Council on Foreign Relations
New York, NY
ROBERT BAZELL: Oh here we go. Thank you. Please take your seats. The second section — session is called Containment and Control, which I assume presumes that such things are possible.
My name is Robert Bazell. I'm the science and medicine correspondent with NBC. I'm honored to have with me on the stage here three men who have enormous experience in public health generally and in issues regarding the threat of avian flu specifically.
On my far left Is Dr. Michael Osterholm, who is now at the University of Minnesota. He has been an advisor to the United States Government HHS on this matter and many other matters of public health and bioterrorism.
To my immediate left is Dr. David Fedson, who is now — says he's retired, although he seems to do a lot of stuff. He's an expert in vaccines of many kinds, including influenza. He worked as the medical director for a company called Aventis-Pasteur.
And on my right, your left, is Dr. David Nabarro, who is the senior system — I have to read this — coordinator for avian and human influenza for the United Nations, recently appointed to that position by Kofi Annan.
I want to start by posing a question to some of the members here. From this morning's session and from a lot of other things you may have read or seen about avian influenza, there are a lot of people who believe that we are being too alarmist about this threat, that it isn't all the threat that needs to be taken seriously, but no matter what the level of threat is that certain things need to be done, such as building up our capability world-wide to manufacture vaccine and increasing our surveillance around the world for new infections of all kinds and not just strains of influenza.
My question — let's start with Dr. Osterholm — is have we reached a political system in this country and in the rest of the world where we have to scare people half to death to get the right things done?
DR. MICHAEL OSTERHOLM: Well, first of all, let me do two perspectives on this and really a follow-up to the first session and actually Richard's opening comments.
Make no mistake about it, pandemics are like earthquakes, hurricanes, and tsunamis — they occur. They're not like terrorism, which may or may not occur. We've had 10 pandemics in the last 300 years. They date back to antiquity. And there is nothing in our modern world that would suggest that they are going to end. In fact, if anything, with the human and animal population we have today would suggest it would only be more.
So we have to understand whatever we prepare for, it will happen. It's the question is when, where, and how bad will it be.
The second part of this is much of the preparation that we need to do for pandemic influenza is long-term preparedness; it's not overnight, immediate-reaction preparedness. It kind of reminds me of the situation right now where it's the guy who's going to his 25th high school class reunion tomorrow night and he realizes today that he needs to lose 50 pounds. (Laughter.) You know, the best that's going to happen to him is he can go get a new suit that fits, get a haircut, shine his shoes, and that's about it. The preparedness we need for pandemic is five to seven year minimum if we make a world-wide investment now, in terms of really impacting on it.
So part of what we're trying to do is get the message out whenever it occurs, we need preparedness. I think what's happened in the last six weeks has been a media on steroids, that basically went from no attention to this, or very limited attention — there'd be a few reporters who dogged this story; Bob being one of them. But then all the sudden everybody discovered it after Katrina and the intersection between lack of preparedness and now we need another story created this. And what we need to do is even that out; we need to get perspective.
The story hasn't changed a lot in six weeks; what has changed is the perspective. And hopefully we can get back to a point where we will see that this is really necessary preparedness.
The final, last very brief point to make is I worry desperately if we don't have a pandemic in six to eight weeks, which we all hope God knows we won't, we will see blow back on this. We are going to see people saying, you did scare the hell out of us needlessly. Why did you do that? When, in fact, again, it's this long, uphill issue; it's not a big peak-and-valley kind of thing. And so I predict that's going to happen in many circles when we don't have a pandemic six to eight weeks from now.
BAZELL (?): But right now we have an unprecedented situation that was described on this morning's panel of sick birds around the world and not just domestic poultry, but migratory birds.
So are we making policy by alarm, but, I'll ask Dr. Nabarro, is the alarm appropriate right now given this unprecedented situation that we see with birds around the world where we have a kind of virus circulating that we have never seen before?
DR. DAVID NABARRO: Well, I can't judge whether the alarm is appropriate, but I do want to slightly take issue with what Mike Osterholm just said.
I don't think it's media on steroids. What's happened is that the decision makers — heads of state, deputy heads, in some cases also ministers of health and agriculture — have suddenly realized that this is a serious issue. They didn't for a long time, and it's only during the last few months that we've seen political attention being given to the issue of the avian influenza epidemic and the risk of pandemic influenza.
When politicians get engaged, that has several consequences.
Number one, it means that bureaucrats, people like us, have to change the priorities of our work and instead of saying our in trays are too full with HIV or child health or maternal health or other health issues, we have to empty them a bit and say well we now will start dealing with pandemic influenza threats, we will start paying attention to the total inadequacy of veterinary services around the world.
Secondly, when politicians get engaged, they have meetings and summits and other events of the kind, and, of course, the media say, well, what's going on? Why is the head of state engaged? Why are 13 ASEAN leaders meeting with the secretary general and talking about influenza suddenly? There's some deal here. And then we get into the inevitable dialogue that results with the attention being raised up in the media, and that's very important that it happens because that then shows that we've got the system working and that explains why the politicians are getting engaged. I don't think there'll be blow back. I think that there is going to be a continued engagement of political leaders for quite some time to come because they have realized that this is something they do need to take seriously.
BAZELL: I want to get back to some of those very important large political issues in just a few moments, but I want to talk about some technical things — not highly technical, but I think a lot of people here, Dr. Fedson, who don't have scientific or medical backgrounds would have the question as why — why is it possible to immunize billions of birds and to talk about a human vaccine being at least a year away and then just for the United States and Western Europe?
DR. DAVID FEDSON: Well, one of the reasons is that at least some of the vaccines used in poultry sell for a penny or two a piece. And you can buy a lot more vaccines at that price than you can at the price that human influenza vaccines sell for and also the regulatory control mechanisms for any vaccines given in the human populations are far, far, far more rigorous than for animal vaccines.
Let me just back up a minute on the — on the vaccine issue and, indeed, on the pandemic issue. We're very concerned about the potential threat of a new pandemic, and avian influenza concentrates that attention. But we — if you think back to 1918, 1920 with the Spanish influenza pandemic, to my knowledge, this pandemic was not proceeded by a global epizootic of avian influenza; it just appeared. And furthermore, if we think historically, not necessarily virulogically, and say history can repeat itself, as we all know, a pandemic of that size today with that level of population mortality would within a period of a couple of years kill 175 to 350 million people. That's arithmetic — nothing more, arithmetic. And, of course, the case fatality rate for avian influenza is much higher.
