detailed information about biothreat isolates including full interrogation of samples for strain content and other genetic traits.

Methods he developed have been applied to forensic analysis of samples and aid in identifying the source of disease outbreaks. He contributed to analysis of the Bacillus anthracis present in the 2001 Amerithrax letters and conducted detailed analyses of human tissue samples preserved from the 1979 Sverdlovsk anthrax outbreak, providing evidence that was inconsistent with Soviet government claims of a natural anthrax outbreak.

His current work continues to focus on development of assays that rapidly detect specific signatures including antibiotic resistance in threat agents and other pathogens. More recent activities include identification and characterization of new antimicrobial compounds that are based on the pathogens' own genes and the products they encode. These include development of such materials as therapeutic antimicrobials, their application to remediate high value contaminated sites and materials, and their use to destroy large cultures and preparations of different bacterial threat agents. Efforts to address issues of antibiotic resistance and treatment of resistant organisms have recently been expanded to look at non-threat agent pathogens that cause problematic nosocomial or community-acquired infections of particular interest to the military.

Paul spent 24 years as a Technical Staff Member at Los Alamos National Laboratory where he was heavily involved in development of the biological threat reduction efforts there. He was appointed a Laboratory Fellow at Los Alamos in recognition of his efforts. He moved to Lawrence Livermore National Laboratory in 2005 where he is presently Senior Scientist in the Global Security and Physical and Life Sciences Directorates. In addition to his work at the National Laboratories, he has served on the FBI's Scientific Working Group for Microbial Forensics, on NIH study sections and review panels, and continues to serve on steering and oversight committees for other federal agencies.

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Paul J. Jackson Visiting Scholar Speaker CISAC
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The production and distribution of counterfeit medications has become a significant global public health issue. Though not as rampant in the United States, the Food and Drug Administration (FDA) has seen a 10 fold increase in the number of cases investigated, particularly a rise in illegally imported and diverted medications entering our legitimate drug supply. In order to curb these illegal activities, California and the federal government have introduced various pieces of legislation to address this. In addition, international entities, State Boards of Pharmacy and the FDA have begun promoting utilization of radio frequency identification technology and other technology to effectively track the medication supply. In a recent California survey, pharmacists felt strongly that the presence of counterfeit medications poses a problem in their pharmacy practice, but they still face several challenges in identifying counterfeit medications, counseling their patients, and forging their role in implementing legislative requirements.

This presentation will aim to provide an introduction to the international and domestic counterfeit drugs situation, discuss possible factors facilitating patient exposure to counterfeit medications, examine potential sources for counterfeit medications in the United States, identifiy federal legislation issues, discuss various forms of technology being used to combat counterfeit medications, and recognize the role of pharmacists and the challenges they face in dealing with counterfeit medications.


Speaker Biography:

Dr. Elaine Law is currently a Clinical Pharmacist specializing in Adult General Surgery at UCSF Medical Center and an Assistant Clinical Professor in the UCSF School of Pharmacy. She received a B.S. in Molecular, Cell and Developmental Biology from UCLA, earned a Doctor in Pharmacy from UCSF School of Pharmacy and completed a General Practice Pharmacy Residency at UCSF Medical Center. She holds a Board Certification in Pharmacotherapy and her research interests include roles pharmacists can play in public health issues including counterfeit medications and pharmacist-based immunization programs. She is an advocate of patient care in underserved areas and reaches out regularly to the Tenderloin communities and elderly populations of San Francisco through pharmacy health outreach programs.

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Elaine Law Assistant Clinical Professor Speaker UCSF School of Pharmacy
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Ten years after the terrorist attacks, five leading experts weigh in on the state of the jihadist movement, U.S. intelligence, and the cost of safety.

Martha Crenshaw It depends on what we mean by safer. If we're asking how likely it is that we'll experience an attack of the magnitude of 9/11, I don't that it's likely. Our awareness of the possibility is so much greater. Khalid Sheikh Mohammed, the mastermind of the attack, is in custody. Other major players are dead or under arrest. Osama Bin Laden is gone. The drone strikes in Pakistan have been very effective. However, we're not entirely safe from the threat of terrorism against U.S. interests and citizens abroad. We're still vulnerable in many ways. Al-Qaeda in the Islamic Maghreb and Al-Qaeda in the Arabian Peninsula are still threats. They've inherited anti-Americanism from the original Al-Qaeda, and while Al-Qaeda central is weakened, these affiliated groups will likely become stronger because of the power vacuum that's left in the jihadist movement. These different factions could unite. Al Qaeda itself was a merger of different national movements. This could happen again -- they could reconstitute themselves into a very powerful organization.

