Experts in this Topic

Thomas J. Bollyky
Thomas J. Bollyky

Bloomberg Chair in Global Health; Senior Fellow for International Economics, Law, and Development; and Director of the Global Health Program

Luciana L. Borio
Luciana L. Borio

Senior Fellow for Global Health

David P. Fidler
David P. Fidler

Senior Fellow for Global Health and Cybersecurity

Tom Frieden
Tom Frieden

Senior Fellow for Global Health

Yanzhong Huang
Yanzhong Huang

Senior Fellow for Global Health

Jennifer Nuzzo
Jennifer Nuzzo

Senior Fellow for Global Health

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  • Public Health Threats and Pandemics
    Climate Change and Public Health Policy
    Play
    David Fidler, senior fellow for global health and cybersecurity at CFR, discusses the factors shaping U.S. health and climate policy included in his Council Special Report, A New U.S. Foreign Policy for Global Health. Penelope Overton, climate reporter at the Portland Press Herald, speaks about her experiences reporting on climate and environment stories in Maine and their intersection with public health outcomes. The host of the webinar is Carla Anne Robbins, senior fellow at CFR and former deputy editorial page editor at the New York Times.  TRANSCRIPT FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Local Journalists Webinar. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR. CFR is an independent and nonpartisan membership organization, think tank, and publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. This webinar is part of CFR’s Local Journalists Initiative, created to help you draw connections between the local issues you cover and national and international dynamics. Our programming puts you in touch with CFR resources and expertise on international issues and provides a forum for sharing best practices. We’re delighted to have over thirty-five participants from twenty-two states and U.S. territories with us today, so thank you for joining this discussion, which is on the record. The video and transcript will be posted on our website after the fact at CFR.org/localjournalists. So we are pleased to have David Fidler, Penelope Overton, and host Carla Anne Robbins to lead today’s discussion on “Climate Change and Public Health Policy.” David Fidler is a senior fellow for global health and cybersecurity at CFR. He is the author of the Council special report A New U.S. Foreign Policy for Global Health. Professor Fidler has served as an international legal consultant to the World Bank, the U.S. Department of Defense, the World Health Organization, and the U.S. Centers for Disease Control and Prevention. And his other publications include The Snowden Reader, Responding to National Security Letters: A Practical Guide for Legal Counsel, and Biosecurity in the Global Age: Biological Weapons, Public Health, and the Rule of Law. Penelope Overton is the Portland Press Herald’s first climate reporter. She’s written extensively on Maine’s lobster and cannabis industries. She also covers Maine state politics and other health and environmental topics. In 2021, she spent a year as a spotlight fellow with the Boston Globe exploring the impact of climate change on the U.S. lobster fishery. And before moving to Maine, Ms. Overton covered politics, environment, casino gambling, and tribal issues in Florida, Connecticut, and Arizona. And, finally, Carla Anne Robbins is a senior fellow at CFR and cohost of the CFR podcast The World Next Week. She also serves as the faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. And previously, she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. So thank you all for being with us. I’m going to turn the conversation over to Carla to run it, and then we’re going to open up to all of you for your questions, which you can either write in the Q&A box but we would actually prefer you to raise your hand so we can hear your voice, and really open up this forum to share best practices and hear what you’re doing in your communities. So with that, Carla, over to you. ROBBINS: Thank you, Irina. And I’m glad you’re feeling better, although your voice still sounds scratchy. (Laughs.) Welcome back. So, David and Penny, thank you for doing this. And thank you, everybody, for joining us here today. This is—Penny, at some point I want to get into the notion of covering cannabis and lobsters because they seem to go very well together, but—(laughs)—and how you got that beat. But, David, if we can start with you, can you talk about the relationship between the climate and public health threats like the COVID pandemic? I think people would tend to see these as somewhat separate. They’re both global threats. But you know, why would rising temperatures increase, you know, the emergence or spread of pathogens? I mean, are they directly driving—one driving the other? FIDLER: Yes. I’ll just give a quick public health snapshot of climate change as an issue. In public health, the most important thing you can do is to prevent disease threats or other types of threats to human health. In the climate world, that’s mitigation of greenhouse gas emissions. That hasn’t gone so well. That creates, then, the second problem: If you have—if you’re not preventing problems from emerging, threatening human health and the infrastructure that supports human health, then you have to respond. And that’s climate adaptation. And in climate adaptation, we deal—public health officials and experts are going to have to deal with a range of issues. Close to if not at the top of the list is the way in which the changing nature of the global climate through global warming could increase—and some experts would argue is increasing—the threat of pathogenic infections and diseases within countries and then being transmitted internationally. And this leads to a concern about what’s called a one health approach because you have to combine environmental health, animal health, and human health to be able to understand what threats are coming. And climate change plays—is playing a role in that, and the fear is that it will play an even bigger role. Coming out of the problems that we had with dealing with the COVID-19 pandemic, this also fills public health officials with alarm because we didn’t do so well on that pathogenic threat. Are we ready to deal with potential pathogenic threats that global warming exacerbates in addition to all the other health threats that are going to come with climate change? ROBBINS: So can we just drill down a little bit more on that, as well as a variety of other health threats from climate change? So, like, with malaria, like, more water; water, you know, pools; mosquitoes; malaria spreads itself. With COVID, there was this whole question about, you know, loss of jungles, and maybe animals come in closer to humans, and things spread that way. Can you talk some more about what changes happen to the world around us that—with climate change that could increase the possibility of people getting sick, as well as other stresses on our bodies? FIDLER: Yes. In terms of vector-borne diseases such as malaria or dengue fever, the concern is that as global warming happens the area in which the vectors that carry these diseases will expand. So if you have malaria-carrying mosquitoes, if global warming is expanding the range of possibilities for those mosquitoes to inhabit, then there’s a(n) increased public health threat from those vector-borne diseases. If you have a situation in which that global warming is also happening in connection with waterborne diseases, it’s both the excess amount of water that you might have with flooding as well as potential shortages of water that you have could also increase the threat of waterborne diseases. So global warming has these effects on potential pathogenic threats. Deforestation is a concern in connection also with humans coming more into contact with pathogens that we haven’t experienced before. Unfortunately, we still don’t really know what the origin of the COVID-19 virus was, largely because of geopolitical problems. But also, as global warming affects forested areas or other types of ecosystems, the possibility for pathogens to emerge and effect public health increases. ROBBINS: And then there are other effects, like loss of access to water, and rising heat, and all these other things which are part of—because I would suppose that in a lot of places, you know, people would think, well, you know, I live in Kansas; I’m not going to be really worried about loss of a jungle or something of that sort. So in the United States, if you’re a public health official, and you haven’t thought about climate change as a—as a public health issue, and you want to go make the pitch, what would you say that—how climate is already potentially affecting people’s health? FIDLER: Yes, and this is one of the most interesting policy challenges about climate adaptation. Different areas of every country are going to experience climate change differently. So in some parts it might be wildfires. In another part it might be extreme heat. In another part it might be the spread of vector-borne diseases. And in other—in coastal areas, you know, sea level rise. In other areas, shortage of water because of drought. And so for any given locality, right, there could be diverse and different effects of climate change on public health from even a neighboring state or certainly a