Transcript, Meeting 19, Opening Remarks and Session 5


November 6, 2014


Salt Lake City, Utah


Lawrence O. Gostin, J.D., LL.D. (Hon.)
Founding Linda D. & Timothy J. O’Neill Professor of Global Health Law
Faculty Director, O’Neill Institute for National & Global Health Law
Director, World Health Organization Collaborating Center on Public Health
Law & Human Rights
University Professor
Georgetown Law

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       DR. GUTMANN: Good morning, everybody. I'm Amy Gutmann, President of the University of Pennsylvania and Chair of the Presidential Commission for the Study of Bioethical Issues.

       I welcome everybody here to our second day of our meeting in Salt Lake City, on behalf of myself and our Vice Chair, Jim Wagner, who is the President of Emory University, let me begin by noting the presence of our designated federal official, Bioethics Commission Executive Director, Lisa Lee. Lisa, would you please stand. Thank you very much.

       I also would like to remind the audience that we will take public comments, but at the -- there are comment cards, both at the registration table and -- staff members, please show the cards. Just ask a staff member for a card, write down your question, and, time permitting, we will answer it. If we can't, we will certainly get back to you.

       Today it's particularly important and exciting that we are beginning our new report deliberations, which I announced in August, on deliberation and bioethics education. All of the Bioethics Commission reports to date have been topic-specific. This Commission has made a particular commitment to education and deliberative effort and that has been a constant thread throughout our reports.

       Recognizing that education is required for informed deliberation, and deliberation enhances education at all levels, this new report will integrate deliberation and education as overarching themes of the Commission's work and focus on their symbiotic relation as twin pillars of public bioethics.

       The report will represent the capstone of the Commission's commitment to advance and promote education and deliberation on some of the most important issues of bioethics in our time.

       So having informed discussions about global public health, and certainly the education necessary to enable productive discussions, has been on the front page in everybody's mind lately.

       There are very few examples that are stronger than a global public health crisis to focus our minds and drive home the importance of public education and proactive deliberation about the issues that we need to have -- to come to grips with -- at the time that the crisis hits, and that there is a need for both an informed public and informed public policy decisions and practices.

       So we are going to start our day with a panel on the Case Study of Public Health Emergency Response. While there are many compelling ethical issues to discuss on this topic, we are going to begin with a few speakers, two speakers regarding the particularly timely debate of restriction of movement provisions in response to an epidemic, with the Ebola crisis being front and center as a case study.

       In the coming months, we will continue to dive deeper into the nuances of this case study of Ebola and public health emergencies and broaden our discussion to the goals and contributions of deliberation and bioethics education, generally.

       Jim, do you want to add anything?

       DR. WAGNER: Very quickly. Welcome everybody. I'm pleased also that we are embarking on this newest project on deliberation and bioethics education, and agree that the Ebola virus disease crisis in Africa and the approach to management of the disease threat on our shores gives an extraordinary platform from which to consider the need for and impact of public deliberation and education.

       Emory University accepted the request to receive and care for the first two patients treated for Ebola in the western hemisphere. And this request included, importantly, that Emory would not only care for these patients but that it would do so with the utmost attention to safety, taking every appropriate measure to ensure health care worker and community safety.

       And we are very grateful, of course, to the physicians, nurses, supporting health care staff who were able effectively to put into practice the protocols with which they had been trained over the years.

       At the same time, though, and I think very germane to what our conversation will be, there were countless hours of education and deliberation engaged in by our communications and public affairs experts. It would be an oversight, a terrible oversight, to fail to recognize the enormous significance of that work in earning and building employee and community and public understanding, confidence, and even cooperation.

       So indeed, attention to this recent chapter of public health history, a chapter that is still open, has provided and will continue to provide helpful insight into the values of effective education and deliberation on bioethical issues, especially as they relate to public health and emergency response. So I'm eager to begin our own deliberations this morning. So thank you.

       DR. GUTMANN: Thank you. Just to underscore what Jim said, in any situation, but it is heightened in a crisis situation and a public health crisis situation or any situation of that sort, we need to know what to do. But we also need to know how to communicate it and when to communicate it and to communicate it effectively.

