Pandemic Influenza: Science, Economics, and Foreign Policy

Description

Session One:
The Science
Arnold Monto, Professor, Epidemiology, University of Michigan
Peter Palese, Professor and Chair, Microbiology, and Professor of Medicine, Infectious Diseases, Mount Sinai School of Medicine
Lone Simonsen, Research Professor and Research Director, Department of Global Health, George Washington University
Presider: Jon Cohen, Correspondent, Science Magazine
8:00 to 8:30 AM Breakfast Reception
8:30 to 9:45 AM Meeting

Session Two:
The Economics
Andrew Yanzhong Huang, Director, Center for Global Health Studies, Seton Hall University
Andrew Jack, Pharmaceutical Correspondent, Financial Times
Michael Osterholm, Director, Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota
Presider: Robert Rubin, Former U.S. Secretary of the Treasury; Co-Chair, Council on Foreign Relations
10:00 to 11:15 AM Meeting

Session Three:
Foreign Policy
Helen Branswell,
Medical Reporter, Canadian Press
John E. Lange, Senior Program Officer for Developing-Country Policy and Advocacy, Global Health Program, Bill and Melinda Gates Foundation
Presider: Laurie Garrett, Senior Fellow for Global Health, Council on Foreign Relations
11:30 AM to 12:45 PM Meeting
12:45 to 1:30 PM Lunch Reception

Audio
Transcript

LAURIE GARRETT: Good morning, and good morning to all of you on the Internet. My name is Laurie Garrett, and you are here in the Council on Foreign Relations in New York on a grim, wet, chilly day. Thanks to all of you who managed to forge through the nasty weather. And I expect that we'll have stragglers coming in as a result of the weather problems.

I am the senior fellow for Global Health here at the Council on Foreign Relations, and I welcome everybody who is both here and in cyberspace with us.

In a few moments my colleague, Jon Cohen, will tell those of you out in the cyber world how you can actively participate all day today via Twitter. Jon is the outstanding, infamous, notorious, famous science correspondent for Science Magazine, which is our co-sponsor today. It's a first for the Council on Foreign Relations. We embrace it wholeheartedly and hope it will be the beginning of many more to come, for this symposium entitled "Pandemic Influenza: Science, Economics, and Foreign Policy."

On August 24th, the President's Council of Advisers on Science and Technology, some of whom are with us today, so-called PCAST, issued a remarkable analysis of what's in store with the H1N1 virus, the so-called swine flu, and the likely pandemic impact this fall on the United States of America.

The PCAST offered a scenario -- not a prediction, let me say -- a scenario that suggested the virus would indeed return, having already been here in the spring, for a second wave, and that we would see it appear sometime in September and be peaking right about today in the United States, and that sometime, by the end of the year, roughly half of the American population would have had H1N1 influenza.

The PCAST warned that this H1N1, despite being a not terribly dangerous virus in and of itself on a scale of influenza dangers, would overwhelm many of our hospitals and pose a great burden to our intensive-care-unit capacities across the country.

After circulating in the southern hemisphere for the last three or four months, H1N1 did indeed return as forecast, or shall we say scenario'd, by PCAST and has now been back in most of the United States for at least two weeks. It is indeed surging very rapidly around the country.

On Tuesday, Dr. Ann Schuchat from the Centers for Disease Control opened a press briefing with these remarks: "Unfortunately, we're seeing more illnesses, more hospitalizations and more deaths from it. Flu is widespread in 37 states. That's up from 27 states just last week. Unfortunately, 19 more pediatric deaths from influenza got reported to us this past week. We're now up to 76 children having died from the 2009 H1N1 virus." She means in the United States.

To put that in context, in the past three years the total pediatric influenza deaths ranged from 46 to 88. We've had 76 children dying from the 2009 H1N1 virus, and it's only the beginning of October.

There's a great deal of uncertainty about this flu pandemic. One thing is certain: It is a worldwide event, and it is occurring in the dawn of our age of globalization.

With us today is a stellar group of scientists -- some of them PCAST members, as I said -- analysts, journalists, and, as usual at the Council on Foreign Relations, a highly diverse and intelligent audience.

Before we jump into the subject at hand, a few quick bits of housekeeping and a set-up for what we're going to experience today. We have three panels with two short breaks. And because this is live on the Web, we're going to ask that the audience that's physically here in New York please clear out quickly during breaks and come back quickly during breaks so that we stick to our time schedule absolutely.

In addition, a couple of other things. Because we are live on the Internet, absolutely no wireless devices can be on in this room. It's not just we don't want them to ring; we don't want them to interfere. So PDAs, cell phones, laptops, whatever they are, please turn them off.

We welcome that webcast audience. And as I said, Jon is going to tell you how you can twitter. And because this is the first big event co-sponsored with Science Magazine, we really want to thank and welcome all the folks from AAAS and Science for their participation and the tremendous help we got in organizing today's event.

We also want to thank Council member Richard Brown from Philadelphia, who generously provided some personal support for today's event. All of the proceedings will be available to you after today on our website, CFR.org, and on the Science website.

So, finally, I just want to hand things over to Jon Cohen for the first panel with these words. I have had a long and storied career myself in journalism. If I had one competitor who rode me harder than any other journalist in the business, gave me more trouble, scooped me more times, it was Jon Cohen.

Jon.

JON COHEN: Thank you, Laurie. That was very kind. (Laughter.) And the feeling is mutual.

I did breathe a sigh of relief when Laurie first came to the Council. And Laurie really put a lot of effort into making this happen, and I thank her and the Council, because it really takes a great deal of coordination to make something like this happen.

As a journalist, I rely on the smartest people to be my teachers, and fortunately three of them are here with me on the panel. I've learned a lot from each of them as I've tried to keep up with covering the spread of the novel H1N1.

On my far left is Dr. Arnold Monto, who is an epidemiologist from the University of Michigan and has been covering -- studying flu probably since I was born and knows a tremendous amount about the virus. Peter Palese, who's from Mount Sinai School of Medicine, is one of the foremost basic researchers of influenza and has done really fascinating work looking at how different viruses transmit and why they transmit when they do under the conditions. Lone Simonsen, who's with the George Washington University, is also an epidemiologist and has done really eye-popping historical analyses of past pandemics.

So we're going to have a conversation for about 40 minutes. Then we'll open it up to the audience. We are not here to agree with each other. This is not to develop a consensus document. If they disagree with each other, that's just fine.

If you do want to ask questions on the Web, you can tweet your questions. And the tweet hashtag or pound sign is cfrq@a.

So I think one of the questions that most people are curious about is why is this flu different, and why should anyone care about it? And so I open it up to the panel. Is this one any different? Has it been hyped?

ARNOLD MONTO: I think they're all different. That's a standard influenza statement, that if you've seen one outbreak, you've seen one outbreak, or if you've seen one pandemic, you've seen one pandemic. And this is clearly different and a little challenging in terms of how to handle it, because it is so different.

Our two past pandemics in the 20th century, '57 and '68, had characteristics which we associated with seasonal influenza, most of the mortality in people with risk conditions -- older individuals, very young. And this one is behaving a bit differently -- high attack rate, but selecting out for problems a small percentage of children and 20- to 50-year-olds.

And that really is a challenge in terms of how you handle this by vaccination, because we can't come up with our usual recommendations; older individuals should get vaccinated. In fact, we've said just the opposite.

So this has presented a challenge, and I think it's also created a challenge in terms of mortality, trying to give scenarios about mortality, because without ventilation, without ECMO and the rest in emergency rooms, we may -- we could be seeing a much higher mortality than we are.

So it's been a challenge trying to deal with this. And part of this, which I'm sure Peter can talk about, is the fact that this is not a totally new virus. And this explains some of the phenomena that we're seeing.

COHEN: Dr. Palese, you've questioned whether this is a real pandemic. How do you see it?

PETER PALESE: Okay, let me sort of say -- (inaudible) -- there is a saying the more things change, the more they stay the same. One can look at this as a very different virus. And clearly Dr. Monto pointed out what some of the differences are with this new 2009 virus.

On the other hand, I feel it is sort of like the fourth regular seasonal influenza virus. And let me explain a little bit. With regular influenza, we have three different strains. We have two what we call influenza A viruses, and they belong to the H1N1 -- and many have seen this for a long time -- H1 meaning hemagglutinin subtype 1 and neuraminidase subtype 1 -- and H3 and 2 viruses. So the regular seasonal influenza viruses belong to two subtypes, H1N1 and H3N2, and there's a third type which is an influenza B virus.

So over the last 20, 30 years, every season, every winter season, we had three influenza viruses circulating. And what happened now is we have, in essence, what I see as a fourth seasonal influenza virus which is circulating, and that is another H1N1. So I feel that also in severity it is similar to the other three seasonal strains which we have experienced, and therefore I don't think it is sort of a virus we have to be very afraid of. We don't have to panic. This is a virus which we can handle. It's, in my opinion, a fourth seasonal regular influenza virus strain.

COHEN: What do you think, Lone?

LONE SIMONSEN: Well, I take issue with that. My perspective is in studies of the past four historical pandemics, and I also disagree with Arnold.

I think that actually these pandemics -- there are things that you can call signature features of pandemic influenza that we should pay a lot of attention to. The first one is that the burden, in terms of mortality, shifts towards younger people, especially in this one. You see actually very few deaths and severe outcomes in people over 65 years of age. That's highly unusual for influenza.

The reason why people maybe think this is mild is that actually, when you count deaths only -- and this is very unique, frankly, that we don't count more fancy, complex metrics for a burden of disease. If you started counting the years of lives lost, if you would start counting 50 years' life lost for everybody who's 30 years old who dies of primary viral pneumonia and start adding up -- (inaudible) -- so that way there's something to be said for really looking at this with years of life lost, metrics and other ways to really highlight that the burden is completely different, like a different picture it has.

The other thing that we know from pandemic, as far as pandemic flu, is that it's not over just because we're here right in the middle of the wave. It's not over yet. It's really just the beginning of our experience with this virus. We've seen it in all the past pandemics. We see over the first five years, that's when the deaths play out.

So, for example, if you look at the 1889 pandemic, most deaths happened in the third wave. If you look at the 1918 pandemic, most deaths happened in the second wave. And then in '57 and '68, it was in the first wave; so just to say that it's not for sure that everything has come yet.

So I would just say that there's definitely a different picture of it. And the signature feature, the age shift towards the young, is something that sets it apart from seasonal influenza.

COHEN: I think there's a lot of curiosity about why young people in particular and pregnant women are seeing a lot more severe disease. Flu typically causes the most mortality in the elderly. That's not happening with this. Do you have any ideas as to why the younger population is being hit so hard, and pregnant women? Is it biological? Is there an epidemiologic explanation?

MONTO: Well, I'll try to add a few things from the historic record, which I'm sure Lone can further add to, and that is, in 1918 -- and this is a whole lot different from 1918; I think Lone and I can have a conversation about that -- but in 1918 it was very clear that pregnant women were at particular risk. There are some contemporaneous curves looking at puerperal mortality, deaths in pregnant women. And there is a big spike in 1918 when this was going down on a year-to-year basis.

Women were heavily infected and quite ill, and they often lost their babies if they were in late stages of pregnancy. So this is not particularly unique. It's a little more questionable in some of the later pandemics. And because of this, we in the U.S. -- and we're one of the few countries that has this recommendation -- recommends the use of seasonal vaccine in pregnant women, because we know that this is a particularly vulnerable population.

Why in this pandemic is it so much more extreme in terms of what's going on? It's hard to say. We can speculate about that. We can speculate about obesity as an -- whether it's an independent risk factor. But I think a lot of what is going on is really based on the fact that there has been past experience with this virus. And we see this in terms of the way the vaccine is working; the fact that we only need, for most of the population, one inoculation with this vaccine, which means there is some degree of relative immunity in the population.

And there's been a debate about whether, to have a pandemic, a real pandemic, you need to have a totally novel virus. And one of the reasons we've seen partial sparing in older individuals in past pandemics is these were not totally novel viruses. There was some degree of antibody in the population.

COHEN: A challenge, Peter.

PALESE: I think I just want to sort of explain why the older population is more immune against this new novel 2009 virus. And it has to do that both the regular H1N1 virus as well as this new 2009 virus are both descendants from the 1918 virus. So the 1918 virus went into humans, and in essence we had this virus descendants of the 1918 virus until 2009. But it also went into the pig population. And the 2009 swine virus is actually a descendant and has changed less in the pig population as compared to the human virus in the human population.

And so people who have been around in 1930, 1940, 1950 actually were infected with a descendant of the 1918 virus, which is closer to the 2009 virus. So people who have been around 50 years and longer have been exposed to such a virus or a much more similar virus in the 2009, and therefore the older population is more protected against this new 2009 virus. And also the older ones have experienced many more infections with H1N1 viruses. And that explains why the older ones are better off. It's one of the few things in life -- (laughter) -- where age -- (inaudible).

COHEN: What about the kids and the pregnant women?

I mean, why are they -- is it simply that they don't have -- I mean, the pregnant woman may well have some immune memory to lots of different strains. What is it? Is it the diaphragm has a harder time clearing the lungs? I mean, any thoughts about why?

MONTO: Well, that's one of my speculations but I think it's pure speculation. You can come up with any number of theories to day why pregnant women are different from them because there's relative immune suppression as well because of the fetus, and there are many, many reasons.

I think one of the things we need to learn -- and a number of us are talking about research agendas, trying to figure out where to go in the future based on what's happening now. One of the speculations would be that there is some degree of immune suppression in pregnant women, but seeing the cases that we're seeing, seeing the virus pick out in the 20- to 50-year-olds, individuals -- you know, when the infection rates are relatively high and a small percentage of people are winding up very -- in the ICU and getting very sick very rapidly, there's something different about these people.

And we don't really understand it yet, and this should be an agenda for trying to figure out what is going on that makes people not more susceptible to infection but more susceptible to a severe outcome.

COHEN: What do you think?

SIMONSEN: Well, I think that the pregnant lady is susceptible doesn't surprise me that much. When you read in the literature you will see horrible accounts of case reports of pregnant women with systemic infections in '58 and the '68 pandemic -- the '57, '68 pandemic. So what's more intriguing to me is the two patterns that we're seeing with this one, which is the -- (inaudible) -- and it's this increased extreme risk in younger adults 20 to 50 years of age or a little older, or to 65.

And, in fact, we know a lot about it now that we didn't know at the PCAST meeting. We know that the 20-to-64-year-olds had 54 higher risk -- 54 more people end up in the ICUs and clog the ICUs. What is that?

So, in a way, we started speculating about this in our 1918 stories because it was the same situation exactly and the elderly experienced nothing in 1918. They actually had a three-fold worse time two years before in an epidemic season.

So we came up with two explanations which might actually have to be -- go together. One is the recycling that we were hearing about, that there is some immune experience in the elderly that protects them, but at the same time you have to explain why other -- young have increased risk. That doesn't explain -- the first doesn't explain the second observation.

So what is that, and is it some kind of adverse immune potentiation process, some kind of -- where the immune system is actually reacting in a way with a virus that causes the severe outcomes? So there these things.

And then you can add a third thing, which is could it be that there is a need for a bacterial co-pathogen, in come cases at least, and is it something that actually sometimes is there and sometimes is not there? And we use that to explain why the first wave of the -- in the 1918 pandemic was very mild, for reasons we don't understand clearly. It had the same footprints in every other way but didn't kill people the same way, and when it came back in the fall it did. Could it be that there was a bacterial co-infection for -- that suddenly was available?

So I think there is just so much we don't know about this and it's fascinating.

COHEN: So the bottom line is we don't know.

SIMONSEN: Yes. (Laughs.)

COHEN: If you look at the virulence here, there was a great deal of hand-wringing at the World Health Organization about whether to declare this a pandemic, and it came down to the fact that pandemic doesn't really reflect severity. And so this wasn't as severe as the H5N1 bird flu, which maybe killed 50 to 60 percent of the people it infects.

And so now the question has become, why bother getting vaccinated? And you even hear a lot of public figures standing up saying that they're not going to do it. I will state my bias. I have two younger boys who both have been vaccinated against H1N1 and I'm very happy about that. But I'm curious what you think. Would you get vaccinated, and do you think your family, your colleagues should get vaccinated?

PALESE: Maybe let me start this one out. So even though I mentioned that this 2009 novel influenza virus is really like a regular seasonal influenza virus in many of its characteristics, that doesn't mean that I underestimate influenza. Regular seasonal influenza is a very bad disease. And we all know that in the U.S. alone we have about 30,000 deaths and we have about 200,000 hospitalizations every year.

So regular flu is a very serious disease and therefore we should really use all the tools we have to combat and to fight the regular flu, and that includes vaccination. And by the same token I think it is really compelling that we should use the vaccines which are being produced and being distributed right now against the 2009 virus. So, by not taking the vaccine, by underestimating this disease, I think we are not helping us.

COHEN: Any dissent?

SIMONSEN: No. I mean, it's very clear that vaccination is the best defense we have against pandemic influenza. In fact, when you have a pandemic unfolding and really high transmission rates, it becomes very hard to mitigate with any other strategy than that.

So, from a personal point of view, I have the advantage of natural immunity at this point, I'm pretty sure.

COHEN: You're from 1918?

(Laughter.)

SIMONSEN: No, not that, but because in the May and June --

COHEN: You got --

SIMONSEN: -- our whole family experienced it. But I would still get the vaccine because what's not to love? You get a vaccine that's not risky and you have the protection, so --

COHEN: Dr. Monto, you showed many years ago the importance of vaccinating children in flu season, and indeed children have the worst vaccination rate of any age bracket in this country, and yet there is a big push right now to protect our children. They're first in line. How do you see it?

MONTO: Well, I'm not sure that children have the worst vaccination rate in this country. Health-care workers are pretty low as well. (Laughter.) I think we're doing a lot better there because there are more and more society recommendations and approach to getting -- to mandating that health-care workers, if they're taking care of sick individuals, be vaccinated.

But I think we've got two reasons to be vaccinating children here. We know that they have the highest attack rates. We also know that children, not only those with underlying risk conditions such as asthma, are being hospitalized at a very high rate -- and we're heard the quote from Anne Chuhud (ph) about the pediatric mortality that's showing up.

So there are a lot of reasons other than the fact that by vaccinating children you're actually preventing transmission or reducing transmission, I should say, to the entire community to have -- to vaccinate children with the current vaccine.

I think there's a bit of a challenge in terms of this cutoff at age nine or 10 in terms of requiring two doses. I would be happy to see children receive one dose of this vaccine because -- and this is sort of deviating from current recommendations because that's in fact what's going to happen as vaccine arrives relatively late in much of the country so that they'll get at least partial immunity and partial immunity is probably going to have not only an individual but a societal benefit.

To back up to the issue of declaring pandemics, because having been on the WHO Emergency Committee, I had to deal with -- over the telephone with some of these issues on telephone calls that went on for three to four hours. And basically the problem was that WHO, unlike the United States, had not got to the point of defining severity.

The U.S. came up with categories one though five, and we've learned that if you base this on case fatality, you can't very well figure out where you are in terms of the categories. So we had it set up but we've never really been able to implement the categorization the way we thought we would.

But WHO had never done that and there was concern that because there was so much focus on H5N1 in much of the world, especially in Asia where they had been seeing avian influenza, that declaring a pandemic would shut borders because of all sorts of things, and they needed a little time to figure this one out.

And that's why there was a delay between going from phase five to phase six. Interestingly, it took two days for each of the other increments but it took six weeks --

COHEN: There was a lot of hammering.

MONTO: Yes, exactly.

COHEN: Yes?

PALESE: So the issue is what is a pandemic? In the past, a pandemic was defined as a global epidemic -- meaning an epidemic worldwide -- plus -- (inaudible) -- its severity and a change of the subtype. So, in other words, if something was an H1 or an H3, we would not have called that a new pandemic.

So what happened with WHO now is that they've redefined or made a new definition of what a pandemic is, namely limiting it to the global epidemic too rather than severity and change of subtype.

So in a way we have now a new terminology for pandemics, namely just calling it something which goes around the world is a global epidemic, but not including severity and the change of subtypes.

COHEN: Go ahead.

SIMONSEN: Well, I just want to return to your premise for this question, which is why worry? Is it so severe, or something? And I just want to point out that I find it interesting that -- and I think it was a conclusion from the PCAST meeting that the surveillance systems we have in the United States would not be very good at tracking hostile stations and severe outcomes in young populations.

They tend to be biased towards tracking things that happen in old people -- for example the 122-city surveillance system where you are tracking the percent of pneumonia deaths per all deaths every week. And if you have -- because you have a lot of old people dying all the time, that might keep looking unimpressive because you're just drowning a real signal in a very big background.

COHEN: So you think we may be underestimating?

SIMONSEN: Well, we're just not seeing -- we don't have a good sort of picture of this specific phenomenon that you have maybe clogging up the ICUs, but you have really a drain on the hospital system. None of the systems are capturing that right now and CDC is building that right now.

COHEN: So I think a lot of journalists like this question, and I think we like it because the public is curious about it. And I don't want to over-blow it, but the doomsday scenario of this virus combining with another virus -- influenza has a weird property where it can pull genes from other influenza viruses -- and creating a really nasty strain.

What do you think the likelihood is of this mixing? The worst doomsday would be the H5N1 mixing with this one, but it could be this one mixing with any other avian influenza that we have no immunity against. What do you think the likelihood is of this mutating or reassorting, picking up other genes from nastier -- creating a nastier bug?

I know you've thought about this but what do you think, Dr. Palese?

PALESE: Influenza viruses have a very interesting genome, a very interesting genetic composition. And it has eight sort of mini- chromosomes. So we have one virus with eight mini-chromosomes and another virus with eight mini-chromosomes, and they co-infect the same host, and then you can get mixing and get a new virus out which has, let's say, four mini-chromosomes from one virus and four from the other parent. And that gives a lot of combinations.

So clearly we have the H5N1 virus, we have current 2009 viruses, and all of these mixing events can happen, and out of that a new, more virulent, more pathogenic virus can emerge. Never say never. On the other hand, I think these events are probably occurring as we speak all over the world and only very rarely a sort of new virus emerges.

So I think, yes, we cannot exclude the possibility that by this, what we call reassortment, mixing of the genes, a new virus emerges, but I think it happens all the time and very rarely a new very virulent virus emerges.

COHEN: You're not losing sleep over this possibility?

PALESE: I think it is not -- I think it's like -- I'm not waiting for a lottery win. I think it's very rare and I think it is also very rare that a new 1918-like virus would emerge.

MONTO: I agree that we've got a lot to concern ourselves with, and to lose sleep and to divert attention from the really important questions to speculation which could be endless about reassortment events producing a doomsday scenario really divert us from what we should be worrying about.

The one reassortment scenario that I worry about -- again, I'm not losing sleep over it but something that is realistic -- concerns the fact that our seasonal or formerly seasonal H1N1 viruses have become resistant to the antiviral that we most commonly use, oseltamivir or Tamiflu, and we've now got a pandemic H1N1 virus and in some regions they have been co-circulating, and you can come up with a scenario that the NAE (ph) segment, the neuraminidase segment, could reassort from one to another and give us a resistant-to-Tamiflu pandemic virus.

Again, I'm becoming more and more of a fatalist about resistance developing to the pandemic virus against Tamiflu because when this happened with the seasonal viruses, it happened in a country which wasn't using hardly any antiviral. It may have come there from someplace else.

But if it's going to happen, it may just happen, and we have to deal with various scenarios and approaches to deal with it. And I think we are doing that now. A lot of countries are not in as good shape as we are because we do have Relenza, or zanamivir, in our stockpiles. Some countries are 100 percent Tamiflu because -- and the resistant virus is susceptible to zanamivir, or Relenza.

COHEN: And just as a point of clarification for people, when people develop symptoms of flu, there are estimates that about 2 to 5 percent of people actually have two flu viruses at that time. I think that's an important point, that they can't actually mix inside of a human. And the pig can actually mix human and bird viruses as the same time.

So if we're putting H1N1, the new H1N1, back into pigs and turkeys, which has happened now, they could reassort with other avian or human viruses to create -- or pig viruses to create a new monster virus. I think that's the worry that some people have.

Lone, do you have any --

SIMONSEN: I don't know that I would lose sleep over it, but I do say I can't help having an eye towards the 1918 data, where we just had a possibility to look at this really carefully in the beautiful surveillance system in Denmark where you could see everything. In the small population you could see exactly what happened.

And you saw that in 1918 there was a lot of mobility. Everybody saw it. A few people died. And then something came back -- and the people who died were 20 to 40 years of age, just like in the major wave. And then they came back six-fold -- were six-fold higher case fatality rate in the fall.

And I'm not saying it would happen again, but I think it's prudent for CDC and others to keep in mind that they assist our president for things getting worse, and we shouldn't take our mind off of that just because it looks mild right now.

COHEN: Well, that leads nicely into the last question I'm going to ask and then we'll open it up.

The PCAST scenario had a worst-case scenario of about half the American population becoming infected. The virus would be peaking right now in this wave so that vaccination may well arrive too late to do any good. The ICUs would be overburdened, especially with the need for pediatric respirators and deaths could reach as high as 90,000.

What are your scenarios at this point? How do you see this unfolding? What do you see today? When you look into your crystal balls, what are you seeing?

MONTO: It didn't take a whole lot of prescience to be able to figure out that it was coming back this fall. And I'm still amazed when people don't realize that if you're seeing a low level of transmission over the summer besides historic precedence -- when you're seeing low-level transmission over the summer, which we never see -- summer camp outbreaks and things like that -- that as soon as school is open, things are going to start taking off. So that wasn't very hard.

Coming up with scenarios in terms of mortality, that's been very difficult because of the characteristics of severe disease. And, again, you can speculate what it would be like -- and I think this has happened in some developing countries. If we didn't have the number of ICU beds that we do have, and there has been strain on them because these outbreaks have been very focal, and in areas where there have been a lot of cases, severe cases wind up in the ICU very rapidly, especially in the 20- to 50-year-old age group.

