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Global Health Crisis: Swine Flu

Speaker: Laurie Garrett, Senior Fellow for Global Health, Council on Foreign Relations
Presider: Robert McMahon, Deputy Editor,
April 27, 2009, New York, NY
Council on Foreign Relations


OPERATOR:  Excuse me, everyone, and thank you for your patience in holding.  We now have our speakers in conference.  Please be aware that each of your lines are in a listen-only mode.  At the conclusion of the presentation, we will open the floor for questions.  At that time instructions will be given if you would like to ask a question.

I would now like to turn the conference over to Mr. Robert McMahon.  You may begin.

ROBERT MCMAHON:  Thank you, Operator.

Welcome, everyone on this call, to this Council on Foreign Relations media conference call on this fast-developing story on the outbreak of swine flu.  I'm Robert McMahon.  I'm acting editor of

And we are privileged to have with us an expert in much demand, Laurie Garrett.  She is CFR's senior fellow for Global Health, and the author of "The Coming Plague," and "Betrayal of Trust:  The Collapse of Global Public Health."

I'm going to start off by asking Laurie a few questions about the latest developments and policy responses, and then off quickly to callers.  I know we have many of you, and we want to entertain as many questions as we can in the hour we have allotted.

Laurie, the latest reports are indicating 150 dead; more than 1,600 hospitalized in Mexico; about at least eight countries involved, overall, now.  What are the most important facts for the public to focus on in this -- at this stage in this outbreak?

LAURIE A. GARRETT:  I think, at this moment, if you're in the United States you want to focus on the fact that no one has had serious illness from this; that the infections that we know of, to date, in the United States have been self-resolving, meaning the disease just ran its course and the individual got well, just as would be the case with garden-variety flu.

I think that's very important to keep in mind.  It doesn't mean that we have nothing to worry about, but it does mean that we want to keep a level head on this and not rush to a worst-case scenario unless the data guides us in that direction.

Meanwhile, I think in the case of Mexico the unknowns are profound and very important, in order for us to begin to figure out exactly what it is we're looking at.  The biggest unknown is what I'm calling "the denominator problem."  We may say there's 150, or 200, or 300 deaths that someone in Mexico believes are the result of the infection with this particular recombinant virus, but what we don't know is, what does that represent as a percentage of the total number of people in Mexico who have been infected with the virus?

Without knowing that denominator you have no way of assessing whether you're looking at something that exceeds what you would expect from routine mortality rates in a typical flu year, and whether it gets close to the kind of mortality level we saw in 1918, where 100 million people died, world-wide, in 18 months from a flu that had a 2 percent mortality rate -- actually, slightly less than 2 percent.

MCMAHON:  So, this is presumably what the World Health Organization is obviously focusing on heavily right now.  They could be making a decision within the hour, actually, on raising the threat level designation for -- in terms of stepping up public health measures.  What should we look for, in terms of the follow-on to any new designation by the World Health Organization?

GARRETT:  Well, if they do bump the threat level -- and if that occurs during this Press conference, we'll let you all know -- if they do bump the threat level up to four or five, it means --

MCMAHON:  It's currently three, right?

GARRETT:  Yes.  Currently, three.  It means that, immediately, countries all over the world are supposed to activate a set of public health measures that are more stringent, akin to what has officially been revved up here in the United States by Secretary Napolitano in her statement yesterday.

But, it also means expenditure.  And this is why it's not a trivial decision by WHO.  For poor countries, to meet the accelerated level of alert and put their public health infrastructure on standby, and so on, is a not-inconsequential step to take -- an expensive step, and an expensive step at a time of great financial constraints.

So, I'm sure that at WHO they're trying to balance all this and come up with the right algorithm to determine:  Do we know enough to actually say, let's bump it up the four or five, knowing that this is going to be difficult and painful for a lot of poor countries all over the world?

MCMAHON:  Now, how much confidence should we have in the global response, following the experience in 2003 with the Severe Acute Respiratory Syndrome?