       So as I mentioned, our first panel will focus on the Case Study of Public Health Emergency Response. We will hear from our first speaker for ten minutes, and then we are going to open the floor for Commission discussion, and then hear from our second speaker separately, since they are being wired in. Wireless-ed in.

       Our first speaker is Lawrence O. Gostin, who is University Professor at Georgetown University where he directs the O'Neill Institute for National and Global Health Law. Professor Gostin is the Director of the World Health Organization Collaborating Center on Public Health Law -- hi, Larry -- and Human Rights. You just came into my sight. Very large. Larger than life.

       And you serve on the WHO Director General's Advisory Committee on Reforming the World Health Organization. Professor Gostin currently chairs the Institute of Medicine Committee on National Preparedness For Mass Disasters. He has received the IOM Adam Yarmolinsky Medal for distinguished service and the Public Health Law Association's Distinguished Lifetime Achievement Award, among many other important recognitions and accomplishments.

       We thank you so much for joining us this morning. And you can take it away.

       MR. GOSTIN: Okay. Thank you for having me. I really appreciate it. I'm a great admirer of your work and the Commission's work. And I also have to say I thought Emory University did a superb job caring for the Ebola patients.

       DR. WAGNER: Thank you very much.

       MR. GOSTIN: And so I'm actually very, very big and large there. I'm actually not. I'm a little guy. So don't let that fool you.

       I know my brief is mostly quarantine but I think that it's extremely important to connect quarantine to what is good for national and global public health. And so I'm going to -- I only have ten minutes. I'm going to go through what I consider to be the five major ethical standards at play here. I'll just mention them and then I'll go into each one.

       The first one is a cosmopolitan ethics which looks at the global picture and our duties to others.

       The second is the government's duty to protect society. And here I’ll look at U.S. preparedness in our public health infrastructure.

       The third is the duty to protect the vulnerable. And for that I'll talk about just allocation and also research efforts.

       The fourth is the duty of civic engagement. This is very much in line with the Commission's work on deliberative process and education.

       And the final is good science equals good law equals good ethics. And for that I'm going to talk about quarantine and risk assessment.

       So I don't have much time. I'm going to try to get through this.

       I think anyone who focuses on Ebola as a case study has to begin by acknowledging the sacred duties that all of us have in shared humanity, but particularly high income countries, to devote ourselves to alleviating suffering in another part of the world.

       This is particularly, of course, important with an epidemic because it's both in our -- it's both in our shared humanity, but it's more than that. It is also in our self-interest because truly the only way that we can avoid risk in our society, in a modern globalized world, is to reduce the reservoir of infection in West Africa.

       And I think that has to be the very, very first thing that the Commission or anyone else says about this, because that is ethics principle number one. And many in the United States have lost perspective about that. We've only had one death in the United States. There will be tens of thousands, maybe even 100,000 deaths projected before the end of the epidemic in West Africa. So I think some humility and compassion is very, very important.

       My second principle is the duty to protect society and of course the United States, the Executive Branch, the Legislative and Judicial, have a duty and a prior duty to protect people in the United States. I don't think we execute that duty by travel bans. I can explain that in questioning.

       And also I don't think we can do that with blanket quarantines, which I'm going to get to. But we can do it with U.S. preparedness.

       One of the things that is very striking in this is that the United States has engaged in multiple preparedness efforts from the anthrax attacks in October of 2001, through to SARS, Hurricanes Katrina and Sandy, and H1N1. And we thought that we were prepared. And it turned out that we weren't.

       And in the last few years -- and I forwarded this to Lisa, some articles that show really significant cuts to our public health infrastructure that I think have harmed us.

       And in addition, when we say we have the most advanced health system in the world, what does it mean? Well, it means we do have the most advanced, Penn and Emory and others are the best in the world. But it is highly variable. And particularly in public health systems. There are 3,500 local health departments. Some of them only have a half-time sheriff in their staff. So we need to try to find more uniform capability.

