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Washington, DC

NANCY ROMAN: [Inaudible] of the Council on Foreign Relations, and I’m very pleased about tonight’s program with Laurie Garrett, who is the Council’s first fellow on global health. The Council has recognized that, in a globalized world, disease has to be thought of as a foreign policy issue; it’s not just security, human rights, and the traditional foreign policy issues. So her work is very exciting, and I think you’ll see that for yourself when she speaks in a few moments. And we have Susan Dentzer presiding, from the “NewsHour” with Jim Lehrer. Many of you know her and have seen her work.

But this is the second in our series on science and technology— the nexus of science and technology and foreign policy. We at the Council have decided that we really want to devote some energy and attention to those issues. And some of you were here when Shirley Jackson and Benjamin Wu talked about whether the United States was losing its competitive edge to China and India. This is our second in the series tonight, which we’re looking forward to.

And on January 19th, we’ll be talking about the foreign policy applications of nanotechnology. And I learned from Laurie just today that in fact there are health policy implications as well. Nanotechnology may allow, with a single drop of blood, to diagnose as many as 60 infectious diseases. So we want to look at nanotechnology and the foreign policy implications. But I thank you for being here and for supporting the series. And feel free to contact me with ideas that you have for more topics along these lines. Thank you very much.

SUSAN DENTZER: Thank you, Nancy. And good evening to all of you. If you till in the fields of global health on a daily basis, as people like Laurie and I do, you possibly saw today that the National Institutes of Health [NIH] announced the beginning of the first clinical trial involving a vaccine for the SARS virus, Severe Acute Respiratory Syndrome. And it was proclaimed that this has all happened in record speed. Of course it was just about exactly two years ago that we noticed this thing going on in southern China. It turned out to be SARS. It rapidly exploded, at least in that context, to create about 9,000 cases worldwide, about 900 deaths, most of them in four key countries, the primary one of which of course is China. And we’ve moved from the period of learning about the existence of that virus to going through that first cycle of the epidemic to a vaccine in two years. And as I say, it was pronounced that this happened in record speed. In fact, it was record speed, but— and it tells you what the global health community can do— the epidemiological community, the vaccine research community, et cetera— can do when it does move on a dime in the context of a serious threat.

However, as Laurie will be the first to tell you tonight, that is the exception rather than the rule in global health. The rule is prolonged denial, fudging of facts, a lack of focus on the underlying problem, et cetera, et cetera, leading to some of the crises we are living with today, not the least of which is HIV. So we’re delighted to have with us probably the world’s leading journalistic expert on all of these questions, Laurie Garrett. She is the only writer ever to have been awarded all three of the big P’s in journalism— the Peabody Award, the Polk Award, which she won twice, and the Pulitzer. Her more extended bio is in the packet that you have with you. Rather than spend more time on that now, let me urge you indeed to consult it. And let’s listen now as Laurie treats us to a holiday season [laughter] disquisition on the threats that we face from the possibility of another global flu pandemic erupting, as— as she will note, has been predicted for many years, and we may finally begin to prepare for it someday— bioterrorism, the overall global health gap that we face, and of course HIV/AIDS.

Before she begins— she will begin with about a 20-minute presentation; and after that, I’ll ask her a question, and we’ll open it up to questions from the audience. Let me mention that we will end promptly at 7:30 p.m. I’d like to ask everybody in the audience to turn off your cell phone. And as a courtesy to the speaker, please stay in the room until she’s finished speaking tonight. When we get to the Q&A session— I’ll remind you about this again— we’d just like you to identify yourself by name and affiliation. And with that, Laurie.

LAURIE GARRETT: Thank you. I want to start by showing you some photographs that were shot from the space shuttle. Some of you may recognize what you’re looking at. These pictures were taken on September 11th, 2001, and the plume that you see of course is coming from the World Trade Center site, blowing across Manhattan into Brooklyn. From the very first moment, this was a public health event, as well as a horrendous tragedy and a despicable act of terrorism, because that plume turned out to represent a biological event for which we had no precedent. The pH ran between about 12 and 13, and most natural-occurring respiratory assaults are acidic, with a pH down between 3 and 5. And it contained two molecules never before seen in the atmosphere of Earth, and we have no way of knowing what it will mean to all those who inhaled this as the time went on.

But what we really understand, if we think about that day, is that instantly the psyche changed here in Washington, the psyche changed in cities all across America, as people asked, “What if”--not just a hypothetical— ”What if it were real,” as we had been asking in New York for some time since the 1993 attack on the World Trade Center, but asked, “What if there’s more to come? What if the next thing is a biological assault?” And indeed just a matter of days later, on October 3rd, we had the reported death of [American Media photographer] Robert K. Stevens in West Palm Beach, Florida, from anthrax, and you all know what followed from there.

