From LSTM’s DTMH to the frontline of global health

Town hall – Dr Kevin De Cock-20261001_114300UTC-Meeting Recording
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[00:00:00] Thank you very much for coming to the seminar. So my name’s Tom Fletcher. I’m a professor of emerging infections at the school and a clinical academic. There are many parts of my job I do not particularly like, but the one part that gives me huge amounts of pleasure is the privilege to introduce people like Kevin who’s coming to do this seminar.

So I’m a stand-in for Miriam, so apologies for that already. Miriam said that she first met Kevin when she was a PhD student 26 years ago, I think, in Kenya, and he’s been an inspiration and a mentor to Miriam ever since, really. And she said, uniquely, you have this lens of being able to focus on what’s most important for the patient from a clinical point of view, but also understand the system problems that really hamper delivery of equitable care to that patient.

So when Miriam’s impressed with someone, I instantly am, and obviously, I’ve known of Kevin’s work for many years. So after being an alumnus in the DTM&H in 1979, he has then had extremely senior roles across CDC, even country director of Kenya, and Côte d’Ivoire, and then also been the director of HIV/Aids and WHO as well during a pivotal time [00:01:00] in 2006, I think, 2009.

And so it gives me great pleasure to introduce Kevin to give a talk. The last bit of housekeeping that I have to do is just to say there’s no firearms that, fire alarms that are planned during this time, so please, in orderly fashion, if one goes off, we’ll migrate out of the school. There are bathrooms just through to the right if anyone needs that too, and we hope to break for questions at around twenty past.

So Kevin, thank you very much. . So yes, thank you to the school. so I’m gonna talk about, this book, Deployed. one of the first things they tell you when you’re promoting a book is don’t talk about any other book, and I sort of break that rule for a couple of reasons.

about three years ago, we did publish this other book, Dispatches from the AIDS Pandemic, and I mention it for a couple of reasons. One is I spent a lot of my time working on HIV, and in Deployed don’t really discuss it that much. s- at somewhat at a general level, but less than the time I spent on it for sure.

but more actually to raise the issue of mentorship ’cause I wrote it with two senior [00:02:00] colleagues, senior to me, somewhat older than I am, who really influenced me a lot in my, especially in my early days at CDC. Harold Jaffe, a young Harold Jaffe on the extreme end of the slide there. He was the lead epidemiologist in the early HIV days.

and Jim Curran, who really was, who was the overall supervisor and really the, the face of the public health response to AIDS in the very early days in the United States. So I j- I just wanted to highlight them, and occasionally I’ll mention HIV, but s- gloss over it. But that, that book, Dispatches, really examines the history of the AIDS epidemic through the eyes of CDC and the sort of sequential learning that went on, including, our early, international work.

so Deployed is, it’s really a book about transitions. I mean, certainly some personal ones from a child to a student to a young physician. and then a transition somewhat unexpectedly from, you know, great commitment to clinical [00:03:00] medicine to public health, somewhat unexpectedly, and then later to, more senior managerial type work.

It was published about a year ago by Johns Hopkins University Press. It’s organized into three parts, clinician, epidemiologist, and bureaucrat. And I use the term bureaucrat actually not in a pejorative sense, because I think the world needs good and better health bureaucrats, but it is a different stage certainly of one’s, career and life.

And it has a prologue and an epilogue. One of the interesting challenges writing this was, I was getting the proofs in early 2025, which was sort of a pivotal period in what might be described as the rupture in global health and a lot of other affairs. And I did … I thought to myself, “My gosh, you could write a whole different book on all of this.”

But I sort of modified the s- the prologue and the epilogue to give some comments on that rather difficult time. I was born in Belgium. [00:04:00] I’m actually a dual citizen, Belgian and American. I’m not English. my father was Belgian. He was a surgeon of the very old school, the people who did absolutely everything, and my mother was American.

And, we got sent to boarding school i, in England at the age of seven, and I couldn’t speak English. This was kind of a, what shall we say, a back-stiffening experience. and it obviously does sort of affect the rest of your life actually in, you know, at a personal level as well as a professional level.