       I got a call from Tom Frieden yesterday and then the President thereafter announced an emergency supplemental budget request of $6.2 billion. I think it's very, very important not only for the Ebola response but also for our public health preparedness.

       I think that Ebola is a pivotal moment for the United States and the world and how it's going to think about reforming our public and global health system. And I have written a lot about that in The Lancet, which I have also shared with Lisa.

       The third duty is the duty to protect the vulnerable, because I think it's widely understood in bioethics that protecting those who can't protect themselves is a high calling.

       And we need do this in a couple of ways. One, of course, is the major question of research ethics. We have vaccines and potential candidate drugs in the pipeline. Where will we test them? On who? Et cetera.

       And then once we have decisions about their effectiveness, how soon would we roll them out, where would we roll them out?

       And then finally, how would we allocate them, and under what priority? Because the ethics debate really forged in the Ebola crisis when ZMapp was perceived not to have been given to people in Africa when it was given to U.S. aid workers. I think there were reasons for that. But nonetheless, it prompted a WHO ethical examination of that problem.

       The fourth is the duty of civic engagement. You've, I think very appropriately, called it a deliberative process. But whatever decision policymakers make, they need to be made in partnership and shared understanding with those who are most affected.

       I know that the Commission has been a great leader on this and so I won't get into it. But for Ebola in particular, and as it affects the poor and vulnerable, and particularly when we are talking about two post-conflict countries, three countries who are the lowest in global development, I think this is particularly important. We solved that with quarantines in Monrovia and country-wide lockdowns in Sierra Leone.

       You need to get the community behind you. If AIDS taught us anything, it taught us that with epidemics, the first response is social mobilization. And that changed -- AIDS changed the world, and we need to do that more.

       And then finally, good science is good law equals good ethics. I think you need all of those things. One of the -- the big problem about what several states have done in terms of quarantine is not only the obvious one, which is that it actually could impede the rescue response in West Africa. So think back to the cosmopolitan ethics. Because there will be a chilling effect on health workers to come and go from the region. But not just health workers; it would be essential food, supplies, medicines, diplomats, journalists, many others.

       So we have to think carefully about it. And when we think carefully, I think we should use good science and good constitutional law, both of which require an individualized assessment of risk before limiting liberty. We need to have a good balance between public health and civil liberties.

       I'm well-known for always preferencing the public health, but not at the expense of gratuitous deprivations of liberty.

       So in this case, any blanket rule does violate CDC policy. It goes against WHO policy. Frankly, I talk to global health experts all around the world, everywhere, nobody understands why we would have a blanket quarantine for people coming from the region. I think the CDC's guidance, which the main judge accepted, is based upon a segregated form of risk which I think is reasonable, it's scientific. And from a constitutional perspective, I think the touchstone of the Constitution suggests that quarantine and other restrictions of liberty can never be based upon a  generalized class but have to be on an individualized basis.

       And so throughout my career I have always followed this basic rule that if you want to know what's ethically right or what's legally right, you actually have to follow a rational scientific basis and balance a significant risk with the autonomy, privacy, and liberty of the individual.

       So thank you very much for this opportunity. I'm really appreciative of it. And I would be so delighted to talk with you for a little while.

       DR. GUTMANN: Well, thank you, Larry. And amazingly, you made five points in ten minutes and that gives us all the more time to hear more from you because you have hit all of the major issues that we, as a Commission, will need to be thinking about in the weeks to come, because we do expect to write a report featuring this as a case study in deliberation and education with regard to bioethics.

       So with that, I'm going to ask Jim Wagner to begin.

       And we will just ask you questions, then.

       DR. WAGNER: If you don't mind, we will feed you questions.

       DR. GUTMANN: And then you can elaborate on anything. And I'm going to just recognize people and I'll tell you who I'm recognizing.

       Jim Wagner to begin with.

       MR. GOSTIN: Thank you.

       DR. WAGNER: Larry, thank you so much for your being here. And the preparation of those points, as Amy said, right on point.

