H1N1: The Global Response to the Swine Influenza

This session was part of the CFR Symposium on the United States and the Future of Global Governance, which was made possible by the generous support of the Robina Foundation.

JAMES TRAUB: (In progress) -- is Laurie Garrett. And now my microphone is on.

Welcome to the third session. Let me put my spectacles on so I can read this --

MS. : (Off mike.)

TRAUB: The sixth session -- this is a misprint -- the sixth session of the CFR conference on the United States and the future of global governance. This session is entitled "H1N1: The Global Response to the Swine Influenza."

Of course, you all know by now, turn off -- don't put on mute or vibrate or anything like that -- turn off all together your cell phones. And this meeting is on-the-record.

One thing I probably should explain in advance is that I've noticed in the previous sessions I've been sitting in on that the moderator has been at least as knowledgeable as the person he or she is interviewing. This will be different. (Scattered laughter.) Laurie, fortunately, is supremely knowledgeable about the subject, I have agreed to be thrown in to the breech. So please excuse my ignorance in advance but at least that way I can be a kind of tribune for the ignorance of which ever ones of you don't have deep knowledge of the subject.

Now Laurie Garrett, as perhaps you all know, is -- has been a fellow here at the Council since 2004. Before that, for many, many years Laurie was a journalist and she won every award that it is possible for a journalist to win, which, I guess, is why she finally stopped because she had already achieved everything.

She has written several best-selling books, I'll just mention two. "The Coming Plague: Newly Emerging Diseases in a World Out of Balance"; and "Betrayal of Trust: The Collapse of Global Public Health." Most recently Laurie authored this really compelling cover story in Newsweek. So it is still, I believe, on the stands and it is available to one and all.

So, let me begin, Laurie, by asking you a dumb question, which is that as of today there have been a little over 2,300 cases of swine flu resulting in 48 fatalities.

LAURIE GARRETT: Identified cases.

TRAUB: Identified cases, resulting in 48 identified fatalities.

So you might think, well, why are we having a meeting on it here at the Council on Foreign Relations? That doesn't sound like a pandemic. But it is a pandemic. So could you explain that to us?

GARRETT: This is a new organism. It emerged in a manner that had not previously been seen or chronicled. It definitely was a pig virus here in North America, in the United States, that through means not yet fully elucidated made its way to Mexico and emerged in human populations in Mexico.

After having caused -- depending on what the ultimate genetic sequencing tells us, five or six isolated infections in the United States before that never really went human to human. So individuals acquired it from a pig, from exposure to pigs, but did not pass it on until it gets to Mexico.

The timetable is very fast and the response was very fast. And the reason we're worried about this is because this particular one, because it had long been believed that pigs serve as genetic mixing vessels -- that's the term that's used -- for recombination of flu viruses, allowing viruses to swap and exchange genetic information that they've gathered from infecting birds, from infecting humans, from infecting pigs and other species. And thereby, the virus becomes potentially more dangerous and can take on the capacity to truly cause something like the 1918 influenza which killed 100 million people.

So we want to really keep close tabs on any newly emerging flu strains that seem to have unusual characteristics.

TRAUB: Could you just briefly explain -- you call it -- it's called a triple re-assorted virus. Could you just briefly explain what that means?

GARRETT: This particular H1N1 flu, as it's called, for hemagglutinin type one and neuraminidase type one flu, has within it genetic information that it has gathered over the years, not just suddenly but over the years, from wild birds, so flu strains that were in wild birds, from pigs, mostly North American pig populations, domestic pigs, and from pigs in the Eurasian region, so a type of flu genetic information that had been circulating in pigs and -- as far east as Thailand and Vietnam, and then human H1N1 components.

And so it had three different species' contribution and at least four different geographic areas of circulation of flu contributed. And the virus itself, when it reproduces, falls apart. That's what flu does; it really falls apart as a virus. It doesn't have real strong chromosomes as we do. And when it does this sort of falling apart it picks up, not only in making copies of itself, not only the appropriate RNA genetic material, but also whatever else is in the environment it has fallen apart in. So if it falls apart in a pig cell it picks up some pig genetic information. If it falls apart in a chicken cell we get some chicken and in a human cell some human.

And this virus shows evidence of all of that, the ultimate gamish -- (sp). So --

TRAUB: There you have it. So the underlying causal phenomena of a virus like that, does this have to do with far greater human mobility such that these viruses are moving around much faster than before? Does it have to do with the way pigs are farmed, in massive densely clustered areas as opposed to the way they were before, or what?

GARRETT: Well this particular H1N1 seems to have taken advantage of growing in environments of industrial pig operations in the United States. The hallmark of industrial pig operations is that you have hundreds of pigs packed right next to one another.

It's a little bit like saying if I light a match at the edge of a very diverse forest, I may or may not start a fire or it might burn one tree and then it hits a really green tree and the fire sputters out. But if I light a match at the edge of a forest that is entirely uniform, all the trees are the same amount of dryness, they're the same type of tree. And if it's going to catch one it's likely to go burning all the way through.

And when you have -- we've known for years with agriculture that when you farm in these giant farming operations where you have several thousand acres of the same type of corn, pests take advantage of that kind of environment and they easily acquire resistance to pesticides and they easily acquire resistance to anything else you throw their way and they go right through.

TRAUB: Now don't we --

GARRETT: They're doing the same thing now with animals.

TRAUB: -- but now don't we respond to that by jamming pigs full of antibiotics?

GARRETT: Antibiotics have nothing to do with viruses, number one. And number two, yes --

TRAUB: I said I was ignorant.

GARRETT: -- yes, we jam them full of antibiotics and we do that as growth promoters, not because they're sick and not to prevent sickness but because, for reasons never fully figured out but probably related to -- commensal species of beneficial bacteria in their guts not clear, if you medicate regularly livestock with antibiotics they will be about 4 (percent) to 5 percent bigger at time of slaughter than if you don't medicate them.