GARRETT:  I think the whole entire world community has been on a learning curve since the SARS outbreak of 2003.  We learned a lot from that epidemic.  One of the key things everybody learned, governments learned all over the world was that transparency is smart, and cover-up and hiding outbreaks is not smart -- not smart for any hope that you're going to control the epidemic and not smart for your national image.  China suffered deeply for having made the choice to pretend that they didn't have an outbreak in the capital city.

So, that's a good learning experience.  I think a lot of tremendous learning was made in Hong Kong regarding infection control in hospitals; and how to best alert public -- how to put out public information and mobilize public response.  And these are all things that I would hope we would take a look at right now, as a government, here in the United States, and that other governments across the world would look at.  Let's share the learning experience.

MCMAHON:  And we've seen some of the strongest actions yet from Hong Kong, in terms of restricting flights and other measures, based on their own recent experience.

GARRETT:  They are very nervous there.  They've been through bird flu. They've been through SARS.  They don't take any of this lightly.  And, if anything, there will be a tendency to over-respond.  You know, the last government suffered for failing to respond swiftly in the case of SARS.

MCMAHON:  All right, well, I'm ready to open it up now for our callers' questions.

Operator, can we -- can you please open it up?

OPERATOR:  At this time we will open the floor for questions.  If you would like to ask a question, please press the star key, followed by the 1 key on your touch-tone phone now.  Questions will be taken in order that they are received.  If for any reason you would like to remove yourself from the queue, please press star-2.  Again, that's star-1 to ask a question.

Our first question comes from (Peter Panepinto ?), from the Daily Collegian at Penn State.


MCMAHON:  Go ahead, please.

QUESTIONER:  Okay.  I just wanted to know, do you think -- (inaudible) -- is under-responding to the threat -- possible threat?


QUESTIONER:  Could you explain, like, exactly how do you -- how you feel they're responding at the moment?  Like, how do you think they're doing?

GARRETT:  I think the current U.S. and Mexican responses display a great deal of maturity that has occurred in the public health apparatuses, and in global health, generally.  We've seen tremendous improvement in both a sense of the necessity of public health infrastructures to be prepared; and a kind of sobering, post-Katrina, here in the United States on the dangers of either complacency, or a failure to properly mobilize both the federal and local responses.

And I think we're seeing a much clearer, more cogent response at this time than we have in the past.

MCMAHON:  Thank you for that question.

Operator, next call, please.

OPERATOR:  Our next question comes from David Brooks, from -- (inaudible) --.

QUESTIONER:  Hi.  Thank you.

Two related questions:  There seems to be some mystery as to why Mexico took so long to alert the public and make a public declaration; and went from nothing, to closing one of the major cities of the world, essentially.  And, given that that city is closed, why isn't there a travel alert from the United States yet, if somebody has taken such a drastic step as to close down one of the major cities of the world?

GARRETT:  Well, first, let me take the second part first, because having -- for the United States to put up a travel alert, that blocks travel to and from Mexico, would be pretty crazy since we already have the virus here --


GARRETT:  -- so what would be accomplished?

And, as far as individuals are concerned, they're voting with their feet.  You either do or don't get on that airplane flight to Mexico.  I think the advice from the administration on that has been pretty clear.  It's a matter of personal choice right now, but we already have it here.

Now, let me go back a step further and say the first evidence of swine flu transmission actually was in the United States.  It was last September.  It was Texas.  It involved a 10-year-old boy.  The second incidence were right shortly after we had announcement that H1N1 -- the common flu that was already in circulation in the United States, that was human flu -- had developed a capacity to resist the primary drug, Tamiflu.  That also seems to have emerged in the United States.

Then, our first big reports of what now we can say is this virus, this -- what we're calling the "swine flu virus," this particular mutational event occurred and afflicted two individuals in Southern California, and an individual in Texas, and those were in mid-March.

So, if I'm Mexico, and I hear questions like this, I may wonder, "Why is America pointing its finger at us?"  It kind of is reminiscent of 1918 when people went out and started calling it "the Spanish flu," but Spain was merely -- as far as the record shows, a recipient of the flu, that had been promulgated elsewhere and actually had passaged through Kansas before taking on its super-virulent form and slamming Europe with troop movements in World War I.