       But I'd ask for clarification or at least an opinion. You talked about the need for more public health system preparedness, and were encouraged about the $6.2 billion commitment to that. But later on you also talked about -- you used the phrase social mobilization under civic engagement.

       Can these two things be done together or is part of public health and social mobilization -- public health preparedness and social mobilization preparedness also include a communication -- a deliberate communication preparedness that should go on hand in hand with health system preparedness?

       MR. GOSTIN: Excellent point. You’ve made two interrelated points. If I may, I'd just like to address each of them.

       The first one is, does funding and social mobilization go hand in hand? Yes. They are  absolutely, completely integrated. And I can give you a great example of that and also some contra examples if you want.

       DR. GUTMANN: Sure.

       MR. GOSTIN: The best example is why does the Global Fund succeed in terms of funding but WHO doesn't? Well, the reason is that Global Fund has marshalled enormous social mobilization in its replenishment. And when it does that, people at the civic level, a community level, an advocacy level push their governments to fund those services. And I think that's been absent with Ebola. And I think -- so social mobilization is actually critical to that.

       I should mention that although the President has proposed the $6.2 billion, it still needs to be enacted by Congress, and that's well up in the air.

       I've been in touch with members of Congress, and there are two concerns. One is that they just might not fund it. But the other is that they might attach riders to it that would be, in my view, counterproductive, like a travel ban. And I can explain why I think a travel ban would be just a really horrible idea. Finally --

       DR. GUTMANN: Could you do that? Would you do that? Do your “finally,” but also go on because that was -- I recognized that you said no travel ban but didn't have time to say why.

       MR. GOSTIN: Okay. Sure. I just wanted to get to the point of risk communication.

       DR. GUTMANN: Right.

       MR. GOSTIN: Because really it's critical. And one could see it so carefully both in West Africa and actually even in the United States.

       Certainly in West Africa there's been widespread concern about -- that this is a plot, Ebola doesn't exist. Lots of questions about culture and burials and a dignified death. All of these things have loomed very, very large. And what made Nigeria's response better and more effective than the three most effective countries is that risk communication.

       So it's critical. We have seen it in the United States with heightened fear and panic and backlash. And so risk communication is important.

       And that would lead me to the travel ban. Because if you look, the vast majority of Americans support a travel ban. And virtually every Republican and I'm told possibly a quarter to a third of the Democrats might vote for it.

       Why is it a bad idea? Well, for so many  reasons. One, I think it would be devastating for West Africa. But actually, I think for all of Africa because travelers don't make the distinction between these three countries or West Africa and all of Africa. And we are actually seeing reduced economic and travel activity throughout Africa. And if it continued and if the United States had a travel ban, I think that it would have a cascading effect and other countries would follow suit.

       So for example, when we did our enhanced screening, the very next day Canada did it. The very next day after that, the UK did it. So I think it would be symbolically a horrible thing for the United States, particularly when we have been so good. I have been very proud of America sending troops, being at the fore, sponsoring the UN Security Council resolution. And this would just be exactly the wrong message. And I think it could ultimately devastate the economy of these three countries and other countries in the region.

       I think it would come back to haunt us because it would escalate the epidemic there and therefore put us at a greater risk. But also, it would come back to haunt us because I think diplomatically Africa wouldn't soon forget this. And if we want their cooperation in trade, commerce, diplomacy, we need to have an attitude of shared humanity.

       I frankly -- I think WHO, any UN international organization is horrified by the idea that we might do that. There's no scientific basis to do it. It certainly would never work with SARS. So it would -- I think it would be a very unfortunate idea and something that I think we need to find a compromise for if Congress is really committed to some kind of an answer to security.

       DR. GUTMANN: Thank you.

       Nita Farahany.

       DR. FARAHANY: Hi, Larry. It's great to see you again.

       MR. GOSTIN: You too.

       DR. FARAHANY: I was hoping we could focus on your last point a little bit, just the good science equals good law equals good ethics. And expanding it beyond Ebola, since Ebola is really a case study for us rather than the sole study, to understand from your perspective the legal issues that might arise with respect to a quarantine; and how you would think in other situations where quarantine might be an appropriate response as opposed to just isolation -- how we should approach that. What is the appropriate legal  and ethical framework to think about that?