state, you know, across the country. City and county public health officials and state public health officials are already trying to start to get their head around the types of threats that their communities are going to face. And that’s what’s going to be interesting to me about today’s conversation, is how those types of effects are being discussed at the local level. A critical principle that’s usually put in—on the table for any policy discussion, whether it’s foreign policy or local policy, is that if you don’t have community buy-in, you don’t have community commitment to dealing with some of these problems, the policy solutions are going to be far more difficult. ROBBINS: So, Penny, you are new—reasonably new to this beat, and your newspaper created this beat, which is—you know, which is a sort of extraordinary thing. I mean, how big is your newsroom? OVERTON: I think it’s about fifty people— ROBBINS: And the notion— OVERTON: —if you include, you know, sports reporters and everybody. ROBBINS: So the notion that they would—maybe your newspaper’s the rare local newspaper that’s doing really well, but most local newspapers are, you know—(laughs)—are battling these days. Why did they decide that they wanted to create a climate beat? OVERTON: I think that our readers were asking for it. I mean, everybody—I think you find that every newspaper is writing climate stories, you know, in some way, even if it’s just running wire—like, national wire stories. And of course, papers are and every news outlet is obsessed with metrics, and we know what readers are looking for. Sometimes the stories aren’t necessarily labeled climate, but they are, you know, climate-related. And so in trying to sort out during a general newsroom kind of reshuffle about what readers, especially what our online readers—since that’s where everything is kind of moving towards—what they were really looking for, climate was one of the topics that kind of rose to the top. And then also we’re part of a newspaper family in Maine where there’s a—you know, every—a lot of weeklies, several dailies that all belong under one ownership. It’s actually a nonprofit ownership now, as of about a year ago. So I don’t think it’s a coincidence that it went nonprofit at the same time that they decided to do a climate beat. But one of the topics that unite all of the papers across a really, you know, far-flung state with the areas where you have really well-off people that live along the shore, people who aren’t so well-off in the interior, there’s not a lot that sometimes unites our state, but everybody was interested in this from the fishermen—who may not want to call it climate change, but they know that things are changing and it’s impacting their bottom line; to the loggers up north who can’t get into their—you know, their forest roads are now basically mud season for much longer than they used to be, they’re not frozen anymore for as long as they were so they can’t get in and harvest the way that they were; farmers. I mean, the three Fs in Maine—forestry, farming, and fishing—are, you know, pretty big, and they all care immensely about climate because they know it’s affecting their bottom line. So I think that that really united all of our newsrooms. ROBBINS: So can you talk a little bit more about that? Because I—you know, you’ve lived in places other than Maine, right? I mean, I used to live in Miami, and it’s really hot in Miami these days. And the New York Times had this really interesting interactive a couple of years ago in which you could put in the year you were born and your hometown, and it would tell you how many more days of the year would be over 90 degrees. And it was just wild how many more days in Miami it would be. I mean, it’s pretty hot in Miami, but many more days now than it was. And you’ve seen already this spring how bad it is in Miami. So I think to myself, Maine. I mean, Maine—I went to school in Massachusetts; I know what Maine is like. So I would think that Maine would be—it’s going to take a while for—you know, for it to come to Maine, but what you’re saying is it’s already in Maine. So can you talk about how—you know, how it is? And, obviously, it’s affecting Maine for them to create a beat like that. So what sort of stories are you writing? OVERTON: Well, I mean, Maine is definitely—you know, its impacts are going to be different. The actual climate threats are different in Maine than they are, say, like in Arizona where I used to live and report. You know, but contrary to what you might think, we actually do have heatwaves—(laughs)—and we have marine heatwaves. The Gulf of Maine is warming faster than 99 percent of the, you know, world’s ocean bodies, and so the warming is definitely occurring here. But what we’re seeing is that just because it’s not—the summer highs are not as high as, like, you know, Nevada, Arizona, Southern California, the Midwest, we also are completely unprepared for what’s actually happening because nobody here has ever really had to worry about it. Our temperate climate just didn’t make air conditioning a big, you know, high-level priority. So the increasing temperatures that are occurring even now are—we don’t have the same ability to roll with it. Warming stations in the winter? Yes, we have those. Cooling stations in the summer? No, we don’t have those. And I mean, there are a few cities that are now developing that, but if you don’t have a large homeless population in your city in Maine you probably don’t have a public cooling station. It’s really just the public library is your cooling station. So some of those—that kind of illustrates how sometimes it’s not the public health threat; it’s actually the public health vulnerability that a local reporter might want to be focusing in on. So you can go to the National Climate Assessment and you can pull up, like, exactly what, you know—even if you don’t have a state climate office or a climate action plan, you can go to one of those National Climate Assessments, drill down, and you can get the data on how, you know, the projected temperature increases, and precipitation increases, and the extreme weather that’s projected for 2050 and 2100 in your area. And those might not be, you know, nightmare stuff the way that it would be for other parts of the country, but then you’d want to be focusing in on how—what the infrastructure in your state is like. Are you prepared for what will be happening? And I think the air conditioning thing is a really good example. Maine also happens to be, you know—Florida will love this, but Maine’s actually the oldest state as far as demographics go. And so you have a lot of seniors here that have been identified as a vulnerable population, and so with the combination of a lot of seniors, with housing stock that’s old and doesn’t have air conditioning, and that they’re a long distance from hospitals, you know, don’t always—they don’t have a lot of emergency responder capability, that’s kind of a recipe for disaster when you start talking to your local public health officers who are going to start focusing in on what happens when we have extreme weather, and the power goes out, and these people who need—are reliant on electricity-fed medical devices, they don’t have access, they can’t get into the hospital. You can see kind of where I’m going with the vulnerability issue. ROBBINS: David, Penny has just identified the sort of things that one hopes a public health official on a state, or county, or local town or city level is thinking about. But in your report, it says the United States faces a domestic climate adaptation crisis. And when we think about climate and adaptation, and when we look at the COP meetings, the international climate change meetings, the Paris meetings, we usually think about adaptation as something that we’re going to pay for for other countries to deal with, or something of the sort. But can you talk about the concerns of our, you know, adaptation policies, and particularly state-level weaknesses? FIDLER: Yes, and I think Penny gave a nice overview of what, you know, the jurisdiction in Maine, you know, faces, and public health officials and experts are beginning to think about how do we respond to these new types of threats, which for most public health agencies and authorities across the United States is a new issue. The data is getting better, the research is getting better. The problems that public health agencies face sort of a across the United States are, one, they were never really built to deal with this problem. Some of it overlaps, so for example, if you have increased ferocity of, you know, extreme weather events—tornados, hurricanes—public health officials in those jurisdictions that are vulnerable know how to respond to those. They work with emergency management. As the scale of those types of events increases, however, there is a stress on their capabilities and their resources. Other things are new—air pollution from wildfire, the extreme heat of that; sea level rise, salination of drinking water from that; or even sinking in places where groundwater is being drawn out because of a lack of rainfall. Part of the problem that we have, that I talk about in my report coming out of COVID, is that among many issues today, the authority that public health agencies have at the federal and state level is polarized. We don’t have national consensus about public