Well, once that had happened, there began to be the question: Are we ready? And what would it take to create some sense of readiness in the United States? And the first thing that that meant was recognizing that the public health infrastructure, a phrase rarely uttered in Washington, D.C., before, was virtually nonexistent; that we had allowed it to be budget-cutted to death over a couple of decades’ time, partially because we’d become rather smug about infectious diseases. We’d come to consider them completely under human control, at least for the wealthy world, and we had come to think of health as a private-sector function, a medical function, a function for which anything that could be thrown our way, the NIH could find a solution overnight.

Of course, all that time we were conveniently ignoring HIV, for which we had not found a solution overnight. But nevertheless, once it was recognized that the public health infrastructure was in fact in dire shape and not by any means prepared to dealt with a bioterrorist assault, money began to flow at very high rates from here out to the states— a total of $3.3 billion, so far, gone to bolster state public health infrastructures.

Now, the general thinking was that any dollar spent was going to work and that just simply making the public health infrastructure a little stronger would, by definition, improve the situation. But a recent survey conducted by Columbia University shows quite the opposite, at least in terms of public perceptions. The general population actually believes that the health system is less prepared today to handle a bioterrorism event, and in fact, the percentage of the population that feels confident that we could handle a bioterrorism event has plummeted in the last two years, despite heavy expenditure. And more than three-quarters of the population says we have no idea what we’re supposed to do if there is a bioterrorist event. So efforts to try and educate have also failed.

Now, part of the problem is, from the very beginning, Congress made decisions about how this money should be spent that were very political, which is to say all the states were supposed to get the same amount of money, regardless of perceived threat, per-capita population, and so on. So if you break down the spending on a per-capita basis, Wyoming, the vice president’s home state, gets this massive per-capita expenditure, while New York, a genuinely threatened state, gets this very, very modest comparative per-capita expenditure, and its neighbor right across the Hudson River an equally low— and one might easily imagine targets in California, and again, a very low per-capita level of spending. So right from the beginning we knew we had problems. Now today let’s ask the question: Why should we worry? You know what? That’s my phone. [Laughter] And—

DENTZER: Okay. There’s always one.

GARRETT: Scott, it’s in my bag, right there. Oh, my goodness. Is that embarrassing? [Laughter] Now right from the beginning, we could ask the question: What has happened since 9/11 to actually up the ante on the threat? And there have been a number of things. Scientists have now actually built an artificial polio virus from the molecular building blocks, the DNA— or RNA, up— right up to an actual living infectious virus. That feat has now been repeated with the 1918 strain of influenza, the strain of flu that killed at least 50 million people globally in 18 months’ time, prior to the existence of commercial air travel. It has now been built from literally the nuclei-type scratch up, and the genes responsible for the unique virulence of that virus have been isolated and identified. And one of the things I would point out is that the 1918 strain primarily killed 15- to 45-year-olds. So when you consider the fact that we’re now imagining that the best way to rationalize use of limited supplies of vaccine is to prioritize senior citizens, it’s worth remembering that in 1918, it was not the senior citizens that were devastated by that flu. One of the reasons was it had the unique capacity to cause actual lung hemorrhage and kill lung cells directly.

We’ve also had a lot of leading pathogens fully sequenced, including some of your worst-actor viruses and microbes that we would be concerned about. And the genes responsible for making them transmissible and virulent have been identified and published.

And finally, we had an experiment that was a complete failure. The intent by the Australian scientists was to figure out a way to take a factor commonly found in the immune system, a chemical that is produced in the human body and in the bodies of most mammals, and use it to enhance the response against a lethal virus, and it boomeranged because it turned out they got an enhancement of the lethality of the virus, rendering mousepox 100 percent lethal. And this has since been repeated on other species of pox viruses, showing that the exact same effect can be done. And needless to say, I assume that one could do this with smallpox.

So this leads us to some serious questions about smallpox and is why there’s— one of the reasons why there’s been a big targeting of spending on smallpox and smallpox vaccine. Now we’re trying to be prepared to respond to smallpox or any other likely highly contagious terrorist agent, or naturally arising. And the last time we had to deal with smallpox was 1947, when a tourist who’d been in Mexico and unknowingly acquired the virus visited New York, and hit all the hot spots from one end of New York to the other before dying of smallpox.

In 1947, they were able to immunize six and a half million New Yorkers in about six weeks’ time— a phenomenal achievement, and one that I must say is not repeatable today in any city in America. Since 9/11, I’ve been in 47 states, I’ve been in every imaginable size of city and municipality, and I’ve talked to public health officials all over the country, and no one feels that this is a repeatable effort at this time. Now, why? Well, one of the reasons is our local capacity. Yes, we’ve put a lot of money into the system, but the truth is, we still have really primitive medical microbiology capacity in most hospitals across America. We still are operating as if there’s anything bad out there, suspicious out there, we’re going to collect samples and ship them to Atlanta, and the CDC [Centers for Disease Control and Prevention] is going to take care of the problem, which in a serious epidemic would mean an awfully beleaguered, exhausted CDC, as was the case during anthrax.

