I'd like to ask everyone to get to their seats and we'll get started momentarily. Good afternoon and welcome to CSIS. Thank you all for joining us this afternoon. I'm Steve Morrison from CSIS, the Global Health Policy Center. This is part of our regular speaker series and we're thrilled today to be hosting Peter Small, who for the last six years has been the senior program officer and team leader for tuberculosis at the Bill and Melinda Gates Foundation. We spoke with Peter, Charles Freeman, and I visited with him way back in September and put on the table the idea that we were hoping he would come to CSIS and speak specifically about drug resistance to tuberculosis. And he kindly has agreed to do that, so welcome Peter and thank you very much for taking time out of your schedule to come and be with us here. Peter's been in the lead at the foundation in developing its tuberculosis strategy, building core partnerships, hiring and managing the TB team, and serving as the foundation's voice on tuberculosis. He received his undergraduate degree from Princeton University, medical degree from University of Florida, and did his postgraduate training in internal medicine at UCSF and infectious diseases at Stanford University where he also served on faculty before joining the Bill and Melinda Gates Foundation. He's arguably among America's foremost experts on tuberculosis. He's published more than 100 articles and chapters and a number of landmark studies in the key journals and has been a leading strategist as well on how to bring forward a more effective international mobilization politically and institutionally to bring forward the global TB agenda. So with that, thank you so much Peter for being with us. Welcome, the floor is yours. We'll follow in this presentation with some comments and questions. Thank you. Hearing that introduction, I'm reminded of the fact that I actually in medical school never learned about the two diseases that dominated my professional life. In 1981, HIV was unknown and tuberculosis was thought to have been conquered. The myth that tuberculosis was a disease of antiquity was dispelled for me during my medical training at San Francisco General Hospital where I was treating increasing numbers of immigrants and AIDS patients with tuberculosis. But the full consequences of this misconception and the decades of neglect that that has spawned became apparent to me in 1990 when I was working at Muhenbilly Hospital in Dar es Salaam, Tanzania. This was my first exposure to the real world in which TB and HIV collude to overwhelm underfunded medical systems. And Muhenbilly Hospital at that time was Tanzania's largest hospital. It was a teaching hospital with about 3,000 beds and an average census that was almost twice that. So on the ward that I worked in, we had TB patients and AIDS patients sharing beds shoulder to shoulder in the same beds. And I have to say that as a clinician, I'll never forget the patients who died because of the things that I did. But there's something particularly haunting about the people who died because of what we didn't do in that hospital. What we didn't do in that hospital was pay attention to interrupting TB transmission and protecting those patients from getting infected while they were in the hospital. It was partly because we had lousy tools. We still have lousy tools today and I'll get to that. But by the time we knew a patient had tuberculosis, they'd already infected probably a dozen other people in the hospital. And I don't know for sure, but I suspect that many of those AIDS patients who got infected with tuberculosis in that hospital on my watch subsequently died for lack of therapy. I returned to the United States to complete my subspecialty training at Stanford University Medical Center. I was very enthusiastic at that time about the use of high-tech molecular bacterial DNA fingerprinting as a way of tracking who was infecting who in the city of San Francisco. It was a truly exhilarating time for me. I was publishing in the New England Journal of Medicine on an annual basis and generating data about what was going on and what was fueling this resurgence of TB that I think helped the TB control program in San Francisco to control the situation. However, with time it became increasingly clear to me that the real TB problem was not in the United States and that the world was only going to go so far in controlling TB with the lousy tools that we currently rely on. I think we're all fortunate whether we know it or not that Bill and Melinda Gates are an incredible couple who have a profound belief in the power of science and technology to solve big problems. I, for one, am incredibly fortunate that six years ago Helene Gale recruited me to Seattle to design and implement a TB program for the Gates Foundation and it was in the early months when I was in Seattle that Bill and Melinda fully realized and I think we're completely shocked to realize that a global epidemic that was killing somebody every 22nd had as its primary intervention tools the diagnostic test that was 125 years old, a vaccine that was 80 years old and drugs that hadn't changed for 40 years. The UN has now committed more than $875 million of their money to rectify that situation and increasingly I'm getting nervous to think that all of those investments will have no impact if we don't get these tools out there. Thus it's really, I totally appreciate the opportunity to come and talk to this crowd. I'm told that you understand political will and resource mobilization. In fact, as I was packing for this trip I asked my wife, I said, Delaney, can you believe that I'm flying across the country to talk to a room full of people in the hopes of a TB nerd somehow helping to close a billion dollar a year funding app? I mean, in your wildest dreams did you ever think that I would be doing this? And she said, Peter, you've never been in my wildest dreams. So with that send off on the plane, I put together a talk in which I'll briefly expand on the TB problem but spend most of my time describing the new tools and the innovations that are coming down the pipeline and some of the encouraging signs that increasing political leadership, not just among traditional donors but also from the emerging economy to have high rates of drug resistant TB may finally be rallied to combat this disease. You know, my medical school teachers were not alone in thinking that tuberculosis was a thing of the past and yet just because TB isn't making headlines it doesn't mean that it has gone away. Globally, tuberculosis remains a huge problem and has the potential to get worse. Next week the World Health Organization will release their new report and this year the actual number of TB cases will once again have increased this time to 9.3 million cases and this year the number of TB deaths will once again have increased this time to 1.8 million deaths placing TB just behind AIDS in global fatalities. Now tuberculosis is a bacterial disease. It causes pneumonia. When someone with that pneumonia coughs, the pathogen turns them into little atomizers, little perfume bottles around, just spreading through the air, infectious particles which if somebody has the bad judgment to inhale will create an infection and in many cases that infection will be controlled and the people will become latently infected. In fact, a third of the world is latently infected and lives in this tenuous balance between a pathogen and their immune system. How many people in this room know their tuberculin status, whether their skin test is positive or not? That's good. I won't ask who is infected but I'm going to just guess off the bat that looking at the demographics it's about 20 or 25%. There are about 15 million latently infected people in the United States and at any point any one of them can reactivate and spread disease to others. But this issue about the central role of the immune system in checking TB is most dramatic in sub-Saharan Africa where the convergence of the HIV and TB epidemics have totally changed the disease.  