But I did all the rest of my education in the UK, specialized in internal medicine. I went to the University of Bristol. And mention this for a couple of reasons. firstly, to younger colleagues, you know, I often think when somebody retires or somebody dies, you read their obituary or somebody gives a speech, they say, “Well, she was the director of this, he was the head of that.”

And yet that early stage of life, of professional life, is absolutely fundamental and foundational, [00:05:00] and in many ways much more difficult than the sort of things that evolve from all of that. And I think it’s important to ment- to, to highlight that for firstly to enc- I mean, to congratulate younger colleagues, but also to encourage that what’s going on in those early stages of life is really important, in many ways more important than what happens later.

Obviously in one’s training there are things that stick in your memory, including mistakes. and I think it’s important to try and learn from those. there is a phrase I came across early on that applies in clinical medicine, but it applies actually outside of that, sort to public health, maybe to life, that you see only what you look for, and you recognize only what you know.

And I include that chest X-ray because it, illustrates what I have in mind. A, a mistake, fatally… For- fortunately not a fatal one, of, being able to put things together. I mean, being able to see all the signs and somehow not putting them together. [00:06:00] That was a, a case of cardiac tamponade that somebody else, the professor of medicine misdiagnosed it as well, so that made me feel better.

But somebody fortunately intervened and it was okay. But you see only what you look for, and you recognize only what you know, I think, is an important, observation. I have the dual, as a dual citizen, I had the, dubious distinction of having to register for two different military draft systems, and this was the time of the Vietnam War.

Now, they didn’t, the U- US didn’t take anybody from overseas or who was studying, but I did have a Belgian military obligation. And, I had the good fortune, A, to, when I decided, okay, I’ve gotta do it now, to come to this institution for a DTM&H, prior to a position in, Kenya at, the University of Nairobi, the University Hospital in Nairobi, Kenyatta, teaching internal medicine.

And it really was a life-changing experience. I often joke or [00:07:00] say that, you know, I was the teacher, but actually Kenyatta was an education that you couldn’t possibly pay for because you literally saw everything. What I realized and what I hadn’t gotten from my DTM&H was that actually we face three types of disease.

firstly and most importantly, the medicine of poverty, and it was mainly infectious, pneumonia, tuberculosis, meningitis, dysentery. Secondly, the sorts of medicine that interns deal with all over the world, but with interesting differences in global epidemiology, hypertension, cancer, diabetes. And then thirdly, the classic tropical diseases, which of course are very focal.

They don’t happen everywhere, and you had to understand what happens where in a country to,to really be sensible in your clinical approaches. And the term geographical medicine is ver- rarely used today. Geographical medicine, [00:08:00] geographical pathology, but actually it means something. and the book, my book, discusses somewhat over the course of the whole work the sort of evolution from i- the classic ideas of tropical medicine to international health to what today we call global health, which is still somewhat, ill-defined It was possible in that, in the sort of chaotic vibrancy of that hospital in Nairobi to ask a question, to collect information, and to draw generalizable conclusions.

And of course, th- that term, that phrase, generalizable conclusions, is essential in the diagnosis of research. I do regret or I am rather envious of younger colleagues, perhaps many of you, who actually get better training in how do you actually do research, ’cause I sort of thought… I sort of made it up as I go along.

but it was, it was very formative in, in, you know, simple research, and also in beginning to write. [00:09:00] And, you know, we, especially in public health, we kind of turn our noses up at, people who write case reports. My first paper was a case report. and yet it’s, they are important. I always point out to people, you know, don’t forget that the, you know, what brought, the world’s attention to the AIDS pandemic was five cases in Los Angeles of pneumocystis.

What brought attention to bioterrorism 25 years ago this month in the United States was one case of anthrax meningitis in, Florida. you know, we should be careful it was important in those days… Th-there are many pictures in these slides, and I– each one has– it tells a little vignette or story, and I don’t have the time to delve into each one, but they all mean something.