Now, how many deaths do you need to talk about before you start getting the attention of politicians and get them to start saying, well we ought to do something about this?
I think that's the only purpose in speculating about how many people might die. I mean, how many people do you have to start talking to — talking about dying before you get people to start taking action? Once they start taking action, then you can start focusing on those actions and forget about the speculation on the numbers.
In terms of developing a vaccine, I think that we ought to think about the last pandemic threat that we had, at least in this country, and that was 1976 when one soldier at Fort Dix died and they isolated this one influenza virus from him. Following that, the NIH conducted clinical trials in over 6,000 healthy adults, children and elderly people, tested four different vaccines at three different dose levels, measured the antibody levels in a single laboratory so they could compare results. And at the end of that research, they knew the formulation for this so-called or threatened pandemic of swine flu, and they knew the schedule for its administration. They completed that work in four to five months.
In October of 2001, when, especially after the anthrax attack, a decision was made in Washington that we needed a smallpox vaccine, and somebody was wise enough to say, maybe if we looked in our freezers and look at our stocks of smallpox vaccine, we can dilute it 10 fold and we might have enough vaccine to vaccinate everybody in the country. They did those studies, and within four or five months, they knew that we had enough vaccine that, if needed, we could vaccinate everybody in the United States if we were concerned about a smallpox threat.
We have had reversed genetics engineered H5N1 viruses since early 2003, and certainly the vaccines that are being tested right now were prepared from viruses that Rob Webster, using reverse genetics, created back in 2004. So here two or three years later, where are we in terms of our vaccine development?
OSTERHOLM: Well, I think we're not very far at all.
BAZELL: Well, are we — Dr. Osterholm, are we not very far because we didn't take either of the threat of the pandemics seriously or we didn't listen to the many public health officials who've been pointing out year after year that seasonal influenza kills 36,000 Americans every year, and, yes, they happen to be often older and weaker or younger, but that's a lot of people, and it's a lot of preventable deaths, and we haven't taken either seasonal influenza or pandemic influenza very seriously until we started having all these sick birds.
What, what, what's changed?
OSTERHOLM: Well I, again, come back to the original comment, and I think that let me take another run at you, David, in the sense because I would suggest that our leaders are talking a good game right now, but they're still not really committed.
I mean, when you think about the fact that this — if a pandemic were to occur today, there's a very high likelihood we would begin to shut borders around the world. We live in a global, just-in-time economy today where this country, in particular, absolutely lives on the goods and services of much of the rest of the world. Many of our critical medical supplies, our pharmaceutical products, our food supply — everything you can name that would come to a screeching and crashing halt if, in fact, pandemic began today.
Now, I can't think of a much greater security risk to this country, or for that matter, to the world, and yet if you look at the investment that's been made, the entire world's investment doesn't equal that of one aircraft carrier. So to me, there's still a major disconnect between the issue of really committed to understanding what a pandemic might do.
Remember — and I agree fully with David's assessment on the numbers of cases — but we don't even need the number of cases to do what I just talked about. Remember anthrax in this country, following 9/11, affected 22 people, killed only five people, and yet we shut down better parts of the mail service around the country. The economic implications were huge.
Today in this world where we do live, in a sense, on steroids of media concern — one day it's a big problem, next day it's not; one day we're at risk of losing the world, the next day it seems as if it's a by-forgotten issue. We don't have sustained and committed resources to go to what could be, I think, the single greatest threat to the global security of the world, at least surely the economic security of the world.
So I think that until we get that, we're not going to get the kinds of commitment to long-term vaccine production. I would just add that even if today, the researchers could come up with all the information that David just very nicely detailed following 1976, we don't have the buildings; we don't have the machines; we don't have the pipes; we don't have the experts to make that vaccine. We are at least five to seven years off (with ?) having the kind of infrastructure that could make vaccines for the world.
Let me just conclude with one last piece on that. What I worry desperately about is everything I've heard so far coming primarily out of the vaccine-production area has been a very American-centric piece. It's been how can we wave the magic wand and protect us? I will tell you right now that if a global economy crashes, there will be many pharmaceutical products that we take for granted — cardiac drugs, cancer drugs, the antibiotic, anti-virals, et cetera — that will not be here tomorrow. There will be many other products that I could list for you that are all made offshore, that all have complicated supply chains that won't be here.
And, so, in a sense, we have to think about taking care of the world. It's not enough for us to think about protecting us, because the collateral damage to this country, even if we could avoid a pandemic, will be huge.
Bob, I've not seen any of that commitment yet on an international level.
BAZELL: Okay. Speaking of that, we'll go to Dr. Nabarro, last week there was a meeting in Geneva of the World Bank — three United Nations Organizations and you. The first thing that came up, and please don't take this too personally, but everybody — a lot of people — at the World Health Organization and other agencies were grumbling in the back room, well who the hell is this guy? All of the sudden, Kofi Annan appoints somebody to be avian flu coordinator, and there's already all these other U.N. agencies, and, you know, what do you see your job as doing and why now?
NABARRO: I think my job is being set out by Mike Osterholm very clearly just now, but let me be very precise what I think it is.
He said the global economy's going to crash when we have the next pandemic. Let's say that's the truth. I personally believe it's pretty close to the truth. My job as the U.N. system coordinator is to help the United Nations prepare countries for the possibility that if they don't act in a sensible and effective and coordinated way, the global economy will crash and the whole world will be hit a blow that it will take a very long time to recover from. That's my job.
Now, in order to do that job, I draw on the expertise, the leadership, of the World Health Organization, which is the technical organization for health, the Food and Agriculture Organization, which is the technical organization for animal health, and lots of other institutions and bodies in the United Nations. But working under the leadership of the secretary-general, my job is to focus on how we organize ourselves to avert a global economy crash as a result of the next pandemic.
BAZELL: That's, of course, a very lofty and difficult goal, but you ended the last session of the meeting saying that you had heard the word coordination among nations so many times that you couldn't count it anymore and it was almost putting you to sleep to hear this — the calls for —
NABARRO: I didn't say that. I didn't say that.
BAZELL: Obviously, you said you had heard it so many times —
NABARRO: Journalistic license. Okay. (Laughter.)
BAZELL: What did that meeting, if anything, accomplish? There was certainly a lot of talk. A few governments, notably Italy and France, committed a few million dollars. And everything else was put off with a spirit of yes, we've acknowledged that there is a problem and we need to coordinate and do more about it. But where does that get us?