And this is really what is fueling the TB epidemic throughout sub-Saharan Africa and many other places in the world. Each year 1.4 million HIV infected people will develop TB and 456,000 in the most recent data died from it. This makes tuberculosis the leading cause of death amongst people with HIV. Shocking to me that while we can prolong a life with antiretroviral therapies we still are incapable of saving a life with $14 worth of drugs. It's particularly tragic from a public health perspective because TB control is one of the most cost-effective public health interventions. $14 can save a life and stop the spread of the disease. It really works well when it's done perfectly and yet it is really hard to do perfectly with those antiquated and inadequate tools. When it's done imperfectly treatment of tuberculosis rather than curing patients turns them into chronic secretors of drug resistant TB. And drug resistant TB is really a very significant threat because what we're talking about is an airborne epidemic of an increasingly untreatable disease. Last year there were half a million cases of multi-drug resistant TB. These are patients who are resistant to the standard antibiotics that are used. And if those patients are treated inappropriately and to treat them you need 12 to 18 months of therapy and if you don't do that right then they will become resistant to more antibiotics so-called extensively drug resistant tuberculosis for whom treatment options are severely limited. Now to adequately address tuberculosis in the context of these new challenges of HIV and MDR the TB community needs to embrace an entirely novel concept and that concept is innovation. The TB community is incredibly disciplined in execution but has really not taken on the challenge of innovation and without innovation we are not going to make progress. I would point to USAID as being innovative. 75% of the USAID money is spent at the country level helping countries respond to the needs that they're perceiving on the ground. For example in Tanzania evaluating the nature of the drug resistance problem and figuring out how to use both the existing and the new technology as it comes online. The primary focus of the Gates Foundation TB program is innovation mostly centered to date on technologies namely new diagnostic tests new drugs and new vaccines. The majority of our investments in these activities are with the so-called public-private partnerships or the product development partnerships. These are non-profit organizations who use the best practices of industry to develop the tools that the world needs and these investments are made by the Gates family not with an eye on the dollars made but rather in terms of the life saved. These organizations partner with for-profit sector in terms of gaining access to know-how and to intellectual property to accelerate the development of these tools and we desperately need these new tools in particular diagnostics is the current test I mentioned is 125 years old I didn't mention the fact that it misses half the cases. The most commonly used test for drug resistance takes two months to get results back to the patient. In the context of HIV that just is filed in the chart because the patient is usually dead by then. Unfortunately we are making great progress in the development of new diagnostic tests better and faster liquid cultures are available they've been endorsed by the World Health Organization and they are being rolled out by programs such as Unitate and PEPFAR. Through one of our product development partnerships FIND the Foundation for Innovative New Diagnostics molecular diagnostics are becoming available which will allow you to know within hours and not months whether patient has drug resistant TB. We need to move rapidly to get these tests from licensure into the field and in particularly in the context of drug resistance because you cannot confront drug resistance if you don't know that it's out there. What's most important exciting to me is the prospect that in 2012 industry will have for us some really transformational rapid diagnostic tests which will be much easier to use and put the power of knowledge into the hands of the practitioner at the health care centers. We also desperately need new drugs. Current first line drugs are cheap they've got that going for them $14 for six months of pills I think that's what I spend in a week and a half on my Zyrtec but they've not really changed in 40 years and they require multiple drugs for a minimum of six months because of this many patients don't complete their therapy and that's part of what is spawning this epidemic of drug resistant TB. Again fortunately we are making great progress in the development of new TB drugs. A four month treatment regime is in a phase three trial by one of our grantees the Global Alliance for TB Drug Development and a number of pharmaceutical companies have gotten fully engaged and there are now three new drug candidates for which there are exciting phase two trial results. My expectation is that in the year 2016 or 2017 we'll have a regime that will work to treat these drug resistant cases. And finally we desperately need new vaccines the current TB vaccine was invented before the car and it has had little or no impact on the epidemic in adults. An effective vaccine is the ultimate game changer in the fight against tuberculosis and again fortunately we are making great progress. Five years ago there was virtually nothing going on in terms of a coordinated process to develop TB vaccines. Today there are six vaccines that are either in or will soon begin human trials. Any one of these has the potential to be the vaccine that we need to protect people from tuberculosis and I'm optimistic that around 2016 we may have an improved vaccine license for tuberculosis. Every bit as exciting as the technical progress for me are the signs that there is increasing political commitment and action to combat tuberculosis. In particular two upcoming meetings by Brazil and China have the potential to galvanize increased global action against tuberculosis. President Lula will open the Stop TB Partners Forum in Rio on March 23rd and at the beginning of April the Vice Premier of China the Director General of the World Health Organization and Bill Gates will open a meeting in Beijing. The meeting in Beijing is hosting the Ministers of Health from the 27 countries who have the highest burden of drug-resistant TB. China is also showing some initiative in that they have ensured that MDR-TB has been inserted onto the World Health Assembly agenda for this year. In addition to these meetings there are early signs of new political leadership on tuberculosis from high burdened emerging economies. China, India, Brazil, South Africa throw in a couple of others and suddenly you have half the world's tuberculosis and more than half the world's drug-resistant TB. These countries who are increasingly vocal leaders on trade, politics and health and science are showing some genuine leadership in confronting their own tuberculosis problem. If they do this I think it will have broad and global impact. In addition to the obvious commitment that Brazil and China are showing, India has a burgeoning pharmaceutical industry which is already making the existing drugs for much of the world. South Africa where TB and HIV in combination is a huge problem is increasingly vocal on tuberculosis and is home to some of the most critical clinical trial that are now underway in terms of vaccines, drugs and diagnostics. I think as it evolves, emerging economy leadership on TB can further catalyze a global response in the established global health paradigm rich countries come up with solutions and pay for it for the rest of the world. For tuberculosis, emerging economies can complement and expand on this important work and over the long term if the emerging economies take care of their own problems it will free up the resources from the rich world to focus on the truly needy regions. Now if the emerging economies do show leadership it will also free up the rich world to do what we do best. And I think one example of this is that with the increase in funding on USAID and PEPFAR they are now reaching out and providing technical assistance to assess the MDR situation in these overwhelmed countries and to help them to understand what the appropriate response is. For countries who don't yet have an MDR program they're providing technical assistance to prevent it and for those that already have a problem on how to treat it. But none of these plans that are being hatched will have any impact without money. And it's clear that a lack of funding for TB contributed to the resurgence of tuberculosis between 1985 and 1992 in this country. That