Pandora Report: 11.18.2022

Well Pandora Report readers, it’s that time of the year where we load our US audience up with plenty to bring up at the Thanksgiving table. 🦃 This week we start on a positive note with updates about what some of our students have been up to. We then dive into discussion of how avian influenza is likely to affect our US readers this Thanksgiving, the Biden administration’s newest National Security Memorandum on food and agriculture security, and a new study on Hendra virus that helps confirm what we already knew-man-made climate change is making infectious disease threats worse. We also cover a number of new publications, including several discussing the upcoming Biological Weapons Convention Review Conference.

Biodefense Program Students Take Atlanta and Milwaukee

When we aren’t buried in the books, enjoying our incredibly unique curriculum and world class faculty, or getting inside looks at exclusive facilities, we do get to spread our wings at professional conferences, trainings, and other trips all over the world.

Just recently, Biodefense MS Student Sophia Hirshfield traveled to Atlanta to attend the National Association of County and City Health Officials 2022 Preparedness Summit. There she learned from experts about what it takes to make us safe at the local level. As she wisely summarizes it, “We cannot say we are prepared for an emergency unless even the most vulnerable among us have preparedness resources available to them.”

Last month, Biodefense PhD Student Omar Mukhlis went to Milwaukee to attend the 65th Annual Biosafety and Biosecurity Conference offered by the American Biological Safety Association. When he wasn’t chowing down on cheese curds, he attended panels on biorisk management, public health’s intersection with law enforcement, and this year’s Eagleson Lecture delivered by Virginia Commonwealth University’s Dr. Richard Marconi-“The Growing Threat of Lyme Disease: Where Do We Stand?”

You can read about Sophia’s trip here and Omar’s here.

It’s Giving…One Health

The seventh annual One Health Day may have already come and gone this month, but there is still plenty to talk about. In case you don’t know, One Health is an approach that recognizes the synergy between human, animal, and environmental health and, as a result, emphasizes collaborative and interdisciplinary approaches to addressing health issues. It certainly isn’t a new concept but, as we’ll discuss below, it is one that is becoming increasingly important in today’s world.

Nothing to Gobble At…Turkey is ≈73% More Expensive This Year

Right now, according to the US Department of Agriculture, the average price per pound for whole turkeys is $1.99. This time last year, it averaged about $1.15, meaning the US is experiencing a 73% increase in price ahead of turkey day. However, this isn’t just a symptom of the general inflation we are experiencing. Remember the spread of highly pathogenic avian influenza we discussed earlier this year?

While avian influenza normally spreads in the colder months, the world saw a number of outbreaks earlier this year and late last year. This continued into the summer months, when commercial farmers typically are preparing for the demanding holiday season. As of November 17, more than 50 million birds in 46 states from commercial and backyard flocks have either died from bird flu or have been culled after exposure to infected birds since early 2022. 47 states have detected avian influenza in about 3,700 wild birds this year as well. While there has only been one reported human case in the US this year, people all over have felt the effects as prices for staples like eggs skyrocketed. The holidays will be no exception with price increases and large numbers of flocks impacted across Europe too.

However, if you (correctly) prioritize sweet potato casserole and cranberry sauce at your Thanksgiving dinner, you’re in luck. The price of sweet potatoes have gone up just about 3¢ a pound, while 12 oz. of cranberries went up about 1% (or 2¢) to $2.24, making them some of the most minimally affected Thanksgiving staples.

President Biden Signs NSM-16 on Strengthening the Security and Resilience of United States Food and Agriculture

This week the Biden administration released National Security Memorandum-16 (NSM-16) which aims to strengthen the resilience of US food and agriculture. This memo includes portions dedicated to threats posed by climate change and cybersecurity in response to recent events like a June 2021 ransomware attack that halted operations at one of the world’s largest meat suppliers’ North American base, the spread of HPAI this year and its impacts on poultry supply and safety, and the threats to global food security and grain supply caused by Russia’s war in Ukraine. NSM-16 provides guidance to help identify and assess threats of greatest consequence, strengthen partnerships and enhance workforce resilience, coordinate interagency efforts more effectively, and enhance preparedness and response capabilities. Among its priorities are “Redefining the way that chemical, biological, radiological, and nuclear (CBRN) threats are defined, in relation to the food and agriculture sector specifically,” and “Enhancing threat and risk assessments, disseminating needed information with relevant Federal, State, local, Tribal, and territorial (SLTT) governments and private sector partners.”

