Peter, it's tax time and of course you're with wealth or WCPD. I don't know where to start. How about flow through and critical minerals? Okay. Yeah. So we've got two more months left to the end of the year. That is the time when you have to buy your tax deductions. And we're also in the good crunch time when there's a lot of money floating around for the issuers to be able to keep those drills running. So both aspects are important and the liquidity providers, we're hearing more and more talk about this is the bottom of this market that we're finally about to move a lot higher critical minerals. We've gotten so much support from all the governments of the world and a lot of newspaper articles, TVs, talking about how we have to find five and some people even say ten times more critical minerals. So we're going to have a massive amount of demand but there's not a lot of supply and we know what that does. That moves prices higher. So we're looking at exciting them with the last two months of the year and then moving into 2024. And of course you actually are the individual who created the model for the charitable flow through. Can you tell us for those of you out there that want to give to a charity and give the tax benefits for flow through, how do they reach you and where do they start if they don't know anything about it? Well I always give away my personal cell number, that's<PHONE_NUMBER>, anyone can call me anytime. Our website is WCPD. Look we've had a 17 year perfect track record on these charity flow throughs. A charity flow through is a flow through which has been our tax code since 1954 but it is volatile and we de-risk it by selling it to an institutional investor that will buy all of your shares immediately after you've owned them for one second in time as long as they're sold at a discount. There's enough tax savings that you can actually sell it at a 20% discount, 15% discount so great for the liquidity provider and you can actually walk away with a very positive rate of return. If you don't give it the charity and if you do give it a charity we're doing a lot of one cent deals where a $10,000 donation only costs $100 and if you don't give the $10,000 charity you can make roughly about 25% net after tax return after fees so that's $2,500 positive benefit. So it's a great product and good for the issuers too. They get a nice extra premium on their flow throughs that they usually don't get with a traditional flow through and that's probably why charity flow through, that's a flow through with a liquidity provider, has become 80% of the market. Only 20% are taking the traditional flow through risk. And of course for some of us who get inundated with flow through opportunity on a regular basis, is there some advice you can give individuals looking at flow through on what are better flow through opportunities or should they just call you Peter? Well I mean I find maybe people are starting to look at this as a portfolio so we're dealing with CEOs, executives in the mining business and CFOs and geologists so they understand the mining business and they've always been taking the risk flow through but lately they said maybe I should be like a balanced portfolio have some stocks and some GICs some bonds and we're the GIC bond component for their individual rates of return on their tax. So a lot more people are combining yes they've got some great winners they've got some great hope and a couple of names that they're following whether that's even you know and critical minerals we've had a good run on lithium we like uranium what's uranium those seem to be the two that are doing well and then of course cobalt copper, zinc, nickel have all done you know have all had very low numbers so we're buying it hopefully off the very bottom lows. I've known you for a few years and so I know the mistake that a lot of people make is they wait too long. So for everybody out there go to wcpd.com is that correct? That's correct and you're right we people would love to buy this on December the 30th there just won't be product available at that time. The latest I mean it gets tight in December and the numbers generally aren't as good so our if you're a read if you're buying it for the tax savings for the investment we find from April to August 31st is to be the best time zone to buy it but we have product today and we'd love to hear from you and of course you'll be hosting our upcoming critical minerals institute masterclass on flow through and critical minerals. Thank you so much for joining us Peter it's always a pleasure. Thanks Tracy, bye bye.


Recall that when two atoms bond, their relative electronegativities will determine whether the bond is polar or not. For instance, the NN triple bond in a nitrogen molecule is non-polar because the two atoms have identical electronegativities, and this means the electron density is equally shared between them. However, in a water molecule the bonds are between different atoms, oxygen and hydrogen. In each bond the oxygen is the more electronegative atom, so that end of the bond has a greater electron density and therefore a partial negative charge. We draw the bond dipole arrow like this to indicate where the greater electron density is. When you look at a molecule as a whole the polarities of all the bonds combine to give the overall polarity of the molecule. So in water these two bond dipoles, which are at an angle to each other, combine to give a molecular dipole that looks like this. In contrast, carbon dioxide has two polar bonds, but because the dipoles are pointing in opposite directions they cancel each other out, meaning that CO2 is a non-polar molecule. It is these molecular dipoles, or lack of them, that cause intermolecular forces, that is the attractions between molecules. And there are three kinds of intermolecular forces that you know about. Dipole-dipole forces, van der Waalsf or dispersion forces, and hydrogen bonding. Let's look at dipole-dipole attractions. These occur in molecules with an overall molecular dipole, a slightly positive end and a slightly negative end. In this picture here from the UC Davis-Kemwicky these little diagrams are meant to represent HCl molecules. When the molecules encounter each other the positive end of one molecule can attract the negative end of another. This attraction is called a dipole-dipole force or attraction. Note that similar ends will repel each other since they have the same charge. When you put a lot of these molecules together, as long as the sum of the attractive forces is greater than the repulsive ones, they will hang together as a liquid or a solid. Next let's look at van der Waalsf or dispersion forces. All molecules have electron clouds, and these clouds are constantly fluctuating. These fluctuations can cause an uneven distribution of electron density, and hence give the molecule a transient or instantaneous dipole. This occurs even in atoms or molecules that have no permanent dipole, such as a helium atom or a hydrogen molecule, as is shown here. An instantaneous dipole on one particle can then cause an induced dipole on a neighboring one. For instance, the slight positive charge on the helium atom here attracts a little bit of electron density on the left of the neighboring atom, causing uneven electron density and hence a dipole on it. The constant appearance and disappearance of these instantaneous and induced dipoles leads to tiny attractions between molecules. And across many molecules, these attractions can hold them together as a liquid or a solid. All molecules and atoms show van der Waalsf forces because all molecules have electron clouds. Looked at individually, van der Waalsf forces are much weaker than dipole-dipole attractions. However, larger atoms or molecules with bigger electron clouds and more surface area across which these fluctuations can occur will have significant van der Waalsf forces. So the trend to remember is that as the surface area of an atom or molecule increases, the greater the van der Waalsf forces. Lastly, we have hydrogen bonding. This is an even stronger form of dipole-dipole forces. It occurs in molecules that have HF, HO, or HN bonds. These are the most polar covalent bonds that you can make. One of those, HF doesn't exist in organic molecules because HF is a complete molecule. Neither H nor F want to form any more bonds. So organic molecules that contain OH and NH bonds are the ones that will show hydrogen bonding. So hydrogen bonds are rather like dipole-dipole attractions in that they arise from a permanent dipole in the molecule with positive and negative ends. But they are significantly stronger than dipole-dipole attractions and also more directional. That is, they occur between specific atoms rather than over the molecule as a whole. For instance, when we look at water, it's not organic but it's a good example of hydrogen bonding. The hydrogen bonding occurs specifically between the oxygen of one water molecule and a hydrogen atom in the next. Now just as a final note, it's important to remember that the hydrogen bond is not the same as a covalent bond. It's a transient attraction between atoms in neighboring molecules. Some people get mixed up and think that the OH-covalent bond in water, for instance, is a hydrogen bond. It's not. It's the attraction between the oxygen of one water molecule and the hydrogen of a neighboring water molecule.


The decline of organismal functions during abstract aging is accompanied by a series of prominent hallmarks, including genetic and epigenetic alterations. These aging-associated epigenetic changes include DNA methylation, histone modification, chromatin remodeling, non-coding RNA, NCRNA, regulation, and RNA modification, all of which participate in the regulation of the aging process and contribute to aging-related diseases. Understanding the epigenetic mechanisms in aging will provide new avenues to develop strategies to delay aging, such as small molecule-based therapies and reprogramming strategies that enable epigenetic rejuvenation. Adopting health-promoting activities, such as caloric restriction, exercise, and calibrating circadian rhythm, has also been demonstrated to delay aging. Clinical trials for aging intervention are ongoing, providing more evidence of the safety and efficacy of these therapies. A better understanding of the critical roles of epigenetics in the aging process will lead to more clinical advances in the prevention of human aging and therapy of aging-related diseases. This article was authored by Kang Wang, who had sewn you, Qin Chaohu, and others. We are article.tv, links in the description below.