combined with the general neglect of our public health system in New York City resulted in an epidemic of drug resistant TB there that cost more than a billion dollars for the city alone to clean up. Partly in response to this the U.S. government in 1992 instituted the Federal TB Task Force Action Plan on TB which has decreased the incidence of MDR TB domestically by 75% down from 485 cases in 1993 to only 119 cases in 2007. The U.S. should be commended for increasing TB funding since the year 2000 but there's still far more that needs to be done. The 2009 budget that Congress recently passed includes in the State Department and Foreign Operations $162 million for TB which is a nine and a half million dollar increase over the prior year. USAID has increased its funding for TB from $22 million in 2000 to $93 million in 2005. In 2008 the NIH spent about $160 million on TB and the recent $48 million reauthorization for PEPFAR includes $4 billion for TB treatment and prevention over the next five years. I think that if all of these monies are well spent and wrapped up together that it provides an opportunity for the new administration to build on a very solid commitment and become a global leader on tuberculosis. The Global Fund has helped to mobilize the global resources. Around 7, about 14% of the funding went to TB. To date the Global Fund has treated 4.6 million cases of tuberculosis but it needs to continue to do much more if we're going to continue to have progress in the context of these challenges of HIV and MDR. To give you some sense of the magnitude of the gap the STOP-TB partnership has a global plan. It's a bit of a business plan for the world in terms of what the response needs to be what it will cost and what the implications will be if they do. In that there's a funding gap of $31 billion including $22 billion for implementation and $9 billion for tools over the next decade. Let me end with a few thoughts about the future. Over history, TB has thrived in the context of poverty and social unrest and the economic downturn that we're in right now presents a really serious challenge to continuing the momentum that we've gained over the last decade. And I think it may become the Mycobacteria's best ally. Despite all our progress today, someone still dies of tuberculosis every 20 seconds and drug resistance is spreading. With the economic crisis, TB has poised to become an even greater threat. I think now more than ever the world needs to pull together to expand our efforts on TB. We need to continue to build on the existent momentum of the meeting in Rio, in Beijing, the G20, the World Health Assembly, and the Pacific Health Summit, which will be in Seattle in June. But most exciting to me is the possibility that the high burden emerging economy leadership could accelerate access to existing TB tools and the development of new, more effective technologies. As the emerging economies address their own TB problems, they can have this global impact. And their biotechnology and pharmaceutical companies can use TB to apply their competitive advantage in new ways to diseases that are much less competitive than the cardiovascular and neurologic realms in which they're currently competing. At the same time, China, India, Brazil, and other emerging economies have a strong interest in engaging and supporting less developed countries through partnerships and twinning programs. These countries can share innovative TB tools, particularly with Sub-Saharan Africa. Finally, and I think most importantly for this group, the U.S. has to continue to support the TB programs. As the Andrews speaker case highlighted, in this globalized world, MDR-TV anywhere is MDR-TV everywhere. We've seen what happens when we ignore tuberculosis in New York City, but we've also seen what happens when the U.S. commits to having an impact on global health. PEPFAR and the President's Malaria Initiative have helped millions of people and has become a source of national pride. I think that now is the time for this country to apply the same level of commitment to tuberculosis. Thank you. Thank you very much, Peter. Let me put just a couple of quick questions out and ask you to respond to those, and then we'll invite our audience to step forward some comments and questions. The picture you paint is of a shift of consciousness among the major emerging economies towards greater leadership. Awareness of this factor of TB and XDR-MDR-TV is requiring a higher level of attention and effort. Is that something that you're reasonably confident is going to be durable through this period? There's this broader question around how the global economic crisis is going to impact these emerging economies. Will they stunt their demand growth? Will they change their budget processes internally? Will they change their diplomatic strategies outside their borders? Will they become founders? They aspire to be leaders. They're taking a greater stake in multilateral institutions and the like. They've pulled the global fund in on many different ways. So as we look forward in this really unprecedented crisis-driven setting, how do you see the TB agenda without knowing? But how would you expect to see how that agenda would be upon in a period where there's greater uncertainty, a certain level of triage and fear and insecurity around this? And we know historically that in similar, severe downturns that health budgets take a big hit. Education budgets, social services take a big hit. That's one question. The other is around the U.S. foreign policy. We know that now we're moving towards a period of re-engagement with South Africa, for instance. We have a new administration. We've had a pretty grim period in terms of our bilateral linkages. Now we have a new foreign, a new health minister, Barbara Hogan. We're going to have a transition of power looking forward. If you could say a bit more about South Africa and what you see as the prospects there, because within U.S. foreign policy in this administration, the South African relationship is figuring as one of the priorities looking forward. And TB, prospectively, and HIV may occupy a significant place. So if you could just comment on those two issues. Yeah, well, let me start by coming clean about what I am and what I'm not. My training is in epidemiology. And I think what we're looking at is perhaps an early trend from the perspective of tuberculosis. This general sense with these meetings, the promises that our leaders are making. And so I'm not saying that this is a fact. I'm saying that this may be an early trend that we're picking up. I've been wrong before in my epidemiology. So I also, though, to say what I'm not, I'm not an economist. And so I really kind of came here hoping to hear some discussion from you folks about what you think of this idea. And in particular, what do you think of the economic situation? I will say that everything that happens in tuberculosis happens in slow motion and over the long haul. And so we're not talking about what's going on in the next six months or even the next couple of years. I think what we're looking for is something that will, if it happens, occur over the next decade and that in a decade from now, looking back, that there will have been an inflection point and we may be there now. I'm optimistic in the long term for a couple of reasons. I would say first and foremost is that it is clearly in the best interest of these countries to address this problem. In contrast to some of the other issues which they're struggling with, they themselves bear the brunt of this problem. And as the World Bank analysis has shown, investing in TV control is an incredibly good investment. The return on investment is on the order of 15 to 1. So I think that there are very selfish reasons why these countries will do so. And not just the countries, but I also suspect that the industries within those countries will come to think of the fact that there are 10 million cases in the world and that a third of the world is infected with this germ as an opportunity and that perhaps in the process of developing a drug which can be used for active disease, if a company stumbles over a drug that can be used to treat latent infection, that is a huge global market. So I'm optimistic but I'm not the right one to answer the question. Nor am I really that familiar with South Africa, so you're probably starting to wonder why I'm