health as an issue. So unfortunately, coming out of COVID, we’re even less prepared for a pandemic as well as climate change adaptation. And that’s something that we need to have better federal, state, local cooperation and coordination on going forward. Again, it’s going to be very different from dealing with a pandemic, or even dealing with a non-communicable disease like tobacco consumption or, you know, hypertension because of the diversity—geographic—as well as the particular problem itself. So this is going to be a real challenge for federal and public health agencies, which at the moment are in some of the weakest conditions that I’ve seen in decades. ROBBINS: Penny, how much do you have to deal with your local public health, state public health agencies? And do they have a climate action plan? How developed are they on this? You talked about going to a particular website. Do you want to talk a little bit about that, as well? The assessments that you are making, is that information that you’ve gotten from your local public health agencies or from your state, or is this something that you yourself have come up with? OVERTON: Well, the state is—I think that the state of Maine is actually pretty far down the road for its size. It’s like punching above its weight, I guess, when it comes to climate. They have—they published their first climate action plan in 2020, and they updated it with a—kind of like how close are we coming to our goals in 2022, and then they’re in the process of developing the next four-year kind of installment, which will be due out in December. So the first one was kind of like—to me as an outsider, it felt like a “climate change is happening, folks” kind of report. In Maine we definitely—we have a split. We have an urban, you know, core that’s kind of—it’s liberal, and you don’t have to convince those people. We have a lot of rural parts of the state where, if you ask, you know, is climate change real, you’re still going to get a pretty good discussion, if not an outright fight. (Laughs.) But one of the things that I’ve found in this latest update is that, as they are focusing in on impacts, you get a different discussion. You don’t have to discuss with people about why the change is happening; you can just agree to discuss the changes, and that pulls in more communities that might have not applied for any type of, you know, federal ARPA funds or even—Maine makes a lot of state grants available for communities that want to do adaptation. So if you can get away from talking about, you know, the man-made contributions, which, I mean, I still include in every one of my stories because it’s just—you know, that’s actually not really debatable, but as far as the policy viewpoint goes, if you can just focus in on the impact that’s already occurring in Maine, you get a lot of people pulled into the process, and they actually want to participate. And I also have found that the two—the two impacts in Maine of climate change that are most successful at pulling in readers—(laughs)—as well as communities into planning processes are public health and extreme weather. I don’t know if it’s, you know, all the Mainers love their Farmers’ Almanacs—I’m not sure. I mean, I’m originally from West Virginia. I still have a Farmers’ Almanac every year, but I just kind of feel like extreme weather has been a wakeup call in Maine. We got hammered with three bad storms in December and January that washed a lot of our coastal infrastructure away. And, I mean, privately owned docks that fishermen rely on in order to bring in the lobster catch every year, and that’s a $1.5 billion industry in Maine. Maine is small—1.5 billion (dollars), that dwarves everything, so anything the messes with the lobster industry is going to have people—even in interior Maine—very concerned. And everybody could agree that the extreme storms, the not just sea level rise, but sea level rise and storm surge, nobody was prepared for that, even in places like Maine, where I think that they are ahead of a lot of other states. So you start pulling people in around the resiliency discussion. I think you kind of have them at that point. You’ve got their attention and they are willing to talk, and they’re willing to accept adaptations that they might not be if you were sitting there still debating whether or not climate change is real. The public health has been something that has really helped bring interior Maine into the discussion. Everybody does care. Nobody wants to lose the lobster industry because that’s an income, like a tax revenue that you just wouldn’t be able to make up any other way, even if you are in a Rumford or a Lewiston that have nothing to do with the shoreline. But public health, that unites—that’s everybody’s problem, and asthma, and, you know, all of our natural resource employees who are out working in the forests, and the blueberry fields, and whatnot, extreme heat and heat stroke—those things really do matter to them. They may disagree with you about what’s causing them, but they want to make sure that they are taking steps to adapt and prepare for them. So I just have found public health to be a real rallying point. And I also think that, for local reporters, if you don’t have a state action plan—because even though Maine has one—we’re a lean government state—they don’t—you know, they’re still gathering data, and it can be pretty slim pickings. But you can go to certain things like the U.S. Climate Vulnerability Index, and you can start looking for—drilling down into your local Census tract even. So you don’t need something at your state. Even if you’re in a state that, say, politically doesn’t want to touch climate change with a ten-foot pole, you can still use those national tools to drill down and find out where your community is both vulnerable to climate threats, but then also the areas that are least prepared to deal with it. And then you can start reporting on what nobody else wants to write about or talk about even. And isn’t that the best kind of reporting—is you kind of get the discussion going? So I think public health is a real opportunity for reporters to do that, and also your medical—the medical associations. If you talk to doctors here at the Maine Medical Association, they may not want to talk about humanity’s contribution to climate change, but they already know that climate change is posing an existing health risks to their patients, whether that be, you know, asthma, allergies, heat stroke, Lyme disease, or just mental health issues; whether you’re a lobsterman worried that you’re not going to be able to pay off that million-dollar boat because the lobsters are moving north, or if you are a young person who has climate fatigue. We don’t have enough mental health providers as it is. Anything that’s going to exacerbate a mental health issue in Maine, I mean, we don’t have the tools to deal with what’s already here. That’s a gap that reporters feast on, right? We write about those gaps to try and point them out, and hopefully somebody steps in to resolve them. So I rambled a bit, but there’s—I feel like this bee— ROBBINS: No, no, no, you— OVERTON: —it’s like never like what stories—boy, what stories can I write; it’s more like how am I going to get to them all, you know, because I feel like everybody out there, even if you are not a climate reporter, I guarantee you there is a climate aspect to your beat, and there is probably a public health climate aspect to your beat. I mean, if you are a crime reporter, are your prisons—(laughs)—I mean, most prisons aren’t air conditioned. Just think about the amount of money that’s being spent to deal with heat stroke, and think about the amount of—I mean, I’m making this up as you go, but I guarantee you if you are a prison reporter, that you’re going to find, if you drill down, you’re going to see disciplinary issues go through the roof when you have a heat wave. That’s what I mean by, like, you can find a climate story in any beat at a newsroom. ROBBINS: That’s great. I always loved the editors who had story ideas if they gave me the time to do them. David, can we go back to this—the United States faces a domestic climate adaptation crisis? If I wanted to assess the level of preparation in my state to deal with some of the problems that Penny is doing, how do I do that? What do I look for—climate action plans? Where do I start? FIDLER: Well, I think you would start at the—you’ve got to start both at the federal level, so what is the federal government willing to do to help jurisdictions—local, county, state—deal with the different kinds of climate adaptation problems that they’re facing. And even as a domestic policy issue, this is relatively new. I think Penny gave a great description of how that has unfolded in one state. This is happening also in other jurisdictions. But again, because of the polarization about climate change, as well as fiscal constraints on any federal spending, how the federal government is going to interface with the jurisdictions that are going to handle adaptation on the ground is important—state government planning, thinking, how they talk about it, how they frame the issue, do they have a plan, is it integrated with emergency management, is it part of the authority that public health officials are supposed to have, how is that drilling down to the county, municipal, and local level. Again, it’s