So, I don't think it's useful to talk about borders or to start blaming -- "who engendered this," and "did the timetable move right?"  One could, very easily, from the Mexican position, say, "Why weren't you telling us that people who might be going back and forth to Mexico were infected in America?"  So, let's be careful about that.

As far as, "Did the Mexicans move swiftly on this," yes.  There was evidence of unusual levels of flu activity in March, but as far as I know there was no specific evidence, other than the American cases in California and Texas, that indicated we were looking at a new type of influenza until you got into April.

And I think that it's reasonable that you would have seen a sudden flurry of activity when you started to see clusters of spread, which really weren't picked up and recognized in Mexico until it hit Mexico City and started spreading within schools, hospitals, and other settings in Mexico City.

I don't think that's terribly different than in the United States.  Frankly, we've had swine flu cases in the States.  We didn't make a big deal of it.  We had isolated cases in California and Texas.  We didn't make a big deal of it until it was in Mexico City, and then now in New York City.  So, let's be fair on both sides of the border.

QUESTIONER:  Thank you.

MCMAHON:  Thanks very much for that question.

Operator, we'll take another question, please.

OPERATOR:  Our next question comes from Mitch Potter, with the Toronto Star Newspaper.

QUESTIONER:  Yeah, thanks for providing this call for us.  It's very helpful.

I'm wondering if you can speak to your sense of the level of preparedness in Canada right now, given Canada's history with SARS.  I wonder if you could speak to what your sense is of the level of preparedness now?

GARRETT:  Well, I think Canada has probably gone through more soul-searching and self-analysis, post-SARS, than any country except China.  And certainly the episodes in Toronto prompted a lot of reviews of hospital practices, basic infection control, local surveillance for infections.  And one can simply hope that Canada is better prepared today than it was in 2003, and that Toronto itself has learned from 2003 some profound lessons.

You know, I want to say one thing slightly off the subject, but because you've brought up Toronto and 2003 SARS.  I've received a lot of calls and queries from Asia and, at this time, I would say the Asian countries that experienced SARS are far more distressed about this new influenza than just about anybody -- except we here in North America and Mexico, just simply because of their experience.

And some of the questions I've had from Asia concerning why haven't we set up the temperature control stations, which became pivotal in controlling SARS in Asia in 2003, and were used also in Toronto.  And these were portals that detect the temperature of people walking through -- either in airports, or in big public buildings, and so on, so that you could spot anybody who was running a fever, pull them away from everyone, and do an examination or put them in quarantine.

The reason that this would not be a terrific thing to do right now is that influenza, unlike SARS, is actually most contagious pre-fever, and people are very contagious when infected but don't even have symptoms yet; don't even realize that they have influenza.

Whereas, in the case of SARS you really had a cut-and-dry situation, where the majority of all contagion is in people who are running a fever.  So, that one particular control measure -- which everybody is relying heavily on in Asia, may not be terribly useful right now for flu.

QUESTIONER:  Good point.  Thank you.

MCMAHON:  That's very interesting.  Thank you for that question.

Operator, next question, please.

OPERATOR:  The next question comes from Bryan Walsh, with Time Magazine.

QUESTIONER:  Hi, thanks for doing this.

(Inaudible) -- at WHO, in terms of changing its pandemic phases.  And, of course, if they do that it will put a burden on countries to respond.  First off, it seems to me as if we've already met most of the criteria for phase four.  I mean, we've seen this pop up in multiple countries now, which actually would be phase five.

So, I mean, what do you think about them, sort of, just delaying this decision so far, on Saturday until perhaps now, perhaps later?

And then, I mean, should the WHO be taking into account these kind of political concerns, I mean, in terms of the political or economic impact that decision might be on these countries, as opposed to really just looking straight forwardly at the science?

GARRETT:  Empiricism is always the best way to go when you're making these public health choices, and basing your decisions on numbers is really important.  The problem here is that a lot of the numbers for Mexico and the United States are missing.

Just let me give you an example by focusing on the United States for a second.  Here in New York City we think we had this very contained problem, involving one school in Queens -- no hospitalizations, or certainly no mortality, and fairly confined spread within the school and some family members.