I– in those days, it was important to get the BA, BA standing for Been to America. And, I came back to this country to write up my MD thesis, and went off to Los Angeles. And this was 1983, the early days of the [00:10:00] AIDS epidemic. HIV had not yet been discovered, no test for, for the disease. and I worked, I, it was a– I did a fellowship and stayed on the faculty at University of Southern California working in hepatology and liver disease with a major interest in viral hepatitis.

And,I mention this story again to bring out another couple of observations which, I probably wouldn’t have made earlier in, in my time, earlier on. this was a very large liver unit, one of the biggest in the world unquestionably, and it was run by a triumvirate of people who were themselves world-famous, two clinicians and a pathologist.

The picture is the man I worked with most closely, the late Alan Redeker, who was a viral hepatitis specialist. we had a major interest and experience in hepatitis delta virus, probably the biggest clinical experience in the world actually. There are a couple of, sort of observations I came away with.

That unit no longer [00:11:00] exists, and, it’s sort of been absorbed into the Department of General Gastroenterology. And I got insight into why that is or why the future didn’t look that good. these were three very eminent people who did not think of succession planning. They just thought they’d work forever, and basically they did.

all other si– there are side stories. Bob Peter’s world-famous liver pathologist actually was murdered while I was there. Another story, probably interpersonal relations. People are human. It is, unexplained to this day, but theories about it. The other two essentially worked till they dropped. And younger people came, could have taken over that unit, but left because really there was no space.

There was a– that was, I thought, an instructive, experience. And the second thing, more unfortunate, Redeker was a good friend of Tom Starzl. Starzl was a brilliant surgeon, really the father of transplantation in the [00:12:00] United States. The big advance in medicine at this stage was actually liver transplantation.

but LA County Hospital, U- USC is a fabulously wealthy and expensive university, but as its teaching hospital at LA County Hospital, which is the hospital for the indigent, half the patients were Hispanic, many undocumented. This is not the sort of field where a liver transplantation unit could be established.

And, so they sort of missed out on, on, on that clinical advance and also on the importance of linking basic science and, with the clinical sciences. You know, they did excellent clinical work over the years, and it was a very instructive experience, why sometimes things just end wanting to do more research,I won’t go into the details.

There’s some description of it in the book. I wanted some further training, research experience, and, my [00:13:00] boss was a friend of people at CDC, and I ended up going there. CDC, the, public health- National Public Health Institute of the United States, set in Atlanta and not Washington because its origin in the 1940s was that it evolved from the malaria control program because malaria had been endemic in the Southern United States.

The fe- the… Y- you… At CDC, if you went into this two-year program called the Epidemic Intelligence Service, which is a field epidemiology training program, you really get thrown in the deep end. And m- my first,on the, this, the… my… the left-hand side of the slide, I won’t go into detail, but a rather folkloric trip.

I’d only been there about two months, sent out to, actually to the Équateur province of the DRC, of Congo, to the location where the first Ebola epidemic ever had happened for an HIV study. rather [00:14:00] implausibly, this ended up with a paper in The New England Journal, which actually is frequently quoted in the origins, in discussion of the origins of the AIDS epidemic.

but coming back in late November, was told two days later that I had to turn around and go back to Africa, to West Africa, to Nigeria, for an un- sort of classic CDC-type exercise, an unknown epidemic. It was thought to be yellow fever. It was unproven. two points from this, partic- well, three points from this particular slide.

Firstly, some very basic information, well-collected or well-communicated, and I’m talking about that graph, can convince decision-makers if it’s, you know, put across the right way. With that single drawing, after about three or four day- about less than a week of field work, we actually persuaded the military governor of the state that he needed to use the army for a mass vaccination effort.

[00:15:00] Secondly, a bit later, the man sitting there at a kitchen table doing an enzyme immunoassay was, the CDC lead, for, arboviruses, Tom Monath, unquestionably the world expert in yellow fever. And the opportunity to work with somebody like that in the field and see how they did their work, dealt with people, communicated work to the ministry, and so on, it was just extraordinary and hugely privileged.

And then the child with, what’s pretty obvious at the bottom there- That first day, one of my first days in the field, you know, they know there’s some doctors there. People come out, presented me with a, a young boy who had a ulcer on his shoulder. And I thought, “Well, it’s an ulcer, you know. Not sure what it is.”