So all across the United States in the livestock industry, whether it's aquaculture or chickens or pigs, we use antibiotics quite liberally and I think quite unwisely. And we know that it does indeed promote resistance, it does indeed promote the emergence of strains of salmonella and staphylococcus and so on that are drug resistant. And they do indeed transmit to people. And it has helped to render many of our antibiotics useless.

TRAUB: So -- so long as we engage in this kind of mass farming we're going to be dealing with these kinds of outbreaks, the one is directly causing the other.

GARRETT: But there's another piece to this puzzle. You could've had an -- and we have had for at least 20 years the occasional case of flu transmitted to some kid who's working on a pig farm, but that's the end of it.

But another event happened here and we don't know exactly what it was that made this turn in to a rapid human-to-human transmitter and we need to figure that out because knowing that answer is important for future potential outbreaks, especially one way more lethal than this H1N1 strain.

The other -- the piece of it that our federal officials have, I think wisely not said out loud that I will say out loud -- and they've not said out loud for fairly obvious political reasons -- is that if you look at the sort of chronology of the outbreaks leading up to the big one in Mexico, this does seem to be a relationship to migrant farm labor. And obviously certain people in this country have made it part of their political agenda to try and shut down the border of Mexico. And we've seen them try to use this flu issue to say, yeah, we should've shut that border to Mexico.

So our federal officials have been very reluctant to say out loud that there does appear, it's not a coincidence, it was Imperial County, California, an agricultural county, Guadalupe County in Texas, all of these agricultural counties with very large migrant labor forces. And of course, migrant labor is the backbone of servicing our pork industry, our chicken industry and so on.

TRAUB: So it's just as truckers, for example, are a key transmission belt for AIDS, migrant workers are a transmission belt for these kinds of outbreaks.

GARRETT: At least in this case that does appear to be the case.

TRAUB: Yeah. So let's talk a little bit about the response to it. Is the fact that there have been so far a very small number of deaths, is that simply because it is not a terribly lethal strain or does that say something about a relatively effective global response?

GARRETT: I think it's several things. I mean, one, we know the genetic analysis of this strain shows us that, thankfully, it does not have the key genes that we know the 1918 flu virus had that made it just super killer.

TRAUB: That's just good luck. It happens not to have that.

GARRETT: That's fantastic luck. And, thankfully, that is the case.

The second thing is that we didn't know early on -- when it looked like we had a big, very lethal problem in Mexico, I was saying over and over again we don't know the denominator. You can't say this is very lethal, you say perhaps 100 deaths, if you don't know is it 100 out of 10,000 infected, 100 out of 1 million infected? You have no denominator to judge.

We still don't know because we don't have rapid diagnostics where we can just go out and have people lick a stick and it changes color and you say, ah, that's an H1N1 person. You were infected. You didn't know it. You felt fine. Maybe you had a headache, whatever. We don't have mass screening technology like that. We need it. We should have it. There certainly have been fantastic developments come out of laboratories in academia that could take us there but it's just never gotten off the ground industrially.

TRAUB: So, in other words, the countries where a lot of these things are originating, which obviously have poor public health systems, they're the ones who would have to have it.

GARRETT: Well, and Mexico was dependent on our country, the CDC, to develop a basic diagnostic that could be done, not rapidly but in a laboratory setting that would discriminate this particular flu from all other flus that are in circulation in the world right now. And that slowed them down because they were waiting for the CDC and then they had to be able to replicate it and be able to do it on a large scale.

So early on, where there was a great deal of concern since we didn't know the denominator the two things that were very worrying was it looked like a lot of dead and a lot of sick. We now know many of those weren't actually H1N1 flu.

And secondly, they were young people. And that continues to be a big worry. That continues to be a big mystery and worry piece in this whole situation is that, both in the United States and especially in Mexico, the majority of identified infections, hospitalizations and deaths have all been people under 35 years of age. And the reason we're worried about that is twofold; one, that's rare with flu. Typically flu is causing serious illness and death in children under 2 years of age and in adults over 70, 75 years of age.

TRAUB: If they have either compromised or immature immune systems.

GARRETT: Exactly. But in this case we're looking at the healthiest age group, with the most robust immune systems, and they're the ones the sickest. And this is very worrying because that was indeed seen with the 1918 flu and it was seen with SARS, to some degree, that a lot of the spread was going on in otherwise extremely healthy people.

TRAUB: So now to get back to the question of the response. I mean, at least one thing I've read said, well, if you look at the quality of the global response now as opposed to SARS, which was in 2003, it actually has been far more coordinated and far more effective and we should at least feel some sense of relief about that. Is that a fair conclusion? If so, what is it that we have learned since then that has now been put into practice?

GARRETT: Well actually, I didn't finish your prior question answer, which leads directly to this --

TRAUB: Oh, okay. All right.

GARRETT: -- which was the third thing that could explain why this appears to be a less dangerous flu than we initially thought, is that we should all stand up and scream gracias Mexico because the Mexican people and the Mexican government have sacrificed on a level that I'm not sure as Americans we would be prepared to do in the exact same circumstances.

They shut down their schools. They shut down businesses, restaurants, churches, sporting events. They basically paralyzed their own economy. They've suffered billions of dollars in financial losses still being tallied up, and thereby really brought transmission to a halt.

What we want to do now -- and Dick Garwin is here, he had done from a couple of years back -- two years ago, was it? The masks -- asked the question, do we really know what kind of masks work when you're dealing with a pandemic and can you reuse them and do you really need these big fancy N95 ones, or what about those dime store masks?

One of the things that's going to be very interesting to study with Mexico is how effective were those masks that the army mass distributed all over Mexico City and in every other major city in the country. If they had any benefit, I assume it was, what I saw with SARS and masks in China -- where people used just about anything as a mask, nothing that should have worked as far as actually blocking a virus -- is that they alarm the person coming towards you. And when --

TRAUB: So keep your distance.