NABARRO: Well, we have to have a measure of agreement between governments and between institutions that are there to support the work of governments if we're going to move from the current woefully unprepared situation, as we have at the moment, towards a state where we are better prepared for this really awful outcome that some of us are starting to focus on.
And so the meeting last week was the first time we had had that number of governments together, that degree of popular, international participation. Over 450 people, I think, were there. And that's stage one.
But the reason why I was frustrated perhaps at times with the repeated use of the word coordination is that it's incredibly easy to talk about coordination and yet, to function in very disarticulated ways.
What I suppose wanting to see is collective responsibility and leadership emerge so that there is at least a degree of convergence on how we address the issues that we've got to deal with. For example, on vaccine development. For example, on antiviral stockpiles. And, for example, on how we're all going to work as a group of countries when the pandemic does start in order to limit the degree of economic damage that is wreaked upon the whole world.
BAZELL: Let's talk about the subject of this meeting — containment and control — and let's make an assumption for a moment that there is an outbreak of sustained human-to-human transmission this year. I know we want to talk about what happens if there's —
NABARRO: Can you give us a bit more of a break? Can you say next year?
BAZELL: No, I can't give you a break and, in fact, the very fact —
NABARRO: I mean, that's the big nightmare situation, this year.
BAZELL: This year is a nightmare —
NABARRO: For me, anyway.
BAZELL: Well, one question for both — (laughter) — I'm sure it is — for I — everyone. (Laughter.)
If there is, we heard a very eloquent and honest presentation from Indonesia just now about it taking a week to confirm whether there — a case of influenza is even H5N1 or whether it's just garden-variety influenza.
By the time, if it were human-to-human transmission, would have been spread very widely in that country. And there is someone who is being very honest and we have questions about the honesty of other countries, which is something we'll get to.
But if there were an outbreak in the way influenza has behaved in the past first, Dr. Osterholm, is it possible that there could be a flare up in one country that could be contained this year?
OSTERHOLM: Well, I've spent 25 years in the trenches of public health working at outbreaks after outbreaks. I led the single largest campaign in this country to control a meningitis outbreak in a community where we vaccinated 40,000 people in one weekend.
I've been on the frontlines, both nationally and internationally. I don't have a sense at all that we could ever stop an emerging epidemic. You know, local area soon to become a pandemic of influenza.
This virus is, from historical perspectives, basically an infectious agent that even under times of medieval history move through entire continents like Europe in four to six weeks.
It has all the ability to move effectively as a respiratory agent. It's not, you know, it's not magical, but in fact it's very effective.
And I can't imagine any country on the face of the earth without very conclusive evidence that, in fact, that circulation is occurring is willing to call the (code ?). Because once they call the (code ?), they will announce the world we are the black hole of the earth, wall us off. Economically we're done because we will basically have no trade and travel in there, and then we'll put the blanket on top of it. And I believe that that will take weeks at a minimum to obtain the kind of information that would, in the minds of reasonable people, say yeah, this is it. By that time, it's long gone.
SARS, which was a much less infectious agent, one for which we had much less concern in terms of the incubation period when you became infectious, how infectious were you. You saw what happened with that. It took one physician to stay one night in a Hong Kong hotel and within days it was in six countries in four different continents around the world.
And so I think this is the same thing that will happen here. I think the numerical studies that have been done, the models, are just that. I have yet to see a model in my 30 years of public health that ever really made any difference in public health practice. And I think they're theoretical. They don't take into account the real world.
The final piece of it is we have no reason to think this is a one-time hit. We have this magical thought that it will happen one time and one time only. Kind of like an Immaculate Conception. And basically it's not. The genetic pressure, the genetic roulette table for this virus will keep spinning in Asia day in and day out and day in and day out. And even if we could take that one stockpile one time and put it somewhere, it doesn't mean that two weeks later, two months later or a year later it won't happen again somewhere else with that very same type of virus, (fit ?) virus, coming out.
So I don't see any way. I don't think we have a choice, though, because we'll always be second-guessed if we didn't try.
So I speak to the U.N.'s efforts in this area, WHO's efforts, are the only thing we can do, but I would say please don't bank on it as being the place where the fire will get stopped. There will be no fire line drawn by early intervention.
BAZELL: Dr. Fedson, your expertise is vaccine. And before we open it to questions, I want to talk about future vaccine production because there certainly isn't going to any for this season.
But the — a lot of talk at this morning's panel and a lot of talk in the media and the world about purchasing Tamiflu and there has been a paper published that shows that theoretically you could contain an outbreak by giving Tamiflu in a circular region around an area of a small initial outbreak. Is that just a lot of nonsense and should we stop thinking about that?
One of the things that happened at this meeting in Geneva was that a lot of poorer countries that are afflicted now with Avian flu in large numbers said, why are you stockpiling Tamiflu in Europe and the United States when we're the ones that have the cases, and if we're going to contain it anywhere, we're going to contain it here, in these poor countries?
FEDSON: That's a complex question and anybody who knows about Atlantic Storm or any of the desktop exercises on bioterrorism knows that countries will take care of their own before they take care of anybody else and it's human nature.
The president of this country is elected by the people of this country to protect this country and so he's going to do that job. That's his job. And if means that in doing that he can't protect people who live in Buenos Aires that's just the way things are. And people in this country would be very upset if he protected people in Buenos Aires before he protected them in Baltimore.
I think in terms of the stockpiles of antivirals, I think we can go back to Samuel Johnson's remarks about second marriages that they represent the type of hope of experience. (Laughter.)
But I think that because they represent an expression of human hope, we shouldn't dismiss them entirely. Anybody who's practiced clinical medicine — and I practiced clinical medicine for a very long time — clinical general medicine on infectious diseases recognizes that a clinician faced with a sick patient, and very often a patient for whom there is little that really seemingly can turn the corner in dramatic fashion, will nonetheless try interventions. Why? Because it's not cost effectiveness at that moment, it's the rule of rescue.
And I think if we take the rule of rescue approach and say what we're seeing in the world today with, as one person who testified before the Senate Foreign Relations Committee last week said, $6 billion worth of Tamiflu orders have been asked for by the one company that makes it. $6 billion.
I mean, what we're seeing here is an expression of hope. We're seeing the public health expression of the rule of rescue.
Now, do I think that that rule of rescue with the three million treatment courses WHO has, or will have, in mid-2006 available to sort of snuff out the pandemic of H5 should it appear someplace in, say, Vietnam or Thailand — do I think that that will work? I think it's extraordinarily unlikely. But I think it probably needs to be tried because it's an expression of human hope and trying.