I'm delighted to introduce today's speaker, a friend and colleague, Dr. Emily Landon. After graduating from Loyola University Stretch School of Medicine, Dr. Landon completed her residency fellowship and chief residency at the University of Chicago. She did her fellowship in infectious disease, and also in 2014, Dr. Landon completed her ethics fellowship at the McLean Center here. Dr. Landon is an assistant professor of medicine at the University of Chicago in the sections of infectious diseases and global health, and also an assistant director of the McLean Center. Dr. Landon also serves as our medical center's hospital epidemiologist and as medical director of the infection control program at the University of Chicago. Dr. Landon's research is focused on healthcare provider behavior, especially behavior modification aimed at reducing the risk of healthcare related infections. Many of you are aware of Dr. Landon's extraordinary work in improving hand hygiene here at the medical center. She's also interested in the ethics of quality improvement research and the application of public health ethics to prevent infections in the hospital setting. When the Ebola crisis hit the United States and globally, Dr. Landon became a national expert on ethics issues related to Ebola management and clinical management in the hospital setting. Dr. Landon's talk today is titled Ebola and Zika, Case Studies in Management of Infectious Diseases and Pregnancy. Please join me in giving Dr. Landon a warm welcome. I don't know if I can make it through a whole hour without talking about hand hygiene, but I'm going to try. I want to start by thanking everybody for inviting me to do this talk today. The speakers in this seminar have been particularly awesome, so I apologize in advance. I hope maybe the newsworthiness of Ebola and Zika will get over any other lacking things that might happen in my presentation. But some of you may be asking yourselves why we are talking about infectious diseases when we have made such an amazing impact on them over the past hundred or so years. It looks as though infectious diseases are off the radar. I mean, our surgeon general said in 1967, because infectious diseases have been largely controlled in the U.S., we can now close the book on them. It might have been a little bit preliminary. So it turns out that there are a lot of infections that we handle every day that affect the way that we think about taking care of patients, and they have a big impact on the way that we think about medical ethics, largely because they add to the stakeholders, the key stakeholders in any ethical decision. The sort of point that I want to make throughout this talk is that when we have a patient-doctor-diad relationship where we work through problems with patients and ethical, sticky situations, it's the entrance of third parties and additional stakeholders that make things difficult for us. And first of all, reproductive ethics involves this key stakeholder of the fetus, which we are not addressing the moral status of the fetus today. That has already been discussed. But one would argue that we also have that same issue in infectious diseases where we think about the health of the providers and the health of the other patients that may or may not be affected by these infections. And that erodes autonomy for the patient. And how we deal with that is an important question that we need to answer in ethics and in ethics in infectious diseases and reproductive medicine. It's a question that we have to answer when we make a decision about whether or not we should allow children in the waiting room of the labor and delivery triage area like we did yesterday, or it makes a difference in making a decision about how we're going to address things like Ebola and Zika. And so I'd like to talk a little bit about our experience with Ebola and Zika and connect that to how we handle things nowadays by talking just a little bit about HIV. And hopefully it will give us some ideas about how we can address some of these problems going forward. So first of all, Zika and Ebola are two very different infections, but they matter to us for two very different reasons. And so let's contrast just a little bit to start out with. Ebola, there's a lot of person to person transmission with Zika, not so much. There's sexual transmission of both infections and maybe prolonged even after the patient is well. They may be able to pass it on sexually. There is not mosquito transmission with Ebola, but there is of course with Zika. The mortality rate far higher with Ebola, far lower with Zika, but the problem with pregnancy outcomes in Ebola, there is almost certain fetal demise. But in Zika, there is a long term problem in the outcome of the fetus that we aren't even completely aware or understand how that's going to affect future generations. Asymptomatic infection is incredibly rare with Ebola, but very common with Zika. And these specific differences make a big changes to make big changes to how we focus on addressing these infections both from a clinical standpoint and probably from an ethics standpoint as well. So let's talk a little bit about how the extra weight on the scale of ethical decision making comes into play when we add in these additional stakeholders. So in medical ethics, we really focus on the individual in front of us. We're really worried about treating illness, about respecting patient autonomy, about diagnosing and treating things and maintaining patient confidentiality. But when we talk about epidemiologic ethics, we're really focused on population health, preventing illnesses, worried about justice, investigating and changing things for the better, and we favor reporting for others' protection. When you're taking care of a patient with an infectious disease, you are not just the doctor or patient dyad that you always are worrying about medical ethics, but you have to, to a certain degree, take on the mantle of being someone who dabbles in epidemiologic ethics and think about those things as well and how we balance them matters. So in pregnancy, Ebola, as you know, much about is a terrible disease that causes a lot of mortality and morbidity. A fetal infection occurs via the placenta and Ebola can remain in the amniotic fluid even after viral clearance from the blood.  But pregnant women with Ebola are at increased risk of spontaneous abortion, pregnancy-related hemorrhage, still birth and death. The question about whether or not pregnant women with Ebola have worse outcomes than people with Ebola is still left unanswered, many would say biologically plausible that, yes, they do have worse outcomes. Fetal or neonatal death has occurred in 100% of the known pregnancies of women that have tested positive for Ebola who are known to be pregnant. The baby has died either as a fetus or shortly early in the neonatal period. And so we have no surviving children of women with Ebola. However, maternal survival is in fact possible and we know, probably, if they receive good care, but sometimes that means both infectious disease care and support and obstetrical care. And that can be really difficult. So there are very poor outcomes in Africa for both moms and the fetus. And this is largely because the way of isolating patients in Africa is to put them in an Ebola unit. There's much less isolation capacity. They use what we would prefer to as cohorting as opposed to isolation. So all the patients with an infection are put together. And so a woman with Ebola who is pregnant needs to make a decision if they are going to the Ebola unit or if they are going to the obstetrics unit. And anyone with confirmed Ebola is going to the Ebola unit, where there is no obstetrical care available. And so there's no cesarean delivery. Even if you could do them, the throws of DIC can make things very difficult for mom and the providers. And vaginal delivery itself is very messy and fluid producing. And we know that obstetrics providers are at much higher risk of any blood borne pathogen than almost any other specialty. So when we talk about doing things differently here in the United States, we have our way of thinking about the Ebola Risk Benefit Balancing Act, which is what I call it, but really refers to any infectious disease. You have the risk to the patient, potential benefit to the patient, and the patient gets to choose how that scale measures out for them. It doesn't happen in the case of infectious diseases. And Ebola is a good example. All of a sudden you have risk to providers, risk to other patients. That woman that may or may not have Ebola yet, you haven't decided. If you put her on the obstetrics unit, she's going to expose every single other woman on that unit. And the healthcare providers, no matter how much PPE they wear, will be at higher risk because that PPE that they have in resource poor settings isn't quite the same as what we have here. And so now we don't just have patient preference weighing in on this scale. We have provider preference and public health preference eroding away the patient's autonomy. And we may say that that's acceptable in the throes of a massive outbreak and a pandemic in a country where there are very few healthcare settings, that it's expected that some people are going to have a higher likelihood of dying than they would if they had better medical care. That is true of all the patients that were in the Ebola treatment centers in Africa. But here in the United States, we might be able to do things a little bit differently. So it was surprising to me when as our Ebola medical specialist here, I read the ACOG practice advisory that recommended for patients with Ebola. It's prudent to avoid the usual obstetric interventions like fetal monitoring, cesarean delivery, induction, surgical repair, oblacerations in this select group of extremely women. I agree with that statement. It may in fact be prudent to do those things or to forego those things. However, it goes on to say that for all women with Ebola virus disease, there will be a window in which Ebola virus disease is suspected, but has not been confirmed with laboratory testing. These women should be treated in a similar fashion to that described above, recognizing that a portion may prove negative. Unfortunately, when a woman presents to a clinic with symptoms of either Ebola or a pregnancy-related complication, the window period in which it takes to get the test results back is often the same period in which that baby is either going to die or be delivered. So some thoughts about what we've learned about Ebola. Over 10,000 people in the United States were monitored for Ebola during the fall and winter of 2014, with people that entered the country having been in Western Africa. More than 400 people were tested for Ebola in the United States. Some of those were about 40 of them came from that 10,000 people who were monitored. The others were people who were identified as being ill on arrival to the country and were put into hospitals like ours to be ruled out or ruled in for Ebola. 