We have seen that even the basic research effort funded now with well over a billion dollars pouring into the NIH, to come up with new solutions to bioterrorist threats, is stymied by security concerns, so that the very scientists working in the National Biodefense Research Centers, the recently established centers, are unable to get basic samples either of the microbes themselves or of the epitopes, so portions of the protein segments on the microbes that they’re— the immune system would respond against, or even certain gene sequences. How can one do research on the microbes and so on if you can’t obtain samples?

And we have a massive shortage of the disease detectives— the people you count on to go into a suspicious outbreak and determine what’s going on, what’s the likely culprit causing it, how is it spreading, how— what interventions will make a difference and slow it down. These are called epidemiologists. In fact, the shortage is so severe, the city of Chicago had one epidemiologist. Next slide.

When you talk to the hospitals, there are four key principles of preparedness for either a naturally occurring pandemic or a bioterrorist event, and these are surge capacity, decontamination facilities, burn beds, and isolation capability. When hospitals are queried today and asked, “What are your four weakest points,” these are precisely the four weakest points. And surge capacity is really the key here. You want to know that if somebody were to release a terrorist agent in Washington, D.C., or if we had pandemic influenza or another terrible naturally arising epidemic in Washington, D.C., that every hospital across Washington could suddenly at least double their bed capacity. And I don’t mean that they just put gurneys in the hallway, but they’ve got staff to take care of the people on the gurneys in the hallway. But in fact, what’s happened with managed care, with all the cost reductions, is that hospitals have eliminated surplus beds and surplus personnel; so that far from being ready to deal with surge capacity, we’re actually understaffed, and we have massive nurse shortages all across America.

Decontamination facilities. Very, very few hospitals have the ability to do decontamination of potentially contaminated individuals before they get into the hospital. Burn beds. We have shortages everywhere, particularly because we lack nursing personnel to staff those burn beds. And isolation capability. I was stunned recently, visiting Hong Kong, to find out that they’ve installed 1,400 negative-pressure isolation hospital rooms all over Hong Kong because of SARS, which is considerably more than we have in any major metropolitan area in the United States.

We should also worry when we think just about— narrowly— any one microbe— anthrax, for example. Now the major way we’ve been trying to prepare for that is by developing vaccine supplies. We’ve spent about $900 million on the problem. But nobody seems to be making note of the fact that, A, the vaccine half-life is only 18 months. So we are to spend $900 million every 18 months to come up with more stockpiled vaccine that we may never use?

The basic conceptual vaccine is the same as the one that GIs protested using on them in the 1990s. VaxGen was recently selected as the primary contractor to come up with another supply of these vaccines, and they’re using precisely the same technology to come up with them— a cellular-based technology— as Baxter [Healthcare] was trying to use to develop a flu vaccine and said it’s too contaminated, we cannot meet FDA [Food and Drug Administration] standards, we’re withdrawing our application. And finally, we don’t actually know what should be the target of this vaccine; which is to say, what constitutes effective immunity against an airborne assault with anthrax spores? Indeed, the very vaccine models we’re using have never proven successful in animal studies. The only successful vaccines in animal studies for airborne exposure have been much larger antigens involving whole spores and so on, and these are not what we’re using as vaccine. So what in the world are we doing here?

When we look around the country and ask again about epidemiology, we can see that we’ve actually had a decline in the number of full-time-equivalent positions for people serving— epidemiologists at the local level and state level around America since 1992, and today nearly half of the so-called epidemiology positions are filled by people who are never-actually trained epidemiologists. Similarly, because public health is accustomed to being cut, accustomed to being treated as the first place you go in with your budget knife and slash it during any fiscal problems, and because most of the states are in fiscal crises and have been for quite some time, in— very, very few of the recipients of federal dollars were willing to spend them to actually hire personnel. The assumption was the federal stream of dollars will end, and then how do we keep paying these people when our state budgets are getting cut? And so in fact what we’ve seen is the shift of personnel into bioterrorism areas away from this list of areas you see, of tobacco and maternal child health, substance abuse, mental health, violence prevention, teen pregnancy, HIV, and tuberculosis, chiefly. So, actually, one program is hurting others.

When we try to imagine what this means on a larger scale and think in global terms— this is a picture I took during the plague epidemic in India as an example, but we can think of it in a whole host of contexts— the first thing that comes to mind is that the world is thoroughly globalized today. So no outbreak is too remote, no outbreak is guaranteed to remain a localized event in our contemporary situation. Why I worry specifically about this, one key thing is Avian influenza. Is this flu likely to become a human-to-human transmissible agent? Very possible. We don’t know for sure. No one can put a probability estimate on it. But a few things are worth considering.

Yes, we do have a vaccine shortage this year, but people fail to understand in no year have we made more than 250 million doses for the world, for 6-plus billion human beings. If we had pandemic influenza, we would be possibly in a position where even if the United States did manage to have sufficient capacity to immunize Americans, we would say, “Oh,” [to] our amigos to the south in Mexico, “Sorry, you guys are all going to die. We’re not sharing vaccine with you.” Imagine the foreign policy fallout that would result.