GARRETT: Yes. And, in fact, I've already taken a bunch of photographs of a rush-hour Mexico City subway and done comparative analysis and just my totally crude analysis shows a great deal more spacing and you see a lot of people side-glancing. They're looking to see where's the other guy when they have the masks on.

And if you take the same subway stations and look at the photograph, everybody's just jammed right in. It looks like New York. And you can't help but wonder how we would respond here under the exact same circumstance.

TRAUB: Yeah. But not only that, I mean, in addition, the consequence of the self-sacrifice, as you said, is a loss of, estimated now, at 0.3 (percent) to 0.5 percent of GDP. Politically it may turn out to be a catastrophe for the president, not clear yet.

And so if you're trying to design a response that you would be able to repeat in future, colossal self-sacrifice followed by economic and political harm is not the way you'd go about it.

So what's the -- is there an answer to that? That is, what ought -- and, of course, the backlash against Mexican tourists, travelers and so on. So what can one do in order to encourage as opposed to discourage the kind of behavior which you've just described?

GARRETT: Well, I think it's a really important question because much of the world will look and say what did Mexico get for all of this? They sacrificed an immense amount.

And you're absolutely right, you're already seeing a backlash inside Mexico against Calderon. The left in Mexico is charging all of this was a giant conspiratorial cover-up and they were trying to create a diversion to keep the people of Mexico from noticing the narco-trafficker problem, as if that were possible. And there've already been protest demonstrations in Mexico against Calderon, specifically around influenza.

So there's going to be a big price. If I'm the rest of the world and countries that are likely to pay a price with emerging diseases I will ask, am I prepared to do, you know, what Mexico did and what reward does Mexico get?

If you look at China, you know, China chose to do the exact opposite in 2003 with SARS. They covered it up. For six months they lied while it circulated inside China and then spread outward.

So when this happens how does China respond? Well, they quarantine an entire planeload of people based on one suspect case and hold -- and they're all Mexican, or travelling from Mexico. They issue masks. You have a sense of alarm. And you had a repeat that signaled memory to Hong Kong 2003, the Hotel Metropole, where a single individual from Guangjiao, who had been exposed to SARS, knew there was something new and dangerous that was being covered up, fled to Hong Kong to try to get away from it and was, in fact, infected, stayed on the ninth floor of the Hotel Metropole and through means still not yet fully elucidated biologically, somehow transmitted to 12 strangers on that floor, two of whom flew to Toronto, took SARS. One flew to Hanoi, took SARS. Two went to Singapore, took SARS. To Beijing, took SARS.

TRAUB: It's like an epidemiological nightmare.

GARRETT: Exactly. So how does China respond this time? There's one suspect case in a hotel in Hong Kong. They quarantined the whole darn hotel immediately and only two days ago allowed the Mexicans to fly back to Mexico where they're greeted wearing masks by an unmasked first lady who shakes all their hands. (Scattered laughter.)

TRAUB: So -- okay, so we've now described a -- essentially a kind of sovereign reaction to this global threat. And so then, I guess, the global governance question about this is given that this actually winds up quite intensely implicating sovereign issues and that for centuries people have been quarantining, blockading, and so forth -- it's the immediate reaction to this kind of threat -- what ought we be doing to overcome that otherwise not terribly surprising but quite dangerous reaction? How can this be better coordinated than it is being now? Or can it be?

GARRETT: Well, first thing we have to do is really see this as a case study and analyze it in great detail so that we really understand which countries did which actions, what worked, what didn't work. Did Mexico over-respond or did they, in fact, stop the transmission and limit the ability of the virus to better adapt to our species? Did they buy the world some time by taking such drastic actions?

I think, just by way of example, most people in the field would agree now that in 1997 when the H5N1 bird flu jumped from mainland China to Hong Kong and caused, I believe it was, six human infections, Hong Kong responded by slaughtering every single chicken in Hong Kong, a phenomenal and expensive, both politically and financially expensive action.

And I think most people in the field would say Hong Kong bought us all a bunch of time. They bought the world time with that virus. It stopped a certain cycle, boom, and, in fact, the virus kind of retreated from visibility until 2005. It was slightly circulating. You hear of the occasional outbreak but it's not until 2005 that we get this explosive situation in birds and in humans all across Asia with that virus.

So we want real detailed analysis, a case analysis. I also think part of that is going to be really looking at WHO carefully. What have they done right and wrong? I think WHO was very slow to issue a -- there is no rationale -- they finally said it only on Monday this week, there is no rationale for travel restrictions. They should have said that well before this time. And they certainly should've come down hard on China for overreacting by quarantining all these people. It sends a very bad signal to the rest of the world. If you're open and honest that you have an epidemic your nationals travelling all over the world are going to be quarantined and isolated and all of that.

And again, it would dissuade the kind of transparency that we absolutely need as a global community to protect all of us from disease.

The other thing that I know is going to be assessed because it's already all over buzzing in the internet world of public health, global health people. Coming out in 2005 the World Health Assembly, which is the legislative body of WHO -- WHO is kind of unique among all UN agencies in that it actually has like a congress with every country having one vote. So Vanuatu and China have equal vote. Not proportional representation.

TRAUB: Must be a tremendously effective body.

GARRETT: It actually is remarkable how well it works given 194 bickering nations.

But this is an example where it didn't work. In 2005 the World Health Assembly said, alright, we're going to take pandemics seriously. We've learned from SARS and from bird flu. We better get our act together. So let's set up a pandemic threat system. And we'll set criteria for telling the whole world we're at pandemic level one, pandemic level two and the biggest one is pandemic six.

The problem -- and so we're now officially at pandemic level five with this H1N1 -- the problem is the system they could all politically agree to, the criteria for bumping up from one to another has nothing to do with the severity or danger of the microbe. It's just about geographic spread.