going to be different if it’s a big urban area or if it’s a rural community, and so, as the impacts—and Penny is right about it—it’s the impacts on human lives, direct and indirect, including damage to economic infrastructure, which supports jobs, supports economic well-being. That’s a social determinant of health. And as I indicated, there are efforts underway, not only in individual states, but also in terms of networks of county and city health officials, tribal health officials, as well, for Native American areas—that they’re beginning to pool best practices. They’re beginning to share information. So I would look not only at those governmental levels, but I would look at the networks that are developing to try to create coordination, cooperation and sharing of best practices for how to deal with different issues. So if you have a situation where you are like Penny described in Maine, you know, you really haven’t had to have air conditioning before; now you’ve got a problem. What are the most efficient and effective ways of dealing with that problem? Share information. Research, I think, is also ongoing in that context. And so there is a level of activism and excitement about this as a new, emerging area in public health. Again, there are lots of constraints on that that have to be taken seriously. At some point, it’s just also a core principle of public health and epidemiology that you need to address the cause of these problems. And if we still can’t talk about climate change and causes for that, this problem is only going to metastasize in our country as well as the rest of the world. And there are not enough public health officials at the state, county, local level, and there’s not enough money if we don’t try to bring this more under control. That’s mitigation. We’ve squandered four decades on this issue. We have no consensus nationally about that question, and so that just darkens the shadow in, you know, looking forward in terms of what public health officials are going to have to handle. ROBBINS: So I want to throw it open to our group, and if you could raise your hand. We do have a question already from Aparna Zalani. Do you want to ask your question yourself, or shall I read it? Q: Can you guys hear? ROBBINS: I will—I’m sorry. Yes, please. Q: OK, yeah, basically I just wanted to know if you guys know if anybody is collecting good heat-related death data—data on heat-related deaths. ROBBINS: And Aparna, where do you work? Q: I work for CBS News. ROBBINS: Thank you. OVERTON: I’m just looking through my bookmarks because, yes—(laughs)—there are. I know that those are factored into Maine’s climate action plan, and I can guarantee you that is not a Maine-only stat. That would be coming from a federal—there’s just not enough—the government here is not big enough to be tracking that on its own. It is definitely pulling that down from a federal database. And I’m just trying to see if I can find the right bookmark for you. If you—and I’m not going to because, of course, I’m on the spot—but if you add your contact information to the chat, or you can send it, you know, to me somehow, I will—I’ll send that to you because there is, and it’s a great—there’s emergency room visits, and there are other ways. They actually break it down to heatstroke versus exacerbating other existing problems. It’s not necessarily just—you don’t have to have heatstroke to have, like, say, a pregnancy complication related to heat illness, or an asthma situation that’s made far worse. So they do have, even broken down to that level. FIDLER: And when I’m often looking for aggregate data that gives me a picture of what’s happening in the United States, I often turn to the U.S. Centers for Disease Control and Prevention, CDC. And so they’re often collecting that kind of data to build into their own models and their research, also in terms of the assistance that provide state and local governments on all sorts of issues. And because adaptation is now on the radar screen of the federal public health enterprise, there might be data on the CDC website. And then you can identify where they are getting their sources of information, and then build out a constellation of possible sources. Again, it’s something—there’s the National Association of City and County Health Officers—NACCHO is the acronym—that, again, it’s one of those networks where you could probably see those health officers that are having to deal with extreme heat and the morbidity and mortality associated with that. There could be data that they are generating and sharing through that sort of network. And on the— OVERTON: And one thing I would add— FIDLER: Sorry. Drilling at the global level, WHO would be another place to think about looking if you wanted a global snapshot at data. OVERTON: I was going to add that will probably be underreported, as well, because in talking to, like, say—because, I mean, we’re just ultra-local, right—talking to the emergency room directors at our hospitals, there are—the number of cases that might come in and really should be classified as heatstroke, but then end up being listed instead in the data, you know, in the documentation as, like, a cardiac problem. You know, it’s—I think you are limited to how quickly someone on the ground might identify what’s coming in as actually being heat-related versus like just whatever the underlying problem was. They might list that instead. And the other thing, too, is to make sure that—this is the hardest part about climate reporting is the correlation aspect versus causation. You’re going to mostly be finding, look, heat waves are—when we have heat waves, you see this spike. You have to be really careful because it could be that the spike that’s coming in emergency rooms is actually because there was also a power outage. Now I would argue extreme weather still adds that—you know, makes that linked, but you have to be careful about making sure you don’t jump from correlation to causation. I’m sure you know this, but it’s the same thing with every statistic, but sometimes my first draft of a story I’m like, oh, look at that. I just made climate change responsible for everything. (Laughter.) And I have to go back and like, you know, really check myself because the minute you overstep in any way is the minute that you, like, lose all credibility with the people out there who are already skeptical. FIDLER: And this is sort of—it’s often where adaptation becomes a much more complicated problem for public health officials because there are underlying health problems that have nothing to do with climate change, that when you meet, you know, warming, extreme temperatures or even, you know, problems with, you know, sanitation, or water, or jobs, it can manifest itself in very dangerous diseases or health conditions that then lead to hospitalization and to biased statistics. So what Penny is saying is absolutely right, and there needs to be care here, but from a public health point of view, this is why this is going to be a monster problem. ROBBINS: Can we just—because we have other questions, but talking about bookmarks, Penny, you had—when you were talking before, you went through some other places that you go to for data and information. Can you just repeat some of those you were talking about? OVERTON: Yeah, the National Climate Assessment, the U.S. Climate Vulnerability Index, good old Census Bureau. (Laughs.) I mean, there are a couple of—the other thing, too, I would say that if you are in a state that doesn’t have—say that public health officers are under intense pressure not to talk about climate change, still go to your local university because I guarantee you that there are grad students, you know, coming in from the blue states someplace that might be going to school in a red state, but they’re going to be studying those topics, and they are going to be collecting data. I, you know—geez, countless stories based on grad student work. So I would keep those folks in mind, as well. And the other thing is that, if we’re talking about public health, I always think of public health and climate in three ways. It’s the threat, you know, the actual increase, something like tick-borne illness if you are Mainer because we never had ticks here really before because our winters were so awful, and the ticks couldn’t last. Well, now they’re here, and Lyme disease has gone through the roof. So I think about it—that’s like a threat. And then there’s the vulnerability issue that I was mentioning. But there’s also the accountability issue—is that you want to make sure as a reporter that you are following the infrastructure money that’s coming through, and that they are actually going to the places that need it the most. And public health is something that I think is a good lens to look at that. If all your money is going into the shoreline communities in Maine because they’re the ones with grant officers that are writing the grant applications to get the infrastructure money, do they really need it, or is it that town in the middle of the state with no grant officer, and huge public health needs and vulnerabilities that really need it. So I would think about public health as being an important accountability tool, as well, because if you’ve got public health data, you can easily point out the communities that need that money the most, and then find out who is actually getting the