And if you’re looking for numbers and you want to be impressed that a health issue might be a serious foreign policy concern, even your worst-case scenarios of what North Korea might have online as nuclear weaponry and its possible utility would not have a death toll that would equal pandemic influenza. If we saw something akin to 1918, we’d be in the hundreds of millions of deaths. And with increasing prosperity in Asia, we’re actually increasing the likelihood of this event occurring. Why? Because flu is actually an aquatic bird virus, and it is spread by migratory birds on the Asian flyways. Because Asia has so devastated their natural ecology, the birds, as they migrate, now land on farms and poach food and water from livestock, chiefly chickens. In so doing, they pass their aquatic bird virus to the livestock. And as they go through the livestock and through other species, the virus mutates and comes closer and closer to a form that can afflict human beings.

Now, with increasing prosperity in China in particular, people who even 10 years ago could only afford chicken perhaps once a month are now eating chicken every day and, similarly, pork consumption has escalated. So now we’re looking at these massive farms full of chickens and pigs, all of which are potential brushfires for spread of any given agent. And then when we think about the lesson of SARS, we can see that the way China responded, the situation of SARS in that region, showed that there is no public health infrastructure there on the ground that can deal with rapid response to disease. It was mostly about temperature guns, and if you have a fever, off you go, locked up in quarantine.

Another consideration is that the mega-city expansion and explosion around the world is occurring primarily in cities and in parts of the world where you lack the fiscal wherewithal and political wherewithal to build up appropriate living environments and health infrastructures to make it possible for people to live in these mega-cities without spreading disease. So we see more and more people moving into the peripheries of these cities, living in this horrible housing squalor without access to all the essentials of health, such as food, water, toilet facilities, shower facilities, paved roads, and so on, right near airports, in ideal circumstances for spread of disease and emergence of serious disease.

And all of this is occurring against the background of our friend, the HIV virus, which is, as you all have now heard, reached up to 42 million people living infected with the virus today, about 70 million cumulatively. Heavily concentrated in sub-Saharan Africa, but the fastest-growing portion of the epidemic is in the former Soviet Union region. About 800,000 of the people today living with HIV are actually children under 15 years of age. We see a steady rise in mortality, just skyrocketing. It’s one of the most frightening mortality curves I have ever seen anywhere. And one of the things you can see, is if we’re going out and we’re looking for a bell-shaped curve, a natural plateau, it isn’t there, people. It’s just going to keep doing this.

The only place where we see a downturn is in North America and the wealthy world. The downturn began in 1996 with the introduction of highly active antiretroviral therapy, which has helped prolong life. But it’s had no statistical impact on the overall epidemic because the therapy’s unavailable to people in the poor world, where the death toll just keeps mounting. And that epidemic, even in Southern Africa, is still only at its beginning. We’re just seeing the beginning of this epidemic, which means the death toll has only begun to be obvious. Most— upwards of 90 percent of people who are infected with HIV are unaware of their infection. They feel fine. They have not— they have no idea they should take precautions for their partners, and you can see the prevalence rates are very, very high. They are already affecting life expectancies, and we’re seeing a widening in the life expectancy gap between the wealthiest, longest-lived societies in the world and the poorest, disease-afflicted societies, utterly and completely restructuring the shape of these societies. And I really just want to show you this and one more slide and compare them.

Let me go back one, if we would, and so that I can make sure everybody understands what we’re looking at. These sorts of demographic projections have been done for quite a number of countries in Africa to get some idea of what the impact is of HIV. This one happens to be a projection put together by our U.S. interest bureau for Botswana. What you’re looking at is a zero-population axis down the middle with the distribution of females on the right, males on the left, and here’s your age groups. So for example, this would be your males. About— what is that?--120,000 who are under a year age, roughly. Now in the red is what the distribution of the society would be had there never been HIV/AIDS. And what you see with the pink in the middle is what AIDS is doing to the distribution and skewing of the entire social structure. What this obviously means as you’re looking at it is that, first of all, your elderly population, which ought to be retired and living— cared for by their children— is on its own because those children are all gone. And that whole age group is not only missing as the children of the senior citizens, but also as the parents of a still-large child and adolescent population. Missing here are your professionals, your army, your police forces, your economists, your productive labor force.

And just to show you what this would mean, let’s compare this— and you’re roughly at the same age line, so this is 80, 80 here. This is France today. So if you look at the distribution demographically of France and compare it to this horrendous distribution here, I think that it doesn’t take much imagination for you to see that what this horrible nightmare means is economic collapse, social catastrophe, massive orphan population, enormous instability, and a ripe environment for zealot demagogues, perhaps for the recruiting of likely candidates for terrorism. So the bottom line I see is that if we’re not thinking outside the box of our own sort of nation-state approach to health issues, creating a Fortress America that will defend itself against every anthrax spore, we’re missing the entire ballgame. What we have to be thinking of is a global picture and a global view of the movement of microbes and the defense against them. Susan?

DENTZER: Great. Thank you, Laurie. I’m thinking about my editors through the years who always asked for those warm and fuzzy holiday stories about this time of year. You have not given us one. Instead, you’ve given us some very powerful things to think about, the most obvious of which, is you really wonder why anybody asks the question, Is there a connection between global health and security? Do you even have to ask that anymore?