So a totally benign microorganism that is newly recognized, theoretically, could result in a pandemic six threat from WHO, which has absolutely no relevance to whether or not any of you in this room are potentially in danger when exposed to it.

And so here we are in this awkward situation where based on the criteria set out for this pandemic threat system, we actually should now be at pandemic six, the highest possible level, because what it says is do you have sustained transmission in two geographic regions of the world. Well, we have sustained transmission in Spain and we have sustained transmission in North America. So we should be at pandemic six.

But what we have seen is as they bumped it to five the stock market went berserk, the sale of everything to do with travel -- oil, airlines, hotels -- everything tanked and the only reason the whole market didn't look like it went down was that that was offset by a spike in all the pharmaceutical and biotech stocks. So it balanced it out.

So there's prices to be paid with these systems and we really need to figure this out and make it better, relevant to real problems.

TRAUB: But even what you've just said described, I mean, this morning for example, the problem we were talking about was nonproliferation. Now -- in some ways a kind of metaphorically at least similar threat.

What you've just been describing is a so far not terribly well put together system of monitoring and surveillance. But that doesn't even go to issues of enforcement, for example. And so if we're now -- if we now believe that we're in a world where drug resistant diseases and pandemics of this sort, for various reasons, may become more frequent or perhaps even more lethal and perhaps even more difficult to deal with then doesn't -- does that also say that the whole institutional structure we have right not only is not effective enough at what it does, in the way that you've just described, but perhaps also not at all comprehensive enough in regard to the threat that it's meant to deal with?

GARRETT: Oh absolutely. Let me put it to you this way; the virus -- what will now happen, what's going to be the next stages just with this H1N1 and how does this governance structure, if we can even be generous enough to call it a structure, respond?

Alright, so if this goes according to normal flu patterns the virus will now head to the Southern Hemisphere and circulate in their winter through humans, pigs, birds, wherever it finds a welcome home and infect cells that it's capable of infecting in those targeted animals -- we're an animal in this equation.

And then if it does not just simply die out because somehow in the Southern Hemisphere it fails to find adequate places to reproduce and spread, transmit, which I cannot quite imagine, it will return here in the fall. And we will some time in September or October start to see the evidence that H1N1A is in North America, possibly in Europe, widely circulating in the Northern Hemisphere.

So here's the decision point. You're Margaret Chan, Director General of WHO in Geneva, you're Bruce Gellin, who happens to be in charge of all vaccine decisions for our government sitting inside HHS. You have a brand new HHS secretary, she doesn't even know who Margaret Chan is, okay, she just walked in the door. So, you're Bruce Gellin and you have to decide and Margaret Chan and her team have to decide what are we all going to do about vaccines for next fall?

So here's your options. Number one, you can say abandon all prior decisions, focus on this virus. Make all vaccine production machinery geared to the H1N1 and let's make sure was have as much as we can possibly make, which turns out to only be 400 million doses for a planet of 6-and-a-half billion humans because we make them on chicken eggs and they're hard to make and you have to have sterile conditions, very hygienic conditions or you easily get contamination and we've certainly had contamination events in the past with flu virus production, vaccine production.

Alright, so first problem is you can only make 400 million doses. And between now and September you really can't make multiple vaccines, you've got to make a decision. So if you decide you're doing H1N1 then -- and seasonal flu comes around and it's a nasty regular seasonal flu -- you risk 36,000 American's dying, as typically -- or 36,000 people dying of seasonal flu because you didn't have a vaccine for them.

Option two; this H1N1 doesn't look as lethal as we thought it was. We're going to gamble that it won't undergo any re-assortment event or mutational event that's advantageous to the virus and proves to be more dangerous to humans.

As it travels around the Southern Hemisphere this next few months --

TRAUB: You should add, by the way, that there already is a variant, as I understand from your article, which is resistant to the principle that occasional --

(Cross talk.)

GARRETT: Right, if we -- if it had a recombination event with the circulating other H1N1 strain that's drug resistant, resists Tamiflu treatment, then we would end up with this potential pandemic strain also being drug resistant.

So you could make that gamble or you could say, look, I don't think that's a dangerous one. I think it's going to peter out so let's focus on the seasonal vaccine. Or, you could say, can we figure out a way really fast to mix them and make a vaccine that's got some of the seasonal component and this new one and get it out, rush it out the door and encourage everybody to get vaccinated.

But now here's the kicker. So you've got 400 million doses and the rest of the world says, hey, what about us? What's with you guys? You get vaccinated and the rest of us are screwed? Here comes the pandemic, you've got a few months to get your act together and there's nothing for us? Why should we cooperate? And that's precisely what Indonesia has said.

So Indonesia happens to be the center now of all the troublesome circulation of the bird flu virus and most of the human cases and even some cases of human-to-human transmission but in very, fortunately, intimate settings of the virus. And they have refused to share any of their bird flu samples with WHO or any other entity since 2006.

TRAUB: For which you said the expression is viral sovereignty.

GARRETT: They've declared viral sovereignty.

TRAUB: Really it's kind of a, kind of appalling -- it's sort of a last most baroque efflorescence of this idea of sovereignty in its -- I guess its feverish form.

GARRETT: And in and -- yeah -- so -- and their rationale is, if we share it you'll make vaccine against it but we'll never get that vaccine, it'll go for your people. And then you'll come to us and say, you have to give us a bunch of money and then maybe we'll let you have vaccine for your own people made from something that circulated in your country.

It's a horrible situation with Indonesia. They're even trying to close down NAMRU-2, which is a big medical research lab run by our navy that's been in Jakarta since the 70s on the grounds that it's a biological warfare center and that they may have even made this flu just to try and hook poor countries on buying medical products from the wealthy west.