       MR. GOSTIN: Okay. Well, first I'm glad you used the term "isolation" and "quarantine" separately. I wanted to explain in case other Commissioners don't study these kinds of distinctions.

       DR. WAGNER: You should do that for the record anyway, if you would, Larry. Thanks.

       MR. GOSTIN: Okay. So isolation is when you separate a known infectious person from the population. A quarantine is when you separate somebody who is not known to be infectious but is potentially exposed and you quarantine them for the period of incubation of the infection. And it goes back centuries, both isolation and quarantine.

       So what are the legal issues? Well, one legal issue, of course, is federalism. And I get that question asked all the time. When is it the responsibility of the federal government, when is it the responsibility of the states and the local government? And that's fairly clear.

       The federal government's quarantine powers are extremely limited. In fact, I can only remember them exercising it once in living memory, which is the Andrew Speaker case, the multi-drug resistant tuberculosis case. Their authority is restricted to preventing interstate and international spread. So certainly at the airport, the CDC has full authority. But once the person leaves the United States -- enters the United States formally, it becomes the responsibility of the states or the local government. And that's the problem which is you have highly variable laws, practices, capabilities at the state level.

       And I think it also cuts -- that kind of variability and differences in policy between the federal, states, and among the states actually undercuts the Commission's belief, and I believe it's a very important belief, that we need to have good education. Because the public will scratch their head when the CDC says one thing, Texas says another thing, New Jersey says another, Maine says another. And so I think trying to find some uniformity.

       Again, it's hard because the federal government doesn't have authority to tell the states to do anything. But that doesn't mean they can't do anything. They can do lots. They can do it through soft power, such as guidelines. And also they can exercise the spending power as we do with Medicaid to try to get more conformity. And so I think there are things that the federal government can do, and  shouldn't just throw up our hands.

       The other questions about quarantine, of course, are when you should use it. Certainly I think if you take Ebola as an example, if somebody has fever or symptoms or even if they don't but they have been subjected to a high-risk exposure, for example an open skin, needle stick, I think in those cases quarantine may very well be necessary.

       But if the person has no symptoms, no exposure, when the epidemiology tells us that sudden onset of symptoms really has not happened, and if you've got very close enhanced monitoring for symptoms and you tell the person not to congregate in crowded places, like airplanes, ship cruises, and things like that, I think it's completely safe.

       And I think the law requires it. Because as I mentioned, the touchstone of constitutional law is that you can only remove -- deprive somebody of their liberty if there's an individual assessment of significant risk. And that, I think, is the crucial touchstone for everything that we would need to be doing. And that's what science tells us. So that's why I say science equals good law equals good ethics.

       DR. GUTMANN: Thank you.

       MR. GOSTIN: And we should never be pushed into depriving somebody of their liberty simply because of exaggerated public fear.

       DR. GUTMANN: Christine Grady.

       DR. GRADY: Hi, Larry. How are you?

       MR. GOSTIN: Hi, Chris. Good.

       DR. GRADY: Thank you for your comments.

       And I want to just ask you a question about the travel ban because the arguments that you made seem very convincing to me. And yet you also pointed out that a large number of members of Congress and the majority, I think you said, of the American public is in favor of a travel ban.

       MR. GOSTIN: They are.

       DR. GRADY: So I guess I'm trying to struggle with the following. In light of what we are trying to do, as well, do you think it is a lack of information about the risks and the possible consequences or do you think it is a tension between the first two duties that you described, the cosmopolitan duties and the duties to protect our own society? And if it's one versus the other, do you think there's a different strategy in terms of how to address it?

       MR. GOSTIN: Yeah. I mean, it's a combination. Those are very, very thoughtful points,


       Yeah, I mean, my -- I've called it a misguided self-interest because I think that the travel ban appeals to folks because we think we can wall off this part of the world. But in a modern globalized world, you can't. And it's really a 19th century view. So I don't think you can actually do it.