11 of those people tested positive, meaning that greater than 97% of the tests done for Ebola were negative. These are people who were just in Western Africa, potentially had exposure to people with Ebola and 97% of them and presented with an illness and 97% of them didn't have Ebola. That's a very low pre-test probability of testing positive for something. And yet pregnancy complications in Ebola present in almost the same way. Bleeding, abdominal pain, fever, vomiting, miscarriage or fetal death or concern for such. These are the things that people come to. These are obstetrical emergencies and they are also Ebola. Yet obstetrics, as we said before, is a very high risk occupation. So actually, I think, I wanted to know who said this. But because I'm missing notes here. But the question of whether or not Dr. Black, I guess, asked the question, is it ethically justifiable to withhold potentially life-saving treatment to someone who is suspected of having an infectious disease? And also, is it ethically justifiable to risk exposing health care providers and patients by admitting and caring for a patient that's suspected of having an infectious disease? And these questions are very difficult to answer in the case of a woman presenting in Guinea. But they're a lot easier for us to answer here in the United States. Because the weight of the fear and the weight of the issue of potentially exposing other patients and other health care providers can be modified with the resources that we have available to us. Fear is very different from reality. And so at the University of Chicago, we took the tack that the right thing to do was to minimize the amount of effort we had, or the amount we had to encroach upon individual patient liberties by doing things like mitigating the risk to providers and mitigating the risk to other patients. For example, we use PPE that is beyond extreme. This is an example of an outfit, Sylvia, wearing the PPE outfit that we expected.  We can train people in this PPE. We can give them simulation-based training where they get the chance to become more facile and more comfortable and more confident in wearing these things. We can also plan ahead by telling patients, by planning what we're going to curtail in terms of their autonomy. By saying, we will allow you to make a decision about whether or not you want to be intubated, but that decision will have to be made when it's elective. So we will make, we will intubate you when it's an elective semi-urgent, but we don't want to do an urgent or emergent intubation. We will allow you to choose dialysis, but you're gonna get CVVH. You can't choose intermittent hemo dialysis because it's not taking you off and on the miscine is riskier. And so there were things that we can do to help mitigate the risk, but allow patients to maintain some sense of autonomy and decision-making about what treatment limitations they'd like to impose on themselves. Now some things are impractical. You can't let a patient with Ebola use an MRI scanner because we only have a few of them and it would take days for it to be ready for any other patient to be able to use it again. And the transport routes couldn't be made safe or sort of closed in in order to allow other people to use that area. So clearly there were some things that were off the table, but we wanted to put as much onto the table as possible. We also recognize that rule out patients are very different from confirmed Ebola patients. Not just because the pretest probability of them ruling out was so high, but also because patients earlier in their infectious disease process with Ebola are far less infectious. The infectiousness of Ebola increases as the disease progresses, and then it comes back down again. So patients who are in this rule out period are by definition less infectious and almost not likely to have Ebola. And so we could be a lot more aggressive with taking care of them when they were in this before we knew about their Ebola status. Careful weighing the risk and benefits was essential. And our plan here was to be able to provide almost as much as to be ready with the supplies and the equipment and the training needed to provide any obstetrics needs that need to happen for these patients with the decision that we could make the complex decision making based on individual patient desires and individual preference of the providers based on the clinical situation at hand with support from ethics and other experts. So that's how we handled Ebola at the University of Chicago, although we never got to be tested with a pregnant Ebola patient, no one in the United States did, which is both good and bad because I suspect we would find the outcomes are somewhat better as we did for the rest of Ebola if you have the highly supportive care of an institution like the University of Chicago. Switching gears to talk about something completely different, Zika. And first I wanted to go over a few specific details about Zika because I think it's less well known to the audience here and so I'm sorry if I'm boring you. But Zika is a flavivirus that's similar to dengue and chikungunya. It can cause fever, conjunctivitis, headache and joint pain and skin rash.  In fact, 80% of people have no symptoms at all and almost no one actually dies of Zika virus. In the person who actually gets the disease, it's no big deal. However, if you're pregnant, it can be a very, very big deal for the baby. It's carried by 80s Egypti mosquitoes, most effectively by 80s Egypti mosquitoes, also mosquitoes that carry dengue and chikungunya and you can see the distribution of 80s Egypti mosquitoes. But lest you think we are safe here in Chicago, it has also been found although less effectively carried, it can be carried by the 80s albapictus mosquitoes as well, the Asian tiger mosquito which we do have in this area. And that's just some basic information. So this is where we've seen Zika. These are all the countries that have reported cases of Zika recently. And I will say that the very first time that Zika was discovered was in a gorilla in the Uganda Zika forest in 1947. The first outbreak was known to us, was in 2007 in the Pacific Island of Yap where 73% of the population was affected by Zika. And in 2013 and 14, there were about 28,000 cases in French Polynesia. And that's the history of what we have about Zika. And we knew from then that there might be some issues with fetal outcomes in women that were pregnant at the time that they had Zika. So how do we test for Zika? We do nucleic acid amplification testing of serum and urine. It's recommended to do up to two weeks after symptom onset, but sooner is better for those of you who are wondering within one week is much better than two weeks, but you can do it up to two weeks. And if you have, we'll get to the recommendations in a minute, but less than two weeks after the last known exposure for an asymptomatic woman who wishes to be tested. And those women who live in areas with endemic Zika or epidemic Zika do need to have more complicated testing regimen that I'm not going to go into. Surrology is available, but with the caveat that there is a lot of crossover between Zika serologies, dengue, and chikungunya, and it can be very difficult to figure out which infection the patient actually had. And so you had something. The real issue with Zika is the concern from microcephaly. So there are initial reports of an increase in microcephaly cases in northern Brazil is what led to the concern about this virus that otherwise wouldn't have really come on the radar because people don't get very sick from it. And it turns out that since those initial concerns, there have been some very robust case control and some very early cohort studies that have described a link between Zika and microcephaly. The odds ratios in the Lancet ID case control preliminary analysis show about 55 with a 95% confidence interval that goes to infinity for microcephaly and lab confirmed Zika. And the correlation is even higher for patients that have babies that have typical CT changes and positive tests for Zika in either the mom or the baby at some point. Turns out that microcephaly is only one piece of what is now being referred to as the congenital Zika syndrome, where you have the severe microcephaly with partially collapsed skull that you saw in the previous picture. There's also a specific pattern of brain damage and decreased brain tissue that it turns out may not be present at birth but can evolve over time in the neonatal period. And so one single time of screening for a newborn baby that has been exposed may not be enough. There's also retinal damage, some joints with limited range of motion and hypertenicity in the newborn. But the bottom line is we don't really know what the entire spectrum of disease is. It's expected that we will find that even children that some children who appear to be normal at birth may suffer from intellectual disabilities down the line. And that's a level of uncertainty that makes it very difficult for us to predict and decide what to do. So there have been a number of Zika cases in the United States. Every state except for Alaska has reported at least an imported case of Zika virus. So we've all been dealing with this. We've certainly had some cases here at the University of Chicago. There's ongoing Zika activity in Florida. This is the most recent active Zika virus transmission in Florida map from the CDC. You can see there's no place where pregnant women are advised not to travel. But there are a big swath of South Florida that is pregnant women should consider postponing travel to this area. There's also an area of Zika cautionary area in Brownsville, Texas where it's recommended that women consider postponing travel to this part of the world if they are pregnant. And what are the pregnancy outcomes been for us? Well there have been 875 completed pregnancies in the United States where the pregnant woman tested positive for Zika. Of these 36 live born infants had birth defects. They have not come forward to say exactly how many of them have microcephaly or one of the other birth defects that are associated with Zika and there were five pregnancies that were lost with birth defects that were thought to be due to Zika. That is the government's information as of 12, 27, 16. So this is a problem that obstetricians are facing and pediatricians are facing today here and we continue to get calls about this regularly from the obstetricians at the University of Chicago. And the uncertainty about the long term outcomes of these babies is a challenge even when women have access to care and many resources. The CDC's recommendations are to just not travel to areas where people have Zika which is great I guess unless you have family there need to be there for a reason. And they say if travel is needed you should discuss with your healthcare provider first in order to get counseling and advice on mosquito precautions. Women who have traveled to areas where Zika is active should have testing within two weeks even if they have no symptoms because 80% are asymptomatic. And pregnant women should use barrier precautions when having sex with a partner who traveled to an area with Zika for the duration of the pregnancy. And should not attempt getting pregnant again for at least six months after the last known exposure of the male partner and then another eight weeks, whatever, it's long, whatever. For women of reproductive age the recommendations are equally strong that planning of pregnancies is recommended. This may be one of the first times that a public health agency has come out and just flat out said, plan your pregnancies and you should have and we should give people safe and affordable access to birth control methods that meet their needs. Zika testing should be done if you travel and you're symptomatic and you're of childbearing age. For those who travel to areas with Zika who remain asymptomatic, women should wait at least eight weeks after the last known exposure to his tempt conception and one should use condoms when having vaginal anal or oral sex with a man who has traveled to an area where Zika is active for six months after the last known exposure. There's a lot of language describing how if the woman chooses not to, she should be, chooses to have unprotected sex with a man who's traveled. She should have reliable birth control during the entire time and for at least eight weeks after that six month period is over so that she doesn't conceive until then and these dates are made, these recommendations are made with the uncertainty of not really knowing if eight weeks is enough. There's pretty good evidence that eight weeks is enough time to clear the virus and that there's no long-term effects for women who previously had Zika, who become pregnant more than eight weeks after their Zika