I think there are other ways and more appropriate, more pragmatic ways, of planning for what we could do for this imminent pandemic than doing that, however.
BAZELL: Dr. Nabarro, what — and I know it could be a long list, but in terms of the goals that you think are achievable by the U.N. agencies and everybody that's trying to work with them, what can we see this year, next year and the year after? I'm not talking cooperation but, you know, actions.
NABARRO: After — sorry, I have to rethink my answer. (Laughter.)
Every country in the world with a pandemic preparedness plan that's been rehearsed, perhaps peer appraised by other countries, and then shown to at least have some chance of mitigating, not snuffing out, mitigating the degree of suffering and economic and social disruption that will result from pandemic appearing within its borders.
A world whose countries have a contingency plan for how they will work in the event of pandemic that has been rehearsed and agrees and that focuses particularly on economic sustainability and social survival with attention to the needs, particularly, of poorer countries and vulnerable people.
A strategy for more sophisticated management of vaccine production in the event of pandemic appearing with a proper scientific strategy for new technologies to be applied to more polyvalent vaccines in the longer term.
Some kind of understanding about the role of stockpiles of antiviral medicines and the way they will be used so that it's not just for rescue and hope, but actually will lead to the survival of frontline personnel and reductions in morbidity and more importantly, the delaying of the pandemic for as long as possible rather than complete containment.
Communications within countries and throughout the world that are, of course, risk communications, but which truly reflect the breadth of uncertainty that we have about the issues, but also the potential for very severe consequences were the pandemic to happen so that we don't underestimate the likelihood of the risk and we get everybody in line.
And perhaps lastly, because the list could go on as you implied, the involvement not just of health professionals and agriculture professionals in the fights against Avian influenza and potential pandemic, but the bringing in of private sector organizations, voluntary groups like the Red Cross movement, who I went to talk to in Seoul at the weekend, so that we actually approach this as a collective movement rather than as a set of professionals. And try to then have everybody sufficiently who's got any kind of responsibility for social and public service sufficiently well trained and understanding of the issues so they can all take part in surveillance and respond to action and supplement the work of formal public health and vet health services.
FEDSON: Bob, can I just — I think drilling down here would be a very helpful opportunity here for people to understand the 30,000 feet discussion versus, you know, knee deep in it in the barnyard.
When you take a look at Tamiflu — let's just take that one as the silver bullet phenomenon. Basically, we have heard yes, it's important. I am on record and will continue to be on record we need to stockpile as much as possible. There are two very important considerations.
One is this illness of H5N1 is not like H3N2. Our data that we have today about the effectiveness of Tamiflu is basically looking at people infected with the regular, seasonal flu, H3N2. This virus causes a different illness in humans. It is, in essence, a virus storm that grows much quicker in many different cell types in many parts of the body. And no one would suggest for a minute it's different than H3N2 in the sense that could it be affected by Tamiflu or any of the neuraminidase inhibitors.
But the question is when do you have to have it in the body to make a difference? And it's very possible that from the animal studies the Rod Webster has been involved with and others that if you don't have this onboard at the time you're exposed, or shortly after you become infected, the efficacy drops dramatically and it's not comparable to H3N2 at all.
On top of it, like we heard if the vaccine dose, we may need a much higher dosage of this. So when somebody talks about four million or 40 million protective doses, I don't know what that means.
Now, if we need it right now, how are we going to get it to people and be certain they really have flue. We heard this morning about the need for better diagnostic kits. Do we realize that most of the diagnostic kits we have for flu in this country right now have component parts that come from outside the country or the entire kit is assembled outside the country? Supply chains are very thin. We'll lose our ability to diagnose this overnight when the pandemic begins because there is no surge capacity, no inventory capacity for making diagnostic kits.
So now I'm going to have to take it somebody's word in their first hour, and then I have to get the drug to them, that yes, in fact, you have flu and I better get it to you right now. Think of the difference now on the logistics of that versus just the theoretical of Tamiflu.
Then on top of it, if we look at the production capacity, and there are representatives here from Roche that can comment on this, but my best guesstimate is that if we opened up all the spigots, all the plants, we look at how we could maximize production over the next three to five years, we maybe could make enough drug for 7 percent of the world's population.
Now how is that going to impact a pandemic?
NABARRO: I would reserve it for frontline personnel.
FEDSON: Don't disagree. I'm only pointing out that a lot of people here have had the sense that Tamiflu is the Cipro of post 9/11. That is we have Tamiflu, we can save the world from this pandemic.
And once you start looking at the real logistical issues, you start looking at the real production issues, then you realize vaccines not going to save us right now. Drugs aren't going to save us right now. So we have a whole other level for preparedness that we have to figure out what we're going to do.
And that's where, I think, we often stick with this Tamiflu level saying okay, if we just had more Tamiflu wouldn't it be okay? That's not going to do it and we have to understand that.
BAZELL: Okay. And I'm going to take questions, but one last question for Dr. Fedson.
There's a lot of technical issues involved. Eggs versus cell culture. I don't want you to go into that right now. But I want to ask you —
FEDSON: Yes, but it's science.
BAZELL: Yeah, I know. But I want to ask you —
If the world were to come to a realization that this should be done, and Mike raised a very important point that yeah, we shouldn't just be immunizing Americans and some Europeans and Japanese.
How long could we realistically — how long — what would it take and how long would it be 'til the world could make enough influenza vaccine to protect against the threat of a pandemic?
FEDSON: Well, what you're really asking me to do is to respond to the question that David couldn't respond to and that is if the pandemic comes next week.
BAZELL: No, I'm not —
Tell you — I can tell you.
FEDSON: Okay. I'm going to give you an answer. Hold on.
In Texas, in politics, they say you dance with the one that brung ya. And that means if the oil company paid for your election, you pay them off when you're in the legislature. And for pandemic influenza, what that means is that you use the resources that you have at hand.
So if we have a pandemic, we have to figure out how can we maximize the utility of whatever we have on hand. And what we have today is a global capacity to make 300 million doses of the ordinary, seasonal influenza vaccine at 15 mcg of hemagglutinin antigen, the key component.