       And ultimately I call it a misguided self-interest because I think that to the extent that it would increase the reservoir of infection in West Africa by impeding the rescue response, I think it actually increases, not decreases, our risk.

       So although one could see that there's a tension between the cosmopolitan and public health, I think ultimately there isn't. And this is one of those fortunate instances where I actually don't think it is. But I do accept, and of course I accept that the primary responsibility for the U.S. or any government is to protect its own people. And so I would never want to do anything that would harm the American public. And so I think that focusing on our own preparedness while engaging in rescue response in West Africa is our surest method.

       Now, whether or not public education would work, I think we should certainly do that, and do a lot more. But we have to understand that Ebola is a very, very frightening disease. And these kinds of fearful diseases, if you go back in history, it always provoked the kind of response of closing your border. And I always thought, well, since I've studied the history of public and global health, that I can teach, that history would teach us and I could have a voice of reason. But it's so hard. You can see history repeating itself.

       DR. GRADY: Thank you.

       DR. GUTMANN: Could I follow up on your response? Because I think if you can see the body language of our Commission members, we are very with you on your perspective here.

       Let me just throw out a possible way of communicating and educating that would also, I think, help make up for some of what I think is a very particular injustice in this case, which is the way we, as a society, are treating these health care workers who are really volunteering to do amazingly important risky work.

       MR. GOSTIN: So important.

       DR. GUTMANN: So we -- and all societies do this, some better than others. But we are often very good at singling out people who, like our troops,  who whether you agree with the war or not, are heroes. They are doing work that otherwise --

       MR. GOSTIN: I agree.

       DR. GUTMANN: Could we do something now? I mean, when the fear is at its peak it is very hard. But could we do something now to honor these people who have been, to date, really subjects of, are they being quarantined? Are they -- how about let's try and could we do this really quite systematically to show people what heroes and how much we need these people as heroes. And the nice thing is they are women as well as men.

       MR. GOSTIN: Yeah. Maybe more so.

       What you said resonates with me very positively and powerfully. I do think they are heroes. And when people have said about, say, Kaci [Hickox] and that she is being selfish, I would think, well, who are we to judge her, who has gone and sacrificed in a faraway region? So I do think they are heroes and I do think our troops are heroes as well.

       Now, I have actually been part of a group of public health people that have been trying to do just that. That is, tried to highlight the majesty and the beauty of individuals with individual stories and what they have done. And I think that those kind of powerful individual stories, as you have suggested so articulately, is exactly a good way to do it.

       Again, we learn from the AIDS movement. And the reason that -- one of the reasons that AIDS social mobilization worked so well is that we focused on individual stories, individual people.

       DR. WAGNER: That's a good point.

       MR. GOSTIN: And that I think has a great power.

       DR. GUTMANN: I think we have to do that if we are going to get public attention in the right way.

       MR. GOSTIN: Yes.

       DR. GUTMANN: Without those stories -- so thank you.

       Anita Allen.

       DR. ALLEN: Hi, Larry. I actually have exactly the same question that Christine Grady asked you about cosmopolitanism and maybe put a little extra twist on it because I do think that in some ways public health emergencies are ideal teaching moments for a country, for a nation, for a world. But they are also very bad teaching moments in the sense that when you are having a crisis it may be not the best time to deal with prejudices, xenophobia, racism, class issues, and  yet you kind of have to in order to reach beyond the local and to get to the global.

       So I'm just wondering, could you say a little bit more about how you think we can achieve both the right public health outcomes and the broader goal of bioethics education around health emergencies in light of what we know to be fairly intractable seeming prejudices, discrimination, and so on?

       DR. GOSTIN: Yeah. I mean, I have the same sense that you do that this could and should be a pivotal moment. I think a pivotal moment both for education and teaching, but also a pivotal moment for learning lessons, making reforms, and going forward. And I think it would be just very, very sad if the Ebola crisis came and went and we didn't really transform our public policy and our public education around that vital moment.

       How to do that is hard. I'm more studied and understand better how to learn the policy lessons and the institutional lessons. And I have worked very hard with WHO to try to do that.