TRAUB: So -- but you haven't even -- in a way, what you've been describing is not so much an architecture in the sense that we've been describing an architecture for climate change, nonproliferation. It's obviously quite a scanty architecture in compared to -- compared to sovereign national decisions. But just so that we can get a clearer idea what the structure is -- we had just spoken right before we got on about this idea of an H1, which you were very much involved with creating, which involved the eight major --

GARRETT: The H8.

TRAUB: -- I'm sorry, the eight major health organizations. So just quickly so we have a sense of what it is we're talking about beyond WHO, and we're talking about the structure, what is that and maybe kind of quickly before we open this to others, what ought it be?

GARRETT: Well, one problem that we see with the whole global health architecture is that there are too many players and they're not coordinated. And just in the last eight years we've seen a whole bunch of new giant players, multibillion dollar, well-funded ones like the global fund to fight AIDS, Tuberculosis and Malaria, or GAVI, which is the vaccine initiative.

And then you have a whole bunch of UN agencies that have overlapping jurisdiction. UNICEF does child vaccination. WHO is supposed to be the main one. But then you also have the world banks funding global health programs and setting agendas and it goes on and on and on.

So the secretary-general, Ban Ki-moon, signaled that he really saw one of the big issues on his agenda trying to bring some coherence to this mess, trying to get all these different pieces coordinated and talking to each other. And here at the Council we were directly involved in that effort on behalf of the secretary-general's office. And what has evolved is this thing called the H8, the Health Eight, and it's the eight key international agencies -- WHO, UNICEF, UNFPA, Global Fund, GAVI, World Bank -- help me Kim -- Gates Foundation and UNICEF, or UNESCO. Who did I leave out?

TRAUB: Okay, you got at least seven anyway.

GARRETT: The point is it's totally informal. It has no actual power but its sort of the second tier of management right under the directors are supposed to be in constant communication.

The main thing it has done that's positive is that we no longer have UN agencies putting out opposing and different policy statements on key health issues. At least, you know, they've thrashed it out before it goes public and they sort of are on the same page. But in terms of as an apparatus that makes decisions about financing and moving priorities and so on, it's not that sophisticated.

TRAUB: So compared to the other subjects we're talking about, it sounds like public health is actually, I suppose, a kind of under-institutionalized sphere, which actually, given the kinds of dangers we're talking about needs more fully articulated, better coordinated, maybe more enforcement equipped institutions than exist now. Is that your sense?

GARRETT: Well I would agree with that. I would go a step further and say, look, one of the things we know -- and here's back to why were we worried about this flu -- we know that viruses are very dangerous to our species when they jump from another species, when they first make that leap. SARS had been a bat virus. It makes it into civets and then to humans and it hasn't toned down. It's a very virulent organism at that time.

And we believe in 1918 the same thing happened. The virus had just jumped basically from birds into people and was quite virulent at that moment in its biological history.

So if we're really serious about protecting humanity we need to better integrate the sort of veterinary side, the animal and wildlife side, of our surveillance, our investigation, our monitoring and our response with the public health side. But what we've seen is that these two communities have a really hard time being on the same page.

In 1999, when we had a mystery virus emerge here in New York City and we had eight encephalitis cases in the same hospital in Queens, that sent an alarm button to our public health people. But when the head pathologist at the Bronx Zoo was saying, but I've got exotic birds dying by the bucketful. I've got a huge problem here. Birds all over the zoo from all over the world are dying of something and they're showing seizures and responses that are indicative of encephalitis. I think it may be the same virus. The attitude of the public health people was, shut up. Who cares about dead birds at the zoo?

And meanwhile, you had veterinarians out on Long Island saying, we've seen horses that are dying and they're having encephalitis. And again, the public health response is, what has that got to do with us?

Well, we learned too late from west Nile that we should've been paying attention to a virus that HAD emerged newly to North America from Africa, never been, as far as we know, on our continent before, and then had found many happy homes. It had found that -- you know, the majority of our bird population, songbirds to crows, were happy homes, that humans were happy homes, horses were happy homes and it's now spread all over North America.

We need to better integrate things like our food and agriculture organization, OIE, which is the animal health organization and all of these things in a much better, smoother orchestrated governance.

And frankly, what the -- as he was leaving, Ban Ki-moon did was to designate one person, one individual to coordinate everything and to run back and forth on behalf of the secretary general following bird flu between this agency, that agency, this minister of Agriculture, this minister of Health. I mean, the guy's super human but come on, one guy?

TRAUB: So there is no one such one. Ought there not be one person or no?

GARRETT: There should be -- one person can't do it. You need a group, a team. I mean, this poor guy never sleeps and he lives on airplanes.

TRAUB: So is this the kind of situation, though, in which there ought to be one, in effect, master institution? Or should WHO be a more powerful, more coordinating institution? Or is it rather a matter that we need to have more effective forms of coordination between the bodies that already exist, these eight bodies that you've described.

GARRETT: Well, it's complicated. We came out of World War II and set up these institutions that are the United Nations, that are WHO and so on in the late 1940s and early 50s. And we set them up to interact with their counterpart at the country level. So food and agricultural organization talks to ministers of agriculture and deals with the ministries. And WHO deals with the ministries of health and so on and so forth.

Well we've partitioned all our national governments in a similarly irrational way from the point of view of biology. I mean, a microorganism doesn't know, oh, I'm being handled by the ministry of agriculture. (Scattered laughter.) I better not infect people.

And yet this is -- the problem is bigger than asking is there a global governance umbrella that will bring it all together because we haven't even brought it together inside the United States government. And you get down to cities and states. New York City has had enough brutal experiences with everything from multi drug-resistant TB to West Nile to 9/11 and anthrax that we're better -- we're more likely to have the various pieces of health and veterinary and the environment speaking to each other.

But we still have bumps in the road here. You leave New York and you see -- you know, the public health person doesn't even know who the lead veterinarian person is in their region.