here. I have been very impressed with the tuberculosis situation in South Africa. The rates of TB there defy what I as an academic modeler could ever get my computer to generate. I mean it's just phenomenal how bad the tuberculosis situation is and inexplicable. I mean part of it is neglect. The question that the country has profoundly neglected their TB situation and for a country like that to deny that there's a link between TB and HIV is only going to have them fighting with one or two hands behind their back. But I am incredibly optimistic by the political changes as I understand them and Barbara Hogan, one of her first public speeches which was at the AIDS vaccine conference, came out very clearly stating that TB and HIV was going to be a priority for her. So South Africa impresses me with the magnitude of their problem but also with the political sea change that I think we're seeing. Thank you very much. I'd like to invite three or four folks to offer comments and questions. We have microphones. Please just stand up and identify yourself. Yes, Lisa? Hi Peter, thanks very much. Lisa Cardi from CSIS. Two related questions. First is in the global TB plan which I believe is a $50 billion plan as you said there's a number of actions enumerated. I wonder if you could comment on what you think the technical capacities are at the country level to actually deliver on that plan and whether there are things within the current architecture around TB whether it be the Green Light Committee or something else that needs to be adjusted or ramped up. That's the first question. And second question, there's an ongoing big debate about health systems in general and how to sell health systems intersect with vertically targeted programs or diagonal or horizontal. What's your view informal or otherwise on the adequacy of health systems to now support a very broad and rapid global scale up on TB? Thank you. Do we have other comments or questions just now? Right here? Kristi Lubinsky, IDSA. Thank you very much for a wonderful talk. I guess I just wanted to follow up on your remarks about the President's Malaria Initiative and PEPFAR and some of us have been thinking in our advocacy about TB that it might be worthwhile to try to persuade the Obama Administration to embrace tuberculosis in the form of some kind of a presidential initiative. It does seem if you just look at the data and you look at the relative spending levels that there's no doubt that that kind of level of presidential commitment has made a real difference both in terms of coordination across government as well as in terms of absolute dollars being spent on the problem. And we have quite a fragmented response, albeit robust in its various departments in the U.S. government, it's still quite fragmented. You have research going on in three places and programming and so on. So I just wonder what your thoughts are about that, again, as a way perhaps to get the TB community of something concrete to rally around as well as a mechanism to really try to bring TB funding and some of these important interventions to the field and through phase three trials, all of which are going to be challenged under current U.S. funding levels. Thanks. Brenda? Yes. I was just wondering, listening to you say that the WHO is about to come out with a report next week announcing another increase in the number of people infected with TB around the world. So I guess my question is having sort of followed this for the last decade or so is when we're going to turn the corner on those kinds of reports. It makes it very difficult to do my job. As a reporter, it's sort of like if nothing changes, there's nothing to report. And when somebody is going to roll out some of these new technologies of which we know some things about diagnostics, whether some of the money that's rolling around that's out there is going to be invested in getting these into countries and whether the countries are capable of using them, whether they have the infrastructure to be able to use them. I realize I'm packing a lot of things in here, but I guess I want to know what sense there is going to be of some real serious change, or whether we're going to have to wait until 2016 when all of those wonderful things you talked about will be rolled out. So, what? I just wanted to add to the way you from IDSA. Please. The Mabardo Open New Services has a project Bileshield program and then an pandemic food program and they're attempting to have one portfolio effort with DOD and NIAID and HHS, USAID, potentially here. If the Obama administration can get through the economic situation and then propose something like, was in the last, you know, the Bileshield program and the big boost that NIAID got back in 2002 following the anthrax attacks and to have a coordinated approach. And, you know, that seems to be maybe the type of thing that they could rally around. I was just wondering what your thoughts are about that. The second question is, do you see that there's money available for the more costly phase three trials of vaccines that need to be conducted after phase two? Okay, well, a lot of questions. See if I can remember them all. I think that the global human capacity, manpower issue is a massive problem and it's not restricted to tuberculosis, obviously. It cuts across all diseases. Where I am optimistic about tuberculosis it is in the basic intervention programs are very well defined, that manpower needs are clear and the value for that investment is an obvious one. So, while clearly there's not enough manpower to execute the plan of the TB community or any community that I'm aware of, I am optimistic that you can make a very coherent argument for doing so. I think that this issue of health systems and the vertical horizontal debate which seems to be such an obsession of policy people, in my limited experience it goes away on the ground where you may be the tuberculosis person but your clinic is in fact providing care at the health center level for a whole spectrum of diseases. I sometimes feel as though this argument about the vertical versus horizontal and ultimately we kind of settling on the diagonal is a little bit of, it gets tedious I think. And the issue of whether these systems will be able to roll out new technology is a problem however that terrifies me. Because the time that we're going to turn the corner is going to be when we fully implement what we can do today and when we start to experiment on large scale with other interventions. And if we just look at the malaria field for a moment, they're way ahead of us. They have a rapid diagnostic test. In fact there are 60 of them that you can buy. And yet the WHO has recently evaluated these and roughly two thirds of them are no better than a coin toss. So how do you roll out a new diagnostic test when there is in fact no regulatory framework? Are we going to assume as we roll out these new diagnostic tests that the manufacturers will only make and sell quality products that every country will have its own stringent regulatory body that the WHO is going to pre-qualify every manufacturer in the world? I mean I don't know which of those thoughts is more ludicrous really. So I do think that now is the time to start thinking about those issues. Start using incremental increases in the health system as it exists to deliver today's products in a continuous process that segues into the delivery of innovative tools as they become available. And in so doing it's a much more holistic problem than dots versus innovation. I think there's no question that the United States doesn't get appropriate credit for what we are doing in tuberculosis. USAID has done an incredible amount of work in Eastern Europe on drug resistant tuberculosis and no one in America knows it. It seems like a pretty well kept secret to me and any effort to both amplify and give credit for the work that we are doing as well as to bring in new resources and as you point out increasing efficiency. The WHO report that's coming out it's like the last 13 reports there. It's a book full of numbers. As a TV nerd I myself find that interesting and exciting in and of itself but I understand that your world's different and just having the ability to know how many people between the age of 16 and 25 had extra pulmonary TB and Rwanda last year has no value really until you can translate that into a message that the world buys into