Actually, it’s guinea worm. and you know, one of the two diseases slated for eradication not going well. polio of course, the other one, also not going that well. Interestingly, for reasons that are not [00:16:00] directly related to the program itself. Guinea worm, the fact that actually we’ve discovered late that there’s also a natural reservoir in dogs, and, polio, the, all the issues.

Polio now restrict- n- wild type polio restricted to Afghanistan and Pakistan, issues of security. I think they made the wrong choice, actually. I think they should have gone with measles and hep- or hepatitis B for eradication I’ll skip over this. Tom mentioned I worked in West Africa. I had the huge opportunity, work- through CDC, we set up a research site in West Africa to study HIV-2, which at that time very little understood about it.

This was nine- the mid-1980s, 1987, ’88. very little understood about it, and the great fear that this could cause a pandemic, like HIV-1 had done, and we really didn’t know anything about it. So a huge opportunity and really,again, sort of kind of life-changing and career-changing. And one of the wonderful things about working [00:17:00] with the CDC is, and I think to some extent coming to institutions like this, is the networks that you enter into, which are very valuable,and really, lifelong contacts.

I ended up working in, Kenya, in the field, and again, there’s a chapter in the book about this, and I just mention two outbreaks here which, one kind of amusing in retrospect, the other very sobering indeed. The, the amusing in retrospect, but not at the time, was that 25 years ago, October nine- October, 2001, get summoned to a emergency meeting at the Ministry of Health becau- and the minister, has just, come in from briefing the press, BBC, New York Times, et cetera, that Kenya also has been attacked with anthrax.

Now, you know, investigating an outbreak or, even a single case, first question is, you know, is there an epidemic? Secondly, if there is, is it [00:18:00] really due to what you think it is or what you’ve been told? And then thirdly, you know, time, place, person, and all of that. And I remember sitting listening to the minister and leant over to a colleague of mine saying, “You better make sure this is anthrax.”

Long story short, it was not, which is good, and could have been, you know, could have been a wonderful, A happy story for everybody, a feel-good story. You know, great international collaboration and, and all the rest. But, sort of things didn’t go very well because the minister wouldn’t back down, and, it all got very embarrassing.

Actually became a political, political, kind of a political firestorm, including cartoons in the newspaper. In retrospect, amusing, but at the time, really quite stressful. The most sobering epidemic was, and was my first exposure to environmental epidemiology. As an infectious disease person, I always had…

I kind of dismissed it. I thought, “You know, it’s just not what I’m particularly interested in.” But we got drawn into an outbreak of, [00:19:00] jaundice with high mortality, about 40% mortality or so, south, east of Nairobi. And, it was pretty evident from the start that, including l-lab testing, excluding other diagnoses, that this was, aflatoxin poisoning.

Aflatoxin, a toxin produced by Aspergillus flavus, a mold that grows on peanuts or, in this case, damp maize, and is a staple food. And, this was a very large epidemic over a very large, geographic area. And again, asking the right question is so critically important because obviously the usual questions, “Is it what you think it is?”

and, “How are you gonna try and control it?” but the critical question here was, is this just a local phenomenon, or is it actually a national point source epidemic where maize, bad maize, is being distributed across the whole country? Very different,[00:20:00] situations. We had very strong technical staff, and a well-done case control study was able to show that actually it’s local maize.

Pe- maize grown locally, pe- people growing it, eating it in their own households. Learnt an awful lot about the market dynamics of maize, which is hugely complicated. but what was so sobering about this was… Well, firstly, it was just an awful situation of people who were really poor in an area that at that time was very neglected.

And people often knew they were eating bad maize, but they had nothing else to eat. They even resisted giving some of it up for laboratory testing because they had so little So it was really, you know, very distressing type of situation. But,the, the other thing that was so insightful, but as I said, sobering, was that actually medicine and public health really don’t have much to offer [00:21:00] here because the problem is agricultural, and the solution, or the emergency solution is confiscating bad food and replacing it.