cash. ROBBINS: So Debra Krol from the—environmental reporter from the Arizona Republic, you had your hand up. OVERTON: I love your stories, Deb. Q: Thank you very much. Just a brief aside before I ask the question because I know we’re running short on time. We did a story here a few months ago about a nonprofit group that’s helping these underserved communities obtain grants and do the grant reporting, and I remembered something that we learned at a local journalist get-together at CFR, so that’s what influenced me to do that. So kudos to our friends over there. But my question is, is data sharing between agencies—you know, we’re always trying to get statistics out of the Indian Health Service, and every other state that has tribal communities or tribal health has the same problem. So how much of these stats do you think are actually coming from tribal health departments? OVERTON: I know in Maine they are coming. In fact, Maine’s five federally recognized tribes are kind of blazing a path as far as looking for grant applications. And of course, once they apply for a grant, you could go through all that data when they’re looking to justify the need, right? And that will help you in just getting the, you know, situation on the ground. But I—yes, I mean, I don’t know about whether there may be certain parts of the country where that’s not leading the way, but also—I would also urge you to look at—go through the Veterans Administration, as well, just because I’m sure that, you know, that there’s a large overlap between Indian Health Services, BIA, and the VA. And it’s the way the VA provides public health care and the outcomes they get when they are serving indigenous veterans are far different than what Indian Health Services and BIA sometimes get. And they are more forthcoming with their data. FIDLER: I know that one of the issues that’s on my list to do some more research for my foreign policy analysis is to look at the way the federal governments, state governments, and tribal authorities interact on climate adaptation. And that comes loaded with lots of complicated problems—just the history of relations between tribes and the federal government, the concerns that the Indian Health Service has about problems that have been around for decades, layering on top of that adaptation. So some of it, I think, gets involved in just political disputes between tribes and the federal government. Some of the data-sharing problems I think relate to a lack of capabilities to assess, process, and share the data. The tribal authorities are on the list, at least, of the federal government’s radar screen for improving how they do adaptation. I personally think that how that jurisdictional tension is resolved could be a very valuable model for thinking about U.S. foreign policy and how we help other countries in adaptation. I also think there is variable experiences between tribal authorities and the federal government. A lot of activity is happening in Alaska with adaptation that I think is more advanced than it is with some of the tribal authorities’ relations with the federal government in the continental United States. So we just also need to start looking, you know, beyond for best practices, principles, ways of making this work better as adaptation becomes a bigger problem. ROBBINS: Debra is—Debra Krol is offering to speak with you offline. She has some recommendations on research. Debra, thank you for that. Q: You are welcome. ROBBINS: And for the shoutout. Garrick Moritz, an editor of a small town newspaper in South Dakota. Can you tell us the name of your paper and ask your question? Q: Yeah, I am the Garretson Gazette. Hello, if you can hear me. ROBBINS: Absolutely. Q: Oh, yeah, we just get frequent—we get frequent notifications from the state health department about, you know, like West Nile and several other, you know, vector diseases, and it mostly comes from mosquitos, and mosquito populations are a real problem in a lot of places. And it’s definitely one here. And so, I guess, in my own reporting and in basically reporting from people across the country, how can—what are practical tips that we can give to people, and things we can recommend to our city, state or county officials? ROBBINS: To protect themselves. OVERTON: You know, I think that if you were to go to the, you know, U.S. CDC, you’re going to see that there’s a lot of, you know, straight up PSAs about how to handle, you know, even right down to the degree of, like, you know, the kinds of mosquito repellent you can use that doesn’t have DEET in it, you know, like it gets pretty specific. I think that that’s—you could probably—and in fact I think they even have infographics that, you know, are public domain that you are able to just lift, as long as you credit the U.S. CDC. So it’s almost like—and also Climate Central. And there’s a couple of—I would say a couple of kind of groups out there that basically serve it up for reporters. I mean, I love Climate Central. I love Inside Climate News. These are some places that specifically work with reporters, and for smaller markets, they even do the graphic work. And it’s a great resource. I would urge you to look there, too. ROBBINS: Can we talk a little bit more about other— FIDLER: And I think one of the— ROBBINS: Yeah, David, can you also talk about other resources, as well as answering—whatever answer to your question. What should we be reading and looking to for information? FIDLER: Well, in terms of vector-borne diseases, many states and the federal government has vast experience dealing with these. There’s a fundamental problem—is that as the geographic range of vector-borne diseases begins to expand into areas where the history of that type of vector control just really hasn’t been, you know, part of what public health officials have had to worry about, so the infrastructure, the capabilities. And then, also importantly, how you communicate with the public about those kinds of threats: what the government is doing, what they can do to protect themselves. We’re sort of present at the creation in many ways, and some of these places have a whole new way of doing public health. One of the things that worries people the most in our polarized society is the disinformation and misinformation that gets in the way of accurate public health communication—whether it’s COVID-19, or whether it’s climate change, or whether it’s something else. So that communication piece is going to be vital to making sure that people can take the measures to protect themselves, and they understand what the state governments and the local governments are doing to try to control vectors. ROBBINS: And Inside Climate News—where else do you get your information that you would recommend for our— OVERTON: Well, I just— FIDLER: Sorry, go ahead, Penny. OVERTON: Oh, no. You can go ahead. I’m actually pulling some up right now that I can put in the chat. FIDLER: Again, my go-to source is the CDC, and the CDC then also has its own information sources that you can track in terms of how, you know, public health authorities, public health policies, practices, implementation plans can be put together for all kinds of different public health threats. And the spread of vector-borne diseases has been near the top of the list longer, I think, than some of these other health threats from climate change. So that’s a little bit more advanced, I think, based on the history of controlling vectors as well as the identification of that being an ongoing threat. There are synergies with what we’ve done in the past. With some of these other problems we don’t have those synergies. We’re having to create it from scratch. ROBBINS: Penny, you were talking about places that actually—smaller, you know, that newspapers can—or other news organizations can get info, can actually, you know, get graphics gratis, or something of the sort. Does Poynter also have help on climate or are there other reporting centers where people are focusing on climate that provide resources for news organizations? OVERTON: Yes, I mean, Climate Central has—I should have just like made them like the co-beat, you know, reporters for me in the first six months when I was starting this because anything that I needed to—you know, every day it was something new. OK, geez, today I’ve got to know everything there is to know about extreme weather and climate, you know, in such a way that I can bulletproof myself when the troll inevitably calls me and says, you know, this isn’t true. And I need to have, you know, a little bit of armor prepared, right down to I need graphics, and I don’t have—we don’t have a graphics person, but—so Climate Central is a great place for a reporter in a small market to start. They actually, like just this past week, came out with what they call a summer package, and it basically has an overarching umbrella viewpoint of, like, here’s like the climate topics that are going to brought up this summer. Inevitably it’s going to be heat waves, it’s going to be drought, or extreme rainfall. It’s going to be, you know, summer nights getting warmer and what that means—the benefits, the longer growing seasons than some areas that, like in Maine, for example, climate change will not be all bad for Maine. It’s going to mean that we have longer growing seasons in a place that has been pretty limited by the—you know, the temperature and by the amount