But, the truth is, New York City, like most of the rest of the United States, has a vast pool of uninsured citizenry and non-citizens, including illegal aliens -- individuals who are highly unlikely to seek medical care simply because they're running a small fever, or have a headache and feel nauseous.

It is, therefore, highly likely that we're missing some cases, just as Mexico is undoubtedly missing a lot of cases because people either are in rural areas that are underserved for health; or they're poor, living in urban areas, and are nervous about the costs of either taking time off work or of actively seeking health care.  So, we're in a tricky situation, trying to guesstimate how serious, how severe is this?

Having said that, you know, the Europeans initially released a statement -- the EU did, saying that perhaps people ought not travel to the United States because of this.  And then the EU pulled back from that recommendation -- softened the blow a bit.  What was Europe saying, and how do we feel about them saying that America is not safe place to travel?

So, if we get to the point where WHO, indeed, raises the threat level for the whole world, it means that the whole world has to take the kinds of precautions we're already taking here in the United States.

Now, empirically, should they do that; and do they have the data that should be the basis for making that choice?  I think the two key pieces of data you need are:  How transmissible is it, and how lethal is it?  What's the case fatality rate?  And right now we don't actually know the answers to either of those, so there's a lot of guess work involved.

And, of course, the dilemma is, why is it so much higher in Mexico?  Why is it zero in North America?  What's the difference?

MCMAHON:  Very interesting, that point of balancing prudent response with trying to not get into a panic mode, I guess.

Thanks for that question.

Next question, Operator.

OPERATOR:  Our next question comes from Carolyn, The Hartford Courant.

QUESTIONER:  Hi, Laurie, this is actually a question from a reader, and it's kind of a question concerning your "why Mexico, and why not the United States?"  The reader asks whether these giant CAFOs, confined animal feeding operations could be a factor here, and their "fecal lagoons" which cause respiratory diseases in the surrounding human population, she says.

How much, you know, could this be a factor?

GARRETT:  Well, let's step back a second and ask ourselves how typical is it that we have a flu in circulation, which has genetic elements that come from three species -- humans, pigs and birds?  How frequently has this been seen in known virological history?  And what might be the reasons this has happened?

The answer is, as far as we know, this has never happened before.  And certainly, to go to the prior question, if I'm in Geneva trying to decide whether or not to go to pandemic threat level, one of the things I'm worried about is "What does it mean that I have three species worth of DNA materials" -- or RNA material, in the case of flu, "sitting here in this virus?"

Now, why do we see pig elements getting in in North America?  What's going on with the H1N1?  Well, as I mentioned before, the first H1N1 swine flu case that we know of occurred in September in North America in the United States.  And, you know, there's -- the individual was directly close to pigs; had been around one of these pig operations, so that played a role.

The other thing that plays a role is migratory birds, and whether or not they are in proximity to any of these giant pig operations -- pork operations; and then the movement of human beings.  And, you know, I would just add one other thing that I'm very, very worried about -- I want to underscore this -- on December 20th CDC issued a bulletin that said, "We now have a form of H1N1 in the world that is completely resistant to Tamiflu," and Tamiflu is the primary treatment for influenza infection.

So far, thankfully, that type of H1N1 has not recombined and mixed with this, what we're calling swine flu -- which could just as easily be called a bird flu or a human flu because it's got genetic material from all three in it.  If we see a recombination now with the Tamiflu resistant strain, I would say that it's time to go to a higher threshold of pandemic alert.

MCMAHON:  And, Laurie, just to follow up on that, the higher threshold has implications, obviously, for cross-border travel, trade, and other things, which is why they're very careful about how they make this designation.  Is that right?

GARRETT:  Well, that's part of why they're careful.  But, I think, really, for the WHO a big concern is the capacity of poor countries and what it will mean to them, particularly for Africa.

And while I'm on the subject of Africa, one giant unanswered question that I'm very anxious to have an answer for, goes to the heart of the observation that the majority of all infections and deaths have occurred in young adults and teenagers so far.  Well, why is that happening?  And what does that say about people who are HIV positive, have AIDS, or have other immunosuppressive conditions, or cancer chemotherapy?