Mariano-Florentino Cuéllar We are safer -- up to a point. In 2003 I wrote that there was little reason to think we were safer than we were on Sept. 11, 2001, and that in order to improve our security we would need to invest in meaningful long-term changes rather than focusing on quick fixes. Much has changed today. American attacks have been devastating to al-Qaeda, showing how 9/11 was perhaps a tactical success for the group but almost certainly a strategic miscalculation. Americans have forged alliances with countries throughout the world, sharing financial intelligence and pooling efforts to disrupt terrorist mobility. Many communities have made important strides in safeguarding airports and chemical plants. Federal lawmakers enacted landmark, bipartisan food safety legislation to bolster the safety of the food supply, and doctors working with public health authorities have enhanced their capacity to respond to infections and biosecurity threats such as the H1N1 virus. Meanwhile, pressing issues like cyber-security and emergency preparedness are starting to receive much-needed attention.

But Americans continue to face profound challenges, too. We must work to enhance the infrastructure that protects our public health, cyber-security, and emergency response.  The Sept. 11 attacks starkly show the need to reconcile security goals with laws and constitutional principles. Policy makers and the public must focus attention on strengthening the economic and social foundations supporting America’s long-term position in the world. At the same time, the nation must remain determined, creative, and vigilant in confronting the continuing threats posed by non-state actors and failed states.

Karl Eikenberry If we talk about the defense of the homeland, we are clearly safer against the international terrorist threat. Our level of awareness is much higher. We were asleep when we got hit. And the systems that we've established, I think have made us safer. Now, that's very specifically against the terrorist threat. Is the United States of America stronger on a relative basis than on 9/11/2001 -- are we a stronger nation? I think the answer is no. I think that our economic strength has declined. And I think there's been a degree of militarization of our foreign policy over the last decade that’s made us less attractive globally.

Thomas Fingar We are safer with respect to the danger of a major terrorist attack than we were 10 years ago but not with respect to other risks that endanger more of our citizens and are more likely to occur. We have spent billions of dollars to detect, prevent, and respond to terrorist threats from abroad and we have reduced the already low probability of death or injury from terrorist attacks to even lower levels. These gains have had a high opportunity cost because achieving them was at the expense of efforts to reduce other dangers. Far more Americans continue to die from inadequate hospital procedures, unsafe food, drunk drivers, and other well-known dangers than have died in terrorist attacks. We will not be much safer until we address these and similar problems, repair and replace our aging infrastructure, and do more to prepare for the more severe weather that will result from climate change. 

Amy Zegart Osama bin Laden is dead. Yet 10 years after 9/11, it would be dangerous and wrong to think that the terrorist threat is behind us. Violent Islamist extremism comes from many places, not just the 50 to 100 core al Qaeda fighters holed up along the Af/Pak border. The years 2009 and 2010 have seen a spike in plots against the U.S. homeland. Nearly all of them have come from radicalized homegrown terrorists or “franchise” groups with loose and murky ties to the core al Qaeda organization.

In addition, WMD terrorism remains a haunting future possibility. And the FBI has not made the leap from crime fighting to intelligence. FBI analysts, whose work is vital to connect dots and protect lives, are still treated like second class citizens -- labeled “support staff” alongside janitors and secretaries, and relegated to middle and lower rungs of the bureaucracy. So long as FBI analysts are treated like second-class citizens, Americans will get second-class security. These three factors -- diversification of the terrorist threat, the potential to combine destructive motives with devastating weapons, and the FBI's continued weaknesses -- suggest that the future may not be any safer than the past.

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Anand Habib

Ten undergraduates recently received the 2011 Deans' Award for Academic Accomplishment, which honors extraordinary undergraduate students for "exceptional, tangible" intellectual achievements. Among them: CISAC honors student Anand Habib, a senior majoring in biology with honors in international security studies. He is completing an honors thesis focusing on health governance.

Habib sees his work as an intentional synthesis of scholarship and larger social commitments. He has lived this out in many ways at Stanford, including working on behalf of politically and medically disenfranchised people in India, Mexico and Guatemala. On campus, he has turned the Stanford tradition of the annual Dance Marathon into a vehicle dedicated to addressing the HIV/AIDS pandemic by engaging not only Stanford students but also local communities and corporations, raising more than $100,000. His exceptional work was recognized by his participation in the Clinton Global Initiative University Conference in April.

English Associate Professor Michele Elam described Habib as a "superb critical thinker" whose work is characterized by "creative genius" and "mature insights." She holds him up as a model for others, saying that "he exemplifies exactly the kind of deeply informed, pragmatic and caring leadership that the world needs and Stanford enables."

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