virus infection but we don't know everything we need to know. This led someone and those recommendations from CDC stem from the World Health Organization led a representative from the World Health Organization to say in the New York Times, it's important to understand that this isn't the World Health Organization saying, hey, everybody, don't get pregnant. It's that they should be advised about this so they themselves can make the final decision. So that brings up the question, is public health statement advice or is it directive? How heavily should it weigh on that scale? Is it like you definitely shouldn't get pregnant no matter what or is it you maybe should think about not getting pregnant and what are the consequences for people who do even though they knew and were advised by their public health agency not to do so? Is there some sort of responsibility? What's the, whose autonomy is this and does it help or hinder the autonomy? These are questions that I don't have great answers to and I think that it's going to be something that happens largely between a woman and her physician but policies and other directives and advice from other bodies to which women and men look to for advice and counseling have been affected. The last year in February the UN special envoy for, let's see, what was he actually? The special high commissioner on human rights urged the abortion banning states in Latin America to allow abortions for women who may have had Zika that it is no longer acceptable according to the UN for them to eschew abortion because they can't provide adequate family planning services. They need to provide this instead in order to protect themselves from all sorts of downstream consequences. Even the Pope suggested that contraceptives could be used but it would be acceptable to use contraceptives if you live in an area with Zika. Some have said that his statement meant that it was the lesser of two evils but it's not clear if the other evil is delivering a child with Zika or having an abortion. We assume he meant abortion but there are some arguments that perhaps the Pope actually means the delivery of a child with Zika that could have been prevented and if the Catholic church can change its mind about its long-term held beliefs about contraception maybe we need to be a little bit more flexible in the way that we make policies going forward. I would argue that the questions that we ask ourselves about whether or not these are directive or advice are important for patients and their doctors but I think it's also important for us to think about these thought experiments of things like Zika and Ebola when we make policies and recommendations about everyday care of pregnant women that we should consider how those hold up in the situation of having issues like Zika and Ebola to deal with. So some obstetricians have written about what they think the duties are of healthcare providers who are counseling patients about Zika and they have said that the most important thing is to talk to patients about travel, to mention, to find out their risk factors and to prevent pregnancy and routes of disease transmission. For those of you who are unaware, DEET and Picardin and IL-3535, all of which are ways of their sort of mosquito repellents are perfectly safe in pregnancy. DEET actually there was a randomized, a double-blinded randomized placebo-controlled trial of using DEET in the second and third trimesters of pregnancy and it was found to be completely safe and there's good evidence in animals that it's safe even in the first trimester. So there's no reason not to use DEET if one is traveling and there are a lot of things that can be done to prevent mosquito-borne illness in patients and people who are traveling to these areas and they absolutely should be, these options should be given to women. For those who don't want to delay pregnancy or who for some reason do not want to delay pregnancy, we need to be respectful of their autonomy. We should offer testing and monitoring and legally permissible ways of termination if that's within their belief system as well and we should support and help women manage that uncertainty that is weighing on their scale. That scale that for us includes our own health when we're taking care of patients with Ebola or the health of other patients or the health of the population at large is weighing that same weight of uncertainty is weighing on these women as they make these decisions about their own child. Before we move on though and I think it's important for us to take a moment to think about these two illnesses as important pieces of what's happening in a global perspective, but there's also another illness that we take care of on a regular basis, HIV, that bears a lot of similarities to these. HIV was once considered to be a disease for which it was a danger for healthcare providers to do any procedures on people with HIV. For a long time there were a lot of surgeons and obstetricians who were worried about taking care of these patients like we have with Ebola. There was also a time when we thought that women who had HIV who had children were essentially, there have been prosecutions of women for delivering a child with HIV or getting pregnant even though they knew that they had HIV sort of echoing the things that we see with Zika and the requirements that people not get pregnant or not travel even though that may be what they really need or want to do for other reasons in their lives. But we have made our way through this by using knowledge and science to help take the weight of some of those uncertainties and fears off the scale. In the beginning without intervention mother to child transmission in the United States was about 20% same in Europe and in the rest of North America. We started using AZT during pregnancy to help reduce the transmission and we started doing C-sections and testing women more aggressively and we found that we could reduce the perinatal transmission to 1% or even less. It's been a very long time since a baby has been born with HIV when the mother knew that they had HIV and had access to care. The clinics that were set up to take care of babies born with perinatal HIV are evaporating as the children grow older and reach adulthood and aren't replaced by new ones. We can early aggressive test in the state of Illinois we now test women with an opt out. In other words, you have to specifically ask to not be tested for HIV if you're pregnant and if you continue to refuse testing for HIV after the delivery of your child will test your baby which will tell us what mother's antibodies were not anything about the baby and that's perfectly allowable in the state of Illinois. Many states have these laws. We do effective antiviral therapy throughout pregnancy. We have elective C-section if the viral load is greater than 1,000 and we recommend formula feeding over breastfeeding in order to help prevent the transmission of HIV and the question has now shifted from how to prevent the mom from giving the baby HIV to how to prevent mom from getting HIV from a partner who may be discordant. And so we've come a long way. We've passed many of the obstacles that are present in Ebola and Zika care but we now are talking about the use of PrEP for discordant couples. That's pre-exposure prophylaxis by taking Truvada every day in order to avoid getting HIV from a partner who's a zero different from you or a zero positive and you're a zero negative. You can also use infertility treatments to help reduce the likelihood of HIV in discordant couples. For example, you can wash the sperm and couple that with in vitro fertilization with intracellular plasmid sperm injection and this has been proven to be highly effective in avoiding seroconversion of uninfected women in HIV discordant couples. And the more we use PrEP to prevent the transmission in discordant couples, the more we're going to see discordant couples who are desiring pregnancy which we have accepted is a totally wonderful thing for patients even those with HIV. And we are happy, it's not an accident, it is a planned pregnancy for these people and now we think how are we going to prevent them from getting HIV but also allow them to get pregnant? There are no reports of HIV infection in laboratory personnel or of cross-contamination of gametes and embryos belonging to other couples and I'll remind you that we handle HIV positive specimens in every laboratory and specimen area of this hospital and in every hospital in the United States without cross-contamination or problems in the past. So there it's been decided and recommended by the Ethics Committee of the American Society for Reproductive Medicine that there's no ethical reason to withhold fertility treatments at clinics with necessary resources to provide care to HIV infected individuals and the necessary resources aren't great, it's a separate freezer. I mean we're not talking about, they're expensive freezers I get it but infertility treatments are not inexpensive and many patients with HIV can't afford them anyway but those that can should have access to them and if a clinic can't provide them then they should find a center that can help serve their needs. Yeah, fewer than 3% of registered U.S. assisted reproduction technology practices provide service to couples in whom one or both partners have HIV. I called 10 centers in the Chicagoland area yesterday to ask if they did reproductive technology for women with HIV or men with HIV where the man has HIV and all of them said they had never done it before. Two said we might be able to do it but we'd have to send your gametes or embryos to another place to store them. Do this, take this step. So I know this is, we still have a little bit of time, I talked faster than I thought but I wanna say in summary that infectious disease in pregnancy there is really a lot of risk to a third party complicates every decision that happens in pregnancy and infectious disease is just up the ante by adding risk to community and sometimes to the healthcare providers themselves. And that void of uncertainty when a new disease comes on the scene or emerges from another part of the world often is easily filled with fear and that fear can weigh even more heavily on our scales where we're determining how much autonomy to afford patients that fear weighs even more than the uncertainty does. When in doubt there's good evidence that we should start with things that are known goods like expanding access to care and support securing additional resources even though we may not know what to tell women who are pregnant and have Zika and decide that they're going to carry their pregnancy to term and take care of this child we can arrange for services and can plan ahead for the babies that will come that may need these services. With emerging infections the situation is always changing but the good news is that we usually know more tomorrow than we did today and so there's always as long as we help people to weight out the uncertainty and to live with the uncertainty we can help them with more information as it comes along and that is all I wanted to say. Thanks Emily. I know you've been giving me grief for asking you to give me this talk but I've been looking forward to it the whole time. Thank you. It's terrific. I will open the floor to questions. I have questions but I will open the floor first. You're gonna have to ask me a question. I will ask you a question. So when ACOG came out with that interesting position about women suspected not confirmed of Ebola exposure and infection the American College of Surgeons do we have any surgeons in here? Yeah. Do you know what the American College of Surgeons said about this? Yeah so about the specific group of patients and they did not say that you should withhold treatment. No they didn't. They said that you should absolutely take care of those patients and obviously use precautions but we should not withhold treatment. So