and I don't know what the message of this year's report is. The facts speak for themselves at some level. It is true. It's very much the half full, half empty and the WHO and the Stop TB Partnership in particular have been tone deaf to anything but the half full message and the fact is that I was involved in tuberculosis for a dozen years before it struck me that while TB rates are going down, which is all I ever read in the headlines, the actual numbers, the only thing we really care about are going up every year. So somehow there's a very mixed message there. There are a lot of success stories and I think that that's the bottom line is that while we may be looking at an overall picture which is half full and half empty, there are innumerable success stories that show that when there is the political will and when there is the commitment that lives can be saved with the tools we have and that the progress will be accelerated in the future and in fact the mechanism for rolling those new tools out is not known but this is where the experimentation and the innovation is in my mind most exciting. So if you look at, for example, what Unitate is doing with the Global Lab Initiative and some of the things that the World Bank is talking about doing in terms of rolling out laboratory systems so that our patients will finally know. I mean diagnostics is the most empowering thing. It gives a patient the ability to demand the treatment they need. It gives the healthcare provider the ability to do the right thing and it gives the whole system the chance to actually even make some money in the process in terms of making this something that is self-sustaining and so I think that without there are stories out there to be told. I don't think it's buried in the World Health Report. And then finally in terms of the TB vaccine situation and just advocacy in general for tuberculosis, it's been interesting to me how tuberculosis advocacy, while tuberculosis has been smoldering with subtle changes that the U.S. attention to it has had several bumps and with each bump it has kind of quietly complacently slipped back to baseline. The bump of drug resistant TB in New York City they got a lot of attention. It certainly ratcheted up investment in the research that probably led to the vaccines that your groups are working with in some way or another. That the push then just fell back and actually it was Andrew Speaker who did more for raising awareness about tuberculosis than any $30 million campaign that we could ever fund. But then again it seems as though we've fallen back into a sense of complacency and I don't know really how with this sort of rolling thunder in the distance that could come out at these large global meetings that gets translated into a message that continues. Clearly part of that message has to be that in product development and vaccines are not alone in this but in all product development the easy part are the early parts. That's and the big expense comes in the later trials. And if we look at the global budget for R&D in the last year for which data were available it's about if I'm remembering correctly $410 million. What is that all about? $410 million the whole world is spending on basic and apply drugs, diagnostics and vaccines less than half a billion dollars. We've been through numbers of exercises to say what should that number be but no matter how you approach it whether you start by getting some advocates in a room or whether you start by getting some people together to build that number from the bottom up and say well this vaccine trial is going to be here at this point it's going to cost this much. It's grossly underfunded and that's got to be part of the message. About a third of the funding is going to drugs right now. Actually a lot of that coming from industry. I believe the vaccine number is on the order percent of that. Most of that's coming from governments actually and the challenge with the vaccines with the diagnostic before you start to produce a diagnostic you have a pretty good sense it's going to work because that's just the way the industry is. Drugs tend to die early in the development process before you've invested a lot of money. The huge challenge in vaccines is going to be that you don't know until the end of the trial whether it worked or not and so I think that the issue of phase 3 funding for all products is a critical one but for vaccines in particular. Next round right here. Please identify yourself. I'm John Voss with Results. Just maybe a quick answer actually to Ms. Wilson's question about sort of what the headline might be my understanding is one of the data points in addition to sort of incidents and deaths is a pretty serious revision so hopefully we'll write that headline for you and that'll be an easy story to write. I want to just maybe make a point and ask a question I think you've laid out several of the sort of compelling components of the case for expanded U.S. leadership in TB. I just wanted to maybe add another one and get your thoughts on that and that is we've talked about subterrain Africa you talked about emerging economies. It seems there's also a set of countries where the U.S. has a very real strategic security interest which is coincident with huge TV burden and also particularly high rates of drug-resistant TV so Afghanistan, Pakistan, but also then the sort of other stands in terms of a former Soviet state so we'll just be curious to hear your thoughts about the TV situation in those countries and how the U.S. might direct some of the frankly massive amounts of foreign assistance that are being poured into those countries to strengthen health systems and address the real problems of people living there. Do I have any other comments or questions just now? Yes, Joel? Joel Spicer, World Bank. One quick comment on South Africa having come back recently from Swaziland and Lesotho I was led to see that no matter what Swaziland and Lesotho do to try and fight MDR, they'll never be able to get a lock on it because most of the cases are imported through minors working in South Africa. So when we talk about South Africa, I think one excellent opportunity for regional leadership on what is clearly a global public goods issue would be for South Africa to play more of a role there in controlling it from a regional point of view supporting countries around it. In terms of the financial crisis it's clear that with insufficient funding for health anyway that the money we have for health has to be spent better. So when I think about the millions and the blood, sweat and tears going into HIV AIDS which by my calculations is between 500 and 1000 bucks to get someone on antiretrovirals. You think about how quickly that is wasted when the person gets infected and dies with TB in a couple weeks in some cases with MDR. It makes me wonder if we're doing enough to wake up our brothers and sisters who are fighting and pulling the wagon on the HIV AIDS side do they get it enough that the people they are trying to protect and the dollars that they are throwing at the problem are actually being eroded by something that's relatively cost effective to address. My personal feeling is no they are not awake enough we see a lot of policy statements but when it comes right down to it at the ground the HIV side is not screening for TB there is not an awareness of this there is no isolation control isolation facilities for people that are treated and it goes on. So what can we do to wake them up is my question. So in terms of writing Brenda's story which I would never really try and do knowing how well she does it but I wouldn't, I don't actually think that the HIV, I would be cautious with the HIV numbers because that's really a reporting artifact. The number of cases didn't just double in the world and I think we have to maintain a degree of care. It's one thing to say it's a big problem but the fact that the numbers have increased because they are actually getting real data is more a statement about the need for real data than it is about the trend. I do also think that maybe it's a slight attention deficit issue on my side but I'm tired of the doom and gloom because it's not where I see the world right now I mean we've known this problem has been out there for a long time and the real story is the optimism which is not in my mind a confabulated story. I mean it's that if you actually go and you look