of time that we could actually grow a crop. And then, also, I mean, we’re going to have—we’re going to have migration in because, like I was saying earlier, we are not going to be dealing with the extreme heat of like the Southwest, so people who are escaping like the California wildfires—we’re already seeing groups of people moving to Maine because it is more temperate, and you do have a longer horizon line before you—you know, you get miserable here. And I think that if you look at those issues and you figure out how do I even start, going to Climate Central where they can actually—not only do they have the infographics, but you can type in, like, the major city in your state, you know. I can’t tell you the number of times I’ve typed in Portland, Maine, and I get some amazing number, and it's, oh, wait, this is Portland, Oregon. So you could pull, like, your individual state, and even Maine has three states that Climate Central—or excuse me, three cities that Climate Central lists. I guarantee you that your state will probably have many more. So it will be probably a place pretty close to where you are located. And you can have the infographic actually detailed, without doing anything besides entering in the city. It will be information that’s detailed to your location. That’s an incredible asset for a small market reporter who doesn’t have a graphics person or the ability to, like, download data sets and crunch a lot of numbers. Also— ROBBINS: That’s great. OVERTON: —I would urge you to look at the National Climate Assessment. There is a data explorer that comes out with those, and that allows you to drill down to the local level. That’s the way that I found out that there’s a small place in Aroostook County, Maine, which is like potato country, that’s going to see the greatest increase in high precipitation days in the next—I think it’s in the next 50 years. I can’t think of many things that aren’t potato related that Aroostook County stands out for, but the fact that you play around with the data enough, and you see, look, there’s a small place here in Maine that’s going to be the number one greatest increase. That’s why I think the climate assessment and the data explorer is so important. ROBBINS: So we’re almost done, David. I wanted to throw the last question to you. I’m a real believer in comparison. I always say that to my students: Comparison is your friend. Is there any city or state in the United States, or perhaps someplace overseas that has a really good state plan for dealing with the health impacts of climate change that we could look at and say, this is really what we should be doing here? FIDLER: I mean, given that I’m a foreign policy person, I’m probably not the best person to inquire about that, but as I began to do my research to see how this is happening in the United States, I’ve been surprised at the number of cities, counties, state governments that have really begun to dig into the data, develop plans, you know, for whatever problem that they’re going, you know, to face. I live in the—you know, the Chicagoland area. The city of Chicago has been working on adaptation for a while. The problems that it faces are going to be different than the problems that Miami faces. There’s also, again, networks of cities that are starting to talk to each other about what they are doing in regards to these issues. The data is becoming better, more accessible, data visualization tools. Penny just described those sorts of things. My recommendation to those working in local journalism is to begin to probe what your jurisdictions are doing, where they are getting their information. How are they implementing and turning that information into actionable intelligence and actionable programs? And I think that local journalism will help fill out our understanding of who is taking the lead, where should we look, what are the best practices and principles around the country. ROBBINS: Well, I want to thank David Fidler, and I want to thank Penny Overton for this. And I want to turn you back to Irina. This has been a great conversation. FASKIANOS: It really has been a fantastic conversation. Again, we will send out the video, and transcript, and links to resources that were mentioned during this conversation. Thank you for your comments. We will connect people that want to be connected, as well, so thank you very much to David and Penny for sharing your expertise, and to Carla for moderating. You can follow everybody on X at @D_P_fidler, Penny Overton at @plovertonpph, and at @robbinscarla. And as always, we encourage you to go to CFR.org, ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on international trends and how they are affecting the United States. Again, please do share your suggestions for future webinars by emailing us at [email protected]. So again, thank you to you all for today’s conversation, and enjoy the rest of the day. ROBBINS: Thanks, everybody. (END)
  • Public Health Threats and Pandemics
    Avian Flu Outbreak and Preventing the Next Pandemic
    Play
    Jennifer Nuzzo, senior fellow senior fellow for global health at CFR, discusses the spread of the avian influenza in poultry and dairy cows in the United States and risks that zoonotic diseases pose to human populations. Rick Bright, former chief executive officer of the Pandemic Prevention Institute at the Rockefeller Foundation, discusses measures being taken to mitigate the spread of avian influenza and U.S. preparedness for future pandemics. A question-and-answer session follow their opening remarks. TRANSCRIPT FASKIANOS: Thank you. Welcome to the Council on Foreign Relations State and Local Officials Webinar Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. CFR is an independent and nonpartisan membership organization, think tank, and publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy.  Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. We appreciate you taking the time to be with us for this on-the-record discussion. We’re delighted to have over 300 participants from forty-seven U.S. states and territories. I want to remind everyone that the webinar is on the record, video and transcript will be posted on our website after the fact at CFR.org, and we will circulate it as well.  We are pleased to have Dr. Jennifer Nuzzo and Dr. Rick Bright with us today to lead the discussion on “Avian Flu Outbreak and Preventing the Next Pandemic.” I will share a few highlights from their distinguished bios. Dr. Jennifer Nuzzo is a senior fellow for global health at the Council on Foreign Relations, where her work focuses on global health security, public health preparedness and response, and health systems resilience. She is a professor of epidemiology and the inaugural director of the Pandemic Center at Brown University’s School of Public Health. And she also directs the Outbreak Observatory, which conducts operational research to improve outbreak preparedness and response.  Dr. Rick Bright is the CEO and founder of Bright Global Health and works as a consultant for pandemic preparedness. He previously served as head of the Pandemic Prevention Institute at the Rockefeller Foundation. He was also the director of the Biomedical Advanced Research and Development Authority, known as BARDA, and the deputy assistant secretary for preparedness and response in the U.S. Department of Health and Human Services. And he was a member of the Biden-Harris Transition Advisory Board on COVID-19.  So thank you both for being with us today. I think we’ll begin with you, Dr. Nuzzo. If you can talk about the current status of the avian flu outbreak, the symptoms, risks it poses to animal and human populations, especially those working in food processing plants. NUZZO: Thank you so much, Irina. I really appreciate the introduction and the opportunity to participate in this session. I wish we didn’t have to talk about H5N1. H5N1 is an influenza A virus, we are—particularly called a highly pathogenic avian influenza A virus. It predominantly infects birds, but humans that have—humans have been infected, particularly those who have had contact with infected animals. And while we’re having this webinar now and we’re talking about this now, and it’s been in the news a lot now, I think it’s really important to understand that this is not a new virus. It’s actually one that we’ve been tracking for quite some time.  In fact, this virus was first recognized in the late ’90s, when it was detected in geese. Then in 1997, it caused a fairly large outbreak among humans. About eighteen cases were identified in Hong Kong, and of these six died. This was enough to prompt, you know, massive concern, you know, big chicken culling operations and attention on live markets, which thankfully sort of, you know, contained that human outbreak. But it didn’t eliminate the virus. In fact, the virus continued to circulate in birds, and ultimately spread to domesticated ducks. And this is thought to have then kind of contributed to the reemergence of the virus in humans in 2003, late 2003-early 2004, when we started to see outbreaks in a number of neighboring countries in Asia. About eight initially and then we saw the virus spread to a number of other countries as well.  