Now, if you pay attention to the arithmetic of making not a tivalent, but a monovalent vaccine, and if you use a universally available, inexpensive, not patented adjuvant, which enhances the immune response and which has been used in childhood vaccines for decades and is registered throughout the world, and if you pay attention to the studies that have been done by European investigators and have been written about for the last five years — something which unfortunately our people at the NIH seem not to have done — you can do the arithmetic and figure out that with a low dose, antigen sparing, alum adjuvanted vaccine, one could, with today's existing egg based production facilities worldwide, produce anywhere from three-and-a-half to over seven billion doses of vaccine to vaccinate people throughout the world.
And they would have to have two doses. So maybe with luck you could produce enough to vaccinate three-and-a-half billion people. Now, that's more vaccine than the world's healthcare systems have the capacity to actually deliver. And certainly a lot of it would come late.
But that's to take advantage of all of the science that has been developed by Rob Webster and his colleagues and other laboratories who can make a reverse genetics engineered virus that is suitable for vaccine production and show that it does not kill eggs and they can do that in a matter of a couple of weeks.
And you put that in the hands of vaccine companies throughout the world and say go to it. Make that low dose alum adjuvanted vaccine and let's get the logistic supply chain organized so we can actually deliver it and deliver it equitably so we don't have political and diplomatic meltdown.
Now, I think that's all doable within — I mean, if we were set up to do it, we would do it. It's a matter of human organization and logistics and, of course, doing the necessary clinical trials with an H5N1 virus, which we have not done. Have not done in any country yet with one exception. We'll get some data out of France in another month or so.
BAZELL: Can I just say there's an important message —
FEDSON: We need to go to — yeah.
BAZELL: When you say there's an important message I don't want people to leave here because there's — as much as I hope David's right, there is a logistic debate in the scientific community whether that will work. And I've heard that back and forth. I hope he's right, but I wouldn't want anybody to walk out of here today thinking we've got three billion doses of vaccine tomorrow.
Let's take some questions, starting in Washington. Susan?
SUSAN DENTZER: Thanks, Bob. Bridging a bit back to the earlier panel, we've got the issues of containment and control in birds and the separate issues of containment and control in humans. And from what we were hearing in the first panel where it was described how the Thais essentially eliminated all of their Avian flu in domestic poultry only to see it come back again with migratory birds.
Does that suggest that we ought to just forget about the strategy of containment and control in birds? And in an era of limited resources, focus all of our energy on the development of vaccines and the possibly achievable things that were just described?
Are we crazy to be fighting this war on all potential fronts at this point?
BAZELL: David, do you want to take that? Yeah, thank you.
NABARRO: I would feel extreme perturbed on behalf of the small holders in Asia who depend heavily on chickens as short term savings — millions of them — and also for the whole chicken production community if that line were followed.
We have, as has been said, an epizootic of Avian influenza that is extremely widespread in a number of countries, but it's spreading beyond that into being introduced properly through wild birds into other locations.
And in the new locations to which it's moving, it's perfectly possible to use control at source — culling and elimination. A little bit harder in Africa, but it's not beyond the bounds of possibility so please, let's not let up on the absolute critical need to continue to fight against H5N1 Avian influenza because of its — the damage it's doing for local economies, to the whole chicken industry and other poultry industries and because of the potential that we have got if we keep working on it to prevent it from getting as bad in other countries as it is in some of the countries where it's endemic in South Asia.
OSTERHOLM: Could I — Susan, I think there's another important point here, though. And this is, again, somebody who tries every year to assure that our children in this country are vaccinated.
In Minnesota, 65,000 new kids are born every year and if we did a hell of a job as of today and then for six months didn't do so well, we have an entire cohort of kids that are now unprotected and we have real proble
We heard earlier this morning that there are about five billion chickens and ducks in China, but that's at any one time. On the average year, about four cycles of those birds occur. Natural culling called consumption. That means you're talking about vaccinating and keeping up with almost 16 billion birds on an annual basis. Now multiply that through all of Southeast Asia.
And I think that we all can get up for a one time and maybe a second time and a third time, but we're now talking about sustaining potentially for years and years this constant need to revaccinate, revaccinate, revaccinate on the same farms in the same areas. I question our ability to do that.
Again, like I said earlier, I think we should at least look at that, put resources into it, but I don't believe we can sustain that. And so your point's a very good one. In the end, what does that mean? As long as that virus remains in those bird populations and we can't sustain very high levels of vaccination then we really haven't done much to the end to stop that.
BAZELL: Susan, do you have some more questions in Washington? A couple more maybe, and then we'll come back to New York here.
QUESTIONER: Yes. Hi, I'm Elizabeth Prescott from Eurasia Group.
The question I have is that we obviously need to integrate with the private sector and I'm wondering what — how does that interface occur? Is the private sector dealing directly with WHO? Is that at the individual country levels — so say in the U.S., would that be private sector interfacing with CDC and then duplicating that in every other country? Or is there a need for a separate organization to look at — or some — or attaching a new responsibility somewhere to do this integration?
And I don't know when we're looking at a problem with a lot of multinationals, how does that — how do you see that type of interface occurring?
OSTERHOLM: Well, let me — can I just add here that I think this is the critical question we're missing right now. It's not in the discussion. I've come up with this concept called critical product continuity, CPC.
There are many other products besides vaccine and antiviral that we're going to need during influenza. A good example is if we don't have drug and vaccine, which you just heard, how are we going to get a U.S. or any healthcare worker for that matter to go to work?
Well, hopefully you're going to offer protection — i.e., masks. Today I would submit that if you don't have an N95 respirator mask as a healthcare worker working in an H5N1 ward, you're not well protected.
Well today, there are two companies in the world that own the vast majority of the market share — very high percentage of the market share of making those masks. Both for U.S. companies. All their product is made offshore. All their plants have complicated supply chains involving raw product that comes from two and three other countries. They are virtually operating right now at full capacity because they're punished for having inventory by tax laws or surge capacity by investors. They won't have any surge capacity. We will run out of masks very quickly into this pandemic and we won't have them on a worldwide basis.
Now, you tell me who is going to go to work with no drug, no vaccine and no mask? And even when we had masks, in Toronto with SARS, we saw the impact of healthcare workers not reporting to work.
I could list off a ton of those kinds of products right now. IV bags, syringes. David hopefully has the answer on vaccine, but has anyone engaged the syringe manufacturers of the world who will tell you right now that, in fact, they don't have the surge capacity to make syringes? So even if we could make the vaccine, we can't make the syringes. And those plants won't come up overnight again.