at those countries who are doing a good job their TB rates are coming down. If you look at those countries that have good TB programs they don't have drug resistance. If you look at those countries who have drug resistance who are starting to take care of it patients are living who would have died and then if you combine that with this very real sea change that we've seen in industry engagement in tuberculosis products you know six years ago there was just very little going on and and now there are five major companies involved in vaccines. There are these three drugs that are incredibly exciting. I mean phase two studies are not a drug. I mean at first to admit that but the idea that you could take a couple of these pills these chemicals mix them in a fixed-dose combination and provide that as first line therapy means that MDRTB is a historical oddity because these would be two molecules the world has never seen before. You could shut down every TB diagnosed every drug susceptibility lab except for the research laboratories and then if we could ensure that they are delivered as fixed-dose combinations and well-controlled programs and really defend against drug resistance you know this is an incredible vision and those are the stories that I'm most interested to be honest I don't know anything about the part of the world that you're asking about so I'm going to actually see if anyone in the audience wants to talk about security and TB it's certainly not something I'm Gene Bonventree just retired from the Department of Defense with the local health policy center the only thing I've heard about TB in relation to security is the risk of multiple drug resistance and SDRTB in prison systems and this is particularly a problem in Russia and some of Eastern Europe where entry into the prison system essentially is a death sentence for whatever for whatever you're arrested for and how that upsets the balance of stability and security inside Russia remains to be seen and there are no effective ways inside Russia to deal with that I'm not sure it will take the epidemiologist and the security folks talking at the same table and trying to come to a common language I don't know if we're going to be there Hi, I'm Charlotte Calvin I've related to that one of the things I'm interested in in your thoughts are in this very same region when we talk about innovation and the tools we have countries that still rely primarily on chest x-ray that aren't even doing smell microscopy culture which less rapid agriculture DNA testing not only do we have an extra barrier there that we don't even face in places like sub-Saharan Africa where smell microscopy is more widely used so I would be curious to hear your thoughts on as we talk about this innovation there are some countries that are really important security wise and that we need to get the techniques out there that are going to be a little bit more behind in terms of being willing to accept and innovate do you have any thoughts on how you can move that forward actually you know Christy so over there Christy Hansie from USID has been thinking quite a bit about this issue of how to roll out innovation as best I can tell there's nobody who adopts anything they adapt everything so the question is how do you adapt in different settings thanks for putting me on the spot Peter in response I think specifically for Eastern Europe and just responding to that not to the overall issue of adopting new tools which is another hour's discussion but in Eastern Europe my understanding is that there's a real hesitancy to use because it is such a unsophisticated disgusting technology that they're not very interested in using and it's really a technology that's for Africa my sense is that if new diagnostic technologies that are much more sophisticated were made available they would be rather rapid adopters of the new technologies so I don't think it's a matter of necessarily at this stage of the game saying we've got to get them on to get them using spudos so that then we can introduce other tools they're going to be the ones that jump I think on the new tools very quickly Peter may I ask a couple questions one the around Russia we have a I realize you're a little reluctant to talk about some specific countries but in the case of Russia you've got this recalcitrance and an outlier factor and yet we're now in a period where there's at least a reappraisal around the bilateral relationship we're holding a consultation with a number of Russian health experts here in Washington in early April which I mean early May which I take is a pretty significant shift in the willingness to engage on these matters do you see my questions do you sense that there's within the community of folks that work officially and unofficially on these issues that there's some rethinking going on the second question has to do with the inability of TV to acquire a dramatic face for an American policy maker it's not it's not something that seems to have the same kind of of compelling personality as HIV I mean it doesn't have the same potency of threat it's not it's seen as a more diffused problem whether incorrectly or incorrectly it's one that as you say there are a little bump ups but it doesn't graduate into something that is seen and understood and exactly what is it endemically about this where you have this vagueness around the personality of something that is so important and the tolerance of an obsolete technology across the board when you talk about the need for patients and a long term time perspective on the development of new diagnostics vaccines and therapies when you pointed out just how antiquated those are I find that very compelling persuasive that it's going to take a while to overcome that because we permitted this obsolescence to to exist and to deepen but I don't understand why that why that would be such a historical experience it wasn't just us it's a global phenomenon so how did we find ourselves in that fix yeah which is to touch briefly on the on the Russia issue I early on Paul Farmer and Jim Kim partners in health working in Tomsk I think showed that there is a way to engage in that country and in particular their efforts in Tomsk which was you know it was a long hard slog at the beginning but it has now become a regional center for excellence and is really looked at as as lead innovators I think that that may be the model for working forward in those settings you know the the fact that tuberculosis is such a underappreciated problem is something that I've never understood I've probably heard 30 different explanations and but I had an experience just in March I was in Inner Mongolia and we were we were starting to scope out some of the drug resistant situation and opportunities there and it was really shocking to me because you know I think part of it is when we think about the success of Tomsk has been incredible but I don't think that when people think of drug resistant TB and they think of a cacetic tattooed prisoner in a Russian system that it has actually captures the real magnitude of the issue because for me the TB issue is about protecting our children from the future and this was driven home to me because we were visiting a man who had been really dragged into poverty because of the having had three courses of therapy and he failed his third course of therapy and the medical system had assumed at this point that he had drug resistant TB and essentially abandoned him nothing more we can do go home the community that he lived in a small community had basically ostracized him they understood enough about airborne contagions we know that if the health system had no time for this guy that the kids certainly shouldn't be playing there and we went into the man's house and as we were talking to him I looked in the back room and I saw his white breastfeeding a small child and kids clothes over in the corner and I realized that this is actually the face of MDR TB MDR TB was going to kill this man and the only legacy that his children were going to have was infection untreatable organism and that it's really you know that to understand that the real threat of drug resistant TB is providing a better future for those children and thousands there are half a million cases and how many children are being affected by those half million cases and what their life is going to be like well there's one scenario where their life is