I think the thing which people don't recognize that has happened is that there was a very strong push to get vaccine out early. And this was based on the prediction -- which, again, was not very hard to come up with -- that we were going to see disease peaking around this time and therefore if the vaccine is going to have any effect, it better be out there.

Because there was a tension between let's treat this differently from a strain replacement scenario, which is what's being used, which requires relatively truncated testing, and doing all sorts of tests in all age groups, which would have meant that the vaccine would have arrived in December-January.

And this is one of the things that the PCAST really emphasized and pushed, and other groups as well. It wasn't simply the PCAST working group. And I think that's one of the real accomplishments, that those of us who see this from a epidemiologic standpoint accomplished in the past couple of months.

COHEN: What do you think, Peter?

PALESE: I think the government should be really commended for having bought the vaccine doses and has been able to really make it happen that they get distributed very early in the season, and I think it's a real great success. And I agree with Dr. Monto that this is really -- the PCAST report was just part of that effort to really make it happen.

COHEN: Do you think it's peaking right now and that maybe the vaccine will arrive too late? In '57 that seems to be precisely what happened.

PALESE: I think if it is really peaking and that was it, I think we should be all happy, yeah.

(Laughter.)

MONTO: But in '57 there was a winter wake --

COHEN: That followed the fall --

MONTO: That followed.

COHEN: Right.

MONTO: And we know -- you know, we estimate the percent that had been infected. We really don't know. One of the things we're proposing to do with the (zero ?) survey, trying to figure up how many people actually have been infected because there's a lot of milder disease and apparent infection. So we really don't know.

COHEN: Well, that's why we have modelers.

MONTO: Yes, well -- (laughs) --

SIMONSEN: Even without models --

MONTO: -- which give us different answers.

SIMONSEN: Even without models we can just look at what actually happened in the past pandemics. And I'll just reiterate what I said before, that because the impact that's going to happen in some severe outcomes is going to play out over years, then it's not too late to get the vaccine, even if this is a peak --

And you're asking if it's a peak year. We can see some cities have actually peaked. They are coming down. If you look at the national surveillance system for CDC for this week you can see it's still going up but that's delayed by one week, so maybe we are approaching the peak.

Your last thing about 90,000 deaths, is that a good estimate of something, well, it sounds pretty reasonable to me, but then I just want to say that we really have to stress this business that it's not 90,000 deaths as usual; this is 90,000 young deaths. If that's 30 years of life lost for each one of them, it could be 300,000 years of life lost compared to a normal season where you have 30,000. So that would be a tenfold higher. So you've just got to think about it in that way.

COHEN: Okay, well, let's open it up now to the audience and to the pleaders. And do we have microphones in the room that can -- and please keep your questions as succinct, if you would. And the Tweet, again, if you would like to Tweet, it's pound or hash symbol, CFRQ&A.

Yes, in the far back?

QUESTIONER: Thank you for the panel. Michael Dal Bello from the Blackstone Group. It seems like the clear consensus is that we should all be getting vaccinations. How do you evaluate the United States' infrastructure to distribute those vaccinations? And in particular, could you compare that to best in class in comparison to other countries? Thank you.

MONTO: Well, this is sort of out of my area. We're very good at making recommendations but the question of implementation is very important one and I think it's going to vary across the country.

This vaccine has been purchased by the government. It's going to be delivered in ways that we are not used to giving influenza vaccine recently. The public health sector has been more involved in giving vaccine than in the past.

I think it, as everything, is going to vary by state and local jurisdiction. Our own county, having the University of Michigan Hospital and St. Joe's Hospital and a very academic and interested group of physicians working together, is going to do pretty well.

I'm worried about the fact that we're in the middle of, number one, a recession, which has affected a lot of the states. And our state, basically, if it doesn't have federal support, it's not being done by the state health department anymore because there's no state funds that are coming into this.

So I think this fits into the decay of public health at the local level in the U.S., which got a bit of a burst during the biodefense kind of era but which has really languished in the last few years. So it's part of a bigger picture.

COHEN: And if you haven't read the book, Laurie Garrett wrote a book about that.

Yes?

QUESTIONER: Betty Masham (ph). Last year, at a discussion here about the flu, we were told that if you get influenza, don't go to the hospital because you'll infect other people. Have enough liquids and food to stay home, and that the Tamiflu and other things would only be given to health-care workers, fire fighters, policemen. So is that the same advice this year? If you get it, stay home and hope you survive?

MONTO: Well, yeah. (Laughter.) It all depends -- it depends who you are and where you are. Certainly that is the advice that has been followed in many areas. If you are a student at the University of Michigan, you are being advised not to overburden the health service by coming in, but there is support at the student housing and the rest to take care of you in case you do really need medical care.

A very different approach has been taken in the U.K. where, at least when they were having -- I don't know what's happening now in the autumn, but at least in the spring they activated their more or less 800 number to call in. And what happened, they had a very large stockpile of Tamiflu. If you became sick and you met a case definition, you had a health-care buddy who would come and get the drug and bring it to you.

The decided that it would not be over-using the drug, because they had plenty, to do it this way. And they also used drug for prophylaxis. And this is one of the reasons I'm a fatalist about development of transmissible-resistant virus because they really didn't see resistant virus developing with very extensive use of Tamiflu.

A very complicated answer but I think the health-care system is going to differ in different places and the responses are going to be --

(Cross talk.)

COHEN: Go ahead.

PALESE: One approach to your question really is get vaccinated -- I mean, get the vaccine. I think that's sort of, I think, the safest advice one can -- and I think the best piece of advice.

SIMONSEN: I just want to offer the other point of view. When you are a patient and you think you might have this influenza and you go in, you're actually putting yourself at risk of getting it from somebody else who is sitting there having it. So that's something to consider.

The reason why CDC has recommended to not treat those who have milder illness is, first of all, to spare the supply for the more severe cases, but also with an eye towards resistance development, that it's probably a good way to delay the time until we have serious problems with Tamiflu resistance.

COHEN: Please identify yourself too, if you would.

QUESTIONER: James Tunkey. I'll introduce myself as a supporter of Laurie Garrett, and thank you for putting this all together.

My question is really about the science of the development of vaccines. With the rapidity with which this set of vaccines has been introduced, what do you think is working? And what's your sense of the different approaches to the development of multi-drug-resistant vaccines, and what do you see as the future for vaccine development? What's really working, in your view?

COHEN: Dr. Palese, you've been involved with making vaccine.

PALESE: The vaccine against the 2009 is very, very good because it's very close to the actual strain which is circulating. With influenza one always has the problem that the vaccine may not be against that particular strain which is circulating but something which was circulating last year or two years ago.

So that's not the case with the 2009. So we are very good in terms of really reflecting what is going outside in the population, what is circulating. So that's very, very good, and as -- I mean, the vaccines are as good as we can only hope for.

The second question is can we sort of -- in the future will there be a universal vaccine against all the strains, and can we make vaccines which will last longer than just one year or two years? And that is obviously in the mind of many of us in the academic laboratories as well as in industry, to really make even better vaccines.

I'm saying even better because the present vaccines are very good, but there is clearly room for improvement, making universal vaccines which are effective against all different strains.

COHEN: Yes?

QUESTIONER: Seth Berkley. If I can make a comment on the vaccines and then ask a question.

The problem with vaccines is most of them are made on eggs and this is a technology that's existed for more than fifty years. It's slow. Obviously if Avian Influenza was to kill flocks and they're protected from that, but it's dangerous, and you have to have that virus that they grow on eggs. So sometimes you can't match the virus as well as you'd like because those aren't the ones that are growing on eggs.

So technology can solve that. There hasn't been a lot of investment in new technology until recently, and I think that's changing, and I think we'll see universal flu vaccines. We'll see lots of new technologies coming out in the near future and I think that's exciting. Unfortunately it isn't here for today's new outbreak.

The question. You didn't talk about -- a lot of things come out. A lot of scandals come out. A lot of discussions about it in the media. One of the things that came out recently was a discussion in Canada suggesting that perhaps people who receives regular flu vaccine had a higher risk for severity of disease. I think that has been done away with but I think we ought to comment on that --

COHEN: And that's an interesting question, and the exact opposite finding came out of Mexico, and Seth Berkley, by the way, is head of the International AIDS Vaccine Initiative, so he knows what he's speaking about when he's speaking about AIDS -- about vaccines. Anyone want to comment on --

PALESE: Yeah, I -- I --

SIMONSEN: Well, how do they refute the --

PALESE: The Canadian problem.

COHEN: Helen Graham (ph) will --

SIMONSEN: I --

COHEN: -- be on a later panel --

SIMONSEN: I think that this was an example of a really, really difficult -- and you had a hypothesis, you really want to go see the study. You're working on it in real time. The Canadians did an amazing job working this problem up. Some of the -- the whole underlying problem with figuring this out is that there is a beautiful potential for confounding and bias in that people who are very severely damaged by asthma -- they are having problems with asthma. They are more likely to get vaccinated. They're also more likely to end up in the hospital. It's very hard to control for their -- (inaudible) -- studies. However, one of the studies I couldn't do away with, and that was a major first one they saw. I just couldn't see how you could explain that observation away. So I don't know. I think that that will give it the benefit of a doubt so that there was something.

MONTO: I'll go further than that because I -- we're one of the sites participating in the CDC observational study that has almost exactly the same design, and we just don't see it. And there are studies in the UK, studies in Australia. WHO has spent hours on conference calls discussing all this because it has enormous implications for policy and this is for unknown reasons and clearly bias confounding seems to be a problem in Canada. And I'm looking at Helen over there.

We don't understand it because in Canada, this is not simply one study. This is three or four studies coming to the same conclusion. So it may simply be the way -- remember we're working here with medically -- basically with a variety of medically attended illnesses, so it may be something -- and it's not a randomized trial. And there's something funny going on.

The other thing is we have no biologic basis for this actually being the case because if this is a problem, natural infection with seasonal H1N1 should also be a problem, and we don't have evidence.

COHEN: So you don't see it but you take the study seriously?

MONTO: Oh, we have to take these studies seriously. They're well done.

COHEN: Yes.

You've been waiting a long time. Go ahead.

QUESTIONER: Thank you. Cynthia Roberts.

You have speculated about the virulence of when the flu pandemics are more virulent than others either because of the mixing or because of perhaps bacteriological covariance, but I'm interested in the other side of the question, the pathogenicity.

Do you we know why -- in the scientific community -- why some of these pandemics are more pathogenic than others, that is they spread more? This one seems to be spreading much faster than '57 or '68. Unlike 1918. Or is that we just don't have enough data yet, we don't know, or that's just incorrect?

SIMONSEN: So I'll say something about the -- (inaudible) -- then you can say something about the virus maybe.

Actually it doesn't spread faster than the other pandemics. That can be -- the estimate that we measure which is called on off (ph) because of this frequency of this on off (ph) thing happening, and that is quite low. It's not that much higher than seasonal flu. Compared to 1918, for example, it was probably over two. Here it was just 1.4. So can't really say that it is transferring faster or transmitting faster.

COHEN: Explain what the two and 1.4 mean.

SIMONSEN: Okay. So it simply means that for every person who is sick on the average today and sick, 1.4 people and when you see that traveled over many generations of infections, it leads to a very different path of an on off spread. So that's sort of the key parameter that we are trying to measure. So from all the studies I have seen they may show -- in Mexico and other -- somewhere between 1.2 infection for each person up to 1.5. So it doesn't seem that high to me, but then again you have this mystery of New York City suddenly had a huge wave in May and June and not in other cities and I think that remains completely unexplained by --

MONTO: Well --

SIMONSEN: -- mathematical models.

MONTO: Well, that's not quite true because in Ann Arbor, Michigan, and the entire Michigan area, we had -- we filled up our intensive care unit and this has been reported in the MMWR. We had a major outbreak, and I think the thing that is different, we speculated on --

COHEN: You mean last Spring?

MONTO: Last Spring. Last Spring. And we're not seeing a whole -- we're seeing university outbreaks. We're not seeing a whole lot in the community because I think we had a lot of our infections last Spring, and what we all speculated about was what the effect of high level air travel would be on the spread, and I'm talking about dissemination rather than the person to person spread. Dissemination of the infection, and we -- now we know because it showed up in so many parts of the North America at the same time and people were coming back from Spring Break and all the rest in Mexico and it clearly was impacted by what we think was a high level of transmission in Mexico, which had to be the case, since it came from all over, and air travel into various parts of North America.

COHEN: But Dr. Palese actually studies what makes influenza viruses nastier, if I can say it that way. Also I should have mentioned. Their bios are all on the web and in your packets which you get.

Dr. Palese, what do you think?

PALESE: Yeah, we know really a lot about -- (inaudible) -- influenza viruses. We can study for example, the 1918 virus in the laboratory under high containment, the conditions. So we really understand a lot about the molecular signatures of these viruses and really I think that this helps us to sort of gauge how virulent a particular virus is and what potential it has. So we really know, for example, that this -- now the 2009 virus lacks certain signatures which other pandemic influenza viruses have and that also I think goes a long the way to suggest that this virus is not an 1918 like virus.

COHEN: Or '57 or '68.

PALESE: Well, I would add also, it won't be like 1957 or 1968 virus.

COHEN: All right.

Go ahead -- (inaudible) -- and if we have any Tweaters (sic) tweating.

QUESTIONER: Tom Wilson (ph), Cornell Medical School.

Sir, I think we're all aware that the anti-vaccine movement is having a field day on the Internet and on media outlooks like Fox News and so on, causing productions in vaccine uptake, and it appears to be a pretty unholy alliance of the ultra right and the ultra left working together to sort of hit with strong anti-tactics, and I'm not sure we're countering these people very well, and one of the things I do in my spare time is counter the AIDS denial as to people believe HIV is harmless or doesn't exist, and who led to the deaths of over 350,000 people in South Africa over the past decade.

And you have to take these people on in a different style than scientists are used to. We have to develop better sound bites. We have to develop better discussion. You don't really -- you can't really debate these people, but you have to develop the counter methods. For example, you hear that we shouldn't take flu vaccines because the mercury will kill us.

Well, Paul Offert (ph) in the New York Times last week pointed out that there is less mercury in a flu shot than there is in a tuna fish sandwich, and that's a powerful sound bite to use against the crazy people who think that vaccines will kill you. That's just one example. We need to develop anti-tactics to get across the message that vaccines are safe and beneficial to society, and we need to learn to deal with the crazy people who would try and stop us doing that.

COHEN: Do you have a question or --

QUESTIONER: That's really the question. How best we can develop methods to stop the anti-vaccine movement causing so much damage --

COHEN: And --

QUESTIONER: (Inaudible.)

COHEN: For me?

QUESTIONER: Yeah.

COHEN: Well, I mean, as far as a journalist's perspective on it, I think our job is to put facts forward and to also expose people and institutions that promulgate things that aren't true, and that's all we can do. There always will be people who think things that are not accurate.

I've never figured out a way to stop them. All I try to do is combat nonsense with truth as much as I can, and that's kind of it. And I will assume that in a place where we allow freedoms of speech there will always be people saying things that I think are pure lunacy. And they'll always be there.

SIMONSEN: I'd like to completely agree with you. I think there's a lot of room for improvement, virtually reaching better across the public health expertise to attract the people who are interested in receiving the facts and actually to prevent the mistrust. Actually, there are many people who sort of (inaudible) that mistrust and I think there's really a very good case for doing more in the area of psychology and communications strategy to actually relate data and so that people can really understand. I mean, we're on the same plane here. This is a disease that's threatening humanity and here is the best vaccine and you need it.

COHEN: Lori had a question.

MONTO: I also have ruined many dinner parties, Jon, over this issue, so I side with you.

GARRETT: I'm Lori Garrett from the Council. Two very, very quick ones. One, Dr. Palese, you said this particular virus, fortunately, does not have the genetic signatures that we look for that tip us off that we're looking at a dangerous, virulent influenza, but there was a report, a reliable one out of the Netherlands, regarding two individuals who appeared to have this what's called the PB2 mutation in their H1N1 so that somehow this had naturally arisen in the Netherlands.

If it could happen in two cases, why couldn't it happen in more? If you could answer that and then to the group generally, one big lesson we're getting from the Southern Hemisphere experience is that there have been very marked differences in mortality between the poorer countries in the Southern Hemisphere and the wealthier, and if we follow the Australia/New Zealand information, a lot of it has to do with really heroic intensive care measures, including artificial lungs that are essentially washing all the blood of the patients and, nevertheless, the mean age of the death group was 34 years of age.

So I guess that leads me to the question -- what does this really tell us about the difference in mortality between wealthy world experience and poor world experience or between areas with less access to health care, even rural America, versus a place like New York City.

COHEN: Dr. Palese, you want to start with the PB1F2 question and briefly explain what that is?

PALESE: Yes. So, clearly when I say this 2009 virus is like another seasonal virus, I don't mean this is a harmless virus which we should ignore. No. The regular flu is bad enough and this 2009 virus is also bad enough. Having said that, it lacks certain signatures, certain molecular signs which are associated with the 1918 pandemic and then explained in 1957 and in 1968, and that is one of the genes.

It's a short one. It has a technical name, PB1F2 and that is missing in the 2009 virus. And it could acquire this by exchanging that mini-chromosome and getting one which carries that PB1F2 or by point mutation. However -- and that would make it more virulent. However, it is sort of like if I put a more powerful engine into a VW, if I put a Lamborghini engine into a VW or a little Fiat or some car, it may not be better. It may not fit. It may not mesh and that, I think, may also be happening with the 2009.

By accumulating and getting mutations or getting this other gene, more virulent gene, it may not end up as something which is really a sports car which runs 200 miles an hour, so there is a lot which has to sort of fit and mesh in order to make a virus really a 1918 or 1957 ---

COHEN: So it's really a multi-genic process? It's more than just one?

PALESE: Yes, and, again, I mean, if you have a marathon runner, just giving him long legs doesn't mean that the guy will win. I mean, he needs also good lungs and so - and one long leg won't help either, so in a way -- (laughter) -- by giving one new virulent stream into that doesn't make it really, in all cases, more virulent.

COHEN: What about the Southern Hemisphere versus the Northern Hemisphere and what Lori was pointing out is, I think, really astonishing, what's happened in Australia, New Zealand and the lengths they've gone to, to rescue people who otherwise would have died, and they've said as much, that they would have lost I think up to 90 percent of the people they saved. What do you think? I mean, are we missing ---

MONTO: I think we've seen this in the United States, as well. It hasn't, because of the focal nature of the outbreak and our being a much bigger and more diverse country, we don't see the reports, as was in the Australian media of cases being --- when the ICU is overwhelmed and Carron's there flying the patient someplace else for care.

And I think Lori has made a very important point, though, about the parts of the world where these kinds of heroic measures are not possible. And that may explain what went on for a very brief time, actually, in the greater scheme of things, in Argentina, probably went on in Mexico, but that's kind of muddled because they were seeing other things being transmitted as well as the novel H1N1 virus.

But the concern is what we -- what is going on in the under- resourced countries -- and we may not even be hearing about it -- because, besides everything else in these under resource countries, they're used to having catastrophic events taking place without good surveillance systems and the rest and sub-Saharan Africa, we know very little about what's going on with influenza viruses in general. That's one of the targets for improvement in surveillance in that culture.

COHEN: Yeah, if you look at the map, it's not there.

MONTO: It's not there. It's sterile because you don't know about any viruses coming from there.

COHEN: We have a question that came in from the web from James Bailey: Why would we want people to get the swine flu vaccine and the seasonal flu vaccine? Wouldn't that in itself cause mixing in the human host and a potential for creating a new pandemic type virus?

SIMONSEN: No.

COHEN: Okay.

SIMONSEN: First of all ---

PALESE: If they're talking inactivated vaccines, no. If they're talking --

COHEN: --vaccines, killed virus, but the other one is live virus. So, inactivated, no, but could the live virus mix, do the two mix to create a new strain? Dr. Palese you've actually helped develop that vaccine. What do you think?

PALESE: I would like to say with great difficulty. I think this is very unlikely to happen.

SIMONSEN: And the only place that it's even a remote possibility would be someone who got the two live attenuated versions of the two vaccines at the same time.

COHEN: Which you're not supposed to do.

SIMONSEN: Yeah.

PALESE: Which you're not supposed to do.

COHEN: Right.

PALESE: Don't take antivirals at the same time because then you won't get infected by the live virus.

COHEN: Let's go to the far rear and then we'll come back to the center.

QUESTIONER: Good morning. Rory Lanceman. I'm a member of the New York State Assembly. We had a 12-hour hearing on H1N1 earlier this week and much of it focused on the mandatory vaccination that the New York state Department of Health has ordered of almost all health care workers in New York state and I was wondering if you could offer an opinion on whether you think such a policy is effective and sound.

MONTO: I have a very strong opinion about it. (Laughter.) And that is I think that's appropriate and I think it ties into a dilemma we're currently having about personal protective equipment and the way health care workers can be prevented from getting H1N1 influenza from their patients and also, the more likely event, transmitting H1N1 infections to their patients because, really, I think the debate about personal protective equipment -- availability of N95 masks -- is a fascinating discussion based on very little scientific evidence so that what you have is sort of inflated in terms of its value.

But the point I keep making is that you're more likely -- a health-care worker is more likely to get influenza from his or her children than from a patient in terms of protection of the health care worker, but even more importantly, because of this, is more likely to be able to transmit to another sick patient than anything else. And this is really what we're getting at, not so much protecting the health-care worker but protecting the patient indirectly because often these are immunodeficient patients and the rest who wouldn't benefit that much from vaccination.

COHEN: And I suppose you wouldn't even be having the debate if health care workers were first in line to get the vaccine, but that's part of the issue, right, is that ---

MONTO: Well, they are first in line to get the ---

COHEN: Well, they're given priority but do they --

MONTO: They're given priority but whether they're going to do it is another issue.

COHEN: Right.

PALESE: That recommendation, really, I think, makes a lot of sense based on scientific evidence.

COHEN: Then should we mandate for children?

(Laughter.)

COHEN: We do for school entry. Individual states do for school entry. Why don't we do that to protect the population? And we know that protecting our children from the vaccine, if they are indeed ten times more infectious ---

MONTO: A very brief answer which covers a lot of problems with influenza vaccine and we've heard it brought up already and that is, a lot of our problems with mandating influenza vaccine, use of influenza vaccine, would go away if we didn't have the need for annual vaccination. I mean, we've got a different kind of vaccine here, and I think we need to recognize the difference between influenza vaccine the way it's used and the fact that it's a good vaccine.

It's not a great vaccine. We've shown in a recent study 70 percent efficacy of the live vaccine in healthy adults young adults, who should have the best efficacy. We need, as we've heard, a better vaccine.

COHEN: Well, it's an interesting question, though. Would you be against mandating?

SIMONSEN: Well, I think this is very interesting because, I mean, especially for the health-care worker example. I mean, there are many, many good reasons why health care workers should be considering immunization for their own safety but also to protect and, first, do no harm to the patients that they are treating. Having said that, does it work to mandate?

I think what would work better would be to say that there was a shortage and people tend to buy more of something that's in demand. (Laughter.) We saw that -- there was one season where, really, people lined up all night to get a flu shot.

COHEN: Right.

SIMONSEN: And I mean ---

COHEN: Well, there is shortage.

SIMONSEN: No, actually, because we thought we were going to need two doses for every adult and since we are - only one dose, so, actually, we have twice as many doses and enough for the whole population at this point, I understand.

COHEN: But it's not there today, so --

SIMONSEN: Right, right. But I mean, that's --

COHEN: You had a question. You've been waiting a long time. And please identify yourself.

QUESTIONER: Alice Wong from Cal Tech. My question relates to the CDC updates and in their reports of isolates from throughout the world, Africa stands out as a continent that has more isolates of the regular annual flu than the other continents. They also do have isolates of 2009 H1N1. Do you think that the data are telling us something or that it is a result of bias in sampling or in reporting?

PALESE: I mean, I don't think it's bias and bad reporting. I think there are regional differences, and whether it really tells us something I'm not sure at this point. I know the data are mostly from South Africa, as I understand it.

PALESE: I'm not sure whether at this point it really tells us a lot, other than that there are differences. As you know, in New Zealand, for example, it's just the opposite. It's mostly 2009, H1N1. Maybe you're already sort of sensing something interesting going on, but I am not sure that it's, at this point, really clear what it means.

MONTO: But it does tell us we'd better use seasonal vaccine because the other viruses haven't gone away.

SIMONSEN: Right. It really goes to that bigger question -- will the other seasonal types come back in the winter and cause the usual epidemic that will kill a lot more elderly people? And, well, personally, I think that's a really interesting observation. I keep my eyes peeled on that kind of thing because if it exists anywhere on the globe it has the potential to come anywhere because, as we know now from understanding better the molecular epidemiology influence, it always comes by import.

It seems to come from the tropics and then every season you will see it, so as long as it exists in Africa and those South African -- (inaudible) --- surveillance systems, but there was also a false alarm from Egypt. Suddenly, we got some reports that there was a co- infection of H5 and H1 in a patient, and that turned out to not be true.

COHEN: We unfortunately only have time for one more question, so somebody go ahead in the rear.

QUESTIONER: Jim Shind from Princeton University. Some people have suggested that the swine flu experience was kind of a fortunate, if tragic because of the deaths, sort of a fortunate warm-up act for the real avian influenza doomsday scenario down the road. Do you concur with that and, if so, what do you think were the most important lessons that came out of the swine flu experience that are particularly important maybe in preparing us for the avian flu?

COHEN: I didn't plant the question, but it's perfect. It's a great wrap-up. What do you think? What have we learned from this teachable moment?

MONTO: I'll say something very brief and then give over to Peter, who I know has some strong opinions about the likelihood of an H5 pandemic and that is that talking with some of the local folks who had prepared, they thought, for an H5N1 pandemic, they felt that they were stressed by this in terms particularly of the surge for pediatric beds. There's not enough pediatric ICU beds so that I think this was a wakeup call in terms of preparing for something which would have different characteristics.