So I think you've hit on a very important point. And no one right now internationally is really working to bring these multinational companies together first of all to determine which products are critical products that we need to have. You know, if we don't sell cars, if we don't sell televisions, we don't sell computers, if we don't sell jewelry during a pandemic, I'm not sure the world will be worse for it. But if we don't have those kinds of critical medical products, if we don't have food supplies, if we don't have those things we need, we are even in a greater state of hurt.
And so I think you've hit a very important point and that's one of the clarion calls I hope that comes out of meetings like this is we can't just focus on vaccine and antivirals. We've got much more to work on and we haven't done it yet.
BAZELL: Okay. Can we take some questions here. Wait for the microphone — in the very back there?
QUESTIONER: Hi. I'm Irwin Redlener of Columbia University.
I just want to reach the obvious conclusion here. Let's say there's general assumptions that we won't have vaccine, we won't have antivirals, we won't be able to do containment very well. And we'll have supply problems, as Michael was just saying.
I think the 800-pound gorilla is the health and hospital system, not only in our country, but around the world. And, you know, if you looked at the proposal from the White House a week or so ago of $7.1 billion focused mostly on antivirals and vaccine development, which is fine, less than seven percent of that budget could be construed as going towards anything that would help bolster a very ailing hospital system in the United States. Which in fact would be the only recourse that we would have if, in fact, we're dealing with a race against time, which we are. And if it becomes real that we get a pandemic prior to the development of sufficient capacity to contain, to vaccinate and to treat with specific antivirals, then all we have left is a health and hospital system.
And right now, even in this country with 45 million Americans who won't even be able to get to a healthcare provider because they're uninsured to get early diagnosis, who if they get into a hospital, we'll find that we don't have sufficient isolation beds, intensive care beds, ventilators, et cetera, et cetera — the level of trouble we'll be in from failure to appreciate and deal with this —
BAZELL: What's the question? And there's a good panel on the United States' preparedness coming.
QUESTIONER: Okay. So the question, Bob, is are we spending too much time and resources in very unbalanced way focused on the things that we are not going to be able to do anything about in the near term?
BAZELL: David, do you want to answer that?
FEDSON: We must pay attention to hospital services globally. That's something I'm working on with WHO. I'm just going to say that — that's all there is as an answer.
And in answer to the earlier question, linking with the different kinds of private sector enterprises, those who are going to be directly involved, or those who are going to be affected by the pandemic, or those who are affected by the current problems in the animal business, is also within my terms of reference. But I need a little bit more time to get my office organized on that.
OSTERHOLM: Bob, it's not an either/or answer. You presented this as are we spending too much on vaccine and drugs and not enough here. We don't have nearly enough in vaccine and drugs right now for a long-term solution for the world — and we owe the world that. But at the same time, we need the resources and the planning to deal with this.
And so I hope we don't get into that. I think once people understand the implications of pandemic influenza, they will see that a billion (dollars) here and a billion (dollars) there is not a big investment in terms of what the ultimate cost will be.
BAZELL: Anyone else here? Yes, ma'am?
QUESTIONER: Tracey McNamara. The other 800-pound gorilla that we're not discussing is —
(Comes on mike.) Really, what's at the heart of this issue is emerging infectious diseases and zoonosis. And especially zoonosis spread by wildlife. What no one's really talking about is the incredible disparity between the wherewithal of the public health sector, the agricultural sector and the wildlife sector. I haven't heard too many discussions about the difficulties we still face in terms of who has jurisdiction over what when it comes to zoonoses. Who is in charge of responding to a zoonotic disease outbreak in the United States if it's seen in a pet cat or in a zoo tiger? We still don't have an answer to that.
I'd like to make an observation and share — respond to the question that we have from Washington DC about how do we — you know, what works? I'd like to remind the audience that we had a very successful private-sector/CDC collaboration during the West Nile outbreak. That was called Arbonet.
It harnessed the entire population of bird-watchers in the United States. It didn't pay them. They collected the samples. Public health got a diagnosis. The problem is, those people are still not represented anywhere at any federal level by any agency. The Banfield (sp) project is now being supported by Homeland Security. They're looking at dogs and cats — urban bio-sentinels.
So I would just like to plant the seed that perhaps the path of least resistance is working with animals that have no economic value but can and have already in the past served as excellent sentinels for the emerging infectious diseases of West Nile and monkey pox, both of which were seen by veterinary practitioners in the private sector.
BAZELL: That point is well-taken. Yes, sir — right there.
QUESTIONER: Joel Cohen, Rockefeller and Columbia Universities. I'd like to ask any of the panelists to discuss the adequacy of the legal and institutional frameworks for quarantine and for rationing of supplies that will and resources that will inevitably be in short supply. Do we have in place an anticipatory legal and institutional framework for such problems?
BAZELL: Mike, do you want to take a shot at that?
FEDSON: Well, first of all, let me just say at the outset, we do have a framework for quarantine. But I will be the first to tell you, I see no major use of quarantine as anything that will be needed or will be effective during a pandemic. Unlike other infectious agents where you're infectious much later in the course of your illness or you're much less communicable in terms of respiratory transmitted agent, the potential to quarantine people or groups and make a difference here is very, very, very, very limited.
The one example I could say I might think would be useful is if we still have no evidence of influenza here in America and we have it in Southeast Asia and we have a plane flying in from Hong Kong to LAX and we know that there's someone on board who has a flu-like illness. You know, quarantine, which is a follow-up of well people after they've been potentially exposed, we could end up considering a voluntary quarantine of those flight crew and passengers of that plane. But beyond that, the idea of quarantine makes no public-health sense. It's not about good or bad.
As far as the other issues, on legal issues we're in big hurt right now. We're in big trouble. We all went through a summer of Terri Schiavo and the idea of when you remove a feeding tube or a ventilator. Today in this country we have 105,000 — (inaudible) — ventilators. That's it — 4,000 in the strategic stockpile. Every day, 80,000 ventilators are in use. And during the inter-pandemic regular flu season, we bump right up to 105,000 ventilators in use, and we move them around almost like we do donated organs to try to accommodate regional needs.
When we get into a pandemic, we will run out of ventilators overnight. And now the question will be, do we keep that 85-year-old vent-dependent person, who has a chronic disease which will obviously be their demise, on that ventilator, or do we save it now for a 25-year-old and give it to them, who's coming in in a critical-care medicine kind of situation?
We have done none of that work to look at standards of care. Our group at Minnesota is embarking on a project just about that very issue, the legal issues of the legal rationing of items, the idea of who gets what limited products are out there, who will get limited Tamiflu, if it does work in a prophylaxis manner or shortly after infection. Who will get the first vaccines?