what do you think was the different what made the difference between the two colleges and their recommendations and how were those viewed and dealt with by the infectious disease community? I think fear. I think there was so much going on. There was a lot of heterogeneity. We did a survey of a lot of academic medical centers and medical schools to ask them what they were planning on allowing patients with Ebola what kind of treatments they were planning to withhold from patients that had Ebola in their Ebola treatment centers and what we found was that almost all of they were all it was all over the map. Who was gonna take care of these patients? Who was gonna be trained? What they were gonna do? Could you be intubated? Could you get a CT scan? Some places were offering none of those things to patients and some places were offering all of them and clearly hadn't thought about how they were gonna clean the CT scanner afterwards. I mean there was some place and then there in the middle you had places that were willing to do this but not that and some of it was clearly thought out like because their resources didn't allow them to do X or Y but some places just it seemed like it was really largely based on a fear of well, none of our nephrologists are willing to do the dialysis so we're just not gonna do it. Without a real serious discussion about what our obligations are to patients and what we really should be doing for these patients but thinking about it as though we are in Western Africa and we are not this is a very different setting here and I think that there were a lot of discussions had around a lot of tables and they all came out in different ways and I think that obviously the American College of Surgeons discussion came out completely differently from ACOG's conversation. I think since then there's been a lot of shifting and moving that it has to be that you should be prepared with as much resource and technology and training as possible to be able to provide everything you possibly can and then the right thing to do is to look at the individual circumstance and that does leave it open to one person not wanting to do X this day at U of C we have a system where we have an ethicist and infectious disease and then whatever expert that's not the person who would be doing the procedure that would be a review panel for whatever procedure would need to be just like whatever was at sort of up for discussion in a patient. We also felt very strongly we had an ethics console from the very beginning and felt very strongly that we needed to provide patients that many patients would test negative and we needed to provide them with the care that they would otherwise get that that was our job. I remember in the discussions there was some nuance right? Yeah definitely. I mean there has to be in terms of for example those should there be a potential exposure we're told that if we in terms of childcare for example because we'd have to be quarantined in terms of childcare arrangements and so some of those other factors were taken into consideration in terms of who would be the obstetrician primarily responsible for caring for that. Of course and we felt that we have a big enough community that it was important to allow individuals to volunteer to participate in this situation as opposed to forcing people to do that. Now in a wider outbreak this is a onesies and twosies outbreak right? Like you're not expecting more than a few patients at a time. If you have a wider outbreak a respiratory born illness where everybody's getting sick you have it's different in two ways. One is that your providers are at risk not just at the hospital but also outside the hospital right? Which is one big difference. And the other is you have bazillions more patients and so you have to rely on people differently and the expectation for service would be higher but it would come with the knowledge that that risk exists not just in the hospital but also everywhere. And so you sort of it's a two-way street the risk is higher all the time. But I think yeah we did we worked really closely with obstetrics to make sure and it was always very clear that we know the outcomes for pregnancy are bad like the baby's probably not gonna survive but we're gonna train a bunch of neonatologists anyway because what if one of them does? What are we gonna do?  Like that's not a plan. So we needed to have a plan. So we had a plan and we figured we knew the outcomes would be better with Western medicine than they would be in a small hospital with very little resources in Western Africa so we planned for it. But I think there was some, obstetrics really is an incredibly high risk field when it comes to blood-worn pathogens and that I think is reflected in that statement. Yeah that's what I was gonna circle back to say is that the amount of amniotic fluid and the amount of bleeding rates of hemorrhage even in this country are quite high so I do think that that probably affected some of the difference. But we also learned that in this outbreak that Ebola had a lot less bleeding than everybody expected it to despite its name as a hemorrhagic fever virus. It just didn't result in as much DIC as was expected. The patients had so much insensible losses from GI illness that they were dehydrated and malnourished and they had electrolyte disturbances. They weren't necessarily bleeding out all over the place which changed things. And I think the American College of Surgeons came out with their statement a little later and every week made a difference so yes. Thank you, Gene. Thank you very much for that talk. I was struck by your illustration of how tenuous are some of our ostensibly deeply held moral sort of ethical views are to circumstance. And so I like your idea that these infectious disease reproductive ethics cases serve as a launch pad for thought experimentation. And I was also struck as a resident at the time of the Ebola outbreak at just how incredible the response was both in terms of resources and organization. So the thought experiment I wanted to propose see what you think would be what? Hypothetically, what do you think that we would react differently with regard to reproductive access if you could control Ebola through planned family planning? I mean, if you could control Ebola through the distribution of contraception, do you think that Ebola would have triggered a more widespread acceptance of contraception and abortion? Or do you think it would have also fallen under the penumbra of our sort of distaste for that intervention? And why would Ebola be different than what makes Ebola different? I think that this is sort of the same as when we talk sometimes about how devastating it is to be the physician taking care of the patient who's refusing a life, like a totally life-saving treatment and they really don't want it and you don't feel like they really get it but they're competent to the best of your understanding and that sort of unbelievable stress that you feel in that situation. I think that's how people feel when they're taking care of patients with Ebola and I think that if you could prevent it with something as simple as contraception that almost no one would be against doing that. I think you'd probably find some people who would be against it because there's gonna be a range of opinions everywhere but I think you would find that the process of watching people die in a miserable, horrible fashion is very, very persuasive. So interesting though, because what is the threshold at which concerns about sequela from infectious disease that could potentially be prevented through family planning or secondarily managed through abortion? What is the threshold at which this country will say, you know what, this is something that we really should be talking more about. There was a lot of discussion and there continues to be discussion around contraceptive access and abortion access both in the United States and in Latin America around Zika but I will say and who knows what the future holds but inherent in this discussion about the future of the Affordable Care Act is a discussion of dismantling women's guaranteed access to contraception through the Affordable Care Act. Similarly, abortion bans are continuing to happen in this country. Specifically, there are a few outliers or like a six week ban on abortion which have not held up so far but the week at which most of these cutoffs are happening in terms of abortion bans are 20 weeks and when we're talking about monitoring for microcephaly. We can't tell until after. Right, that's around when we can start making these diagnoses so I don't know what it takes to shift that view or the kind of the national will to recognize that this is something that is important for women and men in terms of transmission of disease but Zika clearly is not enough and that I think is kind of a, I don't know what the point is. I think there's something really important to say about the fact that you have these like really sort of long term entrenched abortion and contraception bans in countries now really being rediscussed. I mean these are places of the world where I didn't think we were ever gonna really talk about those things and they're being discussed. They're being like encouraged by the UN counts high commissioner for human rights and I didn't know we had that but it's interesting and you know they're being discussed by the pope. Like the fact that you see these people I think we're getting, like we're figuring out where the line isn't. The gray area between the two is becoming smaller, right? We're seeing where we can walk up to that and we're learning something. Maybe we may not be quite there yet. And I think part of that is because we don't know what the outcomes are really gonna be like for these kids and it's really like the small villages in Northern Brazil where they're seeing so many of them are really far away from here. Like I mean it takes along not just by a plane but like they're really different from here and we don't have moms bringing in microcephalic babies to the clinic to sit next to the other moms. We don't have them like at the grocery store and so it sort of has to be a thing. I think. I had a few questions. One being we talk about the recommendations that women not travel with Zika and I was wondering if there was any more specificity that's come out of epidemiological information in terms of when during pregnancy exposure matters. And as a second question you talked about some of the cases of Zika in the US and how it's affected such a wide spot of the country. I was wondering if there were any data on women having an abortion as a result of contracting Zika and being aware of that during pregnancy. And then my third and final question is with Ebola you talked about the pre-test probability being so low in this country and being able to utilize that information in terms of the ethics of what we provide to rule out type patients. But since that's not a static number how do you do that in real time? Okay, starting from the top. There's very specific information about exactly where you can and cannot travel. The CDC website has, and it changes all the time and they say on the bottom of the page when it was last updated. The other part of that question was about, oh yeah, many women have had abortions because they've been exposed to Zika and they're pregnant and they don't want to carry the pregnancy through. But I don't know what more to say besides the fact that absolutely women are being counseled that that's an option for them and that if it's available to them, people are doing it. And the thing is in terms of abortion reporting so there are some requirements in terms of reporting abortions but the indication for abortion is not something that we necessarily ask or certainly not mandated in terms of reporting. So I think those numbers are probably more anecdotal than anything. And I think you had more questions