I'm not going to say more severe, less severe, and I think this is a -- this really was in some ways, and I take exactly what you were saying about it's too bad, but this really helps us in preparing. And I just want to remind everybody that there were only ten years or so between '57 and '68, 11 years, and these were bona fide pandemics without anybody debating was it a new sub-type or not a new sub-type, so we really can't anticipate anything in terms of how long we won't have another pandemic.

COHEN: Peter, briefly.

PALESE: Yeah, I think in a way even the H5N1, the avian threat ten years ago, prepared us for the current 2009 H1N1 outbreak, and I think if a new, real pandemic or a new strain emerges in the future I think it will help us to be prepared in a better way, so I think it also helps us to focus on the regular seasonal influenza, which I think is not being treated well enough in terms of preventing and in terms of a preparedness plan. So I think all of that helps us to get in better shape for future and seasonal influenza.

SIMONSEN: I think maybe this -- one focus that has come out of this particular experience is the focus and search, how important it is to understand the peak performance of a system. For example, in New Zealand, where they got so close to their capacity in the intensive care units, that's really an important thing to be aware of.

It really comes down to when the rubber hits the road, we now understand it's the hospitals we need to -- they need to really be prepared. Did they buy all the gloves and masks and what about the TB patients who now there's no more masks when we treat them. That's kind of where the action was at.

I had one meeting about that, about how, really, when you come from the perspective of the people who are going to treat the patients, that's really where the preparation is needed big time and that's the experience that has been had here.

COHEN: Well, I want to thank the panelists and all of you for coming and all of you for watching on the web. We're going to take a 15-minute break. Please return promptly because the next panel will start on time. Thank you all very much. (Applause.)

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LAURIE GARRETT (Senior Fellow for Global Health, Council on Foreign Relations): Welcome back, both to the webcast audience and to those of you here in the room. I give you Secretary Robert Rubin.

ROBERT RUBIN: I think Laurie was starting to get nervous. (Chuckles.) But one lesson, I think, is that you live in the richest country in the world, but if you're caught in a side street, it doesn't matter. You can't get through. (Laughter.)

Okay. Let me start by welcoming all of you. I'll be moderating this second panel of your symposium on pandemic flu. As you know, the second section will be on economic issues. We are very pleased that the council could be co-sponsoring this, as I'm sure Laurie's already said, with Science Magazine.

We have an outstanding panel. I will mention them in just one moment, but it is really an extraordinarily distinguished panel. Their material is in the -- or, their descriptions are in your material, so I won't go through that. Let me just, though, very briefly name them.

Yanzhong Huang, who is the director of the Center for Global Health Studies at Seton Hall University and an expert on macroeconomic effects of these kinds of events.

We have Andrew Jack, pharmaceutical correspondent for Financial Times, but has also covered many other areas in his times at the FT.

And Michael Osterholm, who is on the phone, somehow or other -- Michael, are you there?

MICHAEL OSTERHOLM: I'm here. Thank you.

RUBIN: Good. Okay, how are you?

OSTERHOLM: Good morning.

RUBIN: Michael I happen to know, and Michael's Center for -- the director of the Center for Infectious Disease Research and Policy at the University of Minnesota and truly an expert in these kinds of areas. He scared me to death a few years ago on the bird flu, so now he's prepared to do so again, I guess. (Laughter.)

What we're going to do is this. We're going to have a format of roughly 35 or 40 minutes in which I'll pose a few questions on the economic dimensions of pandemic, and we'll discuss those amongst the panel. And then we'll have about 30 minutes of questions from you all because also, as I'm sure Laurie's already said, we're being Webcast so you can Tweeter -- or Twitter, or -- what is that thing called?

(Scattered laughter.)

GARRETT: Twitter.

RUBIN: Twitter. (Chuckles.) Okay, whatever. If you've got a passenger pigeon, you can send it to us via Twitter. And the number, I gather, is -- oh. Number CFRQ&A. That's what I was told. Pound mark, CFRQ&A, and apparently that will find its way to us somehow or other.

We'll be on the record, as Laurie has already said. When we get to the questions, if you'd just please identify yourself. Cell phones, et cetera, should be turned off.

And I think with that, we are ready to begin.

Let me start at a simple level. I actually spent a fair bit of time on this. Laurie gave me a ton of material to read, which I figured I'd put my side and not read it. But once I got into it, I really did find it interesting.

And I must say, the more you learn about this, the more complex and uncertain -- at least to me -- the more complex and uncertain these issues become, and that the trade-offs become very difficult.

I thought to myself, if I were back at Treasury where I spent a long time at one time, I think I would have a very difficult time trying to figure out how to weigh and balance all this. And we'll get into that, into some of my later questions.

But I'd like to start with a very simple question, if I may.

If you take the mid-case in the probability of distribution, which I presume you've already discussed, PCAST or whoever else's projections you want to use, take the mid-range probability, whether in this wave or in another wave.

What are the kinds of economic consequences you think might flow from that, both directly -- the developments in the United States and also including supply chain and other kinds of effects from abroad? And why don't we do that. We can just start right here, I guess.

Professor Huang.

ANDREW YANZHONG HUANG: Okay. I guess when you to take the mid-range, that means the infection rate of the PCAST forecast is about 30 (percent) to 50 percent people who will be infected. So I take the 40 percent.

That means, I think -- if that is true, it is going to -- depends on the sustainability of the economic effects and the severity of the disease -- I think it's going to take a heavy toll on the economy at the global, regional and national levels.

Forty percent infection rate is going to cause, I think -- let's think about this, both sides -- the demand side and the supply side.

I think a pandemic is unlike SARS, which -- whose impact is mainly on the demand side. A pandemic is going to have a huge impact on the supply side because of its impact on the health of the labor force.

So according to a report of the Human Security Council a couple of years ago, if 25 percent of people who are sick, then the fuel and food supply will be severely impacted. And that is going to deal a serious blow to the -- to our national economy.

And now we are talking about 40 percent, so imagine how serious that impact is going to be like.

ANDREW JACK: Yeah. I mean -- there's always the impact, sort of, across the -- all across the range, aren't there? There's the direct health impacts -- both positive, if I can put it that way, for the pharmaceutical industry and those who are delivering products, but of course largely negative for most others.

You've seen, obviously, some industries -- face masks, hand gels, all those sorts of deliverers -- who've already done pretty well.

And it seems to me, just looking at the current pandemic, you've had very strong sort of multiplier effects, given actually the nature of the relatively mild severity of the infection so far, there's still been a huge uptick in, you know, demand for vaccines, in purchase of drugs, both antivirals, antibiotics and others.

What's still difficult to play out, but we've already seen some effects with the first wave of almost the -- well, it's now the downturn of the second wave in the States is, as it were, not just the natural effects, but the human-exaggerated effects -- you know, the quarantine measures, for example, the effects of school closures and what effect that's had on driving sometimes a working parent to stay at home, the disruption that causes.

You only need one or two little weak links in the chain. For example, it turns out with just-in-time production and delivery, whether it's goods into supermarkets or whatever, you'll suddenly find that one truck driver falls ill and the entire distribution system of food into grocery stores or, indeed, cash into cash machines can have a huge ripple-out effect for elsewhere.

And certainly, in the U.K., I know, going back a couple of years, there was a lot of scenario planning in the sense that if there's a problem with HUV, heavy-goods vehicle drivers, we can bring in the Army or whatever.

But of course -- (chuckles) -- most of the spare trained HGV drivers in the U.K. Army, for example, are in Iraq or Afghanistan at the moment. And so, very difficult to pull those out, so the system is stretched thin.

Then you add that, of course, to the economic downturn. Arguably, there should be more spare labor around. But on the other hand, so many companies have already cut back in other areas and looked for economy measures that it's a pretty bad time, obviously, to have extra demand.

So I think we're pretty fortunate that at least thus far this pandemic virus has been relatively mild.

RUBIN: Michael, do you want to add to that?

OSTERHOLM: Yeah. I think that Mr. Jack really did a nice job of laying out the current scenario.

One of the concerns we all have is that this pandemic is occurring on top of a global just-in-time economy. And I think that there are far too many times that we relate the severity of a pandemic in terms of deaths as to what it will do to the economy.

There really are two different categories of impacts that it might have on the global economy. One is, first, absenteeism. And while we hear about these large numbers of absenteeism figures out there, remember that's over time.

So that if we even talk about 40 (percent) or 50 percent of the population becoming infected, it's over weeks to months, and so that, at any one time, we shouldn't have large numbers.

Now, having said that, we've recently received reports from U.S.-based companies with plants in Indonesia that are reporting 30 percent absenteeism at some of their plants as a result of what they believe was the H1N1 situation.

Now, that shouldn't be long-lived, if it, in essence, is sweeping through a community. But it can surely cause a problem there.

The second one, though, which I think is even more important, is the exaggerated response of governments or other organizations to the situation.

I mean, I've been involved in outbreaks where two cases of bacterial meningitis can literally freeze a community into inaction when it occurs in that community. And so that what we're concerned about is, is that we don't see border closings, quarantines or inhibition of trade and travel that would be exaggerated in regard to what the real risk is.

And that was what we clearly saw initially in the spring wave, where there were countries that wanted to shut borders, thinking they could keep out this virus -- which is like saying that you've fixed 12 of the 13 screen doors in your submarine. (Laughter.) It's going to get in, and I think people now realize that that's the case.

The final piece I would just add, though, is I don't think anyone really understands what it takes to basically put one rock in the gear of the global just-in-time economy.

We in the health-care area already are very concerned because the vast majority of critical pharmaceutical products -- devices that we use in the intensive care wards, the products that we use in infection control, like masks, respirators, gowns and gloves -- are largely made outside the United States.

And these supply chains are very thin. There's no redundancy, little surge capacity. And so if we do have a hiccup or an interruption in a foreign production site or the trade and travel that occurs with that, we surely could see big problems.

Let me just give close. In the state of Minnesota, for example, the average Minnesota hospital has about 34 days of money on hand. That's enough to pay one month's payroll. They don't invest in anything right now that doesn't have a payout in those first 30 days.

So we've stockpiled virtually nothing. We don't have supplies out here that we can use in light of a surge need, and that's a serious problem.

RUBIN: Michael, before -- actually, the next subject I was going to raise was the kinds of actions that should be considered now in preparation for the possibility of a pandemic, given cost-benefit analyses.

But before we get to that, you raised the Indonesia point. What about supply-chain problems that develop? Because even if we manage this issue reasonably well in the United States -- a big if -- developing countries are enormously less well equipped. And yet we have become tremendously dependent on developing countries across our economy, not just in the medical area that you mentioned.

Anybody want to pick up on that a little bit?

OSTERHOLM: Well, can I just add a piece to that? Because I think we heard in the previous session the issue of vaccine.

And I, like many, are very concerned that for at least the four coming weeks we're going to have very little vaccine out here. Because while the pipeline is starting to flow, at the end of that pipeline are a lot of rusty faucets out here for distribution.

So even in a country like the United States where extraordinary efforts have been made to get vaccine here in a relatively limited period of time compared to what we might expect to see, we're going to have a problem.

But we just did an analysis of the 15 largest importing countries into the United States. And if you just take the orders for vaccine by the governments of those 15 countries, we estimate that less than 3 percent of the citizens of those countries will ever even have access to vaccine. And again, those are going to be delayed.

So I think that the big impact that we're seeing out there, either -- whether or not they'll have intensive care medicine, they'll have vaccines, the developing world's on their own. And I think that's the critical point.

Let me just add just one sense of the importance of that. We've just completed a study where we interviewed a group of world-renowned pharmacists in all areas of medicine and said, what are those life-saving drugs that we have to have in this country every day, or people die? Not cancer drugs, not HIV-related drugs, but what's on the crash cart in the emergency room -- insulin, drugs like that?

And it turned out that over 95 percent of those drugs were generic drugs manufactured in the United States, and most of them were manufactured in India and China. So what happens in India and China? And what the implications are for the H1N1 there has tremendous implications here, because there's no stockpiles of those.

In Winnipeg, Canada, last summer they ran out of sedation medications for keeping people on these machines three different times. They just couldn't get it. And when we have a whole worldwide pandemic, everybody's drawing down those same resources at the same time, it's kind of a perfect storm.

So I think that is the implication that we really need to talk about today. What will the global supply chains mean when the developing world can't respond as, say, a country like ours can?

RUBIN: Yeah. I'm going to get to that. I'm glad you raised that, Michael, and I think that that, for policymakers in the U.S. and the (industrial ?) countries, it's going to pose an exceedingly complex question, which I'll get to in just one second.

But would anybody like to add to the comments Michael made?

I think you're heading into what is a second- or third-order kind of effect issue of immense importance. But --

Yeah.

HUANG: I think the pandemic is going to cause significant disruption to the highly integrated world economy. The difficulties in travel and trade will affect the flow of goods and services with cascading effects on the -- in the industries which are tightly linked to supply chains, that heavily depend upon the supplies, especially in affected countries.

I would add -- Michael probably is the expert on that -- most supplies of the base ingredient of Tamiflu actually are in China. The --

So if actually China, for example -- this is just a hypothetical scenario -- decided to nationalize or restricted the supply of this base ingredient, that would be something really that's going to affect our surge response capability here.

And also, if SARS can be of any guide in terms of economic impact, it's not as much the direct impact that is the medical cost associated with a disease or the lost productivity, but actually the disruption to the trade and travel, investment, the disruption to the supply chains and also the altered consumer -- the behavior changes in the consumers, travelers and businesses.

JACK: Three things, briefly. What about -- (inaudible) -- as the Heparin, the blood thinner, situation obviously illustrated very powerfully here a couple of years ago, striking how much out-sourcing, particularly of the raw ingredients for pharmaceuticals, is now made by third parties, particularly in India and China.

But I'd like to bring the focus back closer to home geographically. Seems to me the cross-border effects, even amongst developed countries, are very important. And if you have different pandemic scenario planning and different responses, that can create huge sort of confounding effects and broader effects, whether it's different approaches to treatment, to prophylactic, to vaccination, and you can get --

Let's say the Dutch cross over to Belgium, for example, and so on. Different nationalistic policies even, because of course in terms of vaccine and, for example, the antiviral manufacture, it's a very small number of plants in different countries.

And one could well see a scenario -- third point, bring you back to the U.S. --which, in the last two or three years, of course, after having a sort of witness to devastation of its vaccine industry, for example, started to reinvest or demand, as a condition for contracts, with international pharma companies that they place their plants within the U.S. Good for the U.S., bad for others.

And I know for quite a long time there was a period when the big drug companies that had lots of orders, investments, as it were, a green light to go ahead and scale up production on vaccines and drugs from parts of Europe and Canada, indeed, and elsewhere, the U.S. was holding back.

But there was always a feeling that the U.S. itself might, dare I say it, close its borders and refuse to allow international production made in the U.S. to go aboard until U.S. capacity had been met.

RUBIN: That gets us to a question I want to raise, and it is both a moral question, but I think an intensely practical question.

But before we get to that, it seems to me one point that that makes --- (chuckles) -- all of us have lived in arenas in which this question of interdependence and globalization and then international governance on transnational issues has become extremely important

It seems to me, in preparation for pandemic flu, having a plan that deals with these kinds of issues about border closings, transportation, transportation restrictions, in advance, rather than trying to do it ad hoc when this thing occurs, could be of enormous importance. Otherwise, it's not very difficult to see governments overreact, and then overreact in relation to each other and really go into some kind of a paralysis.

Let me ask you all a question. I was thinking about this the night before last.

There's a limited amount of vaccine; there's a limited amount of antiviral medication; there are limited number of gloves and gowns and masks and all these kind of things.

And in a market economy, these would get allocated by who can afford to pay for them, in which event the industrial countries would get virtually all of them, plus the elite, the absolute elite in the developing countries.

So number one, is that a moral issue that we should be concerned about? Number two, leaving aside the moral issue, if we go that route and developing countries, as a consequence, have enormous pandemics, that -- could it even cause political instability? How does that affect our economy?

For example, oil from Nigeria, to say nothing of -- you were talking about the medical supplies -- but oil from Nigeria or all the various other kinds of --

Well, virtually every supply chain in the United States today is very dependent on developing countries. If that's the case, then how do we think about the practical aspects of this?

And should the American political system be thinking of some way of rationing -- or the industrial countries' political systems, say -- of rationing vaccines and then the antiviral medicines and all the other kinds of supplies that are needed? And if so, what should the criteria be?

And how do they explain, how would an American politician explain to the American people that we are going to choose to protect less lives in the United States in order to protect more lives in Nigeria because we need Nigerian oil?

Who wants to take that up? (Laughter.)

OSTERHOLM: Well, first of all, I think a really important point here is is that we want to make sure that when we come away from this meeting today, at least we have a status of where we are today.

And I think the good news is is that there has been a lot of work done -- by the WHO and by various governments, that in April, when this first emerged in Mexico and the first calls came out for shutting borders, the public health community and governments alike basically said, no, that that was not going to be an effective way to respond to this. And that has been the case to date. And so I think that while we have isolated events that we think were needless, or out of proportion to what the risk of the disease was, in fact, that's the case.

If could maybe frame this, because it really hit me head-on: I was on CNN live one morning, juxtaposed to Vice President Biden when he was on the "Today" show, and he said he was not going to ride the subway or get in airplanes. And they came right to me and said, so is he right or is he wrong? And my, of course, reaction was, well, this is not a good one -- (laughter) -- to take live here. But I said, he is right and he's wrong. If 10,000 people a day are dying in New York, he's right. If it's what we have now, he's not.

And I think that what we have to do is, first of all, set up a response that is proportional to the risk of what's happening. And if 10,000 people a day are dying in New York, it doesn't matter what we tell governments to do, or what moral contracts we've written, people are going to hunker down and we're going to see major impacts on society. But we haven't seen that. And I think that what we're really asking here is is how do we ramp that up? When is it proportional and what do we do?

And then I think the question that you asked, Mr. Secretary, which is really key, is then what are those things that we have to have? For example, in the United States -- just forget the international piece, coal supplies half the electricity we have in this country. Until the recent economic downturn, coal was a just-in-time delivery product, where we had plants that literally got down to three to five days of coal and almost ran out. And yet we had no plan, internally, for how to prioritize if those 5,000 miners in the Wyoming-Montana area, that supply half the coal in the United States, were to get infected. They were not even on anyone's vaccine priority list.

So I think we need to take a step back and say -- what are those things in society that sustain us? What are those things that we'd like to have, that are nice, but are not critical? And what are those things that are just plain luxury? That would be the first step to then to deciding, how do we deal not only in -- domestically, but how do we deal internationally? Is a computer chip from Indonesia as important as a lifesaving drug is from India? And I think we'd all agree, no.

RUBIN: Well, (I suppose it ?) depends on what that computer chip is used for. It might be used for things that have a tremendous effect on life.

OSTERHOLM: Well, it could on life, but I can guarantee you if that lifesaving drug isn't there right away, the person dies. The computer chip, if it's there, "maybe" they could die. And so, I mean, this is exactly the discussion that we need to have so that we help governments around the world orient to what we're going to do.

You know, there are 50,000 fast freighters out there, that are -- you know, from Shanghai to Long Beach in 10 days, moving things to this country. They're on nobody's radar screen right now for any of the pandemic vaccines. They're not on anybody's radar screen, owned by any country, as "this is something that's a critical asset to our country we have to take care of." Imagine if those 50,000 fast freighters were to be impacted by a more severe pandemic, or by a government action that wouldn't let them in or out of port?

I think that's the kinds of things we haven't thought about that are going to be critical. And I think if the current pandemic stays at the level that it is, we won't have to think about those, because I don't think people are going to feel like it's rising -- is rising to the level of concern where that would be the situation.

RUBIN: Well, I remember a few years ago you talked about the same thing.

Why doesn't the Financial Times, for example -- just since you happen to be here -- (laughs) -- since all of us agree that advanced planning, of the kind of questions that you just raised, Michael, is much better, so that you have a plan in advance, not internationally but transnationally -- and, of course, transnational planning is extremely difficult to do, given the state of global governance, but nevertheless, that that's much better than to arrive at the situation and have to make ad hoc decisions -- why doesn't a respected publication like the FT, on an ongoing basis, alert the people of the world to this problem, so as to try to catalyze that kind of planning?

JACK: Well, I'd like to think --

RUBIN: Or do you just think it doesn't matter, and it's --

JACK: No, no. I mean, I'd like to think that we do. We have, actually, you know, done quite a lot, particularly -- personally, on (some ?) pandemic planning -- for example, scenarios, strategies, and so on like that, and try to debate a lot of those, a lot of those issues. But, of course, there's always room for more.

I mean, coming on to your point about, you know, donations, the moral question and so on, you know, on the one hand it's interesting to me, following the farm industry these days, because they produce something that is so obviously lifesaving -- there is an extraordinary demand -- there's a pressure, you know, that they give it away for free.

But, you know, we don't necessarily expect Citibank, because it's got branches in Africa, to hand out money for free. We don't expect Proctor & Gamble to hand out food for free. But we, sort of, do expect the drug companies to basically sort of hand stuff out. And there obviously has to be a balance reflecting the costs and the risks of development.

But that said, you know, now you see some of these companies that are doing extraordinarily well, out of a very mild pandemic. You know, you has to feel -- you have to feel that there's a, there's both a, you know, there is a moral obligation, I think, to some degree, that they share on that.

And it's kind of ironic to me that, looking in the U.S. case, for example -- you know, we have now this recent initiative led by the White House on vaccine donation, but isn't it interesting, it only came after the tests seemed to show that a single shot of vaccine would actually deliver the job currently. You know, in other words, we will definitely look after ourselves first before we start thinking beyond our boundaries.

But there is maybe a way to -- there's a broader issue, and a moral one. There is a, you know, broader issue of self-interest if we don't provide some degree of structures for greater cooperation. We talked about supply chains and so on, a classic -- a standard example in vaccines, of course, is what happened in Indonesia, where we've got this ongoing battle over the sharing of viruses for flu. And it's quite difficult, sometimes terrifying, exactly what Indonesia's negotiating position is, and keeping it constant.

But that said, you know, this was clearly a case of, you know, here was a country that said, "We should have some of the rights" -- the commercial rights, effectively, or at least the moral rights to benefit from viruses isolated, developed within Indonesia. Of course, the danger of that sort of tit-for-tat approach is, you know, if everyone takes that view we'll never create -- you know, we'll never have the broadest possible range of viruses to analyze and share for the broader global community.

So everyone, developing as well as developed countries, have an obligation to share to some degree. And we haven't worked out what those real mechanisms are.

RUBIN: Well, you keep using the word "obligation." I guess one would -- (inaudible) -- obligation I suppose, or you could just call it self-interest.

But I think -- I must say, having spent six-and-a-half years in government myself, and tried to explain things that I thought were sensible but were very difficult to get (across ?), explaining this politically -- as to why we're going to accept having more deaths in the United States in order to protect people in Indonesia, because we need Indonesian "X," whatever X is, is not going to be a simple task for politicians.

HUANG: No, it is not, I believe, actually. There are strategic economic, political, economic reasons for the developed world to share the vaccines, antiviral drugs to the developing world. But in the meantime, there are practical (difficulties ?) for us to do so.

And, a, we know that the vaccine production capabilities are mostly concentrated in the developed world; and b, while we can say, you know, that during the threat of the -- when we were facing the threat of H5N1, we could say those countries -- the front-line countries, they're more vulnerable to the potential pandemic. But H1N1, they already affecting almost every country in the world., so you cannot say that these countries in the developing world are more vulnerable than us, in terms of the impact of the pandemic.

And thirdly, I want to point it out that while the revised international health regulations make the sample-sharing mandatory, they haven't made the vaccine-sharing mandatory. So it is still -- (laughs) -- the market purchasing agreements that will determine who gets what -- you know, how the vaccine will be distributed. And that, of course, we know will favor the, naturally, the developed world.

That being said, I believe that we still, actually, can make that happen, because, a, we have sufficient vaccines available -- actually, sufficient enough for us to earmark a proportion of that to the developing world. To my knowledge, that the United States has ordered 250 million doses of vaccines. But according to a recent study published by the Science Magazine, modeling on the 1957 pandemic, with only 63 million doses, we (can ?) extinguish a pandemic.

And also that depends, of course, on optimal vaccine rationing, a prioritizing strategy that is focused on the age group -- the groups that, aged between five and 19, and 30 to 39, instead of the current CDC strategy of prioritizing age groups from five months to 25 (years). If we reorient that strategy, I believe we can actually free a significant proportion of the vaccines, making them available to the developing world. And this, in combination with the strategic reasons, I think should actually convince the American public that this is the right thing to do.

RUBIN: Could I ask you a question? If you do what you just said -- I'm older than the group you just (mentioned ?). Does that mean you would not let me buy the vaccine to protect myself?

HUANG: No, it's not that. Actually, this deal that the --

RUBIN: (Inaudible) -- (my life would ?) be sacrificed for the benefit of your model? (Laughter.)

HUANG: (Laughs.)

RUBIN: No, I'm just curious. Is that --

HUANG: The assumption is, actually this --

RUBIN: I understand probabilistically you're taking less risk, but I'm --

HUANG: No, we're not saying that the elderly people should not be protected, they should not receive the vaccine -- (laughter) -- It's just that -- (laughs) --

RUBIN: Elderly? (Laughter.)

HUANG: (Laughs.) I'm not -- I'm sorry, Bob, I should --

RUBIN: No, no, you -- I'm just trying to understand your model.

HUANG: Just based on epidemiological data, you know, people who --

RUBIN: I understand the -- I understand the probabilistic distribution question. I guess, I think, it's going to be -- is it a question, I don't know, maybe I'm wrong, but I just think that in the American political system the idea of rationing medicine in accordance with a probabilistic model -- given that there's not no risk for the people outside the ranges of that model, has its own issues. Optimizing --

HUANG: Yeah -- (laughs) --

RUBIN: -- is going to be very difficult, I think.