going to be fine in 2017 we have a new combination of drugs and when they're sick they get treated it's a good thing and another they grow up without a dad and without a future and when they're sick they too will slowly pass away I actually feel like as a community we've not done a good job of telling the stories when you go to these communities and you talk to the healthcare providers they get it they don't want to talk about pandemic flu they want to talk about what to do with this waiting room full of what to do about any other comments or questions yes my name is my area that I work with path I just want to add the problem of MDR in all the Central Asian countries and it's actually about the need to mobilize other organizations you know beyond the health organizations because in this context a lot of MDR is transmitted for migrant workers so it takes involving for example the international labor organization or international migrant organizations to actually buy into this initiative of controlling tuberculosis because otherwise I guess that it's very important to bring it to the table other opportunities beyond rapid diagnostics because a lot of people don't have access to them just leaves us to where we start off so I think that it's something that the WHO and other institutions have promoted is like private public partnerships and in terms of tuberculosis we have to look also into this other sectors to bring and involve and you know in conversations in a table so that they can contribute somehow to the fight against this epidemics and also about prisoners you know they go back to the communities like we all know and we've been hearing about and actually in those communities like you say they have their children so also involving as it has been done lately the penitentiary and ministers of justice ministers of law so I think you know a very comprehensive approach to bringing other organizations in Africa like the minors you know industries and everything to buy into this and invest in this you know I think that it has to be a kind of like you say holistic approach but also taken into account other aspects beyond the biomedical of tuberculosis I think we'll close on that Peter maybe offer some closing remarks you know I I agree with everything that Myra said I think that we are in the next six months faced with a critical moment in time for tuberculosis where the stakes have been raised the potential is there for upping our game to match that that the issue of HIV and the issue of MDR in particular have the potential to float all of the boats in this point in time and for example I think you can change the economics I mean if right now we can be complacent about treatment of drug susceptible TB but in the context of the cost of treating that case if it's drug resistant that the public health system have to look at TB control with it with an understanding of MDR and with a whole different economic perspective and I think the same is true in the private sector and vaccines in particular you know one of the reasons that vaccines have had problems getting traction is that it's a treatable disease you get TB you get treated but that's no longer true when we're talking about a world in which there is MDR and XDR TB then the market for a TB vaccine goes beyond the truly poor to the entire world and some of the analyses that I've seen suggest that now you're talking about gross sales of $10 a year if the world were really concerned about drug resistance and really had a vaccine that could prevent that that's an opportunity for funding phase 3 trials in my opinion and throughout all of this I feel as though that now is a time in the next 6 months in which we really have to seize the urgency and try and make some real sustainable progress


Hi everyone Joe for jaspyscasebreaks.com coming at you with 2020 Panini plates and patches football 12 box pick your team number 2 From jaspyscasebreaks.com. We have a full case pick your team 3 in the store right now with Which is sold out so I that's gonna be coming up a little bit. Oh, no It's in a it's in a filler now the last four teams are now in a filler. Let's go and get that That's our last case of plates and patches So go ahead and check that out big. Thanks to everyone here for getting into the action. I appreciate it And you see those R&B spots that means random number block and We did that randomizer in a separate video so there it is So it works just like our number blocks breaks But only for that set those set of teams and only for that particular break right there People's keep do this over here right Got golf on the front right here one autograph one memorabilia and one printing plate per box on average base card on the bottom plate on the bottom Okay, there you go All right, we've got Russell Wilson Seahawks Russell Wilson gonna stay in Seattle or will he go elsewhere? Seattle is a number block team. So Seattle won all aboard the Big Hit Express whoop whoop There's a plate in a box plate per box right here. There's Curtis Martin to 60 legends Going to Patrick Davis and the Jets behind James Connor is Devin DuVernay Nice dual relic. It's pretty sharp right here 33 out of 99 rookie reflections dual relic for for mark and the Ravens and back here is Deandre Swift on card autograph 80 out of 99 For the lines lines are a number block team. So that goes to Detroit zero Brandon with that one. We go by that digit right there the zero Nice, there you go Brandon The James Connor to 70 we'll go to the Steelers. That's for Jerry next box. We've got Jordan Agans One of one for Houston and the Texans that goes to Brandon with the Texans Brandon All aboard the Big Hit Express whoop whoop got legends Deon Sanders 27 out of 35 That's a Cowboys edition of Deon Sanders going to John. They feel the same. Yeah What's the hack Oh, yeah It's like I've been slicing here peeling it back open. I like that hack Vanessa Opens up these regular top-loaders all morning easily go through so many. Well, I feel like these these top-loaders These aren't They feel pretty much the same Ultra pro versus other other brands what we're talking about folks. All right behind Jalen Hertz is a dual relic Justin Herbert double coverage For the Chargers That goes to Roy who picked up the Chargers straight up and we got We got highly revered autograph. He is highly revered. Isn't he Javon curse? 54 Out of 75 Rob, can we explain how? The filler works for plates and patches. Yes So that's for the Titans for Joshua. So we actually did the same kind of filler For this pick your team too, right? So you you are you're assigned a serial number Right, so let's say Roy has three, right? So he gets any card that is three out of whatever 13 out of whatever 23 33 43 53 63 73 83 93 103 out of whatever but only for these teams So you can get a Joe burrow 13 out of 99 a Joe burrow three Out of 199 a Joe burrow three out of five 13 out of 25 whatever there's Jalen Hertz right there 17 out of 75. So here's an here's an example right here Eagles are part of that group up there So we go by That digit right there Seven So it's a random number block you get a block of numbers. So this goes to Eagle seven Thomas Gregory and If you read the if you read the rules, too, there's another little thing where it says Zero will get any redemptions even if it's a one-of-one redemption. No, no, it's a whole block of numbers. Yeah It's not it's not just one number There's Josh Allen Buffalo That's for Tony There you go, Tony with the bills All aboard the big hit express There's Troy Palamalu seven out of ten For Jerry and the Steelers behind Joe burrow is Antonio Gandhi golden full coverage relic. That's pretty cool. I like how they How they kind of cut it out with the leg right there to four out of 25 Looking sharp that goes to Mark and the Washington football team and Justin Herbert dual relic and autograph 16 out of 35 Roy with the Chargers there you go Roy some good-looking color in there nice autograph in the middle. He's got good penmanship Pretty strong There's Joe burrow right there. That is five out of 99 So Cincinnati five it'll go to Roy if it feels will it break tonight? Yeah, why wouldn't it break tonight? I don't know what breaking operation would not break something that feels tonight I'd be crazy what what if it feels and I was like, yeah, we'll see you next week for this break It doesn't make sense. All right. Yeah, great case so far nice