about the locations and I can't remember exactly what you were asking. I wasn't asking about the locations. My first and my third question were, does it matter when during your pregnancy you can drag Zika first trimester, second trimester, third trimester? It's expected that the first trimester is worse. That's all we know. Okay, and then the third question was in terms of the pre-test probability. That changes, but when you're in the middle of a situation like Ebola, there's outstanding information coming into you all the time. It may not be available to you but the team of people that are running whatever Ebola outbreak thing, when we had patients here that we were ruling out for Ebola, we had phone conferences with the CDC response team like four times a day. And so they're giving us the most updated information about exactly what's happening here, how many patients they're currently testing where and what and we get lots of information down to the neighborhood where the people lived in Liberia if that was a place where there was a lot of cases or not a lot of cases. So we work with the public health departments when it's a onesies and twosies, we can get that kind of information. When it's a massive outbreak, it's a lot less granular, right? But you get something, you just, there's constant information, like public health works really hard to give us as much information as they can given the situation. We don't, I feel like they've been a big partner in all of this. Thanks. Hi, I was just wondering, so with the shifting cultural tide in the US, we talk a lot about the sort of construct of Western medicine as sort of a pinnacle and what we're striving to get other countries to be on par with our sort of rigidity in terms of the hospital system and understanding. And I guess my question is, do you feel like we're on the brink of a big change as reproductive medicine becomes more restricted in the US and more available in countries where we once thought it wasn't ever gonna be available? I think that's a big question. Like, are you, from an ethics standpoint, do I think that we're gonna be, we're gonna lead the way in a lot of things and we're not gonna lead the way in other things. There are certainly things, I mean we're not, we don't have universal healthcare and there are other countries that are leading the way in a more socially just way of providing medical, in my opinion, a socially just way of providing medical care. So I don't know that it's gonna sort of be a sea change necessarily but I'm supportive of, I think that we need to pay more attention to justice. I mean, I think we both agree about that. There are a lot of us who agree about that but the more you do like this epidemiologic ethics side of things and you think about justice more instead of attempting to not ever think about justice, you want more of it and it becomes more apparent when it's not there. I was wondering if the gentleman in front of you had a question first, thank you. Just want to be just. I have a question about the numbers which actually tie into the probabilities of things going wrong, this is a cratic method. Okay, so with AIDS you've got your risk to the fetus down to 1% but with this virus. Zika. Yeah, the Analsineurology paper last month said that 36% of the fetuses that they ultrasounded had microcephaly, which to me means 100% abnormal. Okay, so I don't think we can say that it's controllable if you're pregnant, first of all. And then you get to the next question here about the autonomy and it sounds good to let people make their decisions. Okay, sounds good. But in medicine we have other rules. You know, like if a person is dangerous to themself or others, the whole thing with the Jehovah's Witnesses and the children with medical interventions, et cetera. Where do you draw the line here? Okay. I want to say that I, no these are great questions. So if to a couple where both are heterogeneous for a genetically recessive disease like say cystic fibrosis or whatever, we don't put any requirement on them to not conceive. One would probably consider that to be on the border of eugenics. We also don't require them to have pre-implantation genetic testing nor do we pay for it. We don't require them to have IVF or pay for them to have IVF with pre-implantation genetic testing. And we allow a 25% likelihood that their baby will have a significant illness that may result in, it will probably result in a lifetime of a lot of medical care, a lot of cost and may end up in a premature death. And that is perfectly allowable by us. And so the likelihood, we also don't, while we do think that, most people now think that most babies born to women who had Zika, especially early in the pregnancy will result in some abnormality. But we don't know how severe that abnormality is gonna be in terms of their life yet because of these babies haven't grown up. And so while severe microcephaly with a crushed skull is probably not gonna have a great long-term outcome, we don't know about the babies that don't have problems and that look okay but have like a mild intellectual disability. So I think you have to be careful that you don't wanna cross into eugenics. There's like this huge valley of grayness between autonomy and eugenics and we're somewhere in here. I'm not talking about eugenics, which is a different conversation. I'm talking about deliberately having a baby that's going to be abnormal. What do you mean deliberately? What is the alternative? I guess my question is what is the alternative and how does that? So let's say you're in a state that doesn't allow abortions. Okay, we do have the experiment going on in the United States. That's not what Donald Trump might do. Okay. Keep going. Right, so you're saying, well, they might just be mildly retarded. That's okay, all right? Is that your argument? What is the alternative mandating abortion for anomalous fetus? Right, I'm not saying that's the alternative but I'm saying that you're arguing that it's a good thing to do. I think that we're probably on the same page and arguing that it's up to the individual to decide what is best for her and her family. And I'm raising the question, is that a valid position? I think that part of the problem here is that, and this was echoed in an opinion piece that was written in the Journal of Bioethics and Developing Countries. And it was an opinion piece where the authors suggested when we only focus on the children, like the outcome of the child, we fail to recognize all of the good things that we can do for the women before this. These are parts of the world where women don't have adequate resources for all of these things. We can do a lot to prevent that question from ever coming up. And so we should, it's incumbent upon us to prevent that question from being asked by doing the right thing from the beginning. And what the right thing is, I'm not sure. And I think that, I mean, everyone who's been to an ethics conference with me knows that I think there are limits to patients' autonomy. But I think that there's, but I think, I mean, you make a very provocative point. And that's what we do here. This is ethics, we make provocative points. Yeah, that's why I'm doing it. But I'm saying that with Zika, it isn't a black, I mean, it's not a shades of gray situation. I mean, this is a very dangerous virus if you're pregnant. It is a very dangerous virus if you're pregnant. But I would argue that we don't know and that there is value to human, we've already decided as a society that there is value to every human being. I am not making a statement about the moral status of the fetus. I am making a statement about moral status of humans that have been born right now. And I'm not making it, whatever, you get it. I'm not going there. But this is, it's so messy to me. I just can't handle it. Keep going, keep going. So I think we've decided that there's value to everyone that's born. And so, it's hard to decide. Your question is the question of the moral status of the fetus. And I also think, I'm not answering it. Right, but further, at a very practical level, performing an abortion on a woman who doesn't want an abortion. Like, how does that happen? You're never gonna find a provider who's gonna do that. Yeah. You know, so to a very, like, there's the kind of ethical- Well, you might, but not here. Yeah, well, yeah. There's an ethical and philosophical question. And then there's also the very practical. Like, I just- The practical is your friend in these difficult situations because you can't escape the practical. And it sometimes negates dealing with the thorny issue. And sometimes you need to, like, escape the thorny issue by just dealing with the practicality. You just have to acknowledge that there's a thorny issue you're not dealing with. Yeah. So I was wondering to what extent Zika will be like a trigger that shifts attitudes more generally. Like, for example, the women who got abortions because of Zika. How many of them were, like, anti-abortion or pro-life or whatever before that? There's no data about that. Right, and I will tell you- I would love to know. How many women who come for an abortion for a fetal anomaly or sexual assault were anti-abortion before they were in that situation? You would know better than I would. Right, and I mean, I'll tell you, it's not uncommon to hear someone say, I don't believe in this, but here I am. It doesn't always necessarily even shift their opinion after the procedure for other women. I think that this, you don't know how you're gonna feel until you're in that situation, and oftentimes when women are in that situation, they are understandably thinking about themselves and not necessarily thinking about the political context of their- A personal justification that they do not extrapolate the meaning to others. But they might. They might, absolutely. And I wonder, now that the Pope has said it's okay to use contraception for Zika, maybe women have started using contraception for Zika and how many of them will continue? Yeah, 99% of Catholic women have used contraception in their lifetime. So, I don't, pardon? In the United States. In the United States. But yes, you're right. I think that it is absolutely an opportunity to have people consider things that they may not have otherwise considered, absolutely. Any other GZ questions? Emily, did you have a question?  