And in the case of Africa, this is not a rhetorical question when you're looking at societies where upwards of 20 percent of the population of adults, in exactly the same age group, may be HIV positive.  And this has to be part --

(At this point, Ms. Garrett's call is inadvertently disconnected.)

MCMAHON:  Hello?  Hello?


OPERATOR:  Yes, sir.  It looks like I just lost -- we just lost her.  She should redial back in here.

MCMAHON:  Okay, for those of you on the line, please bear with us.  It looks like Laurie dropped off the line, but she's going to check back in very soon.

Those of you on the line, you have been speaking with Laurie Garrett, the senior fellow for Global Health at the Council on Foreign Relations.  We still have another 30 minutes or so left on this conference call and we're hoping she will rejoin us very soon.

GARRETT:  Hello?

MCMAHON:  Hello.  Is that you, Laurie?

GARRETT:  Yes.  I was just --

MCMAHON:  Oh, great.

GARRETT:  -- disconnected.

MCMAHON:  Sorry about that.  Glad to have you back.

Thanks for bearing with us, everyone.

You were in the midst of explaining the phenomenon in Africa, especially with the young people afflicted with AIDS --

GARRETT:  Yeah, yeah, yeah.  So, here's this problem:  This "youthful priority" of the virus, there are, I think, three possible explanations for why it's happening:

One explanation would be very, very bad for people who are HIV positive or have AIDS.  All right, so explanation number one is that it's like 1918, wherein the highest risk group was young adults between roughly 14 and 35 years of age.

And, if that's the case, then what's going on is the virus is seen by the immune system as so new, so startlingly unusual, that the immune system is over-responding.  So that it's a robust immune response in a healthy young adult, and it triggers the release of cytokines -- that's c-y-t-o-k-i-n-e-s, for those of you not familiar.  These are extremely potent chemicals that trigger giant cascades of response within the immune system in the human body.

And one of the outcomes is that your lungs fill with fluids and you literally drown in your own fluids.  This occurred in 1918 and it occurred with many of the SARS patients in 2003.  So, that's scenario number one, in which case, if you're immunosuppressed, if you have HIV, or you're on cancer chemotherapy, ironically you would perhaps be at very, very low risk for contracting illness related to this new virus because your immune system would fail to have such a robust over-response.

The second possible explanation for this age differential in infection is that the H1N1 routine vaccine -- that was a trivalent vaccine given out this fall, which was primarily administered to adults -- has some slight margin of protection offered against this new virus.  Now, I am not certain this is the case.  This is pure speculation.  However, it is interesting that we haven't seen, in the family clusters, that the parents have gotten sick.  It's been mostly the kids.  And that says something about the possibility that there's some protective factor for the older adults.

The third possibility is that actually we're looking at something that's just a very, very bad version of a routine flu; and that the clustering we see, by age group, is more related to the behaviors of the age group -- such as kids being in schools together, in dormitories together, and so on, than anything else.  In which case this would be very bad news for HIV positive people, even those who are on treatment, because we now know that there's a higher probability of cardiovascular events associated with being on treatment for HIV and then exposed to influenza.

MCMAHON:  Very interesting.

Thank you.

Operator, do we have another question, please?

OPERATOR:  We do.  And, as a reminder, if you would like to ask a question, it's star-1 on your touch-tone phone.

Our next question comes from Patricia Mello, from Estado de Sao Paulo.

QUESTIONER:  Hi.  My question is -- I would like to know how prepared is the American public health system to deal with an epidemic if that happens; and also the problem of having so many uninsured people?

GARRETT:  Thank you for that.

Well, certainly, the American public health system is better prepared today than it was before Katrina.  There has been a real acceleration in the concept of preparedness and the necessity for it.

However, it's not a completed process.  We have not reached that point where we have a, sort of, level of preparedness that anywhere approaches the ideal targets that were set by the federal government and by most of the states in the United States.

Every state was required to come up we a disaster plan for a flu pandemic, and most of these are very new.  They are -- some of the states have had exercises where they tried to pretend there was an epidemic and have everybody role-play their respective jobs.