TRAUB: One last question and then I'll throw it open to questions.

President Obama just released his global health plan a couple of days ago. And it was criticized by AIDS activists on the grounds that it scanted AIDS, but others were quite pleased because it talked about infectious diseases and indeed, possibly you'll tell us, was to some extent inflected by the swine flu outbreak. So, from your sense is -- did that represent some important kind of progress? Did it include an understanding of the sort of issues you've talked about or no?

GARRETT: Well, the problem right now that we're in with the Obama administration and global health and frankly all foreign assistance efforts, development writ large, is that none of the key positions have been filled in the government. There's nobody running USAID. We're pretty far down the path and we still don't have anybody running it. We just got a name for PEPFAR, the President's Emergency Fund for AIDS Relief. And, you know, we can go across all the tiers of it and there's empty offices and empty seats at the table.

So when the president gives an announcement like this, we don't really know how it's going to play out and what it really means. What we do know is he's committed to a six-year, as opposed to congressionally voted authorized five-year PEPFAR II, Emergency Plan for AIDS Relief Type II, if you will. And that program will eat up around 70 percent of all global health spending from the United States of America for the next six years every single year. So HIV gets 70 percent.

Now with the other 30 percent we need to see how the various agency appointments are going to drill down and break that apart. But all this is happening against a much bigger background, which is in the House -- of the House Foreign Operations Committee (sic), Congressman Berman is the chair, he's introduced a bill to completely revisit the whole foreign assistance act and rethink what in the world are we doing here because it's a train wreck right now -- it's so confusing it's mindboggling.

And John Kerry is running the Foreign Affairs Committee (sic) in the Senate and he's signaled that he's interested in the same effort to try and really fundamentally rethink all of this.

And meanwhile, we have a real struggle going on between the State Department, the NSC and the White House over where's the relative power of USAID and who does it answer to? PEPFAR -- does the secretary of State control all of this?

And all that's a long way of saying we don't have the backdrop yet of the Obama administration's own approach to these problems, much less an international global scale view of how you're going to organize this.

TRAUB: Okay. Well thank you.

Let's throw this open to questions. So, Dr. Garwin.

QUESTIONER: Dick Garwin, IBM Fellow Emeritus.

The workshop we had three years ago looked at some pandemic flu and what could be done with non-pharmaceutical means, so no vaccine, no Tamiflu and so on. And any epidemic propagates by reproduction factor, typically two or three. What Mexico did was to reduce that suddenly, maybe to 0.3 or whatever and then the epidemic dies out.

Now the question is what's going to happen now? Even though it's the end of the flu season the virus has difficulty living in wet weather and so on -- in humid weather. As people go back to their usual interactions is it likely that the epidemic will resume in Mexico? And, of course, Mexico can then take moderate measures and kill that again but it's not clear that that's compatible with a functioning society.

GARRETT: Well the good news about influenza is that it is a seasonal virus. It doesn't particularly like hot weather. It dehydrates quickly on surfaces if the air temperature is above 90 degrees. And it can't tolerate exposure to ultraviolet light. So in the summer the lights -- the daylight is longer than in the winter so you're more likely to get exposure to UV light on any surface. That reduces the transmission from things like a doorknob that somebody just sneezed on their hands and then turned the doorknob, thank you very much, and now you come over and all of that sort of thing.

But what worries me, Dick, is now the virus, if it does follow normal patterns, heading to the Southern Hemisphere, what happens when it hits South Africa, HIV prevalence 25 percent? What happens when it hits Botswana, when it hits Swaziland? When it hits all these places where we have vast pools of individuals who are immunosurpressed and they are in that same age group.

See this whole thing of circulating flu and the relationship to HIV, we didn't have to be as worried about it with a normal flu because it's really whacking out people over 70 years old.

But now we're seeing a flu that's circulated in under 35-year-old adults, that's you prime HIV populations and we don't know what happens. We do know, and I've pressed our National Institute of Allergies and Infectious Disease director, Tony Fauci, on this quite directly and he concedes that we do have a body of evidence that people who are HIV positive, if they are exposed to influenza and get a whopping case they're more likely to die regardless of age than people who are not HIV positive.

And the second piece we know is that people who are on treatment for HIV, so they've -- they may be in Africa but they're some of the lucky minority that have actually been able to obtain anti-retroviral drug treatment, that one of the side effects of that treatment is it makes you more prone to cardiovascular disease in some cases. And so we see that if you are on such drugs and you get exposed to HIV you are statistically more likely to suffer a cardiovascular event, a heart attack, than your peer matched non-HIV positive individual.

So the worry I have, and Peter Navario who is also with the Global Health Program here at the Council and has been working in South Africa quite a bit -- we're both very concerned about what's going to happen with this virus as it circulates in Southern Africa.

TRAUB: Anyone else?

QUESTIONER: Irene Meister, Council member. You mentioned that the work had started on the vaccine but hasn't been decided yet what kind it will be. How much cooperation is there between the different countries working on it? Now, U.S., we know, we hear it on the various radio and television sources. But how much will it be really coordinated and offered to each other to help and to build because one country cannot just produce, in this case, enough to serve the world.

GARRETT: Well no country -- all countries combined that make flu vaccine can't make more than 400 million doses combined, that's the combined total. And the United States is the major manufacturer so the bulk of those, around 300 million, are in the US of A and we will preferentially give them to our own people, as will the other countries that make vaccine.

This is why, actually, the determination of what vaccine to make each year is a fairly well-oiled machine. It's one of the few things where the governance has been in place for a long time, it's a procedure where from all over the world leaders gather in WHO in Geneva, sift through all available data on what's been circulating most recently in the world and decide which vaccines should be made. And it's literally that WHO controls the seed stock for the vaccines and gives to the pharmaceutical industry and says this is what looks like the priority.