HUANG: Yeah, of course, this -- I believe that a lot of this is going to be an ethical issue, a moral issue involved in rationing. I mean, actually we are a market economy; do not like this term "rationing." You know, it's from the efficiency perspective -- (laughs) -- I think, you know, if we were given a limited supply of the vaccine, this is the optimal strategy.

OSTERHOLM: You know, if I could just add a piece here. We actually have a relatively interesting history on the distribution of influenza vaccines in the United States, which I think speak to this.

In previous years, when we've had vaccine shortages, coincidental with increased news reporting of deaths due to influenza, we've seen the elderly literally sit outside in lines for over an hour, in below zero weather, to get their immunization. And then, as soon as there's a perception that it's not a problem anymore, or that there is enough vaccine, nobody wants it and we end up throwing away millions of doses every year with seasonal flu.

So I think the term "optimization" has to have an equal-sign next to "emotion," because in the end, it's really all about what do people perceive to be the problem. And when they can't get it, and it's a problem, they want it really badly. When they can get it, or it's not a problem, "okay, so what?" And I think that's the issue.

I mean, we've already -- I've already received a number of media calls, just in the last 12 hours, about a plan that Massachusetts announced yesterday to put their prisoners who are at high risk of severe disease at the top of the -- one of the tops of the priority lists for how they're going to distribute vaccine in Massachusetts. And there's already an outcry about "this as unfair," and this isn't even a foreign country.

So I think that it really does, I think, Mr. Secretary, come back to what you said, models are going to be meaningless. It's going to be, what's the emotion at the time, and how severe is the problem. And if it's not a severe problem, it's not going to be a problem. If it's a severe problem, there is no allocation plan -- moral or immoral -- that's going to be satisfactory to everyone in this country, and, I think, for most people around the world.

RUBIN: Let me ask a final question before turning to the audience.

Let me ask each of you to very briefly say, what are a few things -- in a sense we've covered some of this already, but what are a few things that you would do now?

Let's assume that this wave sort of peters out, and it's not -- it doesn't have the level of seriousness that many people feared. Nevertheless, you can have another wave, unpredictably, so, we're not through this -- we may very well not be through the thing.

What are a few things that you would do now to prepare -- to be best prepared to deal with the next wave, assuming it is -- if it is a serious wave, taking into effect -- into account the cost-benefit analysis, that is to say, each thing you do has a cost?

We'll start with anybody.

Dr. Huang.

HUANG: Sure.

If we adopt, again, what the, sort of, worst scenario case -- that is, you have 90 million people who need medical service, then I think that this is going to stretch our -- I mean, the United States' surge response capabilities, especially our capability to treat severe cases.

Based on a study, I think, conducted in 2008, the current capability would be sufficient to handle a mild outbreak -- a mild pandemic. But when you talk about a severe pandemic, with 90 million people who need medical attention -- medical assistance, then the conclusion is that we -- that it's going to use 38 percent of the hospital beds, 92 percent of the ICU units, and 40 percent of the ventilators.

And, given that our hospital units usually run at 80 percent of their capability, so I think the focus now should really -- focus our capability to handle the severe cases, especially we need (to) probably consider adding more ICU units.

RUBIN: Well, the 80 percent number, I think, relates to ICUs, right?

HUANG: Yeah.

RUBIN: Yeah. But a billion ICUs is a very expensive proposition. Your thought would be, on a cost-benefit analysis, we should build a substantial additional number of ICUs.

HUANG: Yeah, in that sense, yes.

JACK: Yeah, I mean, I think we should be very fortunate, first of all, that we do have -- first of all that we do have what is a bit of a dry run for a scenario that could be much worse.

So, clearly, the message overall is to really analyze, scrutinize, debate and share, really looking at the real-time experience that we've had, which is unprecedented in pretty much every way, in terms of this virus -- understanding the science of it, testing the systems to respond, and so on.

I suspect that the -- you know, what we've got actually is a scenario -- just thinking about vaccinations, and going back to the previous one, is we're going to have excess supply in the U.S. and a lot of the developed world, which is going to look pretty tragic, actually, you know, with sorts of money that was spent on, ultimately, on vaccines that will be thrown away.

And we're going to have, you know, excess on that demand from the developing world. And actually, one thing that explains -- combines the two is actually what I might call "distribution on health system issues." You know, whether it's about -- both the practical issues of distribution, and that's a big issue in the U.S. -- even more than, dare I say it, in Europe, which has probably a stronger public health system, and therefore easier, you know, systems for access to do massive vaccinations.

There's also a question of, you know, as we talked earlier, the issue of public perception, and cultural understanding of vaccinations, and so on. And those things span along with resources, developing- and developed-world challenges for the future.

OSTERHOLM: You know, let me just take a step back here -- I will answer the question you asked. But, I think, following up on the first panel session, and where we're going, at the risk of sounding like I am throwing some gasoline on the fire here, I don't think that even if this virus doesn't change -- it stays the same, we're out of the woods yet in how we're going to be handling this over the next weeks to months.

If any of you -- and I'm sure many of you in the audience did read either The New England Journal series of articles last Friday, or the JAMA articles on Monday, you saw that, for example, in the Southern Hemisphere, although it did not receive widespread attention, there was a 15-fold increase in the number of hospitalizations to the ICU units in New Zealand and Australia during their winter months -- our past summer, which literally stretched that health care system to the brink.

If you read about what happened even with the relatively minor -- and I say minor in the sense of what it could be "peak" in Winnepeg, you saw that in Manitoba in the month of July every intensive-care bed that was available was used, and it actually rivaled the experience that Toronto had with SARS in 2003.

Now, I would suggest that the pandemic, at worst, has, you know, stayed well "below the top of the levee," you might say, in terms of flooding. But if the virus just continues at the same rate of causing severe disease in the population, but more people get infected as this wave increases -- and we have every evidence right now that over the next weeks, in the absence of lots of vaccine out there, and it's not forthcoming in the next weeks, we could very well go over the top of the levee, in terms of the number of cases.

Meaning, if we just increased by 30 percent the number of cases at any one moment, over what we saw in June and July, we are going to overrun intensive care units in this country. And when that happens, that's where communities can tip. Even though it doesn't fundamentally change the overall perspective of the pandemic -- you know, whether it's 10 deaths, or 50 deaths; whether it's, you know, three more deaths in this community, versus 10 more deaths in this community, again, my public health experience has shown me, time and time again, it's the emotion of how people react.

And I believe that we have to be very careful here because, on one hand, we want to make this be a mild pandemic -- and for the vast majority of people it is, it is absolutely that, but if we suddenly find in communities in this country that, in fact, we can't provide adequate intensive-care medicine to the people who need it, and people start dying -- even if it's just a few a day in large communities, I think you're going to see a very different response in how people react.

And I think what kills us, versus what really hurts us, versus what worries us, versus what panics us, (are ?) often very different. And so I just want to add that note here, because that could have a big impact on business -- will people go to work; will schools continue to be in session? I hope that doesn't happen, but I think that we're not out of the woods on that yet, and I think that far too many people just assumed, "Okay, this one's not so bad. We're done."

Now, to answer your question, "What do we do on priorities," health care right now has to be huge. We have in this country, for example, a major discussion about ventilators. And yet, right now it's not about the ventilator, it's a thing called the "circuit" that attaches to the ventilator. We are seeing shortages emerge there -- people not getting those.

We need to shore up, in the short-term even, not just the long-term pandemic, what are we going to do for the next four to six weeks, to 12 weeks, on medical equipment? Go on any of your supply orderers today, and you can't get circuits. You can't get mass gloves and gowns. You can't get a lot of the medications.

So I think we even have this immediate issue, Mr. Secretary, where we really have to yet solidify that, then we can start talking about, 'what are the long-term solutions?'

RUBIN: And, who in our -- and then we'll turn to the audience, who in our political system, who in our governmental system has responsibility for trying to stockpile, and those kinds of -- ?

OSTERHOLM: Well, first of all, none of it is being stockpiled. The traditional stockpile mind-set has been largely that of around of a bioterrorism event, which has been good. And I must say, we have made tremendous inroads in our government's activities, both in the previous administration and the current administration, around that construct.

But those are typically tied to a single event. New York gets hit, Chicago gets hit, what can we do there?

This is an all-city, all-county. I mean, what distinguishes a pandemic from any other catastrophic event -- a Katrina, even -- is that every village, town, city, county, state and whole nations are in the soup at the same time. And you can't stretch those resources that way.

So it does take on another approach. We have to allocate or we have to limit the amount that we have in terms of any one community getting help from anybody. And then that sets up a whole other set of questions, and we have not addressed those. Trust me, we haven't. And I think that's, from a business standpoint with the health side, that's still going to be a very, very critical one that's wide open in terms of, how do we handle that if we run out of masks, gloves and gowns, ventilators, et cetera? We haven't answered those questions.

RUBIN: Okay. With that, let's open the -- to whoever -- yes, sir. Just state your name, affiliation and a brief question, if you will.

QUESTIONER: I'm Dan Sharp with the Royal Institution World Science Assembly. And I'd like to direct this question to Mike.

The answer to your final question, Secretary Rubin, had been at the macro-national level.

And I'd like to ask you, Mike, since I know you bring together a CIDRP the leaders of corporations and other organizations, to assess the extent to which, at the micro level, the companies are adequately prepared. And what are the principal gaps in preparedness that you would urge leaders of organizations to address as a counterpart to what the country is doing?

OSTERHOLM: Thank you, Dan. I appreciate that. And in fact, as some of you may know, we just held a national summit on business preparedness and pandemic flu two and a half weeks ago here in the twin cities. And a number of the Fortune 500 as well as a number of smaller companies were there.

First of all, one of the things that was very clear and abundant is this economic recession took a big hit on preparedness, because preparedness, in a company's financial page, doesn't show anything incoming, it's all outgoing. And we saw a number of companies that downsized or postponed any kind of preparedness work activity or, in many cases, even let staff go. So we came into this lean.

Second of all is, is that it was amazing. And the Harvard School of Public Health, Bob Landon's group, did a remarkable survey showing roughly that about four-fifths of U.S. companies really were ill-prepared to even begin to address this -- simple issues of just human resource questions about, how do we keep sick people away from home if we're not -- out of work work and keep them home if we're not going to pay them for that? It's a double hit there. They're going to want to come to work and then transmit the virus more.

So I think there are a lot of issues that we're learning, and people are really kind of making it up as we go.

Now, the good thing is this has largely been mild. And for those few patients that have been seriously ill, it has not dramatically impacted the workforce yet. But I think what it points out is is that preparing for a catastrophic event of a localized nature, like a Katrina or a terrorism event, is very different than one that impacts the entire world, the entire country at the same time.

And I think businesses are going to learn a lot from that. And if anything, I think what we're going to try to bring out of this is, what were the critical supply-chain questions? What were the issues around worker communication and worker safety and maintaining your workforce? And how do you just keep your business going during a time like this?

RUBIN: Yes, sir.

QUESTIONER: Good morning. Assemblyman Rory Lancman. I actually chair the Subcommittee on Workplace Safety in the assembly, and we've been looking at H1N1 and its impact on the workplace.

And what we've found is that employers, both public sector and private sector, are completely unprepared for a pandemic or anything that's even slightly more serious than what we're facing now.

If I showed you, for example, the MTA's plan for dealing with H1N1, you'd be shocked and appalled.

You know, last spring, we had schools that were closing. Can you imagine if, instead of the pandemic kind of circulating in the schools or some of the more tragic incidents of people dying not being in the schools but in the subway system or in some other critical infrastructure, you could see the whole economy seizing up.

My question -- and you know, I apologize for the focus on the United States -- but who would you see or designate at the national level coordinating some kind of preparedness plan? Is it the CDC? Would it be FEMA? Would it be some other agency? But I can tell you, one of the things that, you know, prompted me to come this morning is just the lack of preparedness in the public and private sector workplaces.

RUBIN: I'll give you a response to your question, but let me ask you a question first. Who in New York state has been designated to coordinate in the same way you just described?

QUESTIONER: I'm smiling, because I suspect that you're asking that question because you suspect that no one has, and you are right. (Laughter.) You'd be --

RUBIN: I will acknowledge that it occurred to me that was possible.

QUESTIONER: You'd be surprised at the difficulty in coordination between the state Department of Health, the state Department of Labor on such simple issues as vaccination priorities, mandatory vaccinations, personal protective equipment, et cetera.

And in New York state, for example, workplaces are regulated -- the public sector workplaces are regulated by the state Department of Labor, but the private sector is regulated by OSHA. OSHA doesn't even have a director that's been confirmed.

And so the short answer is, there's a lack of coordination, even at the state level.

RUBIN: Look, I think one of the complexities you have in the United States, and one of these documents made the point, is that we have such a distributed system, if you will, where cities have responsibilities, states have responsibilities, counties have responsibilities, federal government has responsibilities, and how do you get all that -- and of course, private sector -- how do you get all that coordinated?

I think it's a very important one.

I think PCAST recommended that it be the Homeland Security adviser, if I remember correctly. The problem with that is -- and I'm not being disrespectful to anybody -- Homeland Security, as a department, it is not universally thought that it has completely figured out how to perform well its current functions to a reasonable degree of effectiveness. And now you're saying take on this additional function.

I'm sure it will do marvelous under its new administration, Governor Napolitano. But in the little time that it's existed, there are a lot of questions about how well all that has worked.

So that's what PCAST recommended. When I read that, and having spent six and a half years in an administration, I had a somewhat different view of how I think I would recommend that it be coordinated. But that was there.

Does anybody else have any ideas?

JACK: Yeah. I mean, going back to the previous sort of thought just, you know, during lessons where we come to the end of this pandemic wave, one of the many things, if only you could normalize for the other confounding factors, will be actually the relative performance of federal systems versus more centralized systems.

Actually, you know, I think, in Europe, for example, of Germany, where I know as well it's been very difficult to get all the different regions to coordinate. They all have, you know -- it's kind of a real-time exercise with a single national system of then testing how that's interpreted and implemented by legislators and regulators and regional authorities. Same in Canada, same in the U.S. It would be interesting to compare, dare I say, with Britain and France and some other more centralized systems, whether that does lead to a more coherent response.

I'm not sure it will, by any times, you know, because it all sort of implies the best information is decided centrally and then that does get rolled out consistently. But it's one extra confounder that we really need to look at in a few months' time, I think.

OSTERHOLM: Well, you know, I think one of the issues we have here, as we well know, the vast majority of critical infrastructure in the United States is actually in the hands of the private sector. It's not in the hands of government.

Now, having said that, I think the government -- and you asked who -- think the CDC has tried very hard to move the workplace agenda forward, but it is within what you might call tangled mess of Washington bureaucracy, whether it's Department of Labor, Department of Commerce, whether it's the White House, whether it's Homeland Security. And I can go on and on and on.

But I think that one of the issues that we have to fundamentally wrestle with is redundancy in search capacity. We have nothing in the private sector today that pays you for that.

So you know, when we have, for example, the classic, you know, government expenditure for this, the Minneapolis-St. Paul International Airport Fire Department, one of the best, well-funded fire departments in the state of Minnesota, it has never had a major plane crash there on-site since its inception more than 70 years ago. And we pay for that every day, though, because as a society we've made that decision to do that.

Companies can't and won't do that. I mean, you would go under if you basically put your balance sheet around widespread redundancy or capability during a plan like this.

So I think we need a whole new discussion about what are those critical things that we have to maintain, whether they're from a foreign source or a domestic source, during times like that, and then have a discussion. Who's going to pay for it? That's why we're in the problem we are with vaccine.

And no vaccine manufacturer is going to sit there and build tremendous capacity so that it can be used once every 40 years and pay for that on their own during that 40-year period.

So I think there's a fundamental question that pandemics beg as to, what is necessary, what is critical and who pays for it to have it there when you need it, like that fire department at the airport?

RUBIN: You know, just to make that more complicated, Michael, if it's something from the supply chain that comes from the developing world, how do you deal with that? Do we stockpile it here? Or do we try to build redundant -- when we try to somehow or other catalyze redundant manufacturing capability in the developing world, and if so, who pays for that, and how does that get paid for?

I suspect not simple questions.

OSTERHOLM: You know, and I think to even follow up on that, I could just add one piece. We tried for a period of several years to get into the mix the discussion why it was strategically critical to talk about moving vaccine quickly from the U.S., the U.S. vaccine stockpile of whatever flu vaccine we had during a pandemic, if in fact we needed to support those supply chains coming from another country.

And that got nowhere, because we saw ourselves as so American-centric that everything was about what was inside our borders. On the one hand, we realized the global economy, but yet we don't when it comes to issues like this.

And so even if you're not trying to be altruistic, if it's not a moral issue, just a straightforward, strategic question, we never have addressed that about, when would it be better -- as you asked the question earlier, Mr. Secretary -- about maybe not you getting the vaccine because you're not in a risk group right now to get severe disease but moving it to Indonesia or moving it to India or China, totally for a strategic standpoint?

Much as we talk about with our military all the time, I mean, imagine if we only considered our military within the borders of our country.

RUBIN: You know, I agree with that, Michael, but I think that if an administration were to be serious about this and take it on -- and I'm not saying they aren't, because I actually have no knowledge what the administration is doing -- I think that you would find that one challenge is the procedure challenge, the substantive planning challenge. But the other is just an immense political challenge.

OSTERHOLM: Well, I agree with that. I'm merely pointing out, if we really want to address it, though, we're going to have to bring that up. And I think you're right, I think, from a reality standpoint, unless you can show direct impact to somebody, you know, in Lake Woebegone that what you did in Indonesia changed their life, they're going to say, keep it in Lake Woebegone.

RUBIN: It's an enormous challenge. By the way, you asked me where I would have put the -- I would have put the coordination not in Homeland Security. PCAST is better qualified to judge this than I did, and that was their judgment. But just having spent six and a half years in an administration, I think I would have been inclined to find some way to do it in the White House. But that's just my view, and it's probably wrong.

Other questions? Yes, sir.

QUESTIONER: I'm Charlie MacCormack, the CEO of Save the Children.

And my question, the takeaway will be about lessons learned. Are any possible? And how will they get rolled out a year from now?

But as background, we have been working at Save the Children on pandemic preparedness in developing countries and monitoring and so on and so forth, for two or three years since the avian influenza issue came up.

But it's a huge effort to keep people focused on this and to keep the supplies in place and, you know, they expire, and you have to go back out and so on and so forth.

So tragically, in some ways, you know, it would almost be better if this is fairly severe enough to get everybody's attention and to be serious about the downstream consequences so that we can actually get the global governance processes in place -- not that I would want to see that -- but is there any way, absent this being serious enough to really get the attention of political decision-makers, to roll out the kinds of recommendations that are made here today?

Because quite tragically, really, so far, the takeaway is, it's not going to happen.

RUBIN: Anybody want to respond to that?

OSTERHOLM: Well, let me just say -- first of all, Charlie, I think you raise a very important point. And let me just give you two examples. I have heard a number of individuals want to disconnect the current discussion about pandemic flu response in this country from health reform, because they're afraid that, you know, if we can't adequately handle pandemic flu, how will the government ever handle health reform?

And I think it's just the opposite. I think the fact that we have such a system that is as stretched as easily as it is right now says something about the whole question of, what do we have for health care in this country?

And I'm afraid that part's going to get missed. Because unless we go back and do what the Aussies and the New Zealanders did to summarize their experience there, people won't really realize that there are major lessons to be learned about our capacity. And what does it really take to take it over the top? And it's not nearly as much as people thought.

I think the second piece that you raise is just this idea of, how do we respond? My worst fear is is that what was going to happen is this wave will continue in through the fall. As we heard in the first panel, we surely could have another wave in the winter, into next spring.

But if we don't have that, and much of this vaccine does not arrive into our local communities until mid-November or later, we're going to end up early next spring with lots of vaccine left over. And people are going to wonder, why did we spend all that money for that vaccine which we didn't use, which will actually set vaccine programs back. It won't help us; it will actually hurt us.

And that instead of more capacity, we're going to talk about less capacity. Why do we even need that? And not realizing that we missed the prevention opportunity, because if we had had a better vaccine and more capacity, we would have had it to people before the pandemic really peaked, not after.

Now, I don't know that will occur, but I'm sure that that's going to be at least one area that we're going to have to watch carefully.

So I think, if anything, I'm more concerned about the negative pieces that are going to come out of this, where people are going to go back and say, one, you scared us needlessly, because everybody thought it was going to be H5N1 and 2 to 50 percent of people were going to die, which we've never said, but that's the case.

The second thing, even in this experience, we didn't learn when we could have from the health-care setting issues. And second of all, with the vaccine, we spent money we didn't need to spend. Why did we do that?

RUBIN: Yeah, I'd just add one thing, if I may. I think it's very hard to persuade the American people to think probabilistically. And secondly, it's very hard in our democracy, unfortunately, to react to things other than in response to crisis. And you can see with our fiscal situation today where we have a horrendous long-term fiscal situation, but we don't want to deal with the very difficult trade-off and judgments that are made to deal with it. I mean, we can't do it right now anyway because the economy is weak. But we don't want to do the kind of things we could do to get ready for that when we have a somewhat stronger economy.

Other questions? Yes, ma'am.

I think your points are well-taken.

QUESTIONER: Thank you. Liz Wishnick from Montclair State University in Columbia.

We've been talking about this pandemic in terms of emergency response. And I wonder, what about the preventive aspects? When we look at the case of bird flu and SARS in Asia, one of the big issues was that the people who didn't have access to health care were the most vulnerable -- the rural populations, the people outside of the health-care system.

So I just wonder, you know, in terms of our country, now in the midst of a bitter health-care debate, why isn't the pandemic issue brought more into this debate as a reason for expanding access? Because if 15 percent of the people are not in the health-care system, that will accentuate any pandemic.

RUBIN: Anybody want to try to take a shot at that?

OSTERHOLM: I think, Mr. Secretary, that's yours. (Laughter.)

RUBIN: Well, Michael, you spend all your time at this.

OSTERHOLM: Well, I think, I mean, I think the issue is around -- the health-care reform issue is one that is remarkable in of its own. And so I think access and cost and all these things are there. And you know, we all obviously want to create the idea of a system.

But on the other hand, what does that mean, and what is that going to cost? And I think you just alluded to the cost issue.

You know, I heard a very sobering figure several weeks ago at a meeting that I was at, that last year the increase in health-care costs in our country exceeded all the revenues of the entertainment industry. And so, you know, we do have a need to talk about cost and who's going to pay for it, whether it's our generation -- which it isn't -- it's our children's generation -- versus access.

So I think pandemic needs to fit into that. And capacity surely is part of it. But this is a much bigger, much more complicated issue that I don't think pandemic influenza is going to be even a hair in the tail of the dog in terms of the overall discussion piece.

HUANG: Well, I think prevention is certainly very important if we agree that this concept of surge capacity is a cornerstone of pandemic preparedness, because the surge response capability is a function both of the surge on the demand side and the surge capacity on the supply side.

On the demand side, the surge can be reduced by all these prevention measures, including a well-functioning disease surveillance and reporting system, well-developed laboratory and epidemiological capabilities, availability of the prophylactic and non-prophylactic measures, a functioning health-care system. This is all very important to actually reduce the surge, therefore maximize our surge capabilities.

RUBIN: Laurie.

QUESTIONER: Laurie Garrett from the council. Just in response to this question about linkage to the health-reform debate.

Actually, we do see very strong linkage being made, but it's being made by the opponents of vaccination, who are arguing -- the Glenn Becks, the Rush Limbaughs of the world -- who are arguing that this is another example of the Nazi totalitarian Obama regime trying to force you to do something, in this case get vaccinated. And they have linked it with health reform.

The constituency that has failed to do so is public health and the advocates of vaccination.

I just have a quick question for Yanzhong Huang. Secretary Rubin suggested that we might think, how would this be different in a more, shall we say, top-down society, compared to a federalist society, as we have in the United States and, in particular, on issues of organizing supply chain and maintaining productivity in the midst of an epidemic?

So how does this look from the Beijing point of view?

HUANG: Thank you, Laurie, for that. I think it's a tough question. And if you want to do the comparison between the U.S. approach and the Chinese approach and the people who say that Obama has totalitarian approach, I think would find the Chinese approach even more interesting if you talk about the Chinese response to the recent -- to the spring H1N1 outbreak. (Laughs.) It's very much a Orwellian approach to public health, you know, that the --

RUBIN: It's a what?

HUANG: The Orwellian --

RUBIN: Orwellian.

HUANG: -- also totalitarian in a way -- approach to public health. The government mobilized a very significant proportion of the state operators, from the central government to the local government, the public health departments, CDCs, public security departments, street-level, residential committees. They mobilized all the state operators, sort of launched a witch hunt of all those, you know, suspected of having the swine flu or having close contact with the swine flu cases.

They are very efficient. And the state reach was indeed very impressive. And I found actually a report basically that said, on April 3rd, you know, a passenger on a flight, they happened to find one case there, arrived home in a remote village of -- (inaudible) -- province only to find the CDC officials already waiting for them. (Laughs.)

So yeah, they are very effective in actually hunting down or tracking down the people who are infected. So that is indeed a top-down approach. But that top-down approach had had actually a big price tag attached, that is they spent a lot on that, I think $731 million at the central level alone. That is twice the money they spent on SARS.

That also means a large percentage of the population, because of that contaminant-based approach, a large percentage of the population was basically not exposed to the virus. You know, I'm not recommending, you know, the flu parties deliberately exposing the virus. But because of the lack of exposure, that caused the problems for the (hurt immunity ?). That is, a lot of people failed to build up this natural immunity.

You know, once the government stringent measures were (begun ?), we found this, you know, dramatic increase of the cases in China, especially since the early September.

RUBIN: Laurie, I just returned from China Tuesday or Wednesday, whatever day it was. I've lost track a little bit. And I was -- we did raise this actually with public officials and even with the premier.

They seem to feel that their system was quite well-suited to making allocation decisions. (Laughter.)

Yes.