But, the truth is that public health has gone so long with lousy budgets, lousy equipment, only infused with cash after 9/11 -- with the concern about bioterrorism, and then the anthrax mailings, that it's by no means at the level it ought to be, where we could feel we're really ready should this turn into a highly virulent roll-out.

And I should just point out that you might want to take a look at the final federal plan -- excuse me one second (coughs), that was not a flu cough -- (laughter) -- you might want to take a look at the final federal plan that was put together at the end of the Bush administration.  It does say, 'here are the responsibilities of the federal government; here's the responsibilities of the states; here's the responsibilities of the community; and here are those of the individuals."  And it basically puts a heavy burden of response on the individuals, their employers, their local communities.

MCMAHON:  Laurie, what about the incomplete transition to Health and Human Services, and other health posts in the federal government with the new administration in Washington.  Is that something that we should be overly concerned about?

GARRETT:  If you were watching today's Press conference from the White House, you undoubtedly noticed that there was quite a lot of questioning on this point.  We still do not have a secretary of Health and Human Services.  We do not have a permanent director of the CDC.  We do not have a surgeon general.  And there is about 17 other key positions related to pandemic response that are not filled.  Some require Senate approval.  Most do not.

There are also a number of international relations positions over at the State Department that would have impact on how we would collaborate with other nations to face down a pandemic threat.  Those are unfilled.  You know, the White House was at great pains to say today that this is not a problem, that the administration has their act together, and that that the Department of Homeland Security is in the lead.

All I can say is, I think we would all be able to sleep more soundly if we had all of the positions of leadership -- for global health and domestic public health response, filled at this time.

MCMAHON:  All right, we're ready for another question, Operator.

OPERATOR:  Our next question comes from Alejandro Dominguez, with the La Raza del Noroeste.

QUESTIONER:  Hello.  My question is mostly which is the regions of Mexico and the United States that are right now more affected by the virus, just because my readers are (highly ?) immigrants and are from Mexico?

GARRETT:  So, say the question itself?

QUESTIONER:  Yes, the question is, which areas of Mexico are the ones that are more in risk, or are more affected by the swine virus, and also from the United States?

GARRETT:  The last I saw, just about every single state in Mexico had reported cases.  But the majority are in Mexico City, just because Mexico City is 20 million people.  That does not actually get to what I think you're really driving at, which is, what about the folks that are in the U.S., who are immigrants from Mexico, and their relationship back to their homes?

And I think it's a different population that is primarily making the exodus to the United States for work, than the population that is affected in Mexico City.  And that doesn't mean that they don't overlap in terms of risk, but I think they are different populations.

QUESTIONER:  Okay, thank you.

MCMAHON:  Thank you for that question.

Operator, another question, please.

OPERATOR:  Our next question comes from Yung (sp) -- (name inaudible) -- The People's Daily.


MCMAHON:  Yes.  Please go ahead.

QUESTIONER:  Okay.  This is Yung (sp) speaking.  Thank you for your introduction.

And my question is, how long does it -- do we need to bring the swine flu under control?  And up to this day, the measures -- could you elaborate on the measures that the federal government has taken?  And I would also like to know your comment on the effectiveness of these measures.

GARRETT:  Okay.  First of all, on the question of how long will it take to bring this under control, I don't think anybody in their right mind would try to speculate on an answer to that.  We're very early days in this.

And, you know, at one point today -- I believe it was today, CDC Director Besser referred to, "This is going to be a marathon, not a sprint."  We're just seeing things unfold now.  So, anybody who would try to speculate, I think, would be off-the-wall at this time.

As far as measures taken by the federal government in the United States so far, pretty much the Obama administration has followed the playbook that was worked out in all the flu pandemic preparedness that went on during the Bush administration.  And most of the response has been very careful to balance a sense of alarm -- a sense of urgency, against panic.

So, I think you're trying to -- hear very deliberately-calm voices out of the government.  President Bush went and played golf, you know, over the weekend -- all trying to send the signal, "Let's not panic.  Let's not go crazy."

And yet you look at the stock market today and just about every single stock that is in any way related to the travel business -- hotels, airplanes, cruise liners, and so on, have all tanked today, just plummeted.  All the pork and meat processing industry stocks have plummeted.