But let’s focus on another question that I think is implicitly raised in your presentation, which is that it’s obvious that we don’t necessarily battle these threats that we face effectively on a nation-state basis at all. We certainly have not done that in the United States from what you’ve shown us. And it’s even more true that, though that remains the case— that we don’t battle them very well on a nation-state basis— we still pretend that these things can be battled on a nation-by-nation basis in an era where, as you demonstrated clearly, jet travel and other things make that a ridiculous proposition. So how do we begin to think about moving to a framework that does much more [to] effectively approach these things from a multilateral perspective? We have entities out there like the World Health Organization [WHO]

GARRETT: Well, I think that’s the fundamental question. And I— the problem is, right now, everything to do with health is either considered to be a local responsibility— in many nations there’s very little national role in health; it’s actually something— for example, India: It’s all parceled out as a state function, state by state, with one state having excellent health issues taken care of and another state having virtually nothing. If you expand that to the global view, you can’t help but notice that most of the planet has no capacity to do disease surveillance, to take care of the health of their own people, to distribute vaccines properly, and so on and so forth. This all is because everything that we do in the global health arena today is based on an old-fashioned set of models that go back to the pre-jet age, to the boat travel age, when you could stave those microbes off by holding the people in a boat at sea until, you know, everybody was well, and then you let them come into port.

And we have also seen a plethora of new global health groups emerge over the last 20 years, but they’re very Balkanized. They’re disease-specific. So you have your malaria groups over here, and your TB [tuberculosis] groups here, and your HIV groups here, and they’re at battle with one another. And worse yet, they’re at battle over a very finite, shrinking pool of skilled healthcare providers in the developing world. So you actually have the ugly scene now of various rival health programs poaching each other’s nurses, doctors, and so on— skilled health providers.

I think that we have to do two things in the way we rethink the whole problem. The first is, we have to combine and integrate our health assault, so that instead of Balkanizing it and saying, “Oh, you tuberculosis people get this pot of money and you malaria people get this pot, and you all go off and fight among each other,” we need to figure out how to consolidate primary infectious disease services into a single assault at the village level to take everything on at once and de-stigmatize HIV, de-exceptionalize it, integrate it right in with everything else, so that you don’t have to walk through a door that says “AIDS” on it, declaring to all your friends and neighbors that you think you might have the virus in order to get treatment.

The other side of it is: When we think of surveillance, when we think of epidemiology and how do we monitor what’s going on in the world, and how do we respond to it, I think we have to stop again thinking about nations and change to thinking about the ecology of the microbes themselves. Where are those microbes? How are they emerging? What human behaviors are promoting their emergence? And tackle those things. So if I were speaking right now about Avian flu, what that would translate into is we will never be able to make enough vaccine. We just will never be able to make enough vaccine. Get that through your heads now. So a vaccine-based policy will fail— in a serious pandemic, [it] absolutely will fail.

So what might we consider? Well, we know— we now understand the ecology of flu. We know where it comes from. We know how it arises. We know what promotes its emergence. So why not have resources directed towards developing the strong ties and assistance with southern China and its neighbor areas— Taiwan, Singapore, Vietnam, Thailand— where flu emerges on a regular basis, helping them to improve their animal husbandry conditions, improve their migratory bird flyways. And if there’s going to be minimal supplies of vaccine, wouldn’t it make more sense to immunize the people who actually handle those animals in Asia, who actually deal with animal processing? And might it be a great idea to push the Asian societies away from selling live animals— live poultry in the market and go to centralized slaughter, as we have in Europe and the Western world, to minimize human exposure to living disease-carrying animals?

DENTZER: That’s a tall agenda and it gives us a sense of why many of these things are not happening. Let’s go ahead and open this up to questions and discussion from the audience. And again, let me just urge you, first of all, to speak into the microphone that will be passed around, and secondly, to identify yourself by name and affiliation, if you would. We’ve got one here in the front.

QUESTIONER: Jonathan Tucker, Monterey Institute. Laurie, you said that we have spent $3.3 billion on public health infrastructure, but we’re actually less prepared today than we were when we started spending the money. So what happened to that money? Was it just frittered away? Where has it gone?

GARRETT: I’m not sure I would say we’re less prepared. I do think some things have fundamentally and radically improved. But overall, is the public health infrastructure, the public health system in better shape today? Probably not. And in a whole set of program areas we’re in worse shape.

What did the money get spent on? A number of things. One, lots and lots of drills. Everybody’s been in drills now. Every health provider, every hospital, they’ve all had scenarios where they pretended that “Agent X” has been released and we have to respond. A lot has been spent on communication equipment and computer equipment. And in many municipalities, they’ve spent money buying laboratory equipment. The real point is that because there’s such a distrust of the funding stream and because the states are in such funding hell, there’s been a tremendous reluctance to spend it on humans. But public health really is people. It really is a labor pool. And that has not, you know, significantly expanded.