Very difficult. Again, not under the control of medicine. and you know, the usual regulatory,requirements of testing food for aflatoxin and so on. Aflatoxin levels, th- there’s a very important, saying, which again, I learnt from my environmental colleagues, in toxicology, that, it’s the dose that makes the poison.

Which of course is true in many things. I mean, it’s true for alcohol, for example. it’s the dose that makes the poison, and the, the, the, you know, the fatal cases were eating hugely elevated levels. But aside from that, and, outside of this sort of outbreak situation, levels of aflatoxin are higher in many places, including throughout Kenya, than the international standard.

But you’d never know because, you know, the dose isn’t high enough to cause acute damage. But the, the long-term health [00:22:00] effects of this are very understudied, and actually it’s a very important,question, I think, and a very widespread one. but this was, for me, certainly an educational experience.

One of the things we… well, this is skipping over the AIDS story. It’s described in the other book. We played, We did play an important role in those early days of, well, throughout until recently, of, on antiretroviral therapy scale-up, a whole experience in its own right. With, Some interesting, you know, questions as we were doing it.

The, the slum at the bottom there, Kibera, one of the largest slums in Africa, several hundred thousand people, a very well-known informal settlement, well-described. we sort of thought to ourselves, if you could deliver ART here, then you should be able to do it anywhere. And actually, it was a very successful pilot program or demonstration, implementation science program we did there, showing that indeed, you- p- adherence was very [00:23:00] high and results were very good.

And I mean, ART is one of those disruptive interventions that, if people take their drugs, they’ll do well. but a very difficult environment. And one did ask oneself sort of philosophic questions at the beginning. You know, what are we doing? We’re giving ART and measuring viral load, which at that stage wasn’t widely available at all, in this environment that doesn’t even have water and sanitation.

And it was an interesting philosophic question and a rather poignant,saying by a woman in a focus group discussion, “If you give us ARVs, please give us food. Just food.” But as I said, a, a remarkable intervention And then Ebola. Ebola, which Tom and others here know much about and have huge experience in.

I got involved in the… I’m a CDC team lead for, the response in West Africa, particularly in Liberia in, from 2014 to 2016, different deployments. I, I always say to my- I [00:24:00] always say that, you know, when I sort of look back and say, “What are the most extraordinary, impressive things I’ve seen in just, you know, medicine in general over the years?”

I would say watching the emergence of the AIDS epidemic, seeing what it did in Europe, in America, in Africa. and then secondly, the introduction of ART, which was, like, life-savingly miraculous. I mean, unbelievable when it was introduced, you know, and it became obvious in, back in 1996. But thirdly, this Ebola epidemic, when it, in the really bad time, was, you know, quite astonishing and awful.

Bodies in the streets sometimes, people sleeping o- dying in hospital grounds ’cause there’s no beds, et cetera. It’s, I mean, literally my first couple of weeks there back in July of 2014, every day something would happen, you say, “I can’t believe this is happening.” including actually the, the first infection, dealing with the first infection in an expatriate American, healthcare worker, a doctor from Samaritan’s [00:25:00] Purse, the faith-based group.

and nobody had figured out, you know, w- what we were supposed to do because previously, it was just thought, “Well, you know, people take their chances wherever they are.” So a very… This whole chapter on Ebola, 20- in that outbreak in the three countries, over 28,000 infections documented, over 11,000 deaths.

I have no idea how accurate that epidemic curve is. it shows in blue that it started in Guinea and it finished in Guinea. Sierra Leone, in yellow, was the most heavily affected, and Liberia, in red, was controlled the most quickly. For CDC, this was an enormous intervention. Hundreds of people at headquarters working on this, and over 1,000 individual, between 1,000 and 2,000 individual deployments to the African field.

An enormous intervention In DRC 2018 to 2020, a very different and much more difficult situation. There’s… Each of these outbreaks, there’s a [00:26:00] chapter on each in the book. DRC very different. much more difficult. Tedros W- the Director General of WHO, described in an interview. He said, “We’ve never seen anything like this, Ebola in a war zone.”