But it's hard to see these outbreak situations and not think of the role that the media plays in all of this, and we're sitting here saying, what's the difference between Zika virus and CMV and the outcomes in the fetus, and it's essentially nothing. So, I wonder how you feel or what you think as far as how the outbreak component is, yes, it's an infection, but truly it's a media frenzy outbreak situation and how that should play a role in determining how people deal with their pregnancies. Because I think most people, when they think of Zika, they think of the child with the itty-bitty head. They don't think of the 80% of people who don't have any effect of it on it. CMV, I think one of the biggest differences is that only 10 to 15% of the population in the United States is susceptible to CMV by the time they're women of childbearing age, whereas 100% of us are susceptible to Zika. And I think that the media plays on that and adds fear. And we have to be, this is, when I say all this stuff about fear, fear weighs, really, it weighs a lot more than uncertainty when you think about it and balancing risks and benefits. When you're just talking to a patient about this one little thing that they need, the fear oftentimes weighs more than the benefit even if the benefit is life and there's like the risk is like a toenail, hangnail. And so we know how heavy fear is. And so the media can do fear, but we also need the media to do education and to help people to see. We can't change our views unless women are on TV talking about how they think it's, or people are on TV talking about how they think it's okay to do things like use contraception to prevent Zika, your pregnancy during a time when they're at risk for Zika. And so I think that's, we need, it's a double edged, well it's a, I mean it's a, really it's a sword that can also be helpful. It can help and not hurt, and hurt. And CMV, we also have more longitudinal data, correct? To no outcome, you know, kind of. Oh yeah, yeah. It's still a moving target, right? We don't have much. The uncertainty fills this, it gets filled with fear. Yeah. Yeah, the more we know, the more we will do. One practical kind of FYI type question, not ethical. A young couple, male is positive for Zika, female is not. Is she at risk in her fetus for lifelong? No, she's, she can get Zika from that partner. She should, the recommendation is she should avoid getting pregnant. She should use barrier precautions. And if she's not going to use barrier precautions, she should use a reliable form of birth control until six months after the, the male's last known risk factor because Zika can last in semen for up to six months because you don't want her to get Zika. She can go ahead and decide to not, not use a barrier method, get Zika. If she is able to zero convert to Zika, then she can get pregnant eight weeks after that. So once the male semen is, is clear, then they're okay? Yeah, so the understanding right now is that there's no long-term issues. And that like, that once you, that it's a direct viral effect from being viremic during pregnancy. And so it is not thought to be an immunologic phenomenon that happens later on. And so that we know because there does not appear to be additional risk for the women who had Zika back during these other outbreaks. It's a limited supply of people and there haven't been a ton of testing done, but there is not a lot of evidence that there are ongoing problems in the future. We think eight weeks is good enough. Once the virus is gone, then mom should be okay. And so some people say, just go get, go get Zika now and then get pregnant. And immunization would be great, but there's a whole, like whole another thing about how we test vaccines. We never test them on pregnant women. We never use them in pregnant women. This is mostly would be needed for pregnant women. And so how are you going to prove its effectiveness if you're never gonna test pregnant women or even women of childbearing age because they might get, have a bad reaction and get pregnant. And so this is, there is a lot of, you can look up Zika vaccine pregnancy and you can see tons of little editorials about how we need to change the way we do vaccines because we're totally, we're hamstrung. The current methods we use to test vaccines, we are completely hamstrung for fixing the Zika problem. Thank you, Emily. This has been very interesting. My question has to do with the justice perspective and that is given the outbreak and anticipation of more children with the effects of Zika virus, have governments appropriated funding for services for these children? And are there advocates out there for them doing so? And I would also comment that I think we have to be careful from an ethics perspective, talking about intellectual disability as a harm in and of itself and maybe kind of look into the underlying assumptions with a diagnosis of microencephaly and intellectual disability and what our biases may be about that. And when we talk about it, I think we all have some sort of understanding about it but I think we need to be careful about the why and when we use the quick buzz words, but I think what do we mean by what is wrong with an intellectual disability if something or what is the harm? Yeah, that's a sticky situation. I know it's a two-part. It's not really a part. I don't wanna get too into the weeds on that aspect of things but the first part that you're asking about is the funding. The most of the countries in South America where there's a lot of Zika do not have good healthcare systems and so they have almost no plan for how they're gonna take care of the Zika babies. No. Do you know if the United States has any funding? Well, it took us how many months to fund mosquito prevention in areas where we have 80s Egypti? Our Congress went home for the summer without appropriating a bill to help get rid.  We're pretty good at that. Like it's not rocket science and yet they all went home for the summer without appropriating funding for that so I'm gonna go with no and I don't think it's on the first 100 days plan. I don't know. Are the Russians doing it? Maybe that might help. Oh my God. That was evil. Right. And with that, we'll call this close. Yeah, thanks.


They still that's their core sound many fresh one of the dopest artists just like that ever, you know For me produced that bounce sound. You know me like this In man, it was just nice The music down here is different they had a bounce sound one while they still that's their core sound many fresh One of the dopest artists just like that ever, you know for me produced that bounce sound You know me like this Oh, I at my age I can tell you I love it Seriously, of course Maybe the smart every single track of his lane he would bring it and play at the store and see the audience But you know reaction to it. Oh, yeah, he would always do that. Oh, yeah Because you know, there was no way we did not know every song or every time, you know There's no way because he you know, he made sure it's just market it. There were no computers or anything to do it Yeah, I mean you know like these guys worked very very hard. They don't have the help of what we have today You know computers to do that. I mean they had to really so I mean It was beautiful all how this thing bloomed and emerged and the work they did Gotta give them credit. They all worked very hard. Wow, man. You know, just a delight to hear. He was a little bit You know, he was a little bit more of a visionary, you know, yeah He really that's why he is who we used today even, you know, he's got an amazing vision and He was willing is willing, you know to do this. Yeah. Yeah, he was always always seemed like a business mind He tells a story about his parents Yeah, given his grandparent giving him ten thousand dollars a month one of his grandparents gave him ten thousand dollars And he went to LA and he got him a store You hear this story basketball and he played basketball. So this guy was Did you ever have a chance and this may have been for the music because it was so early on Kevin Miller's brother that passed away was that before the music or do you even remember? No, I remember all of them. You know, yeah Kevin Miller was alive and during the time the music was circulating He said you are exactly like, you know, my days remember I'm already correct. All like get all mixed up So I wouldn't be answering that very very well. Yeah I can ask you exactly and Who's Kevin Miller? That was that was a brother that passed through that guy. Okay. Yeah, and his children come visit Really, he did have children. I Didn't know that I definitely didn't know that I come to visit. That's nice, man But that they're they're pretty close though, you know cease children all of the fairly close. They're pretty close They're very they're close, but they're also very kind, you know, kind good They've done well. I mean the kids have done something You know, that's the whole thing that people don't talk about and think about the kids have to come up in And you know now they have to readjust and put themselves in a situation where they can't even Move around like others used to move. Oh, yeah, exactly. So it's a different lifestyle for them So they have to be going to school that bond to school and you know got educated and doing something positive and I Always see Birdman son. I'd be like this dude is extra quiet like my son Like my son I talk a lot, but my son's they don't do no talking But his son always Birdman son always seemed quiet to me when I would see me's a young man And I just like I said, I always I did good as far as with people from Louisiana I always loved the people from Louisiana. I would always say spirit though. That's what it is. You're spirit I would do good with them every time. I don't I mean, you know that don't don't get me wrong There's people that may not like me, but I'm gonna still love them anyway But at the end of the day, it's like man, you know, they were welcoming you They were very welcome, but you know, let me remember this is bear a lot of things started here You might have some family here. Yeah, we feel it. You know, you gotta look at I was more than five miles from Louisiana I'm like and on the Texas side.  So we feel it. Thank you so much. That's a good thing though You want to be you want to feel that you want to feel universal like that? Yeah, we on boss talk one-on-one


When we're going to see this butterfly to finish, I don't think we need that space now. And people are saying, why is gold down? Surely that's a safe haven. Well, no. When the baby gets thrown out with the bath water, when it comes to Bitcoin price, I'm happy that it is dropping. You know why? If it touches that 3,700 market gain, I'll be a buyer again on that. Hi, everyone. I'm Giovanni. Welcome back to our show. Today, it's a very dramatic day for global markets. To figure out what is going on, we talked to Chief Market Analyst at AvaTrade, Naima Slam, and co-founder at EasyTrader, Charlie Barton. In the past 24 hours, we have been witnessing a bloodbath in all the markets. We have been witnessing Bitcoin falling by almost a quarter. What is going on? Thanks for having me. Look, Bitcoin has seen the biggest drop today since 2017. And the reason that drop is happening because investors are immensely anxious about the market reaction, what is happening in the traditional equity markets, we all know that both institutional and retail investors have been very active in the last year or so in buying Bitcoin. Now, because of this massive plunge in the equity markets, they have no other option but to liquidate some of their positions in other assets such as Bitcoin and of course, Gold is also seeing massive pressure because of that in order to save themselves from margin calls in traditional assets. That is the only particular reason that I can think of that why we are seeing this massive plunge in the Bitcoin price. Otherwise, right now, this is the moment that we are going to check whether the fundamentals of Bitcoins are going to be put to test because monetary policy around the globe, which is utilized, which is implemented by central bank, is going to be tested. So if that policy is really going to remain in place, now is the time in the coming quarters, we're going to really see enormous amount of a stress test with respect to that monetary policy. So we shouldn't be seeing that this sort of a massive sell-off in the Bitcoin price. In fact, I believe that we should see the massive surge in the Bitcoin price, but that's not happening. The only reason and the actual factual reason that I can share that with you is investors are liquidating some of their positions and putting that money in order to cover the margin call. But when it comes to Bitcoin price, I'm happy that it is dropping. You know why? If it touches that 3,700 mark again, I'll be a buyer again on that. Okay, we know why the stock markets are selling off. The equity markets are selling off because of the economic impact of the coronavirus spreading worldwide. But people are saying to me, why is gold selling off? Why is Bitcoin selling off? Because up until recently, if the equity markets have been coming down, sometimes we've seen the likes of Bitcoin doing quite well. But it is just like I think when I was last doing a call with you guys in January, when everybody's selling everything, if everyone's losing on their equity portfolios, then they end up selling what they've been doing well on to offset some of their losses. So that's why I mean, gold is down massively today. And people are saying, why is gold down? You know, surely that's a safe haven. Well, no, the baby gets thrown out with the bath water when the markets get to this sort of stage. And we saw this in the financial crisis back in 2008, 2009, 2010, for periods where gold actually would have periods where it would pull back because that intense moments when everybody's selling or their equity portfolios are going down, then they need to cash out of some of their profitable positions. And that's what we're seeing with gold. And like you said, Bitcoin is down today as well. And when do you think this bloodbath will be finished? I think there is a lot more to go. Look, you know, if you are to speaking of a wonder percentage moves, right? So look at the percentage move right now in front of you. This is the stock 600. We have not seen these sort of a wonder plunge in the market going back all the way to 1980s. 4,300 massive wonder plunge since 1987. Look at 40, similar message. But when you look at the 4,000, the Italian index, I'm not seeing that sort of a sell-off in the 4,000 index index, which is insane. You know why? Because it is Italy, which is under enormous amount of pressure. It is Italy, which is under lockdown, under a lockdown condition now. And it is Italy, where we're going to see the massive banking crisis. We heard from Christine Lagarde that she didn't reduce interest, right?  