Now, on top of that, in rare cases such as 1976 when we had the swine flu scare here in the United States, a country may decide to do extraordinary efforts to make a targeted special vaccine. And that is what is now being debated here in the United States.

QUESTIONER: So they're in cooperation but then in that case why we didn't make more?

GARRETT: She asked why can't we just make more so 6 billion people can be vaccinated?

The problem is you make them on chicken eggs. It's very tedious. It's handmade vaccine. Just think of it that way. And it takes a long time. And we only have so many chicken eggs in the world. And you only have so many that are hygienically sterile in hygienically sterile facilities, handled by people completely suited up so they don't contaminate them because if there's bacteria in there and now you make vaccine you will potentially pass bacterial contamination. Some countries had to give up making flu vaccine because they never could manage to make safe stock.

So there is a tremendous amount of research and exciting stuff going on all of a sudden and just since the bird flu scare beginning in 2005 on innovative new ways to make flu vaccine involving technologies that could result in six billion doses in a year. But all of that is still in the pipeline, the R&D pipeline and none of them have yet gone to large scale clinical trials. So there certainly won't be available anytime in the near future.

And this is another reason why we were distressed about the foot dragging by the Obama administration on sending Peggy Hamburg's ratification over to Congress. And Congress' foot dragging on bringing her nomination before -- because she was nominated to run the FDA; she's the former health commissioner here in New York City, much admired.

And, you know, the FDA is a shambles. It's an agency that's really been allowed to fall to pieces. The Bush administration had a very unusual perspective on what that agency was supposed to do. And it desperately needs to be brought up to speed to be able to rapidly assess that scene safety and it cannot do that right now. We need new leadership and we need the scientists brought back in.

Actually, if you don't mind, while I'm mentioning scientists, one of the most exciting things we've seen with this outbreak of H1N1 is how fast the science has happened and how internationally cooperative it has been. It gives me goose bumps because I just, you know, having been in epidemic after epidemic after epidemic over my career I've never seen anything move this fast. Within eight days we had online published the genetic sequence of this virus, comparative analysis of how this one was related and unrelated to other known circulating flu viruses. We knew its susceptibility and non-susceptibility to all the available drugs for treatment. And we had electron microscope scanning and transmission microscope pictures of it. And it's been totally public. There's nobody hoarding information, as often happened in the past in the scientific community and fantastically transparent and fast, very exciting.

TRAUB: Sir.

QUESTIONER: As long as there are scientists who are working so hard on this and both on the vaccine but also on, I suppose, how the virus works, it seems to me there will be bad people exposed and that bioterrorism is a threat. Would you comment? You did a little bit. Would you comment further on that?

TRAUB: Could you, by the way, also -- I forgot to ask you, would you just add your name and affiliation?

QUESTIONER: My name is Gordon Aamoth from the Robina Foundation, Minneapolis.

TRAUB: Thank you.

GARRETT: When the Clinton administration was in that was the first time we had a real serious reassessment post Cold War of the probability of any given microbe being used as a bioterrorism agent. And a list was promulgated of about 26 key microbes that were thought to potentially -- and toxins -- thought to potentially be used as biological terrorism weapons.

Influenza was not originally on the list because it is so hard to make vaccine that it was though, man, this would be like thermonuclear war. You would just infect the entire planet, including your own people, and it would obliterate them. And we really hadn't thought, in those days of discussion about bioterrorism, that there was any entity out there so crazy that they would want to obliterate everybody including their own.

After 9/11 we started rethinking that premise but I don't think that anyone has demonstrated, despite Dick Cheney's insistence to the contrary, that Al Qaeda has, you know, biohazard level four laboratories in Torra Bora that are equipped to produce new novel organisms for mass distribution.

Influenza, the bird flu, was indeed put on the CDC's list of potential bioterrorism organisms. I don't really know why that was done. I don't fully understand that because I don't see that there's any, again, any unique way that you could discretely mass produce a vaccine, given how tedious it is and difficult it is to make flu vaccine, in order to protect your own and then release the organism.

I would say of the list of potential bioterrorist organisms at this time, flu would rank very low if not -- I'm not even sure I would see it as on any immediate timetable on anybody's list.

One of the often discussed possibilities was the use of flu basically to kill livestock. So you would introduce a contaminated animal into a rival country's livestock. The problem is that containment is just not a reality, especially if you're going to birds, chickens or what have you.

And it's just very hard to understand how any scientist capable of making such an agent would be stupid enough to believe that it could be contained within a nation or a geographic zone discretely.

TRAUB: We have time for one last question. Sir, and please, again, state your name and affiliation.

QUESTIONER: Herbert Levin. Since I live next door I come to a lot of events and I would say that you have -- the socks are the most interesting I've seen on any event here.

TRAUB: Glad I've had some kind of contribution to the event.

QUESTIONER: What about the pigs? We were told early on don't bother the pigs, they're fine, and go eat your pork chops. And then we got some other things. And, of course, in Egypt and Jordan they killed the pigs because they don't eat them, only the Christians do. So tell us about the pigs, please.

GARRETT: Well there's no doubt that this virus has been circulating in North American pigs for a long time in one form or another. It has evolved literally in the pig populations. I just have to say as a side -- when I used to give talks about bird flu inevitably somebody in the audience would ask me what's the probability that this virus is going to become a human to human transmitter in the next, and then they'd say year, five years, whatever.

And I would say, well, if you're the president of the United States, this is when George Bush was president, and you're asking me that question I would have to say, Mr. President, I can't answer it for you because you don't believe in evolution. And, you know, it's funny but it's true. You have to understand we're looking at an evolutionary process and it has been evolving in pigs.

So the insane messages from certain governments have to do with that somehow eating pig meat that's been cooked is dangerous. That is not true. This virus will fall apart when exposed to heat, no problem. And there's absolutely no evidence that anybody ever got flu from eating, you know, pork sausage. And frankly, because we all know that trichinosis is a problem with pig meat we cook pork considerably before eating it.