Since this virus was first identified till now there have been about 900—just under 900 known human cases. But nearly half of these have died. And this statistic, while incredibly imprecise, is enough to be alarming, because typically when we, you know, find cases and we calculate the percentage of those who died, 50 percent is really—you know, really, really ranks up there in terms of severity. It certainly is on track to put, you know, H5N1 to be a much deadlier virus in terms of that percentage than, you know, the virus that caused the COVID-19 pandemic, certainly more so than seasonal influenza. So there’s a reason why we’ve been worrying about this virus for a number of decades.  As I said, the majority of these cases are known to have had exposures with sick animals. But there is some evidence that there may have been human—very limited human-to-human transmission. You know, people who have gotten it that didn’t quite know what they were exposed to. There was actually a study that looked back at that 1997 outbreak in Hong Kong and found evidence that healthcare workers who cared for some of those sick patients may have been infected, possibly without symptoms—which is concerning. But nonetheless, we haven’t seen any evidence of sustained transmission between humans.  And that’s fortunate because were we to see evidence of that, were we to see that, you know, multiple generations of people—meaning like, one person can give it to the next who could give it to the next—were we to see evidence of that, that would truly signify, I think, the beginning of a new pandemic, or perhaps the start of one, were we not able to contain it swiftly. Remember, this is—this is a new virus. You know, nearly—hardly anyone has actually gotten this virus. And so that that immune—that naive immune state, meaning we haven’t had, you know, background immunity to it, would make us likely all susceptible to this virus. So again, were are we to see evidence of sustained human-to-human transmission, that would very much signify the start of a pandemic.  Now, that hasn’t happened yet. And that is quite fortunate. But nonetheless, the worry about H5N1 persists. You know, I would say this virus has continued to circulate on the planet and hasn’t gone away, but I think some of the attention around the virus really, you know, began to wane a bit. In part because the majority of the human cases that we have seen to date really occurred between 2003 to 2015. And then there was a relative lull in the occurrence of human cases. And why that is isn’t quite clear. But that, combined with the occurrence of other health emergencies—including a pandemic caused by a completely different influenza virus, one that occurred in 2009—that was due to the H1N1 virus, not H5N1—you know, I think it really helped to, unfortunately, distract us from the threat that H5N1 poses. I would say that all kind of came to a screeching halt, that relative quiet and that relative distraction that people, you know, who kind of track these things were experiencing, really about a couple of years ago when we started to see much more viral activity from this virus. Started to see a massive kind of geographic expansion, the virus turning up in parts of the world that we typically hadn’t seen it, and also a massive species expansion. Meaning it was starting to not just affect chickens, and ducks, and other wild birds, but many other species—including mammals. And, you know, for me, that’s when I started getting worried because, you know, mammals are a lot more like humans than chickens are. And so that, you know, increases concerns that perhaps this virus is getting increasingly better at infecting things that are more like humans than chickens are.  That backdrop had been happening. And then really I think concern ratcheted up even higher when in March we heard about an outbreak on dairy farms—dairy cattle farms in Texas. That was surprising. One, because we hadn’t previously seen H5N1 in cows before. But also, influenza A infections have not regularly been reported in cows. And so that, you know, was just unexpected from a scientific perspective. But from a public health perspective it was concerning because, again, yet another mammal that this virus was capable of infecting. But in this case, it’s a mammal that humans have very close contact with. And so that raises concerns that humans would be, you know, exposed to—you know, humans would be exposed to this virus because they are exposed to these mammals quite closely.  Those concerns were realized when then we saw, you know, a case of H5N1 in a dairy worker. And then subsequently we have now found a second case in a dairy worker. This is quite concerning. Fortunately, these two infections were relatively mild. The dairy workers didn’t require hospitalization. They experienced eye inflammation, conjunctivitis. They didn’t have a positive respiratory specimen, which, you know, I think is an important finding. But it does raise the possibility that this virus is starting to do things that we don’t want it to do. There have also been just anecdotal reports from vets who are working on the farms that other workers may have experienced symptoms too. So I think reason to believe that these two cases may not represent the totality of dairy workers who have been infected, and certainly don’t necessarily mean they will be the only two dairy workers infected. Since then, of course, there have been more news developments. You know, finding of viral genetic material in pasteurized milk. Not entirely surprising that we would find it, but certainly concerning given the number of positive samples found, which suggests that this virus may be on more farms than our surveillance is telling us. Also recently, last week, there was a report that they found the virus in muscle tissue from a specimen taken at a slaughterhouse. So, again, concerning that this—concerning evidence that this virus may have a much larger geographic footprint than just the amount of testing that’s happening on farms would suggest.  And that’s really, I think, where I just want to maybe call our attention to. You know, the biggest worry that I have right now is really in protecting farmworkers. We have ample evidence right now to know that this virus, while it is not yet a pandemic threat—it may not cause a pandemic, we don’t know for sure, we have reasons to be worried, we don’t know for sure. But what we do know is that farmworkers who are exposed to this virus in the course of their occupation can get infected. And we know historically that this virus has not produced—you know, has not typically been a mild virus. And so that really, I think, creates an urgent public health situation where we should be acting to protect these farmworkers.  Unfortunately, the level of testing that we’re doing right now is really not sufficient to allow us to protect farmworkers. You know, the testing that USDA is requiring is quite limited. They recently put into place a new policy that people are calling sort of the test to move policy. If lactating dairy cows are going to be moved across state lines, it is required that cows from that herd be tested. But the farmers can basically pick the number of cows that get tested. There’s a maximum number that’s established. So, as you can imagine, that’s not quite comprehensive enough to find all of the infected—all of the cattle that may be infected. Other than that, testing is largely voluntary. It’s limited to cows with symptoms. It does not include beef cattle. And so you can imagine that there are lots of holes in our abilities to figure out which farms have the virus and which don’t. Which makes it hard to protect the workers on those farms. The testing that’s happening is not happening on the farms themselves. It has to be sent to a lab. So the test results aren’t timely enough to protect workers. So there’s just a lot of ways where exposures can happen that we wouldn’t know about, which, again, makes it hard to make sure that the workers can get, you know, access to antivirals that could protect them if they’re—you know, protect them from severe illness if they are infected. It also makes it hard to stay ahead of this virus and to understand what might be next for it.  So that’s the area that I think I’m most worried about right now, is, again, making sure these farmworkers have the protection they need. In my view, enhanced testing is really critical to that. I also think we need, you know, to make sure there’s greater use of protective equipment, particularly eye protection. I think we should also be talking about using vaccines and expanding access to therapeutics. But I know Rick will have a lot to say about that, so I will let him address that.  But I just want to sort of end with this overall notion that this virus has had a lot of ups and downs in the twenty-plus years that we have been tracking it. I will say I am much more worried now than I have been in those past twenty years. And I don’t think we should be waiting for it to be obvious that this represents a broader public health threat for us to act. We should be trying to get ahead of this virus so that it doesn’t become the catastrophe that we fear that it could be. We have tools, but we need to make much more proactive use of those tools. And I know Rick will have a lot to say about that. But I’m grateful he’s here to enlighten us on that front.  FASKIANOS: Wonderful. Thank you so much, Jennifer.  