I've got to tell you, I hope there's enough law enforcement or National Guard members around when that first vaccine clinic opens some months into the pandemic, because I can imagine utter chaos trying to administer that vaccine. None of those legal issues have been worked out.
If you take a look at the recently-released HHS pandemic influenza plan, there is a section in there that deals entirely with legal issues. And I haven't read it in any detail. I can't comment on it. But let me just point out one issue which the plan simply does not face, and that is the liability that the government must assume for vaccine-associated adverse events if any company is to produce a vaccine.
We had experience in 1976 where the vaccine companies which existed in the United States at that time refused to make any swine-flu vaccine unless the government assumed liability. And it delayed production for several months, until in August the government finally assumed responsibility for vaccine-associated adverse events. And, of course, then everybody saw what happened later on and labeled it the swine-flu fiasco when we had the Guillaume Barre Syndrome proble
But the vaccine companies are not going to make — and when I say companies, I've misspoken, because we have only one domestic company that actually produces it — that vaccine company will not make a pandemic vaccine of any kind unless the government assumes legal responsibility for liability. And the pandemic plan right now says in phase three and four of the epidemic or pandemic scenario, the government should consider the liability questions. It doesn't lay out a plan that we all know is inevitable. The government absolutely must assume it or we will not have vaccine, full stop.
QUESTIONER: Laurie Garrett, for David. There are already beginning to be some indications that some countries feel that the phrase “containment” and the concept of containment is code for “Keep the epidemic in your poor part of the world as long as possible to buy us in the rich world time to develop things that will protect us and not you.” How can we possibly be talking about global cooperation if that's sort of the framework of what at least many countries suspect is the operating set of assumptions?
MR. NABARRO: I hope it's not the operating set of assumptions. But I think, in a way, as has come out this morning, there are a lot of potential really horrible issues that we're all going to have to work through. Each time you lift up a phone, you find some very weird things underneath it. And it will be very easy, I think, to start eddies of discussion and conversation around legal-framework issues and sort of the problems that Mike has described — human rights issues, which we haven't really talked about, but they are very serious; or rich-poor issues.
Nobody's going to be in charge of sorting things out so that things are handled in a fair way or in an equitable way. Instead it'll be, as with so many other issues we've had to deal with, each of us in our own spheres of work, whether we're in the media or in scientific research or in public policy or working a local level, each of us is going to have to try to find the best way through this, taking guidance from international organizations when they exist.
For the United States — last comment; I'm sorry — for the United States, your security is going to depend on the way in which the pandemic, if it emerges in a poor country, is dealt with in that poor country. That's your security.
So you have to help the poor country in order to reduce the likelihood of large, unmanaged death and destruction and economic catastrophe for this country. And I think that's understood. And that, I think, Laurie, is, at least for me, the prevailing mood. That's the vein with which I'm working. If people are saying other stuff, then we've got to show that actually that's not the style with which we're working internationally. We're working for a joined-up solution that will be good for everybody.
BAZELL: Laurie, I want to follow up on that, because the question that other people have asked around this morning — and I don't think Dave Nabarro can respond to this — but China, as everybody in the room probably knows, announced its three first human cases this morning. These are cases that have been kicking around as suspect cases for several weeks. And because of the experience with SARS, where China did not report a disease outbreak for a long time, there's been a nagging suspicion that this biggest of all countries in Asia, that has this enormous number of birds that we talked about, it has not adequately — or is perhaps changing its tune; it certainly was talking about increasing numbers of chickens at the meeting in Geneva.
Can we even reasonably expect that countries are going to be honest about reporting when you talk about the doors slamming shut? And if you talk about just an outbreak in birds, where they suddenly lose their poultry industry overnight, is it even possible to think that we can get decent surveillance of what's happening? Mike.
MR. OSTERHOLM: Well, I don't think we get maybe what you would call decent surveillance by U.S. standards, meaning that we would like to see cases reported even as they're being worked up and the potential diagnosis yet to be made.
But I would argue that we have had a remarkable clarity, I think, in the human infections in Southeast Asia, China, to the extent that we have now, based on what I would call third-party information. In this Internet information world, it's hard to keep a secret anywhere anymore. And even though countries try to, I think that we won't necessarily know about these clusters of three or these clusters of two or, you know, one case here or one case there. But between the networks that Rob Webster has, other investigators have, we'll learn at least some. And where I think we'll get the rest of it, frankly, is from the media, who, one way or another, will break out the story.
And when will that threshold be? I don't know if it's 20 cases, 40 cases. I would be very surprised today if we had 20 to 40 cases of flu-like illness in one community anywhere in Asia and we didn't get some inkling through a ProMED, through a news leak of some kind that it was there, and that it's going to be depending on the rest of the world to assure that we follow up on that, just as we did with China. There was great pressure. And to WHO's credit, they brought pressure on China to do further evaluation on those three cases and learned subsequently the answer. I think we'll find it.
BAZELL: David wanted to comment as well on that.
FEDSON: Just two and a half weeks ago, I was sitting with the foreign minister in Beijing. The minister said the following three things to me: “We're a world power. We're going to behave like a world power. We're going to tell you what's happening. We're a regional power. We want to be trusted by our regional colleagues. We're going to tell them what's happening. We're a serious nation. Our people need to know what's happening inside our borders. We're going to tell them what's happening.”
And the dialogue between WHO and the Chinese authorities on these cases, which I've followed very closely, was a dialogue between two responsible partners. Let's, I think, give them the benefit at the moment.
BAZELL: A question in the front here.
QUESTIONER: I'm Ruth Kahurananga with World Vision International. My question is particularly in terms of developing a vaccine. To what extent has pediatric care been taken into consideration? And the reason I'm asking this is because, in the case of HIV-AIDS, we're far behind in terms of ARVs for children in pediatric care.
MR. OSTERHOLM: Well, all I can say is that we're far, far behind, and there are lots of reasons. It would take me a long time to go into that. But the vaccines that have been tested by the NIH right now have been non-agivented. They've been tested only in healthy young adults, and they've been found to be immunogenic only at enormously high doses, so much so that we could never, in the next few years, at least, produce much vaccine to vaccinate more than 5 percent of the entire U.S. population.
Those vaccines have not been tested in children, although, for reasons that completely escape me, they're going ahead and continuing tests of these inadequate non-agivented vaccines in older adults. Now, why, I don't know. They don't work and they should be forgotten. We should move on to agivents.