This is just panic.  So, while the government is trying very, very hard to have everybody keep a very level head in all of this, clearly panic is out there, especially in an already jittery financial community.

MCMAHON:  So, managing expectations are -- just managing what we know right now is crucial at this point at all levels.

GARRETT:  Absolutely -- absolutely critical.

MCMAHON:  Okay, Operator, do we have another question, please?

OPERATOR:  We do, and it comes from Maria Sanminiatelli, from The Associated Press.

QUESTIONER:  Hello.  My question is, as journalists, what should we be looking out for exactly; and what questions do we need to ask?  For instance, you mentioned we don't have a firm number on the mortality rate.  I would assume that is one thing we need to keep an eye on.  What else?

GARRETT:  Thanks for that.

I already mentioned that we need to understand why young adults are the key risk group; and with special attention to what will this mean for people who have immunosuppression or HIV.  I think we need to know, as I said, the denominator.

We also need to have some further understanding of the virus itself and what its relationship is, exactly, to the prior swine flu that emerged in the United States starting back last September.  And we need to really keep an eye out for Tamiflu-resistance, and any possibility that the already-circulating H1N1 strain, that is Tamiflu-resistant, somehow recombines with this one.  That would be a very, very bad thing.

The other thing that would be very important to push, I think, is questions regarding whether or not the routine vaccine given in the fall offered any level of protection to adults who got it.  Certainly, it wouldn't be 100 percent protective, because it wasn't exactly the same H1N1.  But, H1N1 was in there.  And if that offered some margin of protection, that's very good news.  A lot of possibilities flow from that, including perhaps revving up re-manufacture of doses of that, or pulling -- you know, encouraging physicians not to dispose of the 2008 seasonal vaccine, and perhaps to administer it to some of their target populations.

MCMAHON:  And, just to repeat an earlier reference, WHO is actually meeting right now, as we speak, to consider whether raising the threat level, and what that -- and that move could involve some demands, especially on poorer countries, that could be very difficult to implement.

QUESTIONER:  It looks like -- by the way, I'm sorry, I'm Maria Sanminiatelli, from The Associated Press.


QUESTIONER:  -- it looks like we just moved an alert out of Mexico. with the Mexico health department saying WHO is raising the -- WHO is raising the pandemic alert level --

GARRETT:  To four, or five?


GARRETT:  Okay.  That's not unexpected.

MCMAHON:  Thank you for that update, by the way.  And thanks for that question.

Operator, do we have another question on the line?

OPERATOR:  Our next question comes from Christine Gorman, with the GlobalPost.

QUESTIONER:  Hi, Laurie.  A question:  I want to understand what you were talking about, in terms of the fall, the novel swine flu influenza A/H1N1 reported out of Texas.  Has any genetic testing been done to see if that virus is related to the virus that we're -- we heard about in March in California and Texas?

I mean, it feels like we're having nomenclature problems.  I mean, what do you really call this?  You can't really call it "swine flu," because it's not in pigs, it's in people.  You don't want to call it the "Mexico flu," because maybe it's really we should be calling the "Texas flu," but --

GARRETT:  (Laughs.)  You know, I always expect the good questions from you.

Look, there are huge gaps here.  And I am with you all the way, I want to see far better virology done.  I want to see comparative genetic analysis.

You know, one very strong possibility -- just simply based on the epidemiological series of events, is that the original pig mutation -- or, recombination event, is related to that H1N1/A that we saw in Texas, and then California.  But, that the bird moiety may go back to the one that first was reported out of Wisconsin some months back.

And then a third recombination event somewhere along the way -- either in California, or in Mexico, may have occurred.  You know, the thing I just keep trying to remind everybody is that influenza is one of the sloppiest viruses around.  It has chromosomes, so to speak, but they completely fall apart when the virus replicates.

It's an RNA virus, instead of DNA, which has inherent relationship to the lability of the genome, and every time it reproduces it picks up genetic material from the host cell that it's residing in.  This could be anything.  But, what this means, that we have this triple species phenomenon out there, is that this is a virus that went through some recombination event in pigs; went through recombination event in birds; and went through some recombination event in human beings.  And the end result is a triple-whammy.