DENTZER: And isn’t the case— those were public perceptions? Polling—

GARRETT: The poll is a public perception poll.

DENTZER: It isn’t necessarily [inaudible] clear that we are less prepared, but—

GARRETT: Well, but surveys of state and territorial health directors and epidemiologists confirm that they feel very anxious about the situation.

DENTZER: Well, we’re certainly not as prepared as we should be, but arguably I think— hard to argue that we’re less prepared than we were in the last couple of years, I think. But I do think the gap between— the level of preparedness that we know that we should have and what we actually have is large and probably getting larger in that context. Yes?

QUESTIONER:Princeton Lyman, Council on Foreign Relations. Laurie, now that you’ve scared the daylights out of us, where would you put the priorities? That is, what is— if you had to set priorities— that is, you talked about how flu is spread. You’ve talked about various viruses that could be developed at least in the laboratory. But are those delivery systems the most threatening? How would you rank these if you were to spend money against which major threat in public health?

GARRETT: There’s a couple of ways to look at that. One is, how would you rank it on order of the threat of the microbe itself— the likelihood that it would spread radically and so on? Or another way to look at it, is how would you prioritize your spending in terms of the ability to respond generally to any emerging disease and so on?

I find that the notion of targeting it by microbes can take you down possibly a lot of bogus expenditure paths, because it’s not clear that anybody really has smallpox in hand with intent to use as a weapon. And I don’t know that we’ll ever know the answer on that. We do know that the Soviets had developed it as a weapon. On the other hand, if you simply ask the question, what would it take to create a reasonable emerging disease response and where do you want to target your resources?, then I think you can actually come up with a pretty decent shopping list. And one of the really important points is that it’s not an expensive shopping list, but a politically difficult one. It’s more about politics.

One key first step right now is the World Health Organization has for several years now been going through a process of rewriting— with hope that there will be a vote on this in May— their international health regulations. Under the old international health regulations that have been in place now for, gosh, three, four decades and are really antique, you used to get these yellow travel cards, and you had to certify you’d been immunized against X, Y, and Z. And there was a set list of great, threatening diseases for which you had to have a vaccination to cross the border, and that included ghastly vaccines like the cholera vaccine. Well, nobody really abides by this anymore. This has long since been seen as an antique. And it doesn’t guide the kind of contemporary threat response that WHO needs.

The draft new international health regulations envision a WHO that’s much more about responding to the unknown and much more about imposing a sense of transparency requirements on nations saying, you must disclose, you cannot hide, you cannot cover up; if you do, you’re a rogue in the community. You’re imperiling your neighbor states. And it’s much more about when do you say air travel to a region should stop? When do you impose some sort of national quarantine, if you will?

And I would say that a very crucial step right now for anybody who’s in the policy arena in this town and really thinking about these issues is to pay attention to those international health regulations. Read them carefully. If you think they’re in really good shape, our delegation to the health assembly in May should be pressuring for passage; if you think they’re fundamentally flawed in some way, you should be pressuring to change them. That will dictate the course of WHO. If WHO cannot get a mandate that’s shifted in this direction, then we’re really in bad shape, because we don’t have any global governance mechanism besides the WHO in existence that can take care of things like— you know, Country X says that they have something emerging; they’re not sure what it is. It’s a poor country, it needs a lot of help. Please, everybody, come help us. Oh, but Country Y next door says, “We’re the country with an airport and we refuse to let you land.”

DENTZER: Let’s move over here, and we’ll take these three questions in sequence.

QUESTIONER: Robert [inaudible]. Picking up on that last comment, assume one takes a global approach to this, and you have your priorities laid out, and know which challenges are the most urgent. Is the WTO [World Trade Organization] the institution that can tackle these? Does it need to be supplemented by other governmental institutions?

GARRETT: WTO or WHO?

QUESTIONER: I’m sorry. WHO. I’m a trade lawyer so I— [laughter].

GARRETT: Where actually WTO may be in the way. Another panel. [Laughter]

QUESTIONER: Are there other international intergovernmental institutions? Are there private sector institutions? What kind of reforms and new creations would you suggest?

DENTZER: And in that context, Laurie, also address the role of the national agencies like the Centers for Disease Control and particularly the— our current thrust to try to get the CDC more involved in these situations.

GARRETT: First of all, there aren’t enough players on the field regardless. Second of all, the players don’t play well together. And we don’t have any coordinated response in place to [do] anything.

When a great emergency arises, we have shown with SARS that it is possible to see forces unite and execute a set of steps that are almost miraculous in how smoothly they flow, and how effectively even a really powerful nation can be stood down and made to open up, as China was, during the epidemic by April of 2003. But we must admit: our global governance systems for health are extremely weak and grossly under-funded. I mean, the base budget for WHO is only $400 million. So there’s a limit to what anybody can do with that. And WHO can’t go anywhere unless invited in, which is the same situation as our CDC.