And this is actually w- the same area where the current outbreak,is going on in, Ituri Province in North Kivu, although now it’s spread to another four provinces I think. very difficult. some very good work done, including a clinical trial, under the most difficult circumstances. clinical trial of, monoclonal antibodies showing their efficacy.

but, challenging. Many countries, many governments do not allow their official staff into this area because of insecurity. the Italian ambassador was killed in 2021 in North Kivu in a kidnapping attempt. so it’s a very, you know… and everything there is worse than it now, than it was then.

It’s, you know, more fighting, more militias, more instability, more insecurity, displaced [00:27:00] populations, more movement, and the regional capital of Goma with its international airport under the control of M23, the Rwanda-backed rebel group. I think a question we need to ask, perhaps we come back in discussion, and Tom, I’d be interested to hear what you think.

what happens if we don’t control this outbreak? I think it’s gonna go on for at least two years, and nobody seems to be saying that. It’ll be at least two years based on these other experiences, and there is a real possibility I think that it will not be contained, at least not completely. And I think the discu- the, the implications of that, deserve discussion.

so Ebola really, Ebola and HIV really epitomize the whole concept of emerging infectious diseases. it’s interesting to reflect on how our perceptions of Ebola epidemiology have changed because back in… when it was described in, Yamb- in Yambuku in DRC in 1976, it was for many years, for s- two decades or more, s- [00:28:00] almost three decades, just viewed as a sort of obscure, tropical infection of remote Central Africa.

and look where we are today, with that, how things have changed. That picture actually of the man in the blue shirt, that’s, Kent Brantly. He was that first American doctor to be infected in Liberia and then COVID. I wasn’t gonna write about COVID in- initially ’cause I thought I don’t really have anything new to say, but was…

The publisher said, “No, you have to.” So what I ended up doing was sort of looking as a CDC insider, but from outside the United States, looking back into the US and see what happened. and CDC stumbled, and they sort of, stumbled, and then sort of since then has been persecuted. and that the original sin, was that in February, January, February of, 2020, yeah, 20…

Twen- yes, 2020,they released… developed a [00:29:00] test for, SARS-CoV-2, sent it out to the states, to the state health departments. CDC develops new tests sometimes for new infections. It’s not in the business of manufacturing tests. Well, the test was flawed, and there were mistakes, and this went on for a coup- you know, for many weeks, and ground, important ground was lost.

And that was sort of a handicap for quite some time. And of course, the politics that then played out were really quite unfortunate. And anyway, in the book, there’s a discussion of lots of that. And then what happened in Kenya. I was in Kenya. again, I stepped in as lead for the, the CDC response for much of the year.

and we thought initially that this was gonna be a disaster for Africa, for Kenya. We thought there would be hundreds of thousands, just based on sort of back of the envelope calculations, that there would be hundreds of thousands of infections, which there were not. And I think the explanation actually is the age of the population.

I think [00:30:00] that has to be the main explanation, and probably also less comorbidities. As far as the clinical manifestations of COVID, in those who did get sick, it all… I mean, everything played out like it did everywhere else in the world with, the known risk factors. And Kenya actually did, you know, under difficult circumstances, really did quite well The final part of the book, Bureaucrat, there’s a chapter…

it discusses organizations, how they work, organizational structure, strengths and weaknesses, leadership, management. There’s a chapter on health diplomacy, or it’s called Health Diplomacy and Health Bureaucracy. But some of the sort of experiences I’ve discussed, some of the lessons learned, in a way,I repeat several times actually, in a way what it’s all about is the sort of stuff that doesn’t get into the materials and methods of a paper, which often are actually more important than the study results or the study itself.