We are going to take extraordinary measures, meaning they're not going to run the balanced budget anymore. Again, going back to our earlier conversation of testing the monitoring policies by central banks, right? So Germany is going to introduce massive budget spending in order to soften the blow of coronavirus. Now, to answer your question precisely, when are we going to see this blood-butter finish? I don't think we need that space now. The, yes, the massive plunges that I have just explained to you over the charts, like stock 600, FTSE 100, CAD 40, we could see some sort of a retracement because these plunges are, you know, unprecedented. Like I said, the last time we've seen any sort of this sort of a massive sell-off at this magnitude, you have to go back in the history all the way to 1980s to 1970 in order to witness that. But overall, for investors' perspective, I think I'm going to hold my bullets because I'm still waiting for these markets to fall a lot more than what they are because we are still sitting at 25% correction from all time high. And I'm not a buyer until and unless I start seeing that 40% mark. Well, the global central banks, the central banks and the governments around the world, they've still got some armour, so to speak, some ammunition up their sleeves. So there's still going to be measures that will come in. And we saw the Federal Reserve last week make that unprecedented move of cutting rates ahead of next, what is next week's Federal Reserve meeting, the FOMC meeting. And they're going to cut rates again next week, but there could be other measures. And in this environment, what I've just been saying to my traders here today is that you've got to stay connected to what's going on in the news because at any moment, the US could come out with something else at any time. And then all of a sudden you're thinking, oh, hold on a second, the markets are all bouncing or rallying what's going on. It's because maybe someone's gone in the US, the government or the Treasury or the Federal Reserve come out or something. But generally, this isn't over, is it? We're not in a containment stage at the moment. The economic fallout is still there. Now the markets are forward pricing, so they're trying to already forward price in, well, what is that economic fallout going to be? And that's what we're seeing at the moment. We're seeing uncertainty in the markets, which is what's creating this huge volatility. We can talk about what opportunities there are, but I don't think that the equity markets are done yet. Now, don't get me wrong, they could bounce at any stage and put in some good, oversold technical bounces. But I very much doubt that the stock markets have made a lot just yet. I suspect as the stock markets come down, Bitcoin will fall further now. So when I was last with you, we were talking about Bitcoin had been having a nice run, so I'm just looking away at this chart at the moment. Bitcoin had been having a nice run into January and into February. And I was talking about Bitcoin doing a pullback, but I wasn't expecting it to pull back this much, I must admit. But these are unprecedented times. These are beyond your standard deviation events. So most of the time we trade within standard deviations, we know what roughly the markets do, the sort of volatility to expect. And we've now gone to this high volatility environment again, which we haven't seen in the equity markets since the financial crisis. We're going to get a lot of the weaker hands will get cleared out of this. I still actually see the long term prospects for Bitcoin. But this is great because this is going to see a lot of people throw in the town and say, that's it, I'm sick of trading Bitcoin now. I'm off. And that's the way the markets work. It's the same with the way that the equity markets work. And it always has been that way. Markets have good runs, then they either have periods of consolidation where it bores investors out of positions, or they have bear markets. And that gets people out of positions as well. So I see this as a good thing. It's a flush. Could it come back down and revisit 3000? Yes, it could. But I still see in a year, 18 months time, that's where I see it gradually trickle its way back up. Okay, so talking about what you're doing in this exact moment, how are you reacting to this situation? Like, how are you managing your portfolio? Are you just waiting for things to go even worse? Or what are you doing exactly? We're selling into rallies. That's that's all we're going to do. Any debt cat bounces in an opportunity for you to sell the rally. Why? Economic data is going to get even worse. And nothing is baked into the earnings, like we discussed that before. So this is an opportunity for you to sell into the rallies. But be mindful, the moment that we come close to any of those important 200 a moving average, especially let me give you a take, e mini futures for S and P 500 index, touched the already touched the 200 a moving average. And every time we have touched the 200 a moving average over the last 20 years, I'm talking about two error over here, the prices have bounced back sharply up. So I think I'm expecting that bounce today. But I'm still not sure whether, you know, if this is the end of the sell off, I think we're going to still see massive, massive drop from here. And in terms of buying that opportunity, I think I'm waiting for the S and P 500 index to drop below the 200 a moving average by 20%. And then I'm going to come into the market with full force and fit with full ammunition and then start buying everything. Interestingly, I had shorted gold with some of our traders just a week or two ago, week or so ago, remember when it was, we put a gold short in. And we have our reasons for shorting gold when you would think the gold would be flying higher. So yes, I do have a number of different positions in the market. But interestingly, I'm not in the S and P or the Dow right now, I shorted the S and P fun enough, right near the highs with some of our traders. But I came out long ago. And this is the reality, people think the professional traders, they they get in, you know, like the S and P I shorted it the highs, and I'd still be in it right now at the lows. And that's just not the reality. I took a nice little what is now a tiny chunk of the market. But what seemed like a decent trade at the time. And now, you know, you think, I missed out a bit there, but we can't capture it all. So don't worry if you're missing out, because there'll be another opportunity around the corner. These markets are moving fast. The best thing that people can do is manage their risk and just wait for the next opportunity. And don't worry if you've missed out on some because there's going to be plenty more opportunities coming. Yeah. So as far as my trading is concerned, yes, a lot of trading in like some Euro dollar as well to don't mind trading that because it's the world's most liquid currency. So yeah, that's where that's how I feel on Bitcoin. I do think that in the long term, it's going to be fine. But who knows in the short term, because like I said, the baby gets thrown out with the bath water and it could still come lower if the equity markets do still go lower. If you had to give a piece of advice to an average trader who is trying to figure out what to do, how to best profit from this situation of immense crisis, what would that be? Well, first of all, I don't give out advice. So I can show suggestions. So that is if you are an investor, hold your horses for the time being. The markets let this dust settle a little bit and then walk into it. Because remember, we have two strategies. This is your support zone. This being your upper line, this being your door line. Market falls like a knife in this zone. You can buy it right here. Then you have very, very skilled traders who are going to find that bottom. Then you have investors who are slightly risk averse. They want to see, they want to buy it when the market comes out of their support zone. So for retail investors who are not skilled, wait for that moment, wait for the price to come out of that support zone. We still don't know where the bottom is in the market. But we know that we are willing to buy it up to 30% or up to 40%.  You've got to buy it at that particular point. Because this is the closest thing that we have seen near the Bitcoin hype. When that ICO hype happened, look at the activity at broker's level. The volumes are going through the roof because everyone is trying to take some piece of the pie right now. And on the other hand, if you are a day trader, this is the best time for you to get involved into. Because that 1000 percentage point has become a norm. Even today, we've seen circuit breaker in the S&P 500 index. During this particular week, there has been two different occasions when the S&P 500 has broken its circuit, right? Meaning more than 7% move on the market. So to summarise, passive investor, wait, day traders get involved with it, enormous amount of volatility. Okay, all right. There's different parts of what my personal strategy is. One is we have to manage risk. I'm seeing lots of people blowing their accounts out there.  I constantly go on about this with trade about traders. But if you're going to trade without stop losses in this sort of environment, and if you're going to nightingale into positions, adding to losing positions, you're going to get blown out of the water. So please respect your risk management, risk a maximum of 1% per trade. That would be the first piece of advice that I could give as far as a strategy is concerned. Reduce your position size and have wider stops than you would normally have. The market, like I've already said, the volatility is expanded to a great extent. So we've got to have wider stops in order to account for that volatility. The other thing from a risk perspective is be really careful. If you want to trade stock indices, be really careful. The S&P keeps on getting shut, the S&P and the Dow because they're hitting their circuit breakers. So you might well think you're going to capture a bounce and then all of a sudden the circuit breaker kicks in, you get stuck in a position and then the market reopens another several hundred points lower than where you were.  So it all comes under the banner of risk then. That was Naim Aslam and Charlie Barton. Thank you guys. Don't forget to subscribe to our channel with more updates on the turmoil and golfing the global markets.