       If you look at, for example, SARS, both in terms of public education but also policy, I think two critical retrospectives were very important. One was Harvey Fineberg's retrospective for the WHO independent commission. He did it for H1N1, and then Canada did it for SARS. And the SARS report and the Fineberg report both taught us a lot about prejudice, education, what institutions should do, what preparedness is.

       Just to give you a great example -- I mean, in Harvey's report, I pointed this out in Atlanta, he recommended to WHO in 2011 that they have a global contingency emergency fund. That could have really been a rapid response to Ebola or any other emerging disease. They never accepted it. And so I think that would be -- that's a clarion lesson that we could learn.

       But I do think, Anita, you are right; these are very, very important moments and that we really need to capture them.

       DR. GUTMANN: By the way, I should say that Nelson Michael, who is a wonderful Commission member, wishes he could be here and has a lot of experience, obviously, in the community engagement and the AIDS. But he is doing his other national duty which takes priority over the Bioethics Commission.

       Dan Sulmasy.

       DR. SULMASY: Thanks, Larry. It seems to me that you are suggesting that as the alternative to quarantine, quite reasonably, that we have a system of self-restriction and self-monitoring.

       And I wonder what your recommendations are in terms of assuring compliance with that. Is education enough? Because we know that even some health workers haven't been good enough. Or is it permissible, do you think, or reasonable to ask for sort of registration and reporting as a way to balance individual liberties against assuring the public and protecting the public's health?

       DR. GOSTIN: Absolutely. Great question. It's so interesting, I think everybody on the Commission is my friend, so it's very nice to be here to talk with you.

       Well, you know, I actually have said and I do believe that the idea of complete self-monitoring was a mistake. Now, whether it was a mistake from the scientific or policy side or mistake in just being tone deaf politically, I won't make that comment.

       But I did think that the early missteps and the distrust that the public had in authorities was the idea of, well, it's completely voluntary, completely self-monitoring. So I think in order to have a reasonable reassurance of the public, without being draconian, there are lots of ways that we can do this.

       One way, of course, is to have active direct monitoring by the health department. That is, don't rely on a simple self-monitoring but have the health department check in twice a day. Fever, it could be by Skype, it could be by internet, it could be in person or by phone, and find out and do that affirmatively.

       There are also a number of technologies that we could use. We could use technologies that might monitor fever, that might monitor location, things like that.

       And so I think we shouldn't only rely on self-monitoring, although it would work in the vast majority of cases. But I think we need to take a step beyond to reassure the public that we really take this seriously. And I think it's quite reasonable to ask someone to undergo that kind of monitoring.

       DR. GUTMANN: Larry, I know you have to go. If we could do one final question. John Arras.

       DR. ARRAS: Hi, Larry.

       MR. GOSTIN: John.

       DR. ARRAS: Dan Sulmasy asked my question. On the first pass there, I thought you were putting perhaps a bit too much trust in an individual's willingness to comply. If you are going to tell them that they shouldn't go on an airplane, that, you know, indicates that you have a lot of trust in the average person. So I'm glad to hear you talking about, you know, increased measures way short of quarantine.

       MR. GOSTIN: Yeah.

       DR. ARRAS: And I'm totally satisfied with that.

       And I want to commend you for trying to find ways to honor people who have fallen in these various epidemics. I'm an amateur historian of these plagues, and I have felt for a long time that these stories should be taught in medical school.

       MR. GOSTIN: Thank you. Thanks, John.

       DR. GUTMANN: Larry, thank you so very much. And we will take all of what you said and integrate it as we can in our report moving forward and we will be back in touch with you. And we hope to see you closer, but no bigger.

       MR. GOSTIN: That's right.

       DR. GUTMANN: And we all want to thank you.

       MR. GOSTIN: Thank you. It’s a wonderful Commission, with wonderful leadership. So it's a real great privilege for me. Thank you for having me.

       DR. GUTMANN: Thank you very, very much. Bye bye.

       We have ten minutes and then we will bring in Tony Fauci.

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