I think a really huge mistake would be for any American policy-maker to assume that the CDC can fill in the gap indefinitely. The truth is that there are many countries we just simply aren’t allowed to go in. And at this moment, more and more of the world views any suspicious health event as American-inspired. You all probably saw some of the recent statements made by the Kenyan woman [Wangari Maathai] who won the Nobel Peace Prize regarding the very distinct possibility, she thinks— or she sort of hedged it a little bit— that HIV was deliberately manufactured in an American laboratory to kill Africans. The current polio situation in West Africa, now actively out of control in 11 countries, all started from a couple of imams in northern Nigeria telling the masses that Americans had put HIV in the polio vaccine to kill Muslims. And, you know, WHO has the cachet, with 192 member states, and is the only who has the cachet, to go flying into Nigeria, meet with [President Olusegun] Obasanjo and, with him, go sit down with these imams and tell them, “Look, let’s straighten you out here; what will it take to prove to you that this isn’t true?”

So we’re stuck working with this very imperfect, very underfunded, very old-fashioned, creepy agency. If we can’t fix the international health regulations and bring some real money to the table [inaudible].

Now, the other new player on the field is the Global Council [inaudible] to Fight AIDS, Tuberculosis, and Malaria. Now the Global Fund has, you know, a nice chunk of change there at any given funding cycle, but it goes begging every funding cycle. It just gave out, or just awarded, a set of grants to nations to deal with global health issues, for which it has no money to back up the awards. We have a number of countries that insist on being bilateral players primarily, including our own, for global health issues, and I think that’s unfortunate because it reinforces this old nation-state model of how you solve these problems.

Ultimately, we don’t have anything out there right now that’s able to get out of an old bureaucratic mindset, an old box, and think about the 21st century, the new world, the globalization of microbes, and what kinds of new, creative mechanisms we need to confront it.

DENTZER: We had two other questions here. Let’s move here and then to the back.

QUESTIONER: Thank you. I’m [inaudible]. I used to be affiliated with Senate Foreign Relations Committee. You mentioned a shortage of nurses in the United States. One reason for that shortage of nurses is that hospitals are trying to save money because they’re treating a lot of patients for free. The American healthcare system— it’s not exaggerating a whole lot to say that the American healthcare system is in a state, or approaching a state of crisis— without regard to any of these horrific things you mentioned— just to take care of the cost of drugs, and can we get them from Canada, and what do we do about grandma. And so with all of this going on, how do you get the attention of the political structure in the American government to meld global health problems with national health problems with what’s going on in southeast Washington?

GARRETT: Well, that’s a tall order. There’s many elements to your question. Let me start with the nursing situation. We have a global nursing shortage. One study just released by the Rockefeller Foundation estimates Africa alone is short 1 million healthcare workers. That’s mostly nurses. I was in the Bahamas looking at their fight against AIDS. They have the largest nursing school in the Caribbean. As fast as they can train those nurses, who are trained at Bahamian taxpayer expense, they’re ending up practicing in Texas for the United States. Similarly, South Africa complains now that as fast as they can train nurses in South Africa, they’re ending up working for the National Health Service in the U.K. We’re grabbing nurses like crazy from the Philippines, and so on. And all of the crisis is only going to get worse, because as the baby boom generation ages, the need for nursing care rises, both homecare nursing and intensive care, every imaginable form of nursing. And meanwhile, of course, we have a healthcare— I hate to even call it a system, because that’s giving it credit for being more organized than it is, but we have a healthcare whatever-it-is that is having a harder and harder time meeting its current basic needs.

Now, if we introduced SARS on top of that, as Toronto faced, and if Georgetown Hospital, or Belleview in New York, or Cook County Hospital in Chicago suddenly had, unbeknownst to it, SARS patients on its wards in this current climate, there’s absolutely no reason to believe it would have been handled any better than Toronto handled theirs, and it could very well have been much worse.

So now if you flash forward 15 years when all the baby boomers will in fact be on Medicare, and when the burden of health will be much greater to this society in cost and in number of days of hospitalization and so on, and when pharmaceuticals will by definition be more expensive because they consistently are more expensive, how many Americans are going to be interested in seeing us subsidize pharmaceutical delivery to developing countries when they can’t get access to essential drugs themselves right here in the United States of America? I would argue our window for action and for setting up systems that make sense around the world is now. And if we delay, not only does the risk rise that microbes will find their way in and evolve into an effective pandemic, but also the window of, shall we say, compassion and altruism on these issues will shrink right here on the home front.

DENTZER: Personally, as an alternative to “healthcare system” I prefer the phrase “healthcare blob.” [Laughter] I think that pretty much expresses what the system, such as it is, is.

GARRETT: Then we need Steve McQueen.

DENTZER: Right. We had a question in the rear and then we’ll take one in the back.

QUESTIONER: Tom [inaudible], George Mason University Law School. India and China compose about a third of the world’s population. How engaged are they with infectious diseases? And if their current situation is not optimum, what can we, as individuals, as governments, and as institutions, do to improve that?

DENTZER: And it might be helpful in that context, Laurie, to just briefly talk about, and put some more flesh on the bones of your description, of how the response to SARS is really quite different and quite remarkable in the Chinese context.