Deforestation is Driving the World Batty

A bat carrying a virus loses its habitat and, as a result, moves away towards other animals. In the process, it sheds viral particles in its feces and saliva, eventually spreading the virus on to another animal that can, in turn, spread it to human populations. Those infected typically will first experience fever, cough, sore throat, headache, and malaise. Later, they can develop meningitis or encephalitis, bringing on worsening headaches and fever, drowsiness, and even convulsions and coma. Up to 70% of people infected with the virus die, while about 80% of infected members of the intermediate species die. No, it’s not the ending of Contagion. It’s Hendra virus (HeV), a very real member of the same genus (Henipavirus) as Nipah virus, the also very real virus that inspired the film’s fictional virus, MEV-1. While it’s not quite time for EIS officer Kate Winslet to valiantly try to save us all just yet, a new study offered by Nature as an accelerated article preview indicates we might be a little closer to that point than we would like to think.

It started in 1994 in Queensland, Australia. In Hendra, a suburb of Brisbane, a pregnant mare became sick and died two days after arriving from a paddock somewhere else in Brisbane. Eleven days later, 17 more horses in the large racing stable also became ill. Fourteen of those 17 were euthanized. Between five and six days after the mare’s death, a stable-hand and a trainer, both of whom had contact with the mare’s mucous secretions, developed flu-like illnesses. The hand recovered, but the trainer developed pneumonitis and arterial thrombosis before going into respiratory and renal failure and dying from cardiac arrest seven days after hospital admission. As explained in the Medical Journal of Australia, “A morbillivirus cultured from his kidney was identical to one isolated from the lungs of five affected horses. The two affected humans and eight other horses were seropositive for the infection, which was reproduced in healthy horses following challenge by spleen/lung homogenates from infected horses. There was no serological evidence of infection in 157 humans who had had contact with the stables or the sick horses or humans.” That was how HeV made its first appearance, and it hasn’t become any less terrifying since.

Since then, HeV disease has killed over 100 horses, though just seven humans are known to have been infected, all through close contact during care or necropsy of sick or deceased horses. There has been no documentation of human-to-human transmission. The natural host has been identified as fruit bats of the Pteropodidae Family, Pteropus genus, also commonly known as flying foxes. To date, serologic evidence for HeV infection has been found in all four species of flying foxes in Australia, but spillover to horses has been limited to coastal and forested regions in Queensland and New South Wales. Furthermore, late last year, a study identified a novel HeV variant that was discovered in Australian flying foxes after a heat stress mortality event in 2013. This variant was compared to published HeV genomes and it was 84% similar. As it belongs to the HeV species but is part of a distinct lineage, it was designated HeV genotype 2 (HeV-g2). Last October, an equine case of HeV-g2 was detected near Newcastle, NSW outside of the winter season typical for HeV and further south than any previous equine detection, highlighting the expanded geographical area at risk for spillover. Updated diagnostic tests are now available in Australian states and territories to be able to test for all known HeV variants.

There is a registered subunit vaccine available for horses (Equivac), though there is no vaccine for humans. However, as a survey in PLoS One revealed, 43% of horse owners in Queensland have not vaccinated their horses, with that number rising as high as 70% in some parts of the state. The Atlantic spoke with some of these owners, with one telling them “I don’t believe in injecting chemicals into horses, especially if it’s not tested,” Carloss said, referring to the fact that regulators, citing the danger posed by an outbreak, initially allowed the vaccine to be sold under a provisional license. “More people get hit by cars or shark attacks.” This has caused tension with equine veterinarians and broader concerns about low vaccination rates increasing the risk of spread to humans who work closely with unvaccinated animals. This is especially worrisome given recent findings that indicate flying foxes are increasingly crossing paths with horses and humans as they lose their natural habitats.

Source: CDC Public Health Image Library

The New York Times explains that the new Nature study, “…based on 25 years of data from Australia, suggests that environmental changes have been driving these spillovers by radically altering the ecology of black flying foxes. Deforestation, coupled with climate-linked food shortages, has driven the bats into human-dominated habitats like farms, where food is readily available but may be of poorer quality…” Furthermore, a second study published in Ecology Letters suggests that flying foxes may demonstrate more pronounced viral excretion as a result of recent food shortages, meaning they are shedding more virus when they arrive at human-dominated habitats in search of food.