Justin. Hurry. Maybe set that aside for some picture time And we're not we're not even halfway through this break yet. It looks like we've got a redemption on the bottom Another plate here say Juan Barclay One of one for the Giants That's gonna go to Justin Justin all aboard the big hit express We got legends Ed Reed 11 out of 35 go to mark in the Ravens and those Chargers colors Chargers colors really pop. We got Lynn Bowden, Jr. Patch trio Dolphins edition here that's gonna go to Roy and that is 13 out of 15 47 out of 65 Marlon Mack Matt Johnson with the Colts Return of the Mac and the redemption is gonna be It's gonna be Clyde Edwards-y lair. Nice rookie upper echelon red autograph for Kansas City That will be for Cal Kansas is a number block team. So redemptions go to number zero So that goes to Brandon with number zero and brand you get a free top loader too. All right another plate Henry rugs the third for my Raiders That'll be for Steve Steve McCabe With the silver and black all aboard the big hit express It's actually Mark that actually has Alabama on the back. All right, we've got Sam Darnold Is he gonna stay in New York? Is he gonna get traded? What's that? What's gonna happen? We got full coverage chase Claypool full coverage to color patch 43 out of 50 nice. Thanks, Rob We'll get it on the schedule shortly Schedules in the in the chat So you'll know when your break is gonna come up. There's Preston Smith And that is 35 out of 99 marquee marks marquee mark Packers are a number block team. So that'll go to Green Bay 5 Right there. That'll be for Roy and there's 30 out of 65 Russell Wilson Is he really is he really gonna be traded? That's 30 out of 65 Seattle zero Brandon Michael Larry, what's going on getting back into collecting? How do you know what kind of toppler you would need seems like a lot? Yeah, there's a lot of different sizes It's hard to You just kind of have to eyeball it really and just have an assortment of top loaders available There's Gardner Minshew for the Jags. I know that's not very helpful, but It's sort of hard to tell I think there are ways you can measure it online You can kind of get the right top loader or you know, there may be a resource where it lists Hey, this product uses this kind of top loader. There's Minshew Obviously plates are about the size of a standard card will go into regular top loaders Jaguars Jaguars one Michael Luna All aboard the big-head Express So cards like this You know, maybe the size of a few standard cards, maybe three or maybe a small stack of standard cards Would go into a 75 point top loader these these fit pretty snugly in here, you know Without rattling around a little bit Sometimes they're cut weird so they're like they're like in between so we have to do our best to just figure it out Nice Canton cloth 29 out of 99 Dan Marino. So that should be about a 130 top loader No, maybe a little bit bigger. Oh, yeah, maybe a little bit bigger. So we only have 190s So if this is a little bit loose in a 190, but we'll put we'll put blue tape right here So it doesn't rattle around and the last one here is Is upper echelon Kishan bond Super Bowl champ one out of 50 And there's also been some top loader shortages So we haven't really been able to get all the exact sizes like this should be in a 55 point top loader We have to use a 75 maybe with a little blue tape Maybe use a larger penny sleeve so it kind of catches in there There's Matt Ryan's 65 buccaneers capola with the bucks. Yeah, so it's it's a little it's a little tricky But a lot of it's just trial and error You know and Don't don't force the card into the top if it just doesn't kind of Feel that's also kind of a feel thing too But sometimes it feel like it's not the right size, but it's actually the perfect size. All right, there's KJ Hill For the bolts, it's gonna go to Roy. Yeah, no worries Michael. Thank you all aboard the big hit express We got Charlie Joyner to 50 Barry Sanders reveals a Clyde Edward D lair triple relic For the chief chiefs are a number block team. So that goes to chiefs one And that goes to Michael Luna There's AJ Dylan nice upper echelon autograph six out of 25 For Green Bay who is also a number block team. So Green Bay six. That'll be for Roy Design looks really sharp this year. There's Barry Sanders to 65 for the Lions. That's gonna go That's a number block team. So So that's the four Lions five For Roy next box Yeah, speaking of toplers though going back to toplers. They've been kind of hard to find to Been bit of a top floor shortage For the last year or two, it's not as readily available. It was as it was pre-pandemic That's why she joined group breaks ladies and gentlemen call these free toplers you're getting here There's Matt Ryan for the Falcons Robert The one-of-one all aboard the big hit express Woo-hoo Cortland Sutton 17 out of 60 for the Broncos Broncos seven will be Thomas Gregory Cooper Cup will reveal a Joshua Kelly dual rally nice That will be for Roy and the Chargers Beyond Cooper Cup is Antonio Gibson upper echelon autograph 68 out of 99 for Mark and the Washington football team No worries Robert these plates and patches updated this upper echelon autograph really nicely Like the way that looks There's Cooper Cup 23 out of 70. That's gonna go to Adam and the Rams four boxes to go and we've got a Randomizer between the Rams and the Browns I'm exchanging jerseys Rams are is Adam and the Browns is John Wenzel We'll set that over there We got Keeshaan Vaughan Three out of ten for the Super Bowl champion Capola behind Jonathan Taylor is full coverage Cole Comet 17 out of 25 It'll be for da bears. That's gonna go to Steve Wright in Chicago. It's pretty cool. It's a nice color there And then we got Ben D'Nucci upper echelon autograph 61 out of 99 that goes to John Hooten in the Dallas Cowboys And there's the John's tale for the blue horseshoes at 95 out of 99 It'll be for Matt and Indianapolis EJC what's going on Joe wonder if any of the new sports will try some new products this year How do you mean? All right, we got Baker Mayfield for the Browns. That's gonna go to John What a shot by Josh Hart All aboard the Big Head Express Devontae Parker 20 out of 35 for Miami Roy with Miami good photography in these plates and patches to we've got Samaj nope. La Michael Pirinus. It's cousin is Samaj Two-color dual relic that is seven out of 99 go into Patrick Davis and the Jets I think I might have missed the numbering on some of the other ones the numbers hiding right there And that one was 27 out of 50 So yeah, there are some numbering I may have missed We'll do a quick little recap at the end. We got Chase young autograph. Nice 15 out of 25 two-color patch and auto The game wrecker chase young mark with the Washington football team Nice one and their CD lamb 43 out of 75 for Dallas that's gonna be for John John H All right two boxes to go we got here. We got another plate. It's Minka Fitzpatrick Steelers That's Jerry with Pittsburgh Jerry All aboard the Big Head Express whoop whoop Cooper cup four out of 35 For the Rams Adam. We got Jerry Judy full coverage three out of 80 For Denver and Denver is a number block team So Denver three is gonna be for Roy behind Daryton Evans is Charles Haley how boys edition 71 out of 99 Going to John and the boys There's Daryton Evans to 99 For Joshua and Tennessee And the last box ladies and gentlemen Good luck. We got a Rams edition of Todd Gurley Adam with that one-of-one plate Adam All aboard the Big Head Express Aaron Jones 55 out of 60 Green Bay five that's gonna be for Roy. We've got Patrick Mahomes up there as well The full coverage is Chase Claypool 41 out of 50 for Jerry and the Steelers behind Mahomes is Is upper echelon Cole McDonald autograph 10 out of 99 that will be for Joshua and the Titans And there's Patrick Mahomes right there 50 out of 65 Kansas City 0 is branded All right, there you go. And now let's do a quick little randomizer here between the Rams and the Browns Rams Browns randomizer. Let's flip back to some new dice new list Nothing to no other randomizer soon. No Rams Browns Let's roll it. Let's randomize it three and a two five times team on top after five one two three four and Fifth and final time goes to Cleveland Cleveland. This is for you That it's for John and the Cleveland Browns.  I'm Joe for Jaspies case breaks calm. Thanks for watching. Thanks for breaking with us I'll see you next time for the next one