And I… And there is a chapter on tuberculosis, which is not [00:31:00] out of place in this part of the book. I find TB, it’s sort of a disease that it’s kind of pursued me because I’ve been involved with work on it or as a clinician working with it, you know, since the very beginning. And it’s one of those diseases, and it…

There are others, cholera perhaps, or syphilis, certainly congenital syphilis, that you sort of say, “You know, this shouldn’t be happening.” It’s like a barometer of societal welfare. you know, people should not be dying of tuberculosis. we’ve known about this long enough, and it’s, it should be manageable.

so there’s a chapter on TB as well, which has such a rich history as a disease. And then as I said, there is a prologue and an epilogue. Let me skip over that because I want to leave some time for questions. it has some general observations, some of which I think I sort of alluded to last time I spoke here actually when I…

A couple of years ago I spoke at World AIDS Day. I show that etching, of a sur- [00:32:00] of a s- a, a physician fighting death for a reason. it’s actually one of my earliest memories in life. It’s drawn by an Austrian artist in about 1920. His name is Ivo Saliger, and he drew it, in grief, at the death of his 20-year-old sister who died of lymphoma or leukemia.

And I find it, you know, very, thought-provoking. I remember it because a copy of this hung in my father, my surgeon father’s office in Belgium. But it reminds in public health that we cannot forget that actually individuals matter. You know, if you talk about scaling up ART or vaccination programs and targets and so on, you have to remember you get there one by one And then the, the rupture, yes, the, the chaos, that we’ve seen since 2025, the change in administration in the [00:33:00] United States.

Two quick comments. It’s not only the United States, of course, other countries also have reduced their funding. The situation is very, in, in Europe is difficult, the war in Ukraine and all of that. and some of what the Unit- you know, some of what has been said isn’t crazy, but it’s the way it was done that is so destructive.

PEPFAR, the American AIDS program, you know, it cannot last in perpetuity. The United States can’t pay for every AIDS patient in the world for the rest of time. But the way the, and transition should have been better discussed over yea- over some time. But the way this was all dealt with, sort of we’ll do it simply because we can, and it’s like a light switch or pulling a plug, has been very, you know, very destructive, and we’re in a difficult situation, and obviously a situation of transition.

The importance of all of this, well, two outbreaks this year. This could be a sort of a pub q- pub quiz. What’s that ship at the bottom of the, who knows the [00:34:00] name of the ship? It’s the SS Mobius, was the famous ship in South America that, you know, bred the hantavirus outbreak, and of course the extraordinary epidemic in DRC right now coming to the end or finishing, I think this is the last slide.

W- we’re, we are in a, in global health, we’re certainly in a period of transition, and, I mean, there’s a lot that could be said about systems and international organizations and multilateralism and all the rest of it. I, I’ve been sort of struck by, you know, maybe it was my English school and the fact I had to learn Greek from, in my English boarding school.

But I’m sort of struck by Greek, you know, the cult- cultural, the, the culture of ancient Greece. one, the myth of Sisyphus. You know, Sisyphus pushing his boulder up a hill. He gets close to the top, it rolls back again, and he’s condemned in the underworld in perpetuity to struggle with this boulder.

And I sort of think, is that what’s going on [00:35:00] in global health? Well, I think not, but there certainly has been backsliding and, you know, countries will, under very difficult conditions, have to assume a greater burden. The other quote that struck me, there’s a, an Italian book, The Leopard. Actually, Netflix made a series of this last year or the year before.

It’s a very good series. I think it’s six episodes. It’s worth seeing. But there’s a quote that’s I’ve heard over the years that if we… One, one of the characters, and this is Italy in the late 1800s, much social change, sort of fighting going on, and one of the characters says, “If we want things to stay the same, things will have to change.”

And I, w- I thought of that quote in relation to CDC because I don’t know what will happen after, you know, the next two years. And people should start thinking how they want that agency, which now has lost 30% of its staff, and it,and has huge political interference, how they want… [00:36:00] You know, who, who is thinking about what it should be in the future and how we should manage it?

And,it cannot be what it was before because times have changed as well. And it’s really everybody who’s concerned with health and global health really needs to think what happens after this period. How do you deal with this period? Well, you get over it by going through it. but this really I think is, you know, stimulus to thinking, by all concerned.

Tom, thank you.

Thank you very much, Kevin. a- an inspiring talk. You said before that you hadn’t done a very good job of publicizing your book in the last year. Yes. I would beg to differ, and I think my main conclusion is that was obviously far too short a time for a seminar.