Worse yet-they aren’t leaving like they used to once the seasons change. The Nature article notes that, in the past, the bats would normally break up into smaller groups to seek out food sources like urban gardens and agricultural areas during winters or events like El Niño that limit their supply. Typically, these behavioral changes would last only for those periods of acute food stress, and then the bats would return to nomadism and nectivory once their food sources were available. Beginning in about 2003, however, flying foxes often still break off into smaller groups during periods of food shortages, but they now permanently remain in their new habitats near farms and cities instead of returning to nomadism in the forests. The authors suspect this is because of rapid deforestation, with about 1/3 of the bats’ winter foraging habitat having been lost between 1996 and 2018. Between 2003 and 2020, the number of flying fox roosts in the sampled area tripled, the average size of groups shrunk, roosts were increasingly close to one another, and, as a result, the bats foraged in smaller areas.

The authors think the animals may no longer find benefit in trying to maintain their nomadic lives as deforestation has made it more convenient to rely on the low-quality food they can get near farms and cities, rather than expending much more energy trying to search for dwindling supplies of the food they once relied on. This means that these bats are shedding more virus than normal, staying in human-dominated areas, and living in closer proximity to horses, all of which increases the likelihood of HeV transmission. It’s important to note too, as Dr. Cara Brook of the University of Chicago highlighted, that this is not a dynamic unique to Australia. Wild bat populations are reservoirs for different diseases all over the world in many different ecosystems that are also at serious threat. The Pteropus genus also includes the known reservoir for Nipah virus, which first emerged in Malaysia in 1998, devastating the local pig industry and causing fatal disease in humans. In the last few decades, their habitats in Southeast Asia have been reduced by deforestation caused by industrial plantation. In fact, between 1990 and 2010, Malaysia lost nearly 9% of its forest cover, in large part due to logging and clearing for the palm oil industry.

In the end, human, animal, and environmental health are inextricably linked. This new study does a great job of showing change over time and the role of climate change in changing animal behaviors and worsening infectious disease threats. However, it is important to not just absorb this information, but to consider the broad ramifications of these findings across all fields.

What Have We Learned from COVID-19? Apparently Not Much

This week has had a lot of more of the same old frustrating updates and conclusions in terms of COVID-19 and our preparedness for future global health threats. The WHO’s Global Vaccine Market Report for 2022 found that, “Despite progress in recent decades, global market vaccine dynamics are not fully conducive to the development, supply and access for vital vaccines for public health,” limited profit potential continues to hamper investment in vaccines labeled priorities, and (you guessed it) “Lower-income countries have struggled to access critical vaccines – such as against COVID-19 in 2021 and cervical cancer vaccine – that are in-demand by wealthier countries.” While countries like the US have had the luxury to hold onto excess vaccine doses throughout the pandemic, others have gone without. However, as most are keenly aware, this has been far from indicative of a stable situation in the US health system.

Kaiser Health News reported this week that the roughly 4,000 epidemiologists, communication specialists, and public health nurses hired by the CDC Foundation to augment local and state health departments nationally will lose their jobs as the foundation’s $289 million in COVID-19 relief funding runs dry. Pierce Nelson, a spokesperson for CDC Foundation (an independent non-profit that supports CDC), indicated that no more than 800 of these 4,000 hires would remain in their positions. This means many local and state health departments are facing serious staffing shortages as we face a potential winter surge in COVID-19 cases, a concerning start to flu season coupled with lagging vaccination rates, exploding STI rates, and growing calls for a health emergency declaration with more than 3/4 of US pediatric hospital beds occupied in large part because of this year’s explosion of RSV cases.

While the administration has largely moved on from treating COVID-19 like an active emergency, leaving a slim chance of 4,000 professionals hired using COVID-19 emergency funds keeping their jobs, this points to a much large problem-public health is chronically underfunded in the United States. Those 4,000 are dwarfed by the at least 80,000 new public health employees estimated to be required nationally to allow state and local department to consistently offer a minimal level of services. In 2020, just 28% of local health departments had an epidemiologist or statistician on staff. Furthermore, public health workers left the field in large numbers during the pandemic, citing burnout and public abuse related to COVID-19 rules and economic downturn. Though $3 billion is expected to come to state and local departments this month to help support building a public health workforce, another one-off lump sum is not enough, especially after thousands like those hired by CDC Foundation will have already had to move on with their lives.