QUESTIONER: Hello. Kathy Tayler (sp), Benefit Allocation Systems. Thank you for your time today.

We've spoken about the international and the national impact potentially of a pandemic. And I'm wondering if you could talk about whether you think there are risks in the variability with which U.S. states, particularly in a challenging budget environment for states, potentially it causes economically.

And if I could just give you a very, very anecdotal but illustrative example as to why I ask this. A friend in Ohio, who has a 13-year-old daughter who came down last week with H1N1, she was told there's no vaccines in the state if you're under the, I might be off a year or so, under 4 or over 60 or sick or pregnant. And there's also no Tamiflu. So she's told to stay home and suffer through it, which she's doing just fine. The message there is not such a big deal, this illness, you'll be fine.

In New York, I have another friend, who walked into a Soho doctor, with her husband and two kids, vaccinated right then. The message there, much more important to be vaccinated and to be proactive.

And so I'm interested in the variability with which we're handling this from a state level and where you think that impact is.

RUBIN: Who would like to take that?

OSTERHOLM: Well, let me just talk a bit about the vaccine issue, because I've spent the better part of my public health career being that shock absorber between things like vaccine being available and the public getting it.

And I think the experience you just provided us is one that is just a function of where the current vaccine distribution situation is at. We've already said several times in this meeting, we have really witnessed almost heroic efforts by governments of the world, particularly the U.S., and the vaccine manufacturers to make this vaccine safely but quicker than we've ever done before.

You know, but the problem is, when you have a vaccine that takes longer to make than it does to plant, grow and harvest corn in Iowa, then you know you've got a problem. And what we're seeing right now is is that we're just getting that vaccine out just now.

So the physician in New York may have had access to the very first doses of vaccine coming out; the physician in Ohio did not.

What's going to happen, though, is that pipeline is attached to a very, very rusty faucet. Public health has just let go 10,000 people in the last year in this country, from jobs. We have really very little capacity out there to suddenly set up a brand-new vaccine program.

Second of all, we've watched the health-care system, which now has never had a vaccine for adults program -- it has had for children -- suddenly be charged with getting this vaccine out. We have clinics around the country, large health-care systems that have let go 4 (hundred) to 6 hundred people in the last year -- nurses and nurses aides -- just to try to make budget. And so they have no elasticity.

And then when you look at the issue of the private sector, whether it's the commercial pharmacy companies, et cetera, when they get vaccine and how they get it and how they allocate it, it's all a problem.

So I wouldn't look at this as a state-by-state issue. This is a function of where, why are we in the state we are with getting vaccine and getting it distributed in a timely way? That's the problem.

I think the second point you raised, though, the different recommendations of who got Tamiflu or who didn't, also gets back to what your health care is. I happen to have a wonderfully robust health plan at the University of Minnesota. But I, you know, have kids, who are young adults now, who are struggling, trying to get health care, because they don't have jobs and so forth, and it's a very different situation.

So part of it is is universal benefits, when should we get it or not? So I'm not sure that it's a state-by-state issue as much as it is just the state of the reality of vaccine and how to get it out there and just health-care access in general.

RUBIN: Yeah. We'll be taxing your robust plan pretty soon. (Laughter.)

OSTERHOLM: Thank you, Mr. Secretary.

RUBIN: We have time for one more question, I think.

Anybody have one more question? Yes, sir.

And then I'll make one quick concluding --

QUESTIONER: Jon Cohen with Science.

The one thing that we haven't talked about at all is 1976. And I think the lesson from '76 was not that vaccine was made, it was that it was used when it wasn't needed.

And so when Mike was bringing up this notion of there being an excess of vaccine at the end of all of this, I'm just curious, might that be exactly what we want? That could be a very good thing, in a sense.

In '76, had they made vaccine and not used it, it would be just like those firetrucks that don't have to clean up after the plane crash. They're there if we need them. And maybe the lesson from this is that we need to prepare the public to make something that isn't necessarily all used up.

But I'm curious what you all think.

OSTERHOLM: Well, Jon, let me just say, first of all, I think that the difference between '76 and today are the differences between night and day.

In '76, we didn't see widespread opposition to vaccine, in general. Clearly, there were concerns expressed by some small subsegments of our population, but it wasn't on the news every night. It wasn't in the blogosphere, et cetera. It was a different world back then.

I think today, we have people, including in the health-care industry, who are opposed to being mandatorially vaccinated; so therefore, they're trying to find any reason also that they can basically be against vaccination, waiting for this program to fail so that they can say, see, we were right, or whatever.

And I think that, from a financial standpoint, I've already heard it. You know, if we don't use all this vaccine, it was a waste of money. They don't understand that investment.

In '76, we just didn't have that mind-set. So I think your point is right on target. I think you're right about that, we should actually be able to say that was a success. But on the other hand, I think today that's going to be seen as a programmatic issue where it will be a failure.

What I think was the failure of 1976 versus today was we never did figure out what happened in '76. And the long shadow of that experience is overriding today's experience. We answer that question many times a day. Why did that happen? Could it happen again?

And if there was any lesson we learned, just like every time there's an aviation disaster, we cannot rest until we find out exactly why it happened and assure the public it will never happen again, because we can't do that today.

RUBIN: I think we've -- yes, I think we've finished up our time. Let me just two comments if I may.

One, whatever -- I actually don't know the experience of '76 -- but whatever effects pandemics had in the past, the global economy today is so much more interdependent than it ever was before, the supply side effects, the just-in-time inventory effects. The potential for economic impact today has got to be, I would guess -- I haven't tried to model this, obviously -- but it's got to be some, I would guess, substantially multiple of what it was before.

And I think that's what most troubles me. And I read a bunch of stuff Laurie gave me to get ready for this. And then we just had this discussion, and it sort of came out again. It seems to me that if the United States and then, more broadly, the global economy is going to be moderately well-prepared to deal with this, there has to be an enormous amount of planning and an agreed-upon regiment, you know, agreed-upon processes, regiments, decisions before the thing hits. And that is very difficult to do.

And my impression, because I did ask around a little bit, is that precious little of this has gone on. And I don't know how you raise the level of concerns that this takes place. But that's very, very difficult to do in a disparate and complicated political systems we have today.

So with that, we thank you all for being here. And I think the next session on foreign policy should be really fascinating, because all of this very naturally leads into the enormously complicated foreign policy question this raises.

Thank you very much.

(Applause.)

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THIS IS A RUSH TRANSCRIPT.

LAURIE GARRETT: If people could please take their seats.

Broadcast audience, we'll be starting momentarily.

Good morning, I'm Laurie Garrett, here as a senior fellow at Council on Foreign Relations. For those of you that may have just tuned in on the webcast, we've had two fantastic discussions preceding this one:

The first, chaired by my colleague, Jon Cohen, from Science Magazine, which is a cosponsor, with Council on Foreign Relations, of today's symposium on influenza, that really got into the scientific uncertainties that we see with this H1N1 pandemic.

And the second, chaired by Secretary Robert Rubin, who is also the chair of the Council on Foreign Relations, regarding some of the possible economic consequences and impacts for businesses -- the macroeconomic scale, government financing, and so on, that we will see with this mild epidemic, and some of the implications of what might happen if it were a more dangerous virus.

Everything that you're hearing is on the record. That includes your questions, so you better think about that before you open your mouth. We're going to have a conversation for about 40 minutes, and then open it up for a good half hour of questions from all of you, including the webcast audience. If you are a Tweeting, a Twittering aficionado, your tweet is: # or @cfrq&a -- #cfrq&a. And, once again, a reminder to those of you here, please turn off all your transmitting devices as they may interfere with the signaling here in the room.

Well, I think the take-home message from our first two panels is it's a darned good thing we're dealing with a relatively mild flu this time, because clearly we're ill-prepared at this moment for a more virulent, a more dangerous flu pandemic, either if this one takes on a more dangerous form, which fortunately Dr. Palese assures us will not happen -- I'll hold you to it, Peter, or if a second, totally different, virus does emerge.

Nevertheless, we've already seen some very hot-button issues emerge internationally, some of which have just been touched on. And I want to start with Ambassador Lange. John Lange has served for many years in the United States government. He was ambassador to Botswana. But in his last position, before his current (spot ?), working for the Bill and Melinda Gates Foundation, he played a key role as -- I don't remember what your exact title was, but the pandemic aficionado on behalf of our State Department dealing with what was then the key concern, H5N1, aka "bird flu," and our international relations, in terms of surveillance and preparedness.

And I want to start by asking you, there was -- there's been a lot of talk, why doesn't the government have a plan, so on, and so forth. But, indeed, you were part of a process that did promulgate a national plan for pandemic response in the Bush administration. And there's been a lot of talk at WHO, and at other tiers internationally, of trying to come up with a more rational, some sort of advanced planning that could coordinate the global response.

Where does that stand?

JOHN E. LANGE: Well, the previous administration, under President Bush, created a U.S. national strategy for pandemic influenza, and an implementation plan. The strategy was released -- (inaudible) -- in late 2005, an implementation plan in May of 2006.

And, from my observations, and that of many others, the fact that that plan was in place -- the fact that there had been international coordination, through the international partnership on avian and pandemic influenza; the fact that there were several years in which organizations, governments, international organizations, non- governmental organizations -- (inaudible) -- preparing for the possibility of the H5N1 pandemic -- really did a lot, and had a major impact on the ability of the international community to respond to the current pandemic of H1N1.

As we discussed, and heard from the speakers earlier today, it's not perfect, in terms of the response, but the world is much better prepared today than it would have been if this had occurred four years ago.

GARRETT: I should point out, one of the people who had been involved in a lot of that planning was Mike Osterholm, who we just heard from as a sort of "voice of god" in this room -- (laughter) -- in the prior session. And I need to thank Mike -- I hope you're on the webcast, for your valiant efforts to fly out of Minneapolis yesterday in the snow storm, and we're happy that you're able to join us, "telecommuting," in the absence of being here physically. But Mike had raised some of the same points, that we had some level of advanced planning, thanks to our concern about H5N1.

And, of course, the other thing we had in place, thanks in part to the sense of urgency around H5N1 bird flu, was the international health regulations, which form a sort of guidance of how the world should cooperate regarding infectious disease issues.

But, again, sticking with you, Ambassador Lange, we've had trouble seeing how that ends up actually applying, concretely, to compelling or nudging nations to truly share viral samples, open surveillance, outbreak investigation with the global community.

LANGE: Well ultimately the government of Mexico was very forthcoming in sharing samples, and really it could be used as a model for how other governments should react in similar -- a similar situation with the start of a possible pandemic.

There were difficult negotiations going on for two years at the World Health Organization. It was called an "Intergovernmental Meeting on Pandemic Influenza Preparedness." And it dealt with this is of sharing of samples, as well as sharing the benefits that come, such as vaccines and other aspects of pandemic preparedness and response.

And it would be wonderful if we could look at this just from a global health perspective, and the need to share these samples and to share the vaccines, et cetera. But in that context -- that took place at WHO, it involved many political issues, such as intellectual property rights and the sovereignty issues. And, regrettably, while there was certainly progress made, they did not come to a conclusion on some of the basic issues.

One of my personal hopes is that this pandemic, which is milder than we had predicted the H5N1 pandemic would be -- and let's hope it stays that way, there's no guarantee of that, but let's hope that this will be the wake-up call that is, as Jon Cohen said earlier in this symposium, "a teachable moment," and that we can be looking to the lessons learned from this and create systems whereby we don't have ad hoc mechanisms for trying to deal with this, but a more concerted effort.

As you know, I come from a foundation -- the Bill and Melinda Gates Foundation, where our basic premise is that all lives have equal value and that every person deserves the chance to live a healthy and productive life. And to answer Secretary Rubin's question from earlier, there is a moral obligation to help the poorer people of the world, the developing countries with access to vaccines, et cetera.

Right now there has been a very laudable effort on the part of -- at first announcement, nine countries, and few have been added, to provide some of their vaccines to the developing world, and WHO is working on that. But it's still being done in a way that is -- (inaudible) -- in a sense, ad hoc. I would hope that in the longer- run, these issues can be dealt with when looking at the experience from H1N1.

GARRETT: Helen Branswell has been one of a tiny handful of truly outstanding journalists on this beat, on this story doggedly. I think there are people all over Geneva, in WHO, that are terrified when they hear that Helen is calling. (Laughter.)

Secretary (sic) Lange mentioned this agreement that was brokered by the White House -- initially eight countries, now I believe it's up to 11 have agreed that they will donate 10 percent of their vaccine supply to WHO for distribution in developing countries. Before getting into what the real significance of that may be, your country is one that has not signed on. Why is that? Why is Canada not in the game?

HELEN BRANSWELL: That's a fascinating question and I don't have a good answer. I've been trying to get a good answer, and having just absolutely no luck.

I don't think you know, do you?

LANGE: No, I do not.

BRANSWELL: It's puzzling. It's really puzzling, because it's typically the type of thing that Canada does do. In fact, somebody on this side of the border -- I wrote a story about the fact that we were noticeably absent from that group of donating countries, and somebody from this side of the border called me and said, "Interesting story. You guys are normally -- (inaudible) -- and you're not there. What's going on?"

I don't know. I'm told that we're still looking at what the need is, and we're trying to determine what's -- how we could best fill the needs that exist. We're going to swimming in unused vaccine, and I'm not clear at all why we're not -- (inaudible) --

GARRETT: Do you have any idea how much vaccine Canada has ordered, and how much is likely to actually get used?

BRANSWELL: Well, we ordered 50.4 million doses. And that's enough to give everybody -- that was based on the premise that maybe 75 percent of people would want to be vaccinated, and we'd need two doses a piece. We don't.

We have a population of 33.6 million, and if they vaccinate half of that, they'll be very, very -- be doing dances. There's no chance that that's going to happen. Polls suggest somewhere in the low 30s right now.

GARRETT: You have a resistance to vaccination in Canada as we do here in the U.S. --

BRANSWELL: Yeah, there's a lot of fear about this vaccine, and particularly because in Canada we're using an adjuvanted vaccine for the first time. You guys aren't going that route. And there are implications, and pros and cons, but there is quite a bit of concern about whether or not this vaccine is safe, whether people need it, and I'd be very surprised, unless things get worse, if the numbers would be very high.

GARRETT: So we have the possibility of signaling to the world, 'We want everybody to sign on with globalization. And, in the context of pandemic-disease threat, that means we want every one of you, rich and poor alike, around the world, to let us know if you have any weird outbreaks; allow outside investigators to come in, and swoop in when you have an outbreak. We want all the civil society organizations and NGOs, the MSFs of the world to tip us off if there's outbreaks, even in failed-state areas, and so on.'

So we're globalizing this sense of threat. We're globalizing the responsibility to surveil and to observe threat, but we are not globalizing the benefits, in terms of those tools that can help protect societies against the threats. And then, on top of it all, you're saying -- and Mike Osterholm had hinted at this earlier, that when we get to the end of the day, out in January or February of 2010, we may well see giant unused stockpiles of vaccine in the wealthy countries, none having ever reached most of the poor countries of the world.

BRANSWELL: Well, some are going to reach the poor countries through this initiative that Gates was involved in trying to broker, I believe, and the WHO is also spearheading. And that's in real-time, which is really quite an achievement, I have to say. I didn't think that was going to be possible.

But that's a small percentage. They hope to be able to provide enough vaccine to developing countries to vaccinate about 2 percent of their population. And it's true that then there will be this large amount of vaccine elsewhere that isn't going to go -- be used.

John's (sp) question, about whether or not that might be a good thing, I just found was intriguing, because in the context of America, or Canada, or whatever, if vaccine isn't needed, and we bought it, and it was there, and it was an insurance policy, maybe that is a success. But I don't think the world's going to see it that way if, at the end of this, we're going to find that Canada had 25 million doses of vaccine that we couldn't persuade people to take, and we didn't free up to pass along to others.

Now, I will say that the Canadian authorities, I think, are already in discussions with the contractor that we're buying from, GlaxoSmithKline, to turn back the portion that we don't need, so that they can sell it to whoever is next on their list. But I'm not sure when we're going to say, okay, we feel safe to feel -- to say that we don't need this, and so you can sell it elsewhere. And that's selling, that's not donating.

GARRETT: John, I want to go back to you because we need to bring everybody up to speed, and they may not all know what, in particular, went down with the United States government and the government of Indonesia around this issue, and that remains unresolved at this time.

But you were actually there in Indonesia trying to negotiate with their ministry of health to get them to free up samples of bird flu viruses that had emerged in that country, that they were refusing to share on the grounds that, if a vaccine were made, they would never get the vaccine. Correct?

LANGE: Well, yes. It was quite a complicated (approach to the ?) negotiations. Some of them were between the United States and Indonesia, trying to see if we could come to an agreement that we could then pass on to the multilateral forum that I mentioned earlier, under the auspices of WHO in Geneva.

The thing is, once this came to the World Health Assembly in May of 2007, and this intergovernmental meeting process that I mentioned earlier was created, then it became multilateral. And so it was not just Indonesia that was negotiating. And then some other countries started bringing in other issues, whereas Indonesia was concerned with -- more focused on the control of the virus that had emanated from their country and benefits that they had hoped to receive in return.

But I'd like to actually look at this from what I think has been the change in the this -- over the last few years, particularly since this recent announcement there's up to 10 percent of vaccines that are going to be allocated by -- up to 11 countries now, to help the developing world.

There's been a lot of discussion on this and at the Gates Foundation our strategy -- our focus is to ensure that there's an effective strategy to address the pandemic in developing countries. Dr. Tadataka Yamada, the head of the Global Health Program at the Gates Foundation wrote an article that was published in the New England Journal of Medicine last month that listed eight proposed principles to help guide elevation of pandemic vaccine to really ensure that within the same time frame, developing countries receive the vaccine as well as the developed countries.

And if you look at what is happening, you can argue that we are moving in a very positive direction, that while the debate -- we can argue between the sterile debate in WHO over whether this should be done on a voluntary basis or a mandatory basis. Maybe we're now moving to a way in which it's expected even though it's not mandatory. Just as you have one of the huge programs in the world for HIV AIDS -- (inaudible) -- the president's emergency plan for AIDS relief, it's not a mandatory contribution, but it's certainly an expected one. Every observer believes it will continue.

The people who run the Gates Foundation Global Health Program is not required. It's not mandatory. There's no legal requirement for it, but it certainly is a very real positive program to help global health, and I wonder if we've now set some precedents just for the last few weeks, actually, whereby when the next pandemic occurs, a serious and possible more severe pandemic than this one, but that there will be that expectation that those vaccines will be shared.

BRANSWELL: I'm -- (inaudible) -- and I think that's true and I think -- but the issue remains. The issue that Secretary Rubin brings in the last session. This -- it's easy to commit this time because it's a relatively mild disease. Most people aren't getting very sick. Most people -- Australia got through their wave -- you know, they managed to get through their wave and they had no vaccine at all. But if this were -- this were H5N1 or even something not as bad as H5N1, would your government have felt that it could say, let's broker a deal and give away 10 percent of our vaccine in wartime. That's a very hard thing to do when it's a crisis and I think -- I agree with you that a precedent has been set and that expectations have been created and I -- but I'm not certain how hard -- or how easy it will be to deliver on that in a time when things are more difficult.

GARRETT: Well, you know, one of the interesting things here is the question of sovereignty. And David Sidler (ph) has raised this from the University of Indiana, Professor of Law, as the bottom line challenge that we face going forward in this age of globalization when facing pandemic threats -- any kind of disease threat -- the question of sovereignty is if he could get a two-edged sword. On the one hand the government of Indonesia can say we've declared viral sovereignty. It did say this. Any viruses that we find on our soil are our viruses, not to be seen by the rest of the world unless there's some contractual understanding, and any profits derived from said viruses down the road go to Indonesia. That was an interesting perspective.

We conversely could have sovereignty declared in the context of Canada may have ordered vaccine from, let's say, the U.K., but if it turns into a super virulent flu, the Brown government could very well say no vaccines made on British soil will leave British soil -- full stop. And when you consider kind of the chain of production that we were talking about in our prior session that the raw ingredients for most pharmaceuticals are actually coming from China and India, but the masks and protective gear our hospital workers depend on come from outside the United States. You start to be -- imagine a very quick multiplier effect all based on the notion of sovereignty that could make any kind of moral understanding that you and -- (inaudible) -- are talking about completely collapse.

And Sidler argues that we have no legalistic mechanism in place or one that we can even immediately imagine that can get us past this moment. How do you see that?

LANGE: I actually don't have high hopes that there could be some legal mechanism that could be put in place because the negotiations that went on in Geneva were so difficult and positions were so attractive on all sides. And so -- but I guess -- my thoughts in terms of what Helen was saying well what happens in a more severe pandemic when there is the pressure not to give up the vaccine and what Secretary Rubin said earlier.

It seems to me that that argues for actions in the next months and years with that in mind, that if there is the expectation that has been developed that, yes, developing countries do deserve vaccines and we can't have the rich countries first in line and developing countries last in line and this kind of situation.

Well, how do we deal with that? Maybe there are ways, for example, to increase the production capacity for influenza vaccine in some developing countries, not because we expect that there -- that you can have a robust plan just to do pandemic influenza vaccine production once every 25 or 40 years, or whenever the pandemics occur, since there were two in the last century, but also for seasonal influenza flu vaccine.

And so if you increase the global consumption of seasonal influenza vaccine, you could keep these plants going. There may be other ways to do this, whether there's advanced purchases or whatever, so that the political issues that were discussed earlier are mitigated even in a severe pandemic. It's in a sense -- and it's too early right now. I talked to WHO this week and they have twelve task forces going just H1. They're not about to look at lessons learned as they're still in the middle of learning them, but in the coming months and years, we may find a real opportunity in the international community from this wake up call to try to put in mechanisms for that expected, or not mandatory system to benefit the developing world.

GARRETT: Well, Canada is going to be hosting the next -- what we would have called until a year and a half ago G8. Now it could be G20, I assume -- summit will be Ottawa or outside Ottawa and, you know, traditionally when we've had these sorts dilemmas there's some shurpa (sic) on the part of all the G8 shurpiteens (sic) to try and come up with an outline of what might be a proposed mechanism, but then the heads of state at the summit could agree to. Now if we expand to G20, we're bringing in players with very antagonistic perspective.

Indonesia is in G20, Brazil, Egypt, India, China, some of the biggest generic manufactures who have opposed any tightening or even the existing standards of patent protection for the pharmaceutical industry.

Are you aware of any kind of idea what might float at the a Canadian summit?

BRANSWELL: No, I'm not. I'm afraid I'm not here. I don't know about you, but again I share -- I was going to say pessimism, I guess maybe skepticism would be a nicer word. I think these are really tough issues and I'm not clear how much political will there will be going forward on this.

I share the concern of the man from Save the Children that we can't want a more severe pandemic. I'm delighted that this one is playing out the way it is, but I think that one of the things that's it's doing is creating in the minds of most people, and most taxpayers, perhaps that pandemics are not necessarily such a big deal, that we have been over-hyped them, that they're not as scary as we thought or that modern medicine.

The argument that we heard about 1918 that if we had modern medicine in 1918, it would never have been severe as it was. I think it's sort of being overlaid here, and people are saying, oh, well if you have -- (inaudible) -- and ICU's and what not, you're going to be fine. You can get through a pandemic, and I wonder whether the lesson going forward will be we found all these holes because we have found tons of holes and as you pointed out in the beginning when we discovered that we were -- we thought we were preparing for the worst case scenario and actually in fact we are not prepared a very mild pandemic, but I'm concerned that people won't take that lesson going forward, that they'll say, you know, we spent a lot of money. We threw away a lot of vaccines. We've had a pandemic. Another one isn't coming for another two or three decades, let's move on.

GARRETT: Well, the -- you know, Ambassador -- (inaudible) -- that there's about 12 panels advising WHO right now. I know one of them has to do with control of message.

They're -- you know here we have a situation where unlike in 1976 and certainly unlike '68, '57, and 1918, we have the Internet and we have the ability for claims, counterclaims, light insanity to be transmitted globally overnight.

I was in a meeting at the Institute of Medicine where one commissioner of health from New Jersey stood up and said, "Look, let's be frank about what we're up against. The odds are that some woman somewhere in the world will have a miscarriage the same day she gets a flu shot.

BRANSWELL: Actually, that could be 1,000 women; it's not going to be one.

GARRETT: All right. It's a statistical probability, and since we're targeting pregnant women specifically to get vaccinated, then all it will take is one lawyer or a talk-show host or whomever it may be to go on the Internet and start screaming and WHO has lost control of the message; your local health commissioners have lost control of the message.

BRANSWELL: (Inaudible) -- here have control of the message now.

GARRETT: Talk about that.

BRANSWELL: I mean, the blogosphere is going crazy about this vaccine. I mean, that's another -- if you want to talk about concerns going forward, I'm really concerned that this campaign, this biggest probable vaccination effort ever could be -- you know, if anything goes wrong, and things will go wrong -- and whether or not they have anything to do with the vaccine or not, thing are going to go wrong and it could have enormous repercussions for people's willingness to be vaccinated against any number of things.

And if we don't -- in the developed world -- if we don't buy vaccines and if our children aren't vaccinated, there won't be vaccines available for the developing world.

GARRETT: And if you think about it in the context of countries where the capacity to control messages is even more difficult, for example in Africa, we've already seen how going to the Internet prompts an e-mom to say that polio vaccines have HIV and/or a sterilizing agent in them and now we have lost ground on our attempts to eradicate polio worldwide, which is -- and if there's a claim of a health effect in, let's just say Germany, is that likely to resonate around the world and even into the poorest countries of the world, so that we have a globalized sense of incorrect threat, incorrect perception?

BRANSWELL: Certainly. I mean, it's very, very possible. The probable being, you know, something happens that they're looking for. In '76 I think the problem was that nobody knew what the baseline rate of GBS was -- (inaudible) -- syndrome. So when all of a sudden people said it seems like the rate is higher you had to answer the fundamental question, what's the baseline rate?