However, we do have a problem with the pig population and the circulation and the permissive environment for evolution of these viruses, of influenza. And we need to seriously look at how we raise pigs, how we monitor them, how we survey it.

This comes to another global governance question because the same has been true with the chickens since the beginning of the bird flu situation and we've never really come up with a good answer. We've gone in and slaughtered hundreds of thousands of chickens in a given area and it stopped transmission for some period of time but the next year the virus is back again. Do you just keep slaughtering those chickens?

Well, of course, what happens is if it's an area where the farmer is poor and the farm community is poor they will start hiding their sicker animals and not turning them in and not notifying government, even if family members get sick. And we now see that to be the case with bird flu in Egypt very definitely which turns this whole Egyptian slaughter of 300,000 pigs on its head because they've never slaughtered the chickens in Egypt. And they do have bird flu and they don't have swine flu.

So that's a clear case of using --(inaudible)-- for political purposes.

But we need to figure out how to survey the pig populations and all the sort of industrial scale livestock operations all over the world, without it being perceived by the industry as a direct attack on their livelihood. The pork industry is in a defensive posture right now in this country. They're very PR conscious. They're not eager to have outside investigators sniffing around testing their pigs.

We have to figure out a way that the industry continues to feel that they can turn their profits and they don't hide infections and they do allow inspections and we have some barriers put up between these various populations of birds, pigs, and humans that can be hosts for this virus influenza.

TRAUB: Alright. Well, thank you very much, Laurie. That was incredibly educational and I really thank you very much.

I know that Stewart Patrick, who has organized this entire extravaganza, wanted to say some last words so, Stewart.

(Applause)

STEWART PATRICK: First of all, I don't know if this is on but you can probably hear me anyway.

I want to say how great it was to have you here, Dr. --(inaudible). I know that there are a lot of other temptations on a sunny Friday afternoon.

Jim Traub, in addition to being a fabulous journalist and an excellent moderator is quickly becoming one of the go-to guys on global governance. I spent a couple of days in Paris with him on this very subject last week.

And Laurie Garrett, I can't say enough for what a wonderful colleague she is and how she's helped put the global public health agenda on, not just the Council's agenda, but on the world agenda. So it's absolutely fabulous to be able to collaborate together.

We've obviously had an incredibly rich discussion over the last day and a half or so. And, you know, the five different issue areas that we talked about are very different and the challenges are quite different. You know, for the nonproliferation treaty regime we're talking about how to update and close loopholes in a regime which -- in which country's itself -- excuse me -- a prohibition regime which has a lot of contradictions within itself and how to update that to the threats that we find.

In the second session on climate change, we're basically talking about they're dealing with externalities that are created by globalization and these consequences are obviously very unevenly distributed where the burden of adjustment is going to be different depending on what part of the world you live in.

For international finance it was how do we end up managing global interdependence in a way that preserves our prosperity, not just dealing with the crisis as we find it but actually dealing with and updating some of the structures that we have to reflect major changes in the global distribution of power.

For international law the challenge is how do we update our rules and norms to deal with new threats and also to bring perpetrators of mass atrocities to injustice?

And then today, obviously, or in the most recently in this last session, we heard about how -- what are the challenges to try to grapple with global public health emergencies and what's the balance between domestic and international?

I won't attempt in this stage to go through the entire list of lessons that have emerged from these five sessions -- six sessions actually if you include the one last night -- but just will try to telegraph just a few things that seem to be emerging as a result as broad themes.

One of the things we heard today, well all the sessions, was that U.S. leadership is critical. It's not always going to be sufficient but whether or not one accepts that we live in an age of non-polarity it's often going to be necessary.

Another thing that we heard was that solution sets are going to require major players that we haven't in the past incorporated. Regardless, for instance, if you look across the issue areas whether you're talking about disease, whether or not you're talking about climate, whether you're talking the global economy, trying to bring the bricks in, particularly China and as well an India is going to be huge.

And then a third one, and I'll leave it at this, I have many more but it's getting late, is that international problems are too complicated to rely on single formats. To some degree we still live in a UN centered world but, as we've discovered, many of the challenges that we face require some nimbleness and some issue specific groupings. And one of the major challenges is how we marry what is on the one hand this desire for flexibility and multi multilateralism or variable geometry, if you will, with the necessity for also bolstering the universal organizations that have the standing and capacity and the international legitimacy that we're going to need over the long haul. And that's going to be one of the ongoing themes, among many others, that we're going to be focusing on.

At this stage the time has come simply to say thank you and I just do want to identify a few folks. Once again, I want to begin by thanking the Robina Foundation and thank you, Gordon, for being here. This would not be possible, to say the least, the entire program was really, is 100 percent funded at this stage by the Robina Foundation and we have been enormously grateful to that support and we look forward to continuing to work with you in the years ahead.

I also want to express my heartfelt thanks to the panelists who participated in this event. Really superb, top-notch panelist including several colleagues including Laurie Richards, just a fantastic --

Particularly grateful to the meetings department, Nancy Bidertha (sp), --(inaudible)-- did just a superb job in organizing this.

And then finally, my own colleagues in International Institutions and Global Governance program, Casey Brown, Farrah Fizel (sp), and Alex Noyes.

So, thank you all very much. You know, keep looking at our website, please check it out. We're going to get a lot more bells and whistles soon, including something that Richard described yesterday in the global governance monitor, which is going to be a big effort to survey what global governance arrangements exists out there across about 10 to 12 different issue areas. We're getting a lot of input from our Council colleagues on that. And I think it's going to be an exciting thing, including some mini-documentaries and things like that.

But I -- this conference definitely lived up to my expectations and a lot of it had to do with also the participation of the audience and the wonderful questions that you asked.

So anyway, thank you very much. (Applause)

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