Today, at least 1,072,285 people in the US have lost their lives to COVID-19, with 555 of those reported yesterday alone. COVID-19 is the third leading cause of death in the US, behind two noncommunicable diseases-heart disease and cancer. Even if it were true that COVID-19 is no longer a major part of our lives, the fact still remains that these numbers are as high as they are because of how poorly the US responded to the pandemic. This boom and bust funding cycle clearly does not work for public health. Consistent, yearly, secure funding is needed to make sure we have a competent, stable public health workforce that is well-supplied and able to handle whatever we have to deal with next. Dr. Katie Schenk, who served as a Senior Epidemiologist on CDC Foundation COVID-19 emergency fund contracts at the Illinois and District of Columbia Health Departments, was quoted by KHN on this subject, saying “How do you explain that there is no funding for employment in our field when there is clearly so much work to be done?” she asked. “It’s to the detriment of the public health system, which is shedding staff like there’s no tomorrow.”

Tossing a bucket of water towards the neglected, dry, wooden house that is already engulfed in flames is never going to work. Pre-COVID-19, just 3% of healthcare expenditures in the United States were for public health. In 2019, US the National Health Expenditure sat at $3.8 trillion, or $11,582 per capita, accounting for 17.7% of GDP. That number grew nearly 10% in 2020 to $4.1 trillion, or $12,530 per person, accounting for 19.7% of GDP. Of course, in the middle of surging hospital occupation and the rush to find a vaccine, the US spent a lot on health care and related activities like research and insurance. And, to be fair, public health funding accounted for 5.4% of NHE in 2020, but it was in the middle of a pandemic.

Furthermore, in August, Brookings estimated that around 16 million working-age Americans have long COVID. In a longitudinal survey conducted by the US Federal Reserve Bank of Minneapolis, 24.1% of people who contracted COVID-19 experienced symptoms for three months or longer. At that point, 70% of Americans had contracted COVID-19, meaning if that 24.1% holds roughly true in the broader population, about 34 million working-age Americans had long COVID at some point. As many as 4 million workers are likely out of work because of long COVID too, according to Brookings. The annual cost of those lost wages is estimated to be between $170 and $230 billion annually and it is likely to rise in absence of substantial policy changes like expanded sick leave, improved employer accommodations, and wider access to disability insurance in addition to improved prevention. To be sure, this all costs a lot of money. However, it would not have cost nearly as much if we had invested more in things like public health way before COVID-19 even emerged.

This highlights two very important points: 1) Americans spend much more than comparable countries on healthcare, but they have poorer outcomes, and 2) much like it is cheaper to invest in preventative care and social services that improve quality of life rather than pay for medical care down the line when someone is seriously sick, it is cheaper to invest in public health way before a crisis comes. In fact, Academy Health found in 2018 that “Every $1 invested in public health yields improved health outcomes equivalent to as much as $88 in expenditures saved by county public health departments.” One study found that other OECD country spent on average about $2 on social services for every $1 of health care spending, compared to the United States 55¢. The US spends nearly twice as much as the average OECD country on health care as a share of the economy, yet it has a lower life expectancy than comparable high-income countries like Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The US also has among the highest chronic disease burden in the OECD, and its obesity rate is two times higher than the OECD average. Finally, according to the Commonwealth Fund, the US has the highest rate of avoidable mortality among its peers because Americans do not receive timely, high-quality care. All this points not only to problems in efficiency and delivery in healthcare, but also to major risk factors that make the US much more vulnerable to health security threats.

Tackling healthcare spending, insurance issues, and broadening access to care are objectively difficult to accomplish in the current US political environment. Public health has similarly suffered from partisan politics over the course of the pandemic, from the national level all the way to rural county commissions. However, at the end of the day, this is national security at stake. The US is suffering major economic hardships because of the impacts of COVID-19, including the loss of millions from the workforce on top of global inflation. Lack of equitable access to quality, timely care, lack of funding for community and state-level public health, and an overall reactionary system create a population that is bogged down by high chronic disease burden and slim options for healthcare. That population by definition is not secure. Patchwork and crisis-dependent funding is not cutting it and if we do not do something about it now, we will be in a similar or much worse situation not long from now when the next global health crisis strikes.