I think now they know that so they might be able to say, "Okay, this is just actually normal or just maybe if something increased" -- but what if something we're not anticipating happens, something out of left field, like the multiple sclerosis and those Hepatitis B vaccination program in France. If something that you wouldn't think of materializes, and people are starting to say, "okay, so what is the baseline rate for that in children?" And nobody really knows. It's going to take, I don't know, years?

And maybe, as Mike mentioned in the earlier session, people won't know the answer. But at any rate, if something materializes, the decisions, the blogospheres will go crazy and will connect it, cause this. The scientists will spend weeks, months, whatever, trying to figure what has caused this. But the public will make up its mind in the interlude. It's going to be a real problem.

GARRETT: Last question to you before we open up to our audience. The United States would be perhaps in a better position to look like a global player. Your boss Tadataka Yamada, has suggested -- and many others have as well, if we were willing to do what Canada and all of Europe and Japan have done, which is use adjuvants to stretch out the efficacy of our limited antigen supply so that the vaccines, any given amount of antigen could go to 10 times more human beings, therefore greatly expanding our vaccinations capacity.

That would mean that then we would be in a position to not donate, say 10 percent of our vaccine supply, but perhaps 90 percent of our vaccine supply, to developing countries. The United States stands alone among rich countries where it's using to entertain that. And off the record, most the folks at FDA say it's because of the antivaccine movement and fears that people in this country who want 100 percent safety will never allow an adjuvants to go in, even though it means your denying any vaccine, even a one in a billion risk factor vaccine, to the majority of the world population.

How do we resolve that, and can we continue to give a message that says we are a global player if we continue to also refuse to stretch our vaccine supply?

LANGE: I mentioned earlier the poll is principle to guide allocation of pandemic vaccine and one of those principles was to try to develop a consensus on the safety and efficacy of the use of adjuvants. But it has been very difficult within the U.S. government and the Food and Drug Administration to get approval for that and acceptance for the reasons you said.

From our perspective at the Gates Foundation, that is a very important aspect to be able to allow much more that's in production because, as you pointed out, even a -- (inaudible) -- times much vaccine available. And therefore it makes it easier for developing countries to receive it. But it was clearly focused on domestic issues here in the United States in terms of the decision that was made on this. Whether that means the U.S. government isn't the global player that it should be, I'm not so sure because I've heard of other ways in which the U.S. government has been forthcoming, including President Obama's effort with other countries the concept of up to 10 percent of the vaccine going to the developing world.

But it's a serious aspect of this and maybe as time goes on, there will be studies that will allow for the use of adjuvants -- even though the U.S. could change its policy? Could I just mention one other thing we do? We talked a bit about Africa, and if you look at World Health Organization's recent listings of the number of deaths from H1N1, you find the least number in the Africa region and it may be because it hasn't yet spread to certain parts of sub-Saharan Africa. But from my personal view, it's far more likely because of the weak surveillance system.

And there have been studies that show that in a severe pandemic the vast majority of deaths are likely to occur in the developing world, which have the weakest health infrastructures and the fewest number of ventilators, people with already weakened immune systems, et cetera. We talked earlier today about children and youth who are more likely to get H1N1, to become infected. Pregnant women is another concern from some statistics.

We don't know how serious this pandemic will be on a global scale yet. It may turn out to be mild all around the world, but you may find that the death rates are going to be significantly higher than anything close to seasonal influenza, serious problems in the countries that have the weakest health infrastructures. So we shouldn't make an assumption at this meeting that it's a mild pandemic, let's worry about the next one.

GARRETT: That's probably true but we probably have no idea in some of those countries what the toll from seasonal flu is. If they have weak surveillance, they may not know what the burden of disease for seasonal flu is, so we won't even have a totality. Even South Africa, which does have the strongest surveillance system on the continent, is having a hard time keeping a clear idea, partly because they're now in a third wave already of flu. One regular seasonal flu, then an H1N1 and now apparently H1N1 again.

And we've all been really hoping to get good data from South Africa so we'd know about the implications for people with HIV. Though it looks like they are at great risk, the numbers are still not solid enough to say much of anything. Let me open this to the audience, because you've all been very patient. And I'm sure you have many questions. And let me remind the tweeting crowd it's pound CFRQ&A, and that's the A -- ampersand, is that how you say that -- not write out the word and. Pound CFRQ&A. Please be sure to identify yourself when you ask your question.

QUESTIONER: Hi. Isaac -- (inaudible) -- New York City Health Department. How would you rate the vaccine manufacturers in terms of their strategies or activities in dealing with this shortage of vaccine in the developing world?

GARRETT: Anybody want to take that on?

(Laughter.)

When you say rate, what do you mean?

QUESTIONER: (Off mike.)

GARRETT: I think perhaps a way of putting it to you is one of the discussions was to move more manufacturing to encourage multinational companies to locate some elements of their manufacturing in developing-country areas. Has that happened?

LANGE: Well, there's an effort that was done through WHO for several years now called the Global Action Plan to increase pandemic vaccine supply. And there have been contributions to that from -- (inaudible) -- governments -- the U.S. government, Japan and some others have contributed -- to try to build the capacity in the developing countries.

And secondly, you have an effort on the part of Sanofi Pasteur and GlaxoSmithKline to contribute vaccine, 150 million doses, to the World Health Organization. WHO expects to receive that in the coming weeks, so that it can be used for the developing countries. And WHO has gone through an elaborate process, actually, to try to determine which countries are ready to receive it so that they have the delivery mechanisms in place, et cetera. And they've been working with the U.N. System influenza coordinator, Dr. David Nabarro, on this.

But in terms of rating the companies, it's a little difficult, because in the end they've been responsive to the orders that have come in.

GARRETT: Helen, did you (want to add ?)?

BRANSWELL: I know, in addition to the work that WHO has been doing, there's been some discussion of technology transfer to some of the developing countries. I believe Sanofi has signed a tech transfer agreement with Gutaten (sp) in Brazil, have they not?

So, I mean, I think there's some of that going on, but none of that work happens very quickly. It's laborious, long, legal negotiations. And building and certifying a flu vaccine isn't a quick enterprise.

GARRETT: We've got another question in the back.

QUESTIONER: Hi. Isobel Coleman, Council on Foreign Relations. Thank you both for your very interesting comments.

My question is about lead time, or lag time, I guess. If we, in fact, find out that the flu is more severe in some of these developing countries and the death rates are higher, is it possible at that point to take some of these unused vaccines in Canada and the United States and move them at that point to the places where they're most needed, or have they kind of missed the window if that, in fact, emerges?

BRANSWELL: I think that's a two-part question. One, is there a political will in mobilization capacity? And two, on the ground, is there a distribution capacity?

I would jump in with this -- and I think there's a more complex answer that Ambassador Lange can give you. But it will depend on who owns the vaccine at that point in the distribution process. Canada has the first stream coming out of the plant in Quebec City and is buying its vaccine.

If by, say, December we decide we don't need 50.4 million doses, we're going to turn back 25 million or whatever, then GSK starts delivering to the next person on that list. And at that point, I guess it's whether that country is willing to give up a share of their vaccination delivery to pass on. I don't know. I don't know if --

GARRETT: (Inaudible) -- contractual.

BRANSWELL: Yeah. There are lots of contracts that have been signed, advanced-order contracts that have been signed. It's quite a shadowy process. There's not a lot of transparency. A lot of countries haven't really, you know, declared many of the details, whether or not they have options to put further orders in afterwards. And the Americans must have, because you ordered some and then you ordered a whole bunch more. But there isn't a lot of clarity about those contracts. And that, I think, will have a big impact on whether or not there would be available vaccine if things change.

LANGE: But there isn't a process going on that WHO is working on (with ?) contributed -- (inaudible) -- some pharmaceutical companies as well as governments. And the goal that WHO has is to provide enough vaccine for 2 percent of the population, focusing on health workers and other essential personnel. And they expect to be able to do that for all (but ?) the countries with the largest populations.

The idea then of additional vaccines after that would be for other people in the country, including women and others, who could go up to 10 percent. So there are systems in place. WHO is very much working on the logistics of this with various entities within the U.N. system to ensure that the vaccines get delivered and the governments themselves have -- (inaudible) -- systems for delivery to rural Tanzania or wherever the case may be.

And it strikes me that this idea of if there's some leftover vaccine, shall we say, in the spring in some of the countries in the northern hemisphere, that would fit into that same delivery system.

GARRETT: We'll take another question. Let's move over here. Charlie, you had your hand up.

QUESTIONER: Charlie MacCormack from Save the Children.

I'm going to ask the question I asked earlier in a different way, and this is about using this moment to strengthen the ongoing system. And it does seem to me, here in the U.S., it's pretty clear what works in strengthening systems, and that is essentially it starts with private-sector-driven campaigns and celebrities and websites and mass mobilization and social networking, and so on and so forth, with some pump-priming from the foundations that are most interested in all of this. And we've seen it with malaria and we've seen it with HIV, with breast cancer.

It seems to me this could be amenable over the coming several months to that kind of a campaign to get the pretty modest investments that would be needed in strengthening the ongoing system, because the one thing we do know is we're going to get severe pandemic influenza sooner or later. This is not your particular call to make, Ambassador Lange, but would the Gates Foundation and other foundations think about underwriting, priming the pump on a campaign like that?

GARRETT: Not to put you on the spot.

LANGE: It's hard for me to predict exactly what the Gates Foundation view would be on a campaign like that, but if I could give a personal perspective on this. In the period that I was the special representative on avian and pandemic influenza at the State Department, from March 2006 until February 2009, we had a series of international conferences on avian and pandemic influenza. And the first one of these actually was before I took over the position in Washington, D.C., and after that Beijing and Vienna, Austria, and on and on.

And the Egyptian health minister, before the conference that took place that the Egyptian government hosted in Sharm el-Sheikh, talked about flu fatigue. And he was concerned that the focus on H5N1 was waning and it was harder to get governments and various other entities to keep that focus on the pandemic preparedness.

So it seems to me that, in any kind of campaign that you are envisioning, you have to take into account it's not like malaria and HIV-AIDS and other issues that are present on a daily basis. It's preparing for something and you don't know when it will occur.

And, in fact, I used to give speeches saying that if we knew for a fact that the H5N1 virus would cause a global severe pandemic a year from now, we would be acting much differently and we would be writing our last wills and testaments and doing all kinds of things because of the possible 1918-level pandemic that would be so severe and kill so many people.

But we didn't know that, and we're fortunate now that it's a much milder pandemic we're dealing with. I think it is a wakeup call. I think there will be many actions taken that will put us better prepared. But we still have that fundamental issue to deal with of how much money can you put into preparedness when you don't know when it will occur.

GARRETT: Well, we always have that. I mean, when do you build the levees of New Orleans? Oops.

LANGE: After Katrina.

GARRETT: And it seems that you look around the world and you can see that all governments have the same, you know, problem anticipating a long-term risk and spending, without the risk materializing or the threat going to frank presentation.

You know, certainly China has undergone vast changes post-SARS. Its modus operandi before the SARS epidemic and even during it was cover it up; don't let the world know about it. There cannot be flaws in the health apparatus of the communist state. And then, oops, now we go to the total opposite. We're going to start screaming about transparency and being a global citizen.

We certainly had a shift in our U.S. government concern about flu at all, and bird flu specifically, after Katrina, right? I mean, the threat existed before Katrina, but Katrina pushed our government. Is that not true?

LANGE: The initial evidence for this came before I took that position, so I don't want to speculate on what the motivations were. But the whole idea of preparedness, you can look at it from an all- hazards perspective, all these possible things a government needs to prepare for and how we prioritize them.

And my personal view actually is governments don't do a good job of really objectively determining probabilities and then planning for those. There's a tendency that those with the biggest clout in the government can put more effort into their kind of preparations, what their biggest concerns are, not necessarily in looking at it in a broad perspective. "All right, if you're the head of state, what are the probabilities that things may befall us? And if that's the case, how do I prepare for them?" That broad objective analysis is something that's very hard for governments to do.

GARRETT: Back there.

QUESTIONER: Howard Zucker, former assistant director-general for WHO. And I lived through that for two years with the issue of intellectual property.

Actually, this question is for Laurie, but whoever on the panel would like to answer it. I'm really curious as to whether you believe that we can overcome the (inertia ?) of the issues of getting vaccines out there, even antivirals. The WHO announced this morning that, for all people who get sick with swine flu -- or H1N1, I should say -- that they should immediately get access to antivirals -- antivirals may not be available -- until there's really a crisis.

Having lived through this whole thing for two years -- '06-'07 -- and those meetings, it seemed that the intellectual-property issue is critical. And if we can overcome that, then we'll be able to get people to sort of get on board. I'm just curious -- (inaudible) -- the other members.

GARRETT: Well, my personal perspective has changed quite a bit on this issue. I used to think, in my naive days, that these could be incrementally negotiated, that one could take on a given patent dispute, a given equity dispute, and weigh the various concerns, finding an appropriate balance that would both find a profit center for the pharmaceutical industry, deal with sovereignty questions, and increase equity on the ground.

I don't think that anymore. I have seen it fail too many times. I think HIV was the aberration, not the new trend, in terms of widening access to ARV drugs. And I'm now increasingly persuaded that the whole question of equity of access to the benefits in the face of a health threat is part and parcel of equity of access to adaptive technologies and measures for climate change and mitigating energy- conserving measures for climate change.

It's part and parcel of the Copenhagen negotiations and a whole host of transnational-threat issues that find that, not surprisingly, rich countries are able to cope better than poor countries. And most of the coping mechanisms may involve some form of patented technology or a lack of technology transfer and private-sector interests that stand to lose a great deal of money, or at least market position, if access to the tools is broadened across a larger segment of the global population.

And therefore, I think that the answers weigh at a far higher level than the minutia-level decisions we're coming up with. That said, you know, Ambassador Lange has been head-on in these negotiations and may have some differences with my view.

LANGE: Well, it was very clear in the negotiations that we were engaged in through this WHO intergovernmental meeting that some countries were using the same arguments and had the same agenda against intellectual-property-right protection that they were using in other fora. And there were some other conventions, such as the Convention on Biological Diversity, that they were trying to bring into these discussions.

So you could not deal with it as a discrete case involving viruses with pandemic potential. They really have broader applications than this. But the problem is, if you're going to try to look at this holistically and bring in the things that you, Laurie, suggested, such as climate-change issues, et cetera, there is no one global body that deals with it. You're not going to have some broad magic solution on this.

One of the things that I was asked at one point when we were involved in these negotiations is regarding the sharing of samples and the sharing of benefits. Were we coming up with some tinkering, some small changes to the global system and WHO's Global Influenza Surveillance Network, or was it a fundamental change?

And in the end, countries, including the United States and like- minded countries, would not accept fundamental changes. They wanted the tinkering and were happy to be helpful in that regard, but it was tinkering. Whether there will ever come a day when fundamental change occurs, it's very hard to predict. But if you really look at what's going on and what has been going on in these negotiations, it's very hard to see a consensus building for something beyond the tinkering.

GARRETT: Well, I think it kind of -- it's interesting; we sort of see us coming back full circle. Secretary Rubin asked, you know, "Can the U.S. government say that I shouldn't get a vaccine so that there will be some for somebody off in Indonesia?" Charlie MacCormack asked, "Can we not mobilize some sense across a broader range of public outside of government that these sorts of issues need to be addressed and that there need to be kind of global solutions?"

And I think we are at a kind of frustrating spot with all of this where there isn't an easy immediate solution, though there are symbolic gestures -- or a little better than symbolic -- such as the Obama administration pushing to have the 10 percent of vaccine donated. And one would hope that Canada will join the symbolism at some point. (Laughs.)

BRANSWELL: Now I know why I was asked to be on this panel. (Laughter.)

GARRETT: I'm blaming you personally. But it does seem like we're taking on something much larger than we can possibly resolve beyond that sort of, as you say, tinkering level at this time.

Did you have anything you wanted to add to that, Helen?

BRANSWELL: I guess I just think of -- well, I'm not really optimistic that many of these things will be solved in the short term. But, you know, it's the issue of my self-interest, and how far does my self-interest expand? And when is it in my interest that your interests are met? You know, do I feel it's okay for me to forgo getting a vaccination so that somebody in Indonesia can get it? I don't know. I mean, I think those decisions are made in the heat of the particular moment, and it's hard to sort of create a paradigm that will fit all circumstances.

GARRETT: (Inaudible) -- I had H1N1 in early September. And I was talking to Tony Fauci, who runs our National Institute of Allergy and Infectious Diseases, and I said, "Shouldn't we maybe consider, if we're not going to have enough vaccine in time to address the peak of this outbreak in North America, shouldn't we consider possibly saying that everybody like myself that has had H1N1 should not -- should voluntarily not get vaccinated, assume we're naturally vaccinated, and for the sake of the greater good we won't get a vaccine?" And he said, "Well, no, because, first of all, you're not in a risk group, so you shouldn't get the vaccine anyway." I said, "But I have it, so I must be in a risk group."

And secondly, (he ?) said, "Well, we would never be able to handle the liability question. How do I know you definitely had that virus?" and so on. "So we can't make those recommendations." But as you go down the path, how do we get an altruistic sense that is also mixed with a sense of shared risk, shared benefit for the global community? And that is our challenge.

We have time for one last question. David.

QUESTIONER: Hi. David (Wills ?). Really interesting issues.

I thought the point that you were talking about -- do countries, particularly poor and middle-income countries, decide to allocate health resources in this versus other, you know, horrible challenges? If you look at what happened with India just in the media recently with H1N1, they were closing down malls. There was a sense of panic. Yet in the coverage, if you followed it, in some of the newspapers they reminded that "So far 20 people have died from H1N1 and a thousand people are dying every day from TB, basically."

What you see in the global health community is, kind of, some people who are working in different diseases, kind of, roll their eyes. They're like, 'Okay, H1N1, look at all the money that's going in it. Is it really cost-effective in a time of horrible challenges and financial (questions?' ?).

(Inaudible), the point that you made is, how do you, how do you advise countries, and how do we, as a global community -- not just the people who are passionate about pandemics, and the threats, and the true believers; I suppose you could put the AIDS activists on the other side, who really believe that their disease needs to go first, that it's the greatest threat to humanity -- how does a country fairly allocate, based on what you said are the risk probabilities, to make rational decisions, understanding that it's a guesstimate, you know, (taking into some account, that is, ?) and you publicize that, that 'we don't have all the answers. We're making allocations' -- risky.

And the second question is, I'm fascinated by the example of Indonesia -- kind of, maybe it's the lawyer in me, or whatever, saying, okay, this is part of our intellectual property and we don't want to see these samples used to develop products that help people in New York get vaccinated against an illness, while our people have no chance of it.

And I think one of the lessons from AIDS, and from other diseases, countries that do take aggressive measures, even when it offends our sensibilities sometimes, there's some benefits to that. So I was wondering if the panelist have any -- is there any examples in any of the middle-income countries, and the emerging countries, and in the -- (inaudible) -- poor countries that you think have been somewhat modeled, or have tried to deal with this in a way that we can look --

GARRETT: Well, Ambassador Lange, you spent a lot of time in Botswana. There's a country that's grappled with setting priorities more clearly for health than just about any country in the world right now.

LANGE: Well, in Botswana, from the time of President Festus Mogae onward, has really shown tremendous leadership in dealing with this huge HIV problem that they have.

But actually that brings up one of the difficulties I had in my position in the State Department, when one could go to a health minister in Sub-Saharan Africa and say, 'I know you're dealing with your people dying from AIDS, and your people have malaria and tuberculosis,' and maybe it's -- and maybe polio, and other things, 'but what you really need to do is to prepare for a pandemic influenza that may or may not occur in the next decade.' It's very hard for them, in their very resource-constrained environment, to do the preparations that were possible and necessary, I believe, in much richer countries, such as the United States.

There's no easy formula for figuring out, how do you deal with these possibilities. But all you have to do is read books about the 1918 pandemic to realize that a severe pandemic would just be a disaster for the world, and a catastrophe, and you could have tens and tens of millions of people dying in it. So these are not easy efforts and decisions to make.

But one of the things that I had hoped to do in my efforts -- and I think we've succeeded to some extent, was to do our best to ensure that even if there were no pandemic, the monies had been spent for good purposes; not 100 percent of it, because some of it actually was spent to cull chickens, in terms of the avian flu that was going around; and if you cull chickens and reimburse the farmers, you're back to zero; you haven't really gained anything -- but to build laboratory capacity and surveillance systems.

And I remember talking to some of our U.S. government experts in Nairobi, who were working regionally, and they had a built-up capacity to monitor for what had been the concern of H5N1, but it also had that laboratory capacity, and training that was done, et cetera, had much broader capabilities.

So the more you can build your structure to withstand these shocks, wherever the shock may be coming from, the better off you are. And that, I think, is one of the answers to how you deal with these potentially catastrophic events such as a severe influenza pandemic, but you don't know when it will occur.

GARRETT: Now, as you were saying this, and as David was asking his question, I had two thoughts in my mind at the same time and thought, oh, my goodness, if I was the minister of health of South Africa, how would I balance these two thoughts:

On one side, you have the world's largest extremely drug- resistant TB outbreak, and your scarcities of supplies is so great that in the key hospitals -- (inaudible) -- nurses are issued an N-95 mask and they are required to wear it for 30 days -- the same mask. Anybody that's ever worn N-95 knows that'd be pretty horrible. And the risk to them, of course, is extreme, because the mask deteriorates, and so on.

In contrast, you may say, well, this H1N1 thing is all kind of overblown, compared to our HIV catastrophe, and TB, and so on and so forth, but the historical record shows -- now that Chris Murray's (sp) group, and the University of Michigan group have really gone in and parsed the data that we could find for developing countries, shows 1918, the low-ball estimate of 30 million dying in 1918 and 1919 was based on the rich world; and that when you really start looking at what records we have for South Africa, and India, and handfuls of other countries we have records for, a figure closer to 100 million is probably the reality.

So if I'm the minister of health, or if I'm a USAID director trying to figure out where to allocate resources -- we don't have one, by the way, allocate resources to help poor countries, I would have a tough time, day in and day out, balancing those two.

(Pause.)

BRANSWELL: Absolutely. I mean -- (laughs) -- what more can you say, really. There are no answers to that one, I don't think.

GARRETT: Do we have any tweet questions? Apparently not.

Hi, tweeters. Apparently, you're not chiming in.

I could take another question or two from the audience. I was looking incorrectly at the clock.

Here you go.

QUESTIONER: Ryan Scalise, from Control Risks Group.

Just curious to determine -- and, by the way, thank you all for your comments, your insightful comments, wanted to know what your thoughts were on the prospect of the private sector, and their role; what role they can play, in terms of the surveillance effort, globally. There are infinitely more multi-national corporations in the world than governments, although governments have the primary responsibility for dealing with these issues -- public health issues.

It strikes me as, it's interesting that companies that are operating internationally have an obligation to -- a "duty of care" obligation to protect their employees, as well as being mindful of the operating environment in which they're in. What sort of role, how could this go forward, and what sort of private-sector role do you see in that effort? Thank you.

GARRETT: Let's break this up. There's two pieces to that:

One is, what duty to report may there be, or role may there be for multi-national companies to report interesting infections, or what have you, among their labor force, even in far-flung places; and even if the government, in a far-flung place is not interested in having that reported?

BRANSWELL: Or if their competitors aren't -- would get a leg up if they acknowledged that they've had problem going on.

GARRETT: A very good point.

And the second would be the question of -- how did you phrase it exactly, it was "engaging, as a global citizen, in preparedness in developing policy?" Is that what you were getting at?

QUESTIONER: (Off mike.)

GARRETT: Duty and care to protect your own employees?

QUESTIONER: (Off mike.)

GARRETT: And so it seems --

QUESTIONER: (Off mike.)

GARRETT: Okay, you're off-mike for the Web cast, so I'm going to cut you off.

(Inaudible) -- just put it this way, that we've seen in the HIV experience a lot of private-sector sense of obligation and duty in both these areas has arisen. We have the Global Business Coalition on AIDS, Tuberculosis and Malaria, which I believe is now about 280 corporations around the world. And it's both a duty to develop a strategy for your own employees, to protect them, and then it ends up also being engaged in the activities of the communities in which your company sites may be nested.

And certainly in Botswana you had that with several external company players on the ground in Botswana, feeling they had an obligation to provide treatment to their employees for HIV.

LANGE: There were various activities the U.S. Chamber of Commerce, through their international focus, had been doing a lot with multi-national corporations that were trying to prepare for a pandemic. And you can look at various ways in which the private sector, because of the concern for their employees, were dealing with, and engaging in some pandemic preparations, (coming at the ?) personnel policies -- what do you when people are sick? You don't want to have people coming to work because they show an obligation to do so. If they're sick, you want them to be home. And then you give them sick leave. It gets very complicated, very quickly, as we heard earlier, about some of the Department of Labor issues here in the State of New York.

So there were various efforts, over the last few years, to deal with these issues, but I have to say that I had the general impression that the larger multi-national corporations were focusing more on this than smaller companies; and that the smaller companies had much more difficulty trying to devote the resources to this kind of contingency planning when they weren't sure when or where it would occur.

So there is a role, clearly, for the private sector in its own pandemic preparedness. And as we learn the lessons from the current H1N1 pandemic, I would expect additional opportunities to come up, in various, as we try to -- to whatever extent the world community can do it, to build better preparations for a possible future pandemic.

Could I say one thing on something that no one mentioned earlier, about the self-interest issue? I would hope that, coming out of this H1N1, governments would realize that there is going to be an expectation of a contribution of vaccine to developing countries, just as 11 countries have now made clear they will do for this current pandemic; that in the future they -- well, it's a different situation than had existed in the past because of the precedents that are being set right now, and, therefore, the calculation of self-interest will be different.

If you knew that you would be expected to provide vaccine for the developing countries, how would you deal with this if you had a severe pandemic coming about in your -- the United States or another developed country? Maybe then you'd say, well, let's help (for ?) laboratory capacity in developing countries, or maybe we'd so some advance purchases, or whatever. But if you -- the self-interest could be a different calculation in the future than it was in the past, because of precedents we're setting now.