This is something we need to understand much better, and to see if the earlier events were steps towards this ultimate event.  And then, finally, whether or not it's mutating further in another direction.

QUESTIONER:  Thank you.

MCMAHON:  So, not swine flu, the "sloppy flu outbreak" that we're dealing with now?

GARRETT:  The "sloppy flu."  I like that one.

MCMAHON:  Thank you for that question.

And we're ready for another question, Operator, please.

OPERATOR:  Our next question comes from Bryan Walsh, from Time Magazine.


Should we be especially concerned about the Southern Hemisphere?  Obviously, the flu season on the Northern Hemisphere is coming to a close now, but of course then it starts up in the Southern Hemisphere.  And that, sort of, -- (inaudible) -- the problem of thinking about what, particularly, poor countries, Africa, and so forth, are going to have to do to deal with that?  I mean, is that something that should be very high on our alert -- as much of the focus as we put on the United States, and so forth, but that could be where things could get bad?

GARRETT:  I think that's a very important concern.  And when you think about migration from Mexico, you know, and movement from Mexico, you should also be thinking about southward movement, and the, you know, the pathways of movement of Mexicanos to Argentina, to Brazil.

We now have at least one confirmed case in Brazil.  And I would definitely be worried about south of the equator.


MCMAHON:  A very good question.  Thank you.

Operator, any more questions on the line?

OPERATOR:  Yes.  We have two questions.

The next question comes from Zagyashi Durekar (ph) from the -- (affiliation inaudible).

QUESTIONER:  Hi.  You spoke about the Tamiflu-resistant, where -- (inaudible) -- combining with the current virus.  My question is, what are the chances?  And in what kind of situations or circumstances would you expect that to happen?  Thank you.

GARRETT:  Thanks for that.

You know, this is one of those moments when people who don't believe in evolution should just cover their ears, because they won't like what I'm going to say.  Flu is a perfect example of evolution.  It's a constant evolutionary process.

The virus is responding to both the environment, or host, in which it is residing, and to all sorts of external conditions to the host; and constantly seeking ways to become a newer, better, stronger virus that can infect more hosts.  That's the dictate.  That's the Darwinian principle here.

And, you know, we can't predict -- we don't yet have adequate scientific understanding of this process to predict when, and how, and under what circumstances a given flu strain will mutate into a secondary flu strain, or one with new attributes.

But, what we can say is what's in circulation out there in human beings right now.  And we know that Tamiflu-resistant H1N1 is in circulation in North America and Mexico right now.  Typically we see that these recombination events often occur when somebody, or an animal, are co-infected with two types of flu at the same time.  And then you can have the attributes of one flu strain get shared with another flu strain.

QUESTIONER:  Thank you.

MCMAHON:  Thank you for that question.

Operator, we'll take the next question, please.

OPERATOR:  As a reminder, if you would like to ask your question, press star-1.

Our final question comes from Alejandro Dominguez, with the La Raza del Noroeste.


Just to go back to the -- (inaudible) -- of the immigration, I just want to know if they just raised the level, if it's going to affect -- how it's going to affect the (movement ?) of people from the border on foot, or in any case?

MCMAHON:  In other words, the WHO's adjustment of the threat level?


GARRETT:  My understanding is that it will not have any effect on cross-border movement.  That's up to the individual nations.  And the United States has made it very clear they have no intention of closing the border with Mexico.

QUESTIONER:  Thank you.

MCMAHON:  Thank you.

Operator, is there anyone else on the line with questions?

OPERATOR:  At this time there are no further questions.

GARRETT:  Well, I'd like -- I have to run to yet another media event.  But, I want to thank all of you for your interest, and, of course, here at the Council we remain available to you to help you as needed.

MCMAHON:  Yes, I'd just like to further that by thanking Laurie for taking time to brief you all.  This has been very enlightening and very instructive, and there's a lot more learn, obviously, as this thing unfolds.

But, thanks very much to all our callers and questions, and especially to Laurie Garrett, CFR senior fellow for Global Health.  Thanks a lot, Laurie, and thank you all.

GARRETT:  Thank you.

MCMAHON:  This concludes the conference call.







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