“A Plan B to Strengthen Biosafety and Biosecurity”

Dr. Gregory Koblentz (Director of the Biodefense Graduate Program) and King’s College London’s Dr. Filippa Lentzos recently published this piece in CFR’s Think Global Health. In it they discuss what Russia’s invasion of Ukraine likely means for the upcoming BWC RevCon, challenges posed by spoiler states in international negotiations, and the potential for “minilateralism”-“a collective action strategy that brings together the smallest number of countries that can have the greatest impact on an issue”-to help overcome these challenges. They conclude, “Given these stakes, the geopolitical constraints on multilateralism, and Russia’s abuse of the BWC, a concerted effort to harness minilateral strategies offers the best chance to advance collective action on ensuring that life sciences research globally is conducted safely, securely, and responsibly. This effort can begin by fostering the widespread adoption and implementation of the ISO laboratory biorisk management standard, but minilateralism has the potential to take cooperation well beyond this first step too.”

CBWNet Working Papers

CBWNet recently released multiple working papers ahead of the BWC RevCon, including “International Biosecurity Governance Evolution within the Biological Weapons Convention” and “The Legal Effect of the BWC Review Conferences”. These papers offer great background ahead of RevCon on the evolution of the BWC, recent developments like the 2015 Tianjin Biosecurity Guidelines, and the international legal consequences of review conference agreements versus actual changes to the BWC itself.

“Russia (Again) Peddles Its Debunked US-Ukrainian Bioweapons Claims at the United Nations”

While on the topic of the drama we have endured in the lead up to RevCon this year, we (again) could not skip out on more of Russia’s masterful wasting of everyone’s time with its nonsense biological weapons claims. This time Dr. Lentzos and Jezz Littlewood tackle Russia’s fourth time taking these claims to the UN Security Council this year for the Bulletin of the Atomic Scientists. In it their piece, they discuss state abstentions on the vote, highlighting that eight of the 10 non-permanent members of the UNSC made it clear that they abstained from voting because they wanted to make it clear they support the right of any state to invoke Article VI, which may have been muddied if they had outright rejected Russia’s claims that they argue have no merit. They also discuss the absurdity of going to the UNSC with an Article VI complaints after the BWC consultative meeting previously failed to get Russia more support. In fact, they explain, “Of the 15 Security Council members Russia would be making its complaint to, six had rejected Russia’s allegations at the consultative meeting (Albania, France, Ireland, Norway, United Kingdom, and the United States), while six others had been silent (Ghana, Kenya, and the United Arab Emirates) or had supported the process of the consultative meeting but without supporting Russia’s specific claims (Brazil, India, and Mexico). Only China supported the claims in September. (Gabon was absent from the September meeting.)”

“Russia’s Apoplexy Over Biological Research – Implications for the BTWC and Its Articles V and VI”

Dr. Jean-Pascal Zanders also took a crack at this on his site, The Trench, offering a detailed explanation of Russia’s claims, their recent moves under Articles V and VI of the BWC, and what issues this process has illuminated ahead of RevCon. In particular he notes that 1) “In both instances [when Article V was invoked], the FCM did not resolve the controversies for lack of consensus among the participating BTWC state parties.” 2) The BWC does not outline a clear procedure to trigger Article VI. Because Russia simultaneously filed a UNSC complaint and used its status as a permanent UNSC member to submit a draft resolution that would form an investigative commission, proposals aimed at strengthening Article VI at RevCon may have to address the question of if this permissible. They would also need to “…determine whether a request to act on a concurrent draft resolution amounts to the request to have the complaint considered by the UNSC as explicitly stipulated in Article VI,” and 3) Russia resubmitted the same documentation in its Article VI complaint that UNODA had questioned four times before the UNSC, and that the FCM previously did not conclude demonstrated there was a violation of the BTWC. Zanders concludes, “The question, therefore, arises whether Russia did not brutalise Article VI by submitting documents in evidence that the international community had already repeatedly judged as wanting.”