GARRETT: Okay, interesting point, but it could go either way. As Andrew Jack pointed out, you know, the pharmaceutical industry gets a kind of expectation and pressure on them that isn't on -- I think the example you gave was Citibank. Nobody expects Citibank to give out free money from its ATM machines in Africa, but Novartis may be under pressure to give out free drugs in Africa.

And, of course, the retort that the industry would make is, 'We can't afford this. You're pushing us to the wall.' But I saw a report in the Wall Street Journal estimating that GSK alone is going to make about a $3 billion nut off of the H1N1 vaccine. So that doesn't sound like 'pushed against any wall.'

I think we're heading into a confrontation in this area. And where this will sort out is going to be really tough. I don't think that you can say to the industry, 'You should now have an expectation, every time you make something, that you're going to have to ultimately give away some of it.' (We don't think ?) industry will play that game.

BRANSWELL: I actually think the paradigm is shifting as a consequence of the Indonesia situation. It used to be that the vaccine manufacturers got viruses for free. They didn't pay. They were developed for them -- (inaudible) -- and that was the way it worked.

I don't think that's necessarily going to be the way it is, going forward. I suspect that there's going to be an expectation of a quid pro quo of a sort. And I don't know if -- not suggesting that that means, you know, you're going to get -- 'You want the -- (inaudible) -- (strain? ?) Okay, here's what it costs.' But I think that there's going to be an expectation that industry has a role to play in this kind of response; and, by benefitting from the continual share of viruses for seasonal vaccine, that there's going to be an expectation (of something before very long. ?)

LANGE: I'm not so sure that the quid pro quo, though, is going to come forward. In part, because Mexico, which had been -- in the negotiations, been kind of an intermediary between those who were very much insisting on the control of the virus, versus others who thought that it should be given freely to the -- (inaudible) -- surveillance network for the benefit of global public health.

Mexico, it's my understanding, has now been much more forthcoming on 'we've got to share it for the benefit of everyone' -- it does benefit global public health. So if you look at the very strong and positive responses from Mexico, when they first discovered H1N1, I'm not sure the world would move toward that quid pro quo requirement.

BRANSWELL: Maybe I shouldn't have characterized it in that way, but I do believe that WHO is -- (inaudible) -- that there is an expectation that there will be -- that this, you know, the donations into their funds are not going to be a one-time thing.

GARRETT: Well, that's quite a note to end on. And I'm afraid that we are out of time. This concludes the Web cast and our basic meeting, jointly sponsored by Science, and the Council on Foreign Relations.

I want to say, on behalf of the Council on Foreign Relations, that Science has been a wonderful partner to work with. We hope that we'll have an opportunity to partner again in the future; and that the staff, both here at the Council, and at Science, and the American Association for the Advancement of the Sciences, have performed in stellar fashion in pulling this very ambitious event together.

I want to once again thank Richard Brown (sp), who made a kind donation that helped subsidize this event.

This concludes the webcast.

For the rest of you, we will now have lunch, and you can continue your discussion on an informal basis. Thank you very much for joining us. (Applause.)

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THIS IS A RUSH TRANSCRIPT.

LAURIE GARRETT: If people could please take their seats.

Broadcast audience, we'll be starting momentarily.

Good morning, I'm Laurie Garrett, here as a senior fellow at Council on Foreign Relations. For those of you that may have just tuned in on the webcast, we've had two fantastic discussions preceding this one:

The first, chaired by my colleague, Jon Cohen, from Science Magazine, which is a cosponsor, with Council on Foreign Relations, of today's symposium on influenza, that really got into the scientific uncertainties that we see with this H1N1 pandemic.

And the second, chaired by Secretary Robert Rubin, who is also the chair of the Council on Foreign Relations, regarding some of the possible economic consequences and impacts for businesses -- the macroeconomic scale, government financing, and so on, that we will see with this mild epidemic, and some of the implications of what might happen if it were a more dangerous virus.

Everything that you're hearing is on the record. That includes your questions, so you better think about that before you open your mouth. We're going to have a conversation for about 40 minutes, and then open it up for a good half hour of questions from all of you, including the webcast audience. If you are a Tweeting, a Twittering aficionado, your tweet is: # or @cfrq&a -- #cfrq&a. And, once again, a reminder to those of you here, please turn off all your transmitting devices as they may interfere with the signaling here in the room.

Well, I think the take-home message from our first two panels is it's a darned good thing we're dealing with a relatively mild flu this time, because clearly we're ill-prepared at this moment for a more virulent, a more dangerous flu pandemic, either if this one takes on a more dangerous form, which fortunately Dr. Palese assures us will not happen -- I'll hold you to it, Peter, or if a second, totally different, virus does emerge.

Nevertheless, we've already seen some very hot-button issues emerge internationally, some of which have just been touched on. And I want to start with Ambassador Lange. John Lange has served for many years in the United States government. He was ambassador to Botswana. But in his last position, before his current (spot ?), working for the Bill and Melinda Gates Foundation, he played a key role as -- I don't remember what your exact title was, but the pandemic aficionado on behalf of our State Department dealing with what was then the key concern, H5N1, aka "bird flu," and our international relations, in terms of surveillance and preparedness.

And I want to start by asking you, there was -- there's been a lot of talk, why doesn't the government have a plan, so on, and so forth. But, indeed, you were part of a process that did promulgate a national plan for pandemic response in the Bush administration. And there's been a lot of talk at WHO, and at other tiers internationally, of trying to come up with a more rational, some sort of advanced planning that could coordinate the global response.

Where does that stand?

JOHN E. LANGE: Well, the previous administration, under President Bush, created a U.S. national strategy for pandemic influenza, and an implementation plan. The strategy was released -- (inaudible) -- in late 2005, an implementation plan in May of 2006.

And, from my observations, and that of many others, the fact that that plan was in place -- the fact that there had been international coordination, through the international partnership on avian and pandemic influenza; the fact that there were several years in which organizations, governments, international organizations, non- governmental organizations -- (inaudible) -- preparing for the possibility of the H5N1 pandemic -- really did a lot, and had a major impact on the ability of the international community to respond to the current pandemic of H1N1.

As we discussed, and heard from the speakers earlier today, it's not perfect, in terms of the response, but the world is much better prepared today than it would have been if this had occurred four years ago.

GARRETT: I should point out, one of the people who had been involved in a lot of that planning was Mike Osterholm, who we just heard from as a sort of "voice of god" in this room -- (laughter) -- in the prior session. And I need to thank Mike -- I hope you're on the webcast, for your valiant efforts to fly out of Minneapolis yesterday in the snow storm, and we're happy that you're able to join us, "telecommuting," in the absence of being here physically. But Mike had raised some of the same points, that we had some level of advanced planning, thanks to our concern about H5N1.

And, of course, the other thing we had in place, thanks in part to the sense of urgency around H5N1 bird flu, was the international health regulations, which form a sort of guidance of how the world should cooperate regarding infectious disease issues.

But, again, sticking with you, Ambassador Lange, we've had trouble seeing how that ends up actually applying, concretely, to compelling or nudging nations to truly share viral samples, open surveillance, outbreak investigation with the global community.

LANGE: Well ultimately the government of Mexico was very forthcoming in sharing samples, and really it could be used as a model for how other governments should react in similar -- a similar situation with the start of a possible pandemic.

There were difficult negotiations going on for two years at the World Health Organization. It was called an "Intergovernmental Meeting on Pandemic Influenza Preparedness." And it dealt with this is of sharing of samples, as well as sharing the benefits that come, such as vaccines and other aspects of pandemic preparedness and response.

And it would be wonderful if we could look at this just from a global health perspective, and the need to share these samples and to share the vaccines, et cetera. But in that context -- that took place at WHO, it involved many political issues, such as intellectual property rights and the sovereignty issues. And, regrettably, while there was certainly progress made, they did not come to a conclusion on some of the basic issues.

One of my personal hopes is that this pandemic, which is milder than we had predicted the H5N1 pandemic would be -- and let's hope it stays that way, there's no guarantee of that, but let's hope that this will be the wake-up call that is, as Jon Cohen said earlier in this symposium, "a teachable moment," and that we can be looking to the lessons learned from this and create systems whereby we don't have ad hoc mechanisms for trying to deal with this, but a more concerted effort.

As you know, I come from a foundation -- the Bill and Melinda Gates Foundation, where our basic premise is that all lives have equal value and that every person deserves the chance to live a healthy and productive life. And to answer Secretary Rubin's question from earlier, there is a moral obligation to help the poorer people of the world, the developing countries with access to vaccines, et cetera.

Right now there has been a very laudable effort on the part of -- at first announcement, nine countries, and few have been added, to provide some of their vaccines to the developing world, and WHO is working on that. But it's still being done in a way that is -- (inaudible) -- in a sense, ad hoc. I would hope that in the longer- run, these issues can be dealt with when looking at the experience from H1N1.

GARRETT: Helen Branswell has been one of a tiny handful of truly outstanding journalists on this beat, on this story doggedly. I think there are people all over Geneva, in WHO, that are terrified when they hear that Helen is calling. (Laughter.)

Secretary (sic) Lange mentioned this agreement that was brokered by the White House -- initially eight countries, now I believe it's up to 11 have agreed that they will donate 10 percent of their vaccine supply to WHO for distribution in developing countries. Before getting into what the real significance of that may be, your country is one that has not signed on. Why is that? Why is Canada not in the game?

HELEN BRANSWELL: That's a fascinating question and I don't have a good answer. I've been trying to get a good answer, and having just absolutely no luck.

I don't think you know, do you?

LANGE: No, I do not.

BRANSWELL: It's puzzling. It's really puzzling, because it's typically the type of thing that Canada does do. In fact, somebody on this side of the border -- I wrote a story about the fact that we were noticeably absent from that group of donating countries, and somebody from this side of the border called me and said, "Interesting story. You guys are normally -- (inaudible) -- and you're not there. What's going on?"

I don't know. I'm told that we're still looking at what the need is, and we're trying to determine what's -- how we could best fill the needs that exist. We're going to swimming in unused vaccine, and I'm not clear at all why we're not -- (inaudible) --

GARRETT: Do you have any idea how much vaccine Canada has ordered, and how much is likely to actually get used?

BRANSWELL: Well, we ordered 50.4 million doses. And that's enough to give everybody -- that was based on the premise that maybe 75 percent of people would want to be vaccinated, and we'd need two doses a piece. We don't.

We have a population of 33.6 million, and if they vaccinate half of that, they'll be very, very -- be doing dances. There's no chance that that's going to happen. Polls suggest somewhere in the low 30s right now.

GARRETT: You have a resistance to vaccination in Canada as we do here in the U.S. --

BRANSWELL: Yeah, there's a lot of fear about this vaccine, and particularly because in Canada we're using an adjuvanted vaccine for the first time. You guys aren't going that route. And there are implications, and pros and cons, but there is quite a bit of concern about whether or not this vaccine is safe, whether people need it, and I'd be very surprised, unless things get worse, if the numbers would be very high.

GARRETT: So we have the possibility of signaling to the world, 'We want everybody to sign on with globalization. And, in the context of pandemic-disease threat, that means we want every one of you, rich and poor alike, around the world, to let us know if you have any weird outbreaks; allow outside investigators to come in, and swoop in when you have an outbreak. We want all the civil society organizations and NGOs, the MSFs of the world to tip us off if there's outbreaks, even in failed-state areas, and so on.'

So we're globalizing this sense of threat. We're globalizing the responsibility to surveil and to observe threat, but we are not globalizing the benefits, in terms of those tools that can help protect societies against the threats. And then, on top of it all, you're saying -- and Mike Osterholm had hinted at this earlier, that when we get to the end of the day, out in January or February of 2010, we may well see giant unused stockpiles of vaccine in the wealthy countries, none having ever reached most of the poor countries of the world.

BRANSWELL: Well, some are going to reach the poor countries through this initiative that Gates was involved in trying to broker, I believe, and the WHO is also spearheading. And that's in real-time, which is really quite an achievement, I have to say. I didn't think that was going to be possible.

But that's a small percentage. They hope to be able to provide enough vaccine to developing countries to vaccinate about 2 percent of their population. And it's true that then there will be this large amount of vaccine elsewhere that isn't going to go -- be used.

John's (sp) question, about whether or not that might be a good thing, I just found was intriguing, because in the context of America, or Canada, or whatever, if vaccine isn't needed, and we bought it, and it was there, and it was an insurance policy, maybe that is a success. But I don't think the world's going to see it that way if, at the end of this, we're going to find that Canada had 25 million doses of vaccine that we couldn't persuade people to take, and we didn't free up to pass along to others.

Now, I will say that the Canadian authorities, I think, are already in discussions with the contractor that we're buying from, GlaxoSmithKline, to turn back the portion that we don't need, so that they can sell it to whoever is next on their list. But I'm not sure when we're going to say, okay, we feel safe to feel -- to say that we don't need this, and so you can sell it elsewhere. And that's selling, that's not donating.

GARRETT: John, I want to go back to you because we need to bring everybody up to speed, and they may not all know what, in particular, went down with the United States government and the government of Indonesia around this issue, and that remains unresolved at this time.

But you were actually there in Indonesia trying to negotiate with their ministry of health to get them to free up samples of bird flu viruses that had emerged in that country, that they were refusing to share on the grounds that, if a vaccine were made, they would never get the vaccine. Correct?

LANGE: Well, yes. It was quite a complicated (approach to the ?) negotiations. Some of them were between the United States and Indonesia, trying to see if we could come to an agreement that we could then pass on to the multilateral forum that I mentioned earlier, under the auspices of WHO in Geneva.

The thing is, once this came to the World Health Assembly in May of 2007, and this intergovernmental meeting process that I mentioned earlier was created, then it became multilateral. And so it was not just Indonesia that was negotiating. And then some other countries started bringing in other issues, whereas Indonesia was concerned with -- more focused on the control of the virus that had emanated from their country and benefits that they had hoped to receive in return.

But I'd like to actually look at this from what I think has been the change in the this -- over the last few years, particularly since this recent announcement there's up to 10 percent of vaccines that are going to be allocated by -- up to 11 countries now, to help the developing world.

There's been a lot of discussion on this and at the Gates Foundation our strategy -- our focus is to ensure that there's an effective strategy to address the pandemic in developing countries. Dr. Tadataka Yamada, the head of the Global Health Program at the Gates Foundation wrote an article that was published in the New England Journal of Medicine last month that listed eight proposed principles to help guide elevation of pandemic vaccine to really ensure that within the same time frame, developing countries receive the vaccine as well as the developed countries.

And if you look at what is happening, you can argue that we are moving in a very positive direction, that while the debate -- we can argue between the sterile debate in WHO over whether this should be done on a voluntary basis or a mandatory basis. Maybe we're now moving to a way in which it's expected even though it's not mandatory. Just as you have one of the huge programs in the world for HIV AIDS -- (inaudible) -- the president's emergency plan for AIDS relief, it's not a mandatory contribution, but it's certainly an expected one. Every observer believes it will continue.

The people who run the Gates Foundation Global Health Program is not required. It's not mandatory. There's no legal requirement for it, but it certainly is a very real positive program to help global health, and I wonder if we've now set some precedents just for the last few weeks, actually, whereby when the next pandemic occurs, a serious and possible more severe pandemic than this one, but that there will be that expectation that those vaccines will be shared.

BRANSWELL: I'm -- (inaudible) -- and I think that's true and I think -- but the issue remains. The issue that Secretary Rubin brings in the last session. This -- it's easy to commit this time because it's a relatively mild disease. Most people aren't getting very sick. Most people -- Australia got through their wave -- you know, they managed to get through their wave and they had no vaccine at all. But if this were -- this were H5N1 or even something not as bad as H5N1, would your government have felt that it could say, let's broker a deal and give away 10 percent of our vaccine in wartime. That's a very hard thing to do when it's a crisis and I think -- I agree with you that a precedent has been set and that expectations have been created and I -- but I'm not certain how hard -- or how easy it will be to deliver on that in a time when things are more difficult.

GARRETT: Well, you know, one of the interesting things here is the question of sovereignty. And David Sidler (ph) has raised this from the University of Indiana, Professor of Law, as the bottom line challenge that we face going forward in this age of globalization when facing pandemic threats -- any kind of disease threat -- the question of sovereignty is if he could get a two-edged sword. On the one hand the government of Indonesia can say we've declared viral sovereignty. It did say this. Any viruses that we find on our soil are our viruses, not to be seen by the rest of the world unless there's some contractual understanding, and any profits derived from said viruses down the road go to Indonesia. That was an interesting perspective.

We conversely could have sovereignty declared in the context of Canada may have ordered vaccine from, let's say, the U.K., but if it turns into a super virulent flu, the Brown government could very well say no vaccines made on British soil will leave British soil -- full stop. And when you consider kind of the chain of production that we were talking about in our prior session that the raw ingredients for most pharmaceuticals are actually coming from China and India, but the masks and protective gear our hospital workers depend on come from outside the United States. You start to be -- imagine a very quick multiplier effect all based on the notion of sovereignty that could make any kind of moral understanding that you and -- (inaudible) -- are talking about completely collapse.

And Sidler argues that we have no legalistic mechanism in place or one that we can even immediately imagine that can get us past this moment. How do you see that?

LANGE: I actually don't have high hopes that there could be some legal mechanism that could be put in place because the negotiations that went on in Geneva were so difficult and positions were so attractive on all sides. And so -- but I guess -- my thoughts in terms of what Helen was saying well what happens in a more severe pandemic when there is the pressure not to give up the vaccine and what Secretary Rubin said earlier.

It seems to me that that argues for actions in the next months and years with that in mind, that if there is the expectation that has been developed that, yes, developing countries do deserve vaccines and we can't have the rich countries first in line and developing countries last in line and this kind of situation.

Well, how do we deal with that? Maybe there are ways, for example, to increase the production capacity for influenza vaccine in some developing countries, not because we expect that there -- that you can have a robust plan just to do pandemic influenza vaccine production once every 25 or 40 years, or whenever the pandemics occur, since there were two in the last century, but also for seasonal influenza flu vaccine.

And so if you increase the global consumption of seasonal influenza vaccine, you could keep these plants going. There may be other ways to do this, whether there's advanced purchases or whatever, so that the political issues that were discussed earlier are mitigated even in a severe pandemic. It's in a sense -- and it's too early right now. I talked to WHO this week and they have twelve task forces going just H1. They're not about to look at lessons learned as they're still in the middle of learning them, but in the coming months and years, we may find a real opportunity in the international community from this wake up call to try to put in mechanisms for that expected, or not mandatory system to benefit the developing world.

GARRETT: Well, Canada is going to be hosting the next -- what we would have called until a year and a half ago G8. Now it could be G20, I assume -- summit will be Ottawa or outside Ottawa and, you know, traditionally when we've had these sorts dilemmas there's some shurpa (sic) on the part of all the G8 shurpiteens (sic) to try and come up with an outline of what might be a proposed mechanism, but then the heads of state at the summit could agree to. Now if we expand to G20, we're bringing in players with very antagonistic perspective.

Indonesia is in G20, Brazil, Egypt, India, China, some of the biggest generic manufactures who have opposed any tightening or even the existing standards of patent protection for the pharmaceutical industry.

Are you aware of any kind of idea what might float at the a Canadian summit?

BRANSWELL: No, I'm not. I'm afraid I'm not here. I don't know about you, but again I share -- I was going to say pessimism, I guess maybe skepticism would be a nicer word. I think these are really tough issues and I'm not clear how much political will there will be going forward on this.

I share the concern of the man from Save the Children that we can't want a more severe pandemic. I'm delighted that this one is playing out the way it is, but I think that one of the things that's it's doing is creating in the minds of most people, and most taxpayers, perhaps that pandemics are not necessarily such a big deal, that we have been over-hyped them, that they're not as scary as we thought or that modern medicine.

The argument that we heard about 1918 that if we had modern medicine in 1918, it would never have been severe as it was. I think it's sort of being overlaid here, and people are saying, oh, well if you have -- (inaudible) -- and ICU's and what not, you're going to be fine. You can get through a pandemic, and I wonder whether the lesson going forward will be we found all these holes because we have found tons of holes and as you pointed out in the beginning when we discovered that we were -- we thought we were preparing for the worst case scenario and actually in fact we are not prepared a very mild pandemic, but I'm concerned that people won't take that lesson going forward, that they'll say, you know, we spent a lot of money. We threw away a lot of vaccines. We've had a pandemic. Another one isn't coming for another two or three decades, let's move on.

GARRETT: Well, the -- you know, Ambassador -- (inaudible) -- that there's about 12 panels advising WHO right now. I know one of them has to do with control of message.

They're -- you know here we have a situation where unlike in 1976 and certainly unlike '68, '57, and 1918, we have the Internet and we have the ability for claims, counterclaims, light insanity to be transmitted globally overnight.

I was in a meeting at the Institute of Medicine where one commissioner of health from New Jersey stood up and said, "Look, let's be frank about what we're up against. The odds are that some woman somewhere in the world will have a miscarriage the same day she gets a flu shot.

BRANSWELL: Actually, that could be 1,000 women; it's not going to be one.

GARRETT: All right. It's a statistical probability, and since we're targeting pregnant women specifically to get vaccinated, then all it will take is one lawyer or a talk-show host or whomever it may be to go on the Internet and start screaming and WHO has lost control of the message; your local health commissioners have lost control of the message.

BRANSWELL: (Inaudible) -- here have control of the message now.

GARRETT: Talk about that.

BRANSWELL: I mean, the blogosphere is going crazy about this vaccine. I mean, that's another -- if you want to talk about concerns going forward, I'm really concerned that this campaign, this biggest probable vaccination effort ever could be -- you know, if anything goes wrong, and things will go wrong -- and whether or not they have anything to do with the vaccine or not, thing are going to go wrong and it could have enormous repercussions for people's willingness to be vaccinated against any number of things.

And if we don't -- in the developed world -- if we don't buy vaccines and if our children aren't vaccinated, there won't be vaccines available for the developing world.

GARRETT: And if you think about it in the context of countries where the capacity to control messages is even more difficult, for example in Africa, we've already seen how going to the Internet prompts an e-mom to say that polio vaccines have HIV and/or a sterilizing agent in them and now we have lost ground on our attempts to eradicate polio worldwide, which is -- and if there's a claim of a health effect in, let's just say Germany, is that likely to resonate around the world and even into the poorest countries of the world, so that we have a globalized sense of incorrect threat, incorrect perception?

BRANSWELL: Certainly. I mean, it's very, very possible. The probable being, you know, something happens that they're looking for. In '76 I think the problem was that nobody knew what the baseline rate of GBS was -- (inaudible) -- syndrome. So when all of a sudden people said it seems like the rate is higher you had to answer the fundamental question, what's the baseline rate?

I think now they know that so they might be able to say, "Okay, this is just actually normal or just maybe if something increased" -- but what if something we're not anticipating happens, something out of left field, like the multiple sclerosis and those Hepatitis B vaccination program in France. If something that you wouldn't think of materializes, and people are starting to say, "okay, so what is the baseline rate for that in children?" And nobody really knows. It's going to take, I don't know, years?

And maybe, as Mike mentioned in the earlier session, people won't know the answer. But at any rate, if something materializes, the decisions, the blogospheres will go crazy and will connect it, cause this. The scientists will spend weeks, months, whatever, trying to figure what has caused this. But the public will make up its mind in the interlude. It's going to be a real problem.

GARRETT: Last question to you before we open up to our audience. The United States would be perhaps in a better position to look like a global player. Your boss Tadataka Yamada, has suggested -- and many others have as well, if we were willing to do what Canada and all of Europe and Japan have done, which is use adjuvants to stretch out the efficacy of our limited antigen supply so that the vaccines, any given amount of antigen could go to 10 times more human beings, therefore greatly expanding our vaccinations capacity.

That would mean that then we would be in a position to not donate, say 10 percent of our vaccine supply, but perhaps 90 percent of our vaccine supply, to developing countries. The United States stands alone among rich countries where it's using to entertain that. And off the record, most the folks at FDA say it's because of the antivaccine movement and fears that people in this country who want 100 percent safety will never allow an adjuvants to go in, even though it means your denying any vaccine, even a one in a billion risk factor vaccine, to the majority of the world population.

How do we resolve that, and can we continue to give a message that says we are a global player if we continue to also refuse to stretch our vaccine supply?

LANGE: I mentioned earlier the poll is principle to guide allocation of pandemic vaccine and one of those principles was to try to develop a consensus on the safety and efficacy of the use of adjuvants. But it has been very difficult within the U.S. government and the Food and Drug Administration to get approval for that and acceptance for the reasons you said.

From our perspective at the Gates Foundation, that is a very important aspect to be able to allow much more that's in production because, as you pointed out, even a -- (inaudible) -- times much vaccine available. And therefore it makes it easier for developing countries to receive it. But it was clearly focused on domestic issues here in the United States in terms of the decision that was made on this. Whether that means the U.S. government isn't the global player that it should be, I'm not so sure because I've heard of other ways in which the U.S. government has been forthcoming, including President Obama's effort with other countries the concept of up to 10 percent of the vaccine going to the developing world.

But it's a serious aspect of this and maybe as time goes on, there will be studies that will allow for the use of adjuvants -- even though the U.S. could change its policy? Could I just mention one other thing we do? We talked a bit about Africa, and if you look at World Health Organization's recent listings of the number of deaths from H1N1, you find the least number in the Africa region and it may be because it hasn't yet spread to certain parts of sub-Saharan Africa. But from my personal view, it's far more likely because of the weak surveillance system.

And there have been studies that show that in a severe pandemic the vast majority of deaths are likely to occur in the developing world, which have the weakest health infrastructures and the fewest number of ventilators, people with already weakened immune systems, et cetera. We talked earlier today about children and youth who are more likely to get H1N1, to become infected. Pregnant women is another concern from some statistics.