GARRETT: The problem in India is that there is almost no federal responsibility for health. So in India, health is entirely a state responsibility. Right now we have, for example, ballpark estimates of how many people in India have HIV. Those estimates are based on about six or seven of the wealthiest states in India that have actual state public health infrastructures with surveillance systems that form a basis for reaching some guesstimate of the size of HIV. We have no idea how many people have HIV in Uttar Pradesh. And the poorer you get in India, the less knowledge base, the less information, the less of an infrastructure you see. As India has this great disparity widening between its wealthy states and its poor states, this is just getting exacerbated further and further. The federal government has shown no inclination to change the distribution of responsibility, so at least for the near future, I cannot imagine any intervention at the federal level that would mean they are taking on more of the health burden of their people.

The other thing is that it’s extremely well-documented that the No. 1 factor that affects the health of children is the educational status of the mother. One estimate is that for every additional year of education a woman has received, she buys three years of life, statistically speaking, for her child. India has one of the highest, if not the highest— it’s right up there with Bangladesh and a handful of countries— as the most illiterate female population, the least-educated female population. And again, we’ve not seen any indication that at most of the state levels there’s any big move to do anything about that.

In China we have a very different situation. China has a comparatively highly literate and educated population, at least in terms of rudimentary education, and they certainly are well-organized. And even if something is a provincial responsibility, the Central Committee doesn’t hesitate for a second to intervene and demands this, that, or the other thing of any state. So, in theory, from the top down they can accomplish quite a lot. But in its pell-mell race to get GDP [gross domestic product] growth, the No. 1 national security concern of China— GDP growth every year and lots of it— they have utterly sacrificed the entire health infrastructure of China. And while on paper some healthcare is subsidized by the state, in reality it is out-of-pocket, cash-and-carry healthcare.

Now, what [that] means for public health is that people are very reluctant to go and seek medical attention if they suffer any sort of symptoms, including contagious disease, because they can’t afford it. Even during SARS, when I got down at the village level where people set up their own vigilante barricades and quarantine zones, I would ask them, “You know, you’re losing all this money at the village because you’re not letting goods get transported out and sold in the city, and you’re not letting the empty trucks come back in and pick up more. Why would you commit such economic suicide?” And they said, “Because one day’s hospitalization is a year’s income for a peasant family.”

Now, when I was there earlier this year, many of the Chinese officials I talked to indicated that there had been a lot of soul searching as a result of SARS, and [President] Hu Jintao was giving more and more attention to the notion of trying to build up a public health infrastructure in China. But I must say they have a very long way to go.

DENTZER: Let’s quickly take this last question. And Laurie, I’m going to have to ask you to give about a minute response to this one, if you will. It’s a question in the rear.

QUESTIONER: Joe [inaudible], AID [Agency for International Development]. You mentioned in there that a lot of money has probably been wasted on these drills of responses, which I assume means hospital ambulances going up, gurneys around, people all dressed up, and yet you did say that one of the biggest things people could spend money, and most useful, would be the response. Does it make any sense to be thinking of some kind of a look at a disease like SARS coming up again, say, out in Asia, and doing a war games approach to this? Not running out with people with masks and other things, but to figure out how all these countries would cooperate in that kind of a situation. Now, maybe people are just so blind and so unwilling to cooperate that it wouldn’t even help. On the other hand, it might focus people’s attention on the need to cooperate and what has to be done.

GARRETT: You’re talking about at the global level.

QUESTIONER: Well, it could be global or it could be just— I mean, you could take SARS. You don’t have to take every disease in the book. You could take, I don’t know, HIV or tuberculosis in India, you could take SARS in Asia or an Avian flu, some specific disease, and how would you handle those in an area that covers a number of different countries?

GARRETT: On one level, what you’re suggesting has been done quite a bit and is readily available, and there is funding becoming available to do it on a more ambitious scale. But it’s involved, for the most part, [in] computer modeling. Quite a lot of computer modeling has been done looking at if you change this response, how that affects the outcomes from a public health point of view of an epidemic, and then this response, that response, and so on. If you introduce an element of a communications network between police and local health responders, you see this shift. There also have been some exercises conducted in the United States war-gaming a host of different disease emergences, and most of them have actually revealed pretty bad results. Millions and millions of people die in most of these war games.

But at the global level, right now we have too many political obstacles to doing what you suggest. No region, much less [a] country, wants even in a war game scenario to be named as the source site of a disease. So even in a hypothetical setting, you know, Country X does not want to be known as something where they might call it the “Country X virus,” such as we might say the Hong Kong flu. So I think we’re going to have a hard time making that a reality at the global level.

DENTZER: Well, I think we can all agree that [what] Laurie has sketched here tonight is clear, that the challenge of rising to meet these threats is enormous and that it easily— easily— rivals anything that we face in the realm of nuclear proliferation or anything else that people who come to the Council on a regular basis spend a lot of time about. Join me in thanking Laurie. We look forward to more provocative discussions like this in the future. [Applause]

GARRETT: Thank you very much.

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