“Delay, Detect, Defend: Preparing for a Future in Which Thousands Can Release New Pandemics”

This new paper from the Geneva Centre for Security Policy written by MIT’s Dr. Kevin Esvelt discusses information hazards in pandemic research. Esvelt writes, “The world is demonstrably vulnerable to the introduction of a single pandemic virus with a comparatively low case fatality rate. The deliberate and simultaneous release of many pandemic viruses across travel hubs could threaten the stability of civilisation. Current trends suggest that within a decade, tens of thousands of skilled individuals will be able to access the
information required for them to single-handedly cause new pandemics. Safeguarding civilisation from the catastrophic misuse of biotechnology requires delaying the development and misuse of pandemic-class agents while building systems capable of reliably detecting threats and preventing nearly all infections.” You can also find the accompanying article in The Bulletin of the Atomic Scientists.

“Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future”

From the National Academies: “To take stock of lessons learned from COVID-19 around the world and in the United States, the Forum on Microbial Threats held two virtual workshops during 2021. The first workshop focused on what it means to frame the response to COVID-19 through a “syndemic” approach, and what the implications would be for global recovery. The second workshop focused more broadly on key lessons and emerging data from ongoing pandemic response efforts that can be incorporated into current health systems to improve resilience and preparedness for future outbreaks.”

“This workshop explored the long-term effects of COVID-19 on health equity, including considerations for mental health and social determinants of health. It also addressed uncertainties during a pandemic, such as trust, communication, and engagement and explored approaches to systematize recovery efforts to improve the ongoing responses and prepare for the next pandemic. Experts discussed possibilities for a post-pandemic world and a response strategy for stakeholders that ensures sustained community partnerships and prioritization of health equity. This Proceedings of a Workshop summarizes the presentations and discussions from the second workshop.”

What We’re Listening To 🎧

“The Retort” – A History of Chemical and Biological Disarmament

The 9th Review Conference for the Biological Weapons Convention is swiftly approaching and, well, there’s a lot to know about it beforehand. Check out this episode of Dr. Brett Edward’s podcast for a concise rundown on CBW disarmament whether you need a soothing refresher or a 101 style introduction.

This Podcast Will Kill You Episode 109, Chikungunya: Not Dengue (Or Is It?)

Has it been awhile since you got really freaked out by an arbovirus? Don’t worry-there’s a new episode of TPWKY out to fix that for you! From the creators: “Somehow it’s taken us until the penultimate episode to cover this season’s first mosquito-borne virus. But we assure you, this episode is well-worth the wait. Although Chikungunya virus is often lumped in with dengue or Zika, the unique characteristics that distinguish Chikungunya virus from these other arboviruses are just as important to note as the similarities among them. In this episode, we explore these differences and similarities in the biology of Chikungunya virus before reassessing what we thought we knew about the history of this disease, a history that is presently under revision. Finally, we wrap up the episode as we always do, by taking stock of where we stand with Chikungunya virus today. Tune in for a good deal of dengue compare/contrast, a whodunnit (or whichdiseaseisit) in the history of these two diseases, and a frustrating attempt to gather present-day case numbers.”

Book Launch- Tech Wars: Transforming U.S. Technology Development

Dr. Dan Gerstein, an alumnus of the Biodefense PhD Program and current Schar School adjunct professor, is launching his latest book, Tech Wars, at an event hosted in-person by American University’s School of International Service on November 29, at 5:30 pm EST. “This book explores the evolution of the current U.S. research and development enterprise, asks whether this organization remains appropriate to the challenges we face today, and proposes strategies for better preparing for the global technology race shaping our future.” Learn more and register here.

Countering the Misuse of CBRN Materials and Related Information

“On 23 November 2022 (Wednesday) at 10:30 am the Center for the Study of Democracy is organizing an international conference on Countering the misuse of CBRN materials and related information. This event aims to provide an opportunity to consider different approaches to promote the effective management of chemical, biological, radiological and nuclear security risks.” Learn more and register here.

Other Ways to Connect with the Pandora Report

While we don’t have any zingers lingering in our Twitter drafts to release just in case we are at the end of the line, we do have a couple other places you can connect with us if you would like. If you aren’t already, you can subscribe to our newsletter here and get the weekly report straight to your inbox. You can also join our LinkedIn group-Pandemics, Bioterrorism and Global Health Security-and find us on Instagram @thepandorareport. As always, everything we post is available at!

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