We don't know how serious this pandemic will be on a global scale yet. It may turn out to be mild all around the world, but you may find that the death rates are going to be significantly higher than anything close to seasonal influenza, serious problems in the countries that have the weakest health infrastructures. So we shouldn't make an assumption at this meeting that it's a mild pandemic, let's worry about the next one.

GARRETT: That's probably true but we probably have no idea in some of those countries what the toll from seasonal flu is. If they have weak surveillance, they may not know what the burden of disease for seasonal flu is, so we won't even have a totality. Even South Africa, which does have the strongest surveillance system on the continent, is having a hard time keeping a clear idea, partly because they're now in a third wave already of flu. One regular seasonal flu, then an H1N1 and now apparently H1N1 again.

And we've all been really hoping to get good data from South Africa so we'd know about the implications for people with HIV. Though it looks like they are at great risk, the numbers are still not solid enough to say much of anything. Let me open this to the audience, because you've all been very patient. And I'm sure you have many questions. And let me remind the tweeting crowd it's pound CFRQ&A, and that's the A -- ampersand, is that how you say that -- not write out the word and. Pound CFRQ&A. Please be sure to identify yourself when you ask your question.

QUESTIONER: Hi. Isaac -- (inaudible) -- New York City Health Department. How would you rate the vaccine manufacturers in terms of their strategies or activities in dealing with this shortage of vaccine in the developing world?

GARRETT: Anybody want to take that on?

(Laughter.)

When you say rate, what do you mean?

QUESTIONER: (Off mike.)

GARRETT: I think perhaps a way of putting it to you is one of the discussions was to move more manufacturing to encourage multinational companies to locate some elements of their manufacturing in developing-country areas. Has that happened?

LANGE: Well, there's an effort that was done through WHO for several years now called the Global Action Plan to increase pandemic vaccine supply. And there have been contributions to that from -- (inaudible) -- governments -- the U.S. government, Japan and some others have contributed -- to try to build the capacity in the developing countries.

And secondly, you have an effort on the part of Sanofi Pasteur and GlaxoSmithKline to contribute vaccine, 150 million doses, to the World Health Organization. WHO expects to receive that in the coming weeks, so that it can be used for the developing countries. And WHO has gone through an elaborate process, actually, to try to determine which countries are ready to receive it so that they have the delivery mechanisms in place, et cetera. And they've been working with the U.N. System influenza coordinator, Dr. David Nabarro, on this.

But in terms of rating the companies, it's a little difficult, because in the end they've been responsive to the orders that have come in.

GARRETT: Helen, did you (want to add ?)?

BRANSWELL: I know, in addition to the work that WHO has been doing, there's been some discussion of technology transfer to some of the developing countries. I believe Sanofi has signed a tech transfer agreement with Gutaten (sp) in Brazil, have they not?

So, I mean, I think there's some of that going on, but none of that work happens very quickly. It's laborious, long, legal negotiations. And building and certifying a flu vaccine isn't a quick enterprise.

GARRETT: We've got another question in the back.

QUESTIONER: Hi. Isobel Coleman, Council on Foreign Relations. Thank you both for your very interesting comments.

My question is about lead time, or lag time, I guess. If we, in fact, find out that the flu is more severe in some of these developing countries and the death rates are higher, is it possible at that point to take some of these unused vaccines in Canada and the United States and move them at that point to the places where they're most needed, or have they kind of missed the window if that, in fact, emerges?

BRANSWELL: I think that's a two-part question. One, is there a political will in mobilization capacity? And two, on the ground, is there a distribution capacity?

I would jump in with this -- and I think there's a more complex answer that Ambassador Lange can give you. But it will depend on who owns the vaccine at that point in the distribution process. Canada has the first stream coming out of the plant in Quebec City and is buying its vaccine.

If by, say, December we decide we don't need 50.4 million doses, we're going to turn back 25 million or whatever, then GSK starts delivering to the next person on that list. And at that point, I guess it's whether that country is willing to give up a share of their vaccination delivery to pass on. I don't know. I don't know if --

GARRETT: (Inaudible) -- contractual.

BRANSWELL: Yeah. There are lots of contracts that have been signed, advanced-order contracts that have been signed. It's quite a shadowy process. There's not a lot of transparency. A lot of countries haven't really, you know, declared many of the details, whether or not they have options to put further orders in afterwards. And the Americans must have, because you ordered some and then you ordered a whole bunch more. But there isn't a lot of clarity about those contracts. And that, I think, will have a big impact on whether or not there would be available vaccine if things change.

LANGE: But there isn't a process going on that WHO is working on (with ?) contributed -- (inaudible) -- some pharmaceutical companies as well as governments. And the goal that WHO has is to provide enough vaccine for 2 percent of the population, focusing on health workers and other essential personnel. And they expect to be able to do that for all (but ?) the countries with the largest populations.

The idea then of additional vaccines after that would be for other people in the country, including women and others, who could go up to 10 percent. So there are systems in place. WHO is very much working on the logistics of this with various entities within the U.N. system to ensure that the vaccines get delivered and the governments themselves have -- (inaudible) -- systems for delivery to rural Tanzania or wherever the case may be.

And it strikes me that this idea of if there's some leftover vaccine, shall we say, in the spring in some of the countries in the northern hemisphere, that would fit into that same delivery system.

GARRETT: We'll take another question. Let's move over here. Charlie, you had your hand up.

QUESTIONER: Charlie MacCormack from Save the Children.

I'm going to ask the question I asked earlier in a different way, and this is about using this moment to strengthen the ongoing system. And it does seem to me, here in the U.S., it's pretty clear what works in strengthening systems, and that is essentially it starts with private-sector-driven campaigns and celebrities and websites and mass mobilization and social networking, and so on and so forth, with some pump-priming from the foundations that are most interested in all of this. And we've seen it with malaria and we've seen it with HIV, with breast cancer.

It seems to me this could be amenable over the coming several months to that kind of a campaign to get the pretty modest investments that would be needed in strengthening the ongoing system, because the one thing we do know is we're going to get severe pandemic influenza sooner or later. This is not your particular call to make, Ambassador Lange, but would the Gates Foundation and other foundations think about underwriting, priming the pump on a campaign like that?

GARRETT: Not to put you on the spot.

LANGE: It's hard for me to predict exactly what the Gates Foundation view would be on a campaign like that, but if I could give a personal perspective on this. In the period that I was the special representative on avian and pandemic influenza at the State Department, from March 2006 until February 2009, we had a series of international conferences on avian and pandemic influenza. And the first one of these actually was before I took over the position in Washington, D.C., and after that Beijing and Vienna, Austria, and on and on.

And the Egyptian health minister, before the conference that took place that the Egyptian government hosted in Sharm el-Sheikh, talked about flu fatigue. And he was concerned that the focus on H5N1 was waning and it was harder to get governments and various other entities to keep that focus on the pandemic preparedness.

So it seems to me that, in any kind of campaign that you are envisioning, you have to take into account it's not like malaria and HIV-AIDS and other issues that are present on a daily basis. It's preparing for something and you don't know when it will occur.

And, in fact, I used to give speeches saying that if we knew for a fact that the H5N1 virus would cause a global severe pandemic a year from now, we would be acting much differently and we would be writing our last wills and testaments and doing all kinds of things because of the possible 1918-level pandemic that would be so severe and kill so many people.

But we didn't know that, and we're fortunate now that it's a much milder pandemic we're dealing with. I think it is a wakeup call. I think there will be many actions taken that will put us better prepared. But we still have that fundamental issue to deal with of how much money can you put into preparedness when you don't know when it will occur.

GARRETT: Well, we always have that. I mean, when do you build the levees of New Orleans? Oops.

LANGE: After Katrina.

GARRETT: And it seems that you look around the world and you can see that all governments have the same, you know, problem anticipating a long-term risk and spending, without the risk materializing or the threat going to frank presentation.

You know, certainly China has undergone vast changes post-SARS. Its modus operandi before the SARS epidemic and even during it was cover it up; don't let the world know about it. There cannot be flaws in the health apparatus of the communist state. And then, oops, now we go to the total opposite. We're going to start screaming about transparency and being a global citizen.

We certainly had a shift in our U.S. government concern about flu at all, and bird flu specifically, after Katrina, right? I mean, the threat existed before Katrina, but Katrina pushed our government. Is that not true?

LANGE: The initial evidence for this came before I took that position, so I don't want to speculate on what the motivations were. But the whole idea of preparedness, you can look at it from an all- hazards perspective, all these possible things a government needs to prepare for and how we prioritize them.

And my personal view actually is governments don't do a good job of really objectively determining probabilities and then planning for those. There's a tendency that those with the biggest clout in the government can put more effort into their kind of preparations, what their biggest concerns are, not necessarily in looking at it in a broad perspective. "All right, if you're the head of state, what are the probabilities that things may befall us? And if that's the case, how do I prepare for them?" That broad objective analysis is something that's very hard for governments to do.

GARRETT: Back there.

QUESTIONER: Howard Zucker, former assistant director-general for WHO. And I lived through that for two years with the issue of intellectual property.

Actually, this question is for Laurie, but whoever on the panel would like to answer it. I'm really curious as to whether you believe that we can overcome the (inertia ?) of the issues of getting vaccines out there, even antivirals. The WHO announced this morning that, for all people who get sick with swine flu -- or H1N1, I should say -- that they should immediately get access to antivirals -- antivirals may not be available -- until there's really a crisis.

Having lived through this whole thing for two years -- '06-'07 -- and those meetings, it seemed that the intellectual-property issue is critical. And if we can overcome that, then we'll be able to get people to sort of get on board. I'm just curious -- (inaudible) -- the other members.

GARRETT: Well, my personal perspective has changed quite a bit on this issue. I used to think, in my naive days, that these could be incrementally negotiated, that one could take on a given patent dispute, a given equity dispute, and weigh the various concerns, finding an appropriate balance that would both find a profit center for the pharmaceutical industry, deal with sovereignty questions, and increase equity on the ground.

I don't think that anymore. I have seen it fail too many times. I think HIV was the aberration, not the new trend, in terms of widening access to ARV drugs. And I'm now increasingly persuaded that the whole question of equity of access to the benefits in the face of a health threat is part and parcel of equity of access to adaptive technologies and measures for climate change and mitigating energy- conserving measures for climate change.

It's part and parcel of the Copenhagen negotiations and a whole host of transnational-threat issues that find that, not surprisingly, rich countries are able to cope better than poor countries. And most of the coping mechanisms may involve some form of patented technology or a lack of technology transfer and private-sector interests that stand to lose a great deal of money, or at least market position, if access to the tools is broadened across a larger segment of the global population.

And therefore, I think that the answers weigh at a far higher level than the minutia-level decisions we're coming up with. That said, you know, Ambassador Lange has been head-on in these negotiations and may have some differences with my view.

LANGE: Well, it was very clear in the negotiations that we were engaged in through this WHO intergovernmental meeting that some countries were using the same arguments and had the same agenda against intellectual-property-right protection that they were using in other fora. And there were some other conventions, such as the Convention on Biological Diversity, that they were trying to bring into these discussions.

So you could not deal with it as a discrete case involving viruses with pandemic potential. They really have broader applications than this. But the problem is, if you're going to try to look at this holistically and bring in the things that you, Laurie, suggested, such as climate-change issues, et cetera, there is no one global body that deals with it. You're not going to have some broad magic solution on this.

One of the things that I was asked at one point when we were involved in these negotiations is regarding the sharing of samples and the sharing of benefits. Were we coming up with some tinkering, some small changes to the global system and WHO's Global Influenza Surveillance Network, or was it a fundamental change?

And in the end, countries, including the United States and like- minded countries, would not accept fundamental changes. They wanted the tinkering and were happy to be helpful in that regard, but it was tinkering. Whether there will ever come a day when fundamental change occurs, it's very hard to predict. But if you really look at what's going on and what has been going on in these negotiations, it's very hard to see a consensus building for something beyond the tinkering.

GARRETT: Well, I think it kind of -- it's interesting; we sort of see us coming back full circle. Secretary Rubin asked, you know, "Can the U.S. government say that I shouldn't get a vaccine so that there will be some for somebody off in Indonesia?" Charlie MacCormack asked, "Can we not mobilize some sense across a broader range of public outside of government that these sorts of issues need to be addressed and that there need to be kind of global solutions?"

And I think we are at a kind of frustrating spot with all of this where there isn't an easy immediate solution, though there are symbolic gestures -- or a little better than symbolic -- such as the Obama administration pushing to have the 10 percent of vaccine donated. And one would hope that Canada will join the symbolism at some point. (Laughs.)

BRANSWELL: Now I know why I was asked to be on this panel. (Laughter.)

GARRETT: I'm blaming you personally. But it does seem like we're taking on something much larger than we can possibly resolve beyond that sort of, as you say, tinkering level at this time.

Did you have anything you wanted to add to that, Helen?

BRANSWELL: I guess I just think of -- well, I'm not really optimistic that many of these things will be solved in the short term. But, you know, it's the issue of my self-interest, and how far does my self-interest expand? And when is it in my interest that your interests are met? You know, do I feel it's okay for me to forgo getting a vaccination so that somebody in Indonesia can get it? I don't know. I mean, I think those decisions are made in the heat of the particular moment, and it's hard to sort of create a paradigm that will fit all circumstances.

GARRETT: (Inaudible) -- I had H1N1 in early September. And I was talking to Tony Fauci, who runs our National Institute of Allergy and Infectious Diseases, and I said, "Shouldn't we maybe consider, if we're not going to have enough vaccine in time to address the peak of this outbreak in North America, shouldn't we consider possibly saying that everybody like myself that has had H1N1 should not -- should voluntarily not get vaccinated, assume we're naturally vaccinated, and for the sake of the greater good we won't get a vaccine?" And he said, "Well, no, because, first of all, you're not in a risk group, so you shouldn't get the vaccine anyway." I said, "But I have it, so I must be in a risk group."

And secondly, (he ?) said, "Well, we would never be able to handle the liability question. How do I know you definitely had that virus?" and so on. "So we can't make those recommendations." But as you go down the path, how do we get an altruistic sense that is also mixed with a sense of shared risk, shared benefit for the global community? And that is our challenge.

We have time for one last question. David.

QUESTIONER: Hi. David (Wills ?). Really interesting issues.

I thought the point that you were talking about -- do countries, particularly poor and middle-income countries, decide to allocate health resources in this versus other, you know, horrible challenges? If you look at what happened with India just in the media recently with H1N1, they were closing down malls. There was a sense of panic. Yet in the coverage, if you followed it, in some of the newspapers they reminded that "So far 20 people have died from H1N1 and a thousand people are dying every day from TB, basically."

What you see in the global health community is, kind of, some people who are working in different diseases, kind of, roll their eyes. They're like, 'Okay, H1N1, look at all the money that's going in it. Is it really cost-effective in a time of horrible challenges and financial (questions?' ?).

(Inaudible), the point that you made is, how do you, how do you advise countries, and how do we, as a global community -- not just the people who are passionate about pandemics, and the threats, and the true believers; I suppose you could put the AIDS activists on the other side, who really believe that their disease needs to go first, that it's the greatest threat to humanity -- how does a country fairly allocate, based on what you said are the risk probabilities, to make rational decisions, understanding that it's a guesstimate, you know, (taking into some account, that is, ?) and you publicize that, that 'we don't have all the answers. We're making allocations' -- risky.

And the second question is, I'm fascinated by the example of Indonesia -- kind of, maybe it's the lawyer in me, or whatever, saying, okay, this is part of our intellectual property and we don't want to see these samples used to develop products that help people in New York get vaccinated against an illness, while our people have no chance of it.

And I think one of the lessons from AIDS, and from other diseases, countries that do take aggressive measures, even when it offends our sensibilities sometimes, there's some benefits to that. So I was wondering if the panelist have any -- is there any examples in any of the middle-income countries, and the emerging countries, and in the -- (inaudible) -- poor countries that you think have been somewhat modeled, or have tried to deal with this in a way that we can look --

GARRETT: Well, Ambassador Lange, you spent a lot of time in Botswana. There's a country that's grappled with setting priorities more clearly for health than just about any country in the world right now.

LANGE: Well, in Botswana, from the time of President Festus Mogae onward, has really shown tremendous leadership in dealing with this huge HIV problem that they have.

But actually that brings up one of the difficulties I had in my position in the State Department, when one could go to a health minister in Sub-Saharan Africa and say, 'I know you're dealing with your people dying from AIDS, and your people have malaria and tuberculosis,' and maybe it's -- and maybe polio, and other things, 'but what you really need to do is to prepare for a pandemic influenza that may or may not occur in the next decade.' It's very hard for them, in their very resource-constrained environment, to do the preparations that were possible and necessary, I believe, in much richer countries, such as the United States.

There's no easy formula for figuring out, how do you deal with these possibilities. But all you have to do is read books about the 1918 pandemic to realize that a severe pandemic would just be a disaster for the world, and a catastrophe, and you could have tens and tens of millions of people dying in it. So these are not easy efforts and decisions to make.

But one of the things that I had hoped to do in my efforts -- and I think we've succeeded to some extent, was to do our best to ensure that even if there were no pandemic, the monies had been spent for good purposes; not 100 percent of it, because some of it actually was spent to cull chickens, in terms of the avian flu that was going around; and if you cull chickens and reimburse the farmers, you're back to zero; you haven't really gained anything -- but to build laboratory capacity and surveillance systems.

And I remember talking to some of our U.S. government experts in Nairobi, who were working regionally, and they had a built-up capacity to monitor for what had been the concern of H5N1, but it also had that laboratory capacity, and training that was done, et cetera, had much broader capabilities.

So the more you can build your structure to withstand these shocks, wherever the shock may be coming from, the better off you are. And that, I think, is one of the answers to how you deal with these potentially catastrophic events such as a severe influenza pandemic, but you don't know when it will occur.

GARRETT: Now, as you were saying this, and as David was asking his question, I had two thoughts in my mind at the same time and thought, oh, my goodness, if I was the minister of health of South Africa, how would I balance these two thoughts:

On one side, you have the world's largest extremely drug- resistant TB outbreak, and your scarcities of supplies is so great that in the key hospitals -- (inaudible) -- nurses are issued an N-95 mask and they are required to wear it for 30 days -- the same mask. Anybody that's ever worn N-95 knows that'd be pretty horrible. And the risk to them, of course, is extreme, because the mask deteriorates, and so on.

In contrast, you may say, well, this H1N1 thing is all kind of overblown, compared to our HIV catastrophe, and TB, and so on and so forth, but the historical record shows -- now that Chris Murray's (sp) group, and the University of Michigan group have really gone in and parsed the data that we could find for developing countries, shows 1918, the low-ball estimate of 30 million dying in 1918 and 1919 was based on the rich world; and that when you really start looking at what records we have for South Africa, and India, and handfuls of other countries we have records for, a figure closer to 100 million is probably the reality.

So if I'm the minister of health, or if I'm a USAID director trying to figure out where to allocate resources -- we don't have one, by the way, allocate resources to help poor countries, I would have a tough time, day in and day out, balancing those two.

(Pause.)

BRANSWELL: Absolutely. I mean -- (laughs) -- what more can you say, really. There are no answers to that one, I don't think.

GARRETT: Do we have any tweet questions? Apparently not.

Hi, tweeters. Apparently, you're not chiming in.

I could take another question or two from the audience. I was looking incorrectly at the clock.

Here you go.

QUESTIONER: Ryan Scalise, from Control Risks Group.

Just curious to determine -- and, by the way, thank you all for your comments, your insightful comments, wanted to know what your thoughts were on the prospect of the private sector, and their role; what role they can play, in terms of the surveillance effort, globally. There are infinitely more multi-national corporations in the world than governments, although governments have the primary responsibility for dealing with these issues -- public health issues.

It strikes me as, it's interesting that companies that are operating internationally have an obligation to -- a "duty of care" obligation to protect their employees, as well as being mindful of the operating environment in which they're in. What sort of role, how could this go forward, and what sort of private-sector role do you see in that effort? Thank you.

GARRETT: Let's break this up. There's two pieces to that:

One is, what duty to report may there be, or role may there be for multi-national companies to report interesting infections, or what have you, among their labor force, even in far-flung places; and even if the government, in a far-flung place is not interested in having that reported?

BRANSWELL: Or if their competitors aren't -- would get a leg up if they acknowledged that they've had problem going on.

GARRETT: A very good point.

And the second would be the question of -- how did you phrase it exactly, it was "engaging, as a global citizen, in preparedness in developing policy?" Is that what you were getting at?

QUESTIONER: (Off mike.)

GARRETT: Duty and care to protect your own employees?

QUESTIONER: (Off mike.)

GARRETT: And so it seems --

QUESTIONER: (Off mike.)

GARRETT: Okay, you're off-mike for the Web cast, so I'm going to cut you off.

(Inaudible) -- just put it this way, that we've seen in the HIV experience a lot of private-sector sense of obligation and duty in both these areas has arisen. We have the Global Business Coalition on AIDS, Tuberculosis and Malaria, which I believe is now about 280 corporations around the world. And it's both a duty to develop a strategy for your own employees, to protect them, and then it ends up also being engaged in the activities of the communities in which your company sites may be nested.

And certainly in Botswana you had that with several external company players on the ground in Botswana, feeling they had an obligation to provide treatment to their employees for HIV.

LANGE: There were various activities the U.S. Chamber of Commerce, through their international focus, had been doing a lot with multi-national corporations that were trying to prepare for a pandemic. And you can look at various ways in which the private sector, because of the concern for their employees, were dealing with, and engaging in some pandemic preparations, (coming at the ?) personnel policies -- what do you when people are sick? You don't want to have people coming to work because they show an obligation to do so. If they're sick, you want them to be home. And then you give them sick leave. It gets very complicated, very quickly, as we heard earlier, about some of the Department of Labor issues here in the State of New York.

So there were various efforts, over the last few years, to deal with these issues, but I have to say that I had the general impression that the larger multi-national corporations were focusing more on this than smaller companies; and that the smaller companies had much more difficulty trying to devote the resources to this kind of contingency planning when they weren't sure when or where it would occur.

So there is a role, clearly, for the private sector in its own pandemic preparedness. And as we learn the lessons from the current H1N1 pandemic, I would expect additional opportunities to come up, in various, as we try to -- to whatever extent the world community can do it, to build better preparations for a possible future pandemic.

Could I say one thing on something that no one mentioned earlier, about the self-interest issue? I would hope that, coming out of this H1N1, governments would realize that there is going to be an expectation of a contribution of vaccine to developing countries, just as 11 countries have now made clear they will do for this current pandemic; that in the future they -- well, it's a different situation than had existed in the past because of the precedents that are being set right now, and, therefore, the calculation of self-interest will be different.

If you knew that you would be expected to provide vaccine for the developing countries, how would you deal with this if you had a severe pandemic coming about in your -- the United States or another developed country? Maybe then you'd say, well, let's help (for ?) laboratory capacity in developing countries, or maybe we'd so some advance purchases, or whatever. But if you -- the self-interest could be a different calculation in the future than it was in the past, because of precedents we're setting now.

GARRETT: Okay, interesting point, but it could go either way. As Andrew Jack pointed out, you know, the pharmaceutical industry gets a kind of expectation and pressure on them that isn't on -- I think the example you gave was Citibank. Nobody expects Citibank to give out free money from its ATM machines in Africa, but Novartis may be under pressure to give out free drugs in Africa.

And, of course, the retort that the industry would make is, 'We can't afford this. You're pushing us to the wall.' But I saw a report in the Wall Street Journal estimating that GSK alone is going to make about a $3 billion nut off of the H1N1 vaccine. So that doesn't sound like 'pushed against any wall.'

I think we're heading into a confrontation in this area. And where this will sort out is going to be really tough. I don't think that you can say to the industry, 'You should now have an expectation, every time you make something, that you're going to have to ultimately give away some of it.' (We don't think ?) industry will play that game.

BRANSWELL: I actually think the paradigm is shifting as a consequence of the Indonesia situation. It used to be that the vaccine manufacturers got viruses for free. They didn't pay. They were developed for them -- (inaudible) -- and that was the way it worked.

I don't think that's necessarily going to be the way it is, going forward. I suspect that there's going to be an expectation of a quid pro quo of a sort. And I don't know if -- not suggesting that that means, you know, you're going to get -- 'You want the -- (inaudible) -- (strain? ?) Okay, here's what it costs.' But I think that there's going to be an expectation that industry has a role to play in this kind of response; and, by benefitting from the continual share of viruses for seasonal vaccine, that there's going to be an expectation (of something before very long. ?)

LANGE: I'm not so sure that the quid pro quo, though, is going to come forward. In part, because Mexico, which had been -- in the negotiations, been kind of an intermediary between those who were very much insisting on the control of the virus, versus others who thought that it should be given freely to the -- (inaudible) -- surveillance network for the benefit of global public health.

Mexico, it's my understanding, has now been much more forthcoming on 'we've got to share it for the benefit of everyone' -- it does benefit global public health. So if you look at the very strong and positive responses from Mexico, when they first discovered H1N1, I'm not sure the world would move toward that quid pro quo requirement.

BRANSWELL: Maybe I shouldn't have characterized it in that way, but I do believe that WHO is -- (inaudible) -- that there is an expectation that there will be -- that this, you know, the donations into their funds are not going to be a one-time thing.

GARRETT: Well, that's quite a note to end on. And I'm afraid that we are out of time. This concludes the Web cast and our basic meeting, jointly sponsored by Science, and the Council on Foreign Relations.

I want to say, on behalf of the Council on Foreign Relations, that Science has been a wonderful partner to work with. We hope that we'll have an opportunity to partner again in the future; and that the staff, both here at the Council, and at Science, and the American Association for the Advancement of the Sciences, have performed in stellar fashion in pulling this very ambitious event together.

I want to once again thank Richard Brown (sp), who made a kind donation that helped subsidize this event.

This concludes the webcast.

For the rest of you, we will now have lunch, and you can continue your discussion on an informal basis. Thank you very much for joining us. (Applause.)

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