Once we find that an agivented formulation works, then they will do as they always do — move down to studying these vaccines in children. But if you think back to 1976, they studied children as well as healthy adults and older adults, and they did all of that within a matter of four or five months, and they got the answers they needed. We haven't even begun to approach this in the way that we should.
BAZELL: I'll take another question here. And Susan, we can take some more in Washington if there are, but I'll call on you next. Right in the middle, ma'am, in the red.
QUESTIONER: Hi. (Inaudible) — from Nature Medicine. You've said that Tamiflu needs to be taken very early in infection. And there have been reports of resistance to the drug if it's taken at too long a dose. So I'm wondering if you could tell me a little bit about what would happen if people start taking it on their own without supervision, at not the right time, not the right dose.
MR. OSTERHOLM: Well, first of all, let me just say that there are experts in the room here. Dr. Fred Hayden is with us today, and I would urge you to have a discussion with Fred. He's probably as knowledgeable as anybody in the whole world on this topic.
But again, I don't worry as much about the resistance issue now, as we think of it in this country, because while we may engender resistance in the annual flu if we all started taking Tamiflu, we know resistance occurs. It has not been clinically significant yet.
At the same time, it wouldn't have an impact in H5N1 if it's not here. It's when H5N1 occurs here. And I think that one of the things we're more concerned about is if Tamiflu started getting used widely in Asia in that sense there. And even again, remember, as Rob Webster pointed out today, we don't have a lot of viremic people out there with H5N1 yet. It's when that tips and that goes, the resistance really would be indiscriminate use in H3N2 that might breed that one.
So I think that issue has been a little bit of a — how should I say — a misleading fact, because I've heard people say, “We can't use Tamiflu because there would be resistant strains to H5N1.” Now, I don't think that that's the case at all, and I think that we could very well have a very viable drug, if taken early again, in a dose, at the time H5N1 emerges.
Susan, a question in Washington?
DENTZER: Yes, let's take one here, please.
QUESTIONER: Hi. Dr. Wilson Wong (sp) from the office of Senator Lieberman. A gentleman in New York was talking about the gorilla in the room that no one is looking at is the medical capacity. My understanding is that the animal that no one is looking at is a bird, and the big bird in the room is wild birds.
My understanding is that wild birds are what actually spread this influenza to bird populations, domesticated bird populations. And usually when we talk about surveillance and intervention, it's usually in reference to domesticated birds. I was wondering if the panel could comment on what type of surveillance and intervention on wild birds is realistic and whether that is a potentially effective upstream approach to the threat of avian flu pandemic.
BAZELL: We went over a bit of that this morning, but —
FEDSON: Well, I think you heard from Dr. [Tracey] McNamara earlier, who is clearly one of the leading experts in the world on the issue of the infectious agents of wild animals or zoo animals. I personally think it's important to know as an indicator, but I don't see what we're going to do upstream. No one has recommended nor have we accomplished basically wiping this virus out in wild birds. If we think it's a tough sell in domestic poultry, it would be even tougher to even consider that in wild birds.
I don't think wild birds represent necessarily a great threat to much of the world either in that many of the production operations that we have in domestic poultry around the world are in bio-secure buildings. Many years ago in this country, when we did have avian influenza problems from wild birds flying here, we moved much of our poultry operations in this country into confined spaces.
Now, that's not true for Asia. That's not true for some parts of Europe. It's clearly not true for Africa. But for much of Europe, in fact, with avian influenza having been a problem there before, other strains of it, today much of the production is in bio-secure buildings.
I think that the genetic roulette table, again, as I've said over and over again, for this virus is in the wild bird/domestic bird interface in Asia. That's where it's going to stay in terms of the real hit. It's not that it won't happen elsewhere. It's not that Africa couldn't become a bigger issue. But they're not a major poultry production area.
So I just personally don't see it. I don't want to — it's not a good idea. It's nothing I'd like to see happen is wild birds spread this virus. But I don't, at the same time, see the same genetic driving force that I see in Asia. And I'm open to interpretation on that.
BAZELL: The second one back. Yes, and then — yeah.
QUESTIONER: Hi. Dr. Wenyi Wang from the Epoch Times, an international newspaper, circulated in eight language, including the Hong Kong and Taiwan and other. And my first question is in response to the comment from Michael Osterholm. We did see this statement from the minister of foreign affairs in China regarding how they determine to control the influenza in China.
But one issue is our correspondent in China this time experienced great difficulty to investigate the case in Hunan. The girl died of pneumonia — (inaudible). I hope you know this fact. And so our question is, is there any international mechanism to monitor the information flow, especially in controlling the pandemic of the bird flu?
The second question I give to Dr. David Fedson and Dr. David Nabarro. And how effective (will be ?) immunization of animals, too? Because two days ago the Xinhua agency just report there's a — Liaoning Province — a black (mark ?) and there's a big breakup of the bird flu and then they actually killed 150,000 of the chickens and other animals. And the reason they state is they gave the fake vaccines produced by Liaoning, one of the cultural department of the pharmaceuticals. We're just wondering, how could that happen if you give a fake vaccine and trigger the breakup of the —
BAZELL: Thank you. That's a question for Dr. Nabarro, and I'm afraid that's going to have to be our last question, I think, because we're getting close to the end here. Go ahead.
NABARRO: On your first point, on Hunan, I think you directed it at Mike, but I just want to say that the one thing that the World Health Organization can do is to maintain a reasonably good watch over the quality of information on human health, and the World Organization for Animal Health has a similar system for keeping an eye on animal health. They have some instruments. And although you mentioned the difficulty that the correspondent might have had, certainly the WHO did have access to that area. Obviously negotiation has to take place first. But I want people to be reassured that there was not a close-down there.
And on vaccine efficacy for the animals, there the food and agriculture organization is very aware of the possibility of sub-standard vaccines and is trying to institute some quality control on that. But as you pointed out, that's an issue on which we need to work.
And on wild birds, just to pick up earlier, there is a system now being introduced of trackers and spotters on wetlands using a combination of bird-watchers, just thinking a bit about what Dr. McNamara was just saying. It was very good to see you in the flesh, having read about your work.
The same kind of technique is going to be used for tracking what's going on in wetlands, using ornithologists to identify instances of death and also using more sophisticated technology, perhaps, which is satellite technology to also try to track the actual migration patterns. But all these things, everything you talked about, we've got to do better and quicker.
BAZELL: I think that concludes a very excellent, informative session. I want to thank our three panelists. (Applause.) We'll see you back here in 15 minutes.
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