And, Rick, over to you. BRIGHT: Well, great. Thank you for hosting this, Irina. And actually, I could never do a better job than Jennifer laying out that background. You know, I started my post—my graduate student work in 1997 with the spillover of H5N1 in Hong Kong from those birds into humans. And so for twenty-seven years, I’ll age myself, twenty-seven years I’ve been like Detective Colombo with an open—file open case tracking this virus. And we’ve seen it come. We’ve seen it kind of abate. And we’ve seen it come. We’ve seen a kind of abate. And I think at some points we fool ourselves into thinking if it’s abated this many times over history, then maybe we shouldn’t worry so much about it.  And so I tell people that, you know, we are more prepared for an influenza pandemic than for any other pathogen pandemic, probably, that we know of. And that is why I’m concerned, is because of that preparedness. The twenty-something years of investment in understanding the virus, understanding the vaccines, and how they work, their challenges, and antiviral drugs and diagnostics—therein gives me the concern, knowing those vulnerabilities. And that some might be easily misled into thinking we’re ready, that we have this under control. You know, and so because of what we know about this virus, we know it is a shapeshifter. We know it can rapidly change. We know it can jump to different hosts and different species rapidly, and change, and evolve. Part of that is the nature of influenza viruses. They are these negative-stranded RNA viruses, so when they replicate themselves it’s kind of sloppy and they introduce these mutations. And those mutations can help it be more lethal, or adapt, or spread to humans and other hosts.  Sometimes because the genetic makeup of the virus is fragmented, there’s all these segments inside that virus, you can have two viruses infect a person, or an animal, or a seasonal virus and the H5N1 virus. And they’ll recombine and reassort. And you’ll have this virus that comes out with some of the best or worst of all worlds. And so we know the tricks of this virus. And because of that, we’ve been somewhat placated that we kind of think is manageable in the bird population. When we see a jump from the wild birds—ducks, geese—that’s sort of this reservoir. We’re never going to annihilate it from wild ducks. But when we see it jump to birds in the past, domestic poultry, we basically wipe out the flock and decontaminate the area. And that seems to abate it somewhat.  Never in history have we seen this virus spread in such a sustained way to so many different mammalian species. And that is a concern I want to echo that Jennifer’s put forth. Also want to say that this is such a rapidly evolving situation that anything we see today or know today can change tomorrow. It can change very, very quickly because of the nature of the virus. And also, I think, because of the complacency that we might also see now, because we think we have it ready. So some of the things we’ve invested in, we’ve invested probably $10 billion at the federal level. I was the head of the influenza division at BARDA before I became the director of BARDA. And through the many—or, ten years I was there, $10 billion in designing vaccines, changing vaccines, trying to transition from a 1940s technology of egg-based vaccines, to cell-based, to recombinant-based vaccines that could probably be designed and manufactured faster than egg-based vaccines. We’ve invested in antiviral drugs and we’ve invested in diagnostics.  So I’m going to tell you that that’s good news, because we have a lot of experience and a lot of expertise. The bad news is 90 percent of our global capacity of making influenza vaccines are still in 1940s technology of eggs. For the United States supply alone, it would take 900,000 eggs going into a facility every single day for six months without fail just to make a supply of H5N1 vaccine for the United States. In parallel, we would have to make a new—a chemical component of that vaccine called an adjuvant. And the adjuvant would have to be added to that vaccine. And we only have two manufacturers of that adjuvant for the world.  Globally, we only have about the capability, capacity to make four billion doses of egg-based pandemic flu vaccine in a year’s time. And Bill Gates and the Gates Foundation, about 2017 I think it was—2016-2017—did a model a transmission model showing that if we were to have a virus such as the H5N1 influenza virus that transmitted efficiently between people and cause a severe illness and death, in a six month period of time we could see ten million deaths in the United—around the world—around the world. And so that tells you that we have to move swiftly. That tells you 90 percent of our capacity is based on a 1940s technology.  We did invest in a cell-based vaccine approach. We have one manufacturer in the United States, Seqirus, that can make a limited supply of cell-based influenza vaccines. And we have three other manufacturers globally, so four total around the world that can make a cell-based vaccine. So that would come in handy, primarily, if an H5N1, which is a bird flu virus, were to infect the chicken flocks that are required to lay those eggs that are needed for that vaccine. Imagine how vulnerable that supply chain is. Those are fertilized eggs, by the way. So those are embryonated. Those aren’t just eggs we can go to the grocery store and buy. And they’re very select.  So we have this candidate vaccine virus, that CDC mentions, the CVV, which is a starting material for an H5N1 that was made from a virus in 2020. And we could put that in our limited egg capacity. And what we learned from the 2009 H1N1 pandemic, that many of you were probably involved in, that we overestimated the productivity of that vaccine capacity. At the federal level, we were promising the country that we would have 120 million doses of vaccine six to nine months out, by October of 2009. And because the virus did not grow well, that candidate vaccine virus, CVV, didn’t grow well in eggs. At the end of October, we only had seventeen million doses for the United States, mostly for the world. And that came after two major waves of the virus in 2009. So it tells you we need a lot—to do a lot on the vaccine front.  On the antiviral front, we really have two classes of antiviral drugs. We had three in 2003 and 2004. The adamantane drugs, the M2 blockers, many of you might be familiar with. I actually published a paper in The Lancet showing that 100 percent of the viruses circulating, seasonal influenza, were resistant to that drug. We were using that drug for many years thinking it was working and saving our older population when it wasn’t, because no one did the testing. We weren’t doing the right surveillance and monitoring for drug resistance. So we’ve sort of learned our lesson. And we track the neuraminidase inhibitors—so Tamiflu, and Relenza, also Tamivir and Zanamivir.  And in 2008, we learned that every seasonal virus circulating was completely resistant to Tamiflu. We were lucky with the 2009 H1N1 pandemic strain, because it reintroduced a sensitive neuraminidase in that virus that circulated for the pandemic. Therefore, also Tamivir or Tamiflu was effective. But it was only three months into that pandemic we started seeing resistant viruses to also Tamivir or Tamiflu. So it shows you how vulnerable we are to that particular antiviral drug. So we invested in another one called Baloxavir or Zofluza. It works in a different mechanism and a different part of the influenza virus. In our stockpile, we have about 600,000 doses of that. And we have about 75 or 80 million doses of Tamiflu. But that Tamiflu drug was purchased in 2005, and 2006, and 2007, some of it. So it’s past its expiry date.  And I imagine that once we were in a full-blown response and we started shipping our limited supplies of Tamiflu from the stockpile to the states, we’ll see what we saw in 2022 in the influenza season, when we had spot shortages, and they started shipping out the oldest material from our stockpile. Many of the states didn’t accept it. It was hard to describe to people why they were getting a drug that said it expired in 2007 or in 2010. So we have a number of things to do in the antiviral drugs. In the testing space and diagnostics, we don’t have a test that will tell a clinician that a patient has H5N1. We have rapid antigen tests and some other lab tests that would tell you it’s influenza A or influenza B. But we don’t have one that says, this is H5N1. We need to have a test that we can really rapidly detect when a person is infected with this virus, because the antivirals that we have really only work if you use them in the first thirty-six to forty-eight hours of symptoms when you’re infected with this virus. And we also know from H5N1 viruses, traditionally it took about twelve to fifteen times the dose of Tamiflu to inhibit H5N1 viruses, compared to a seasonal H1N1 virus. So the limited supply we have would be cut by maybe fifteenfold.  So when you hear messages that we’re ready, we have this, I want you to really think about how ready are we. And therefore, it leads to the question, what can we be doing now to be better prepared? And that would be accelerated development of tests that can be in the hands of people and clinicians at point of care that could distinguish rapidly an H5 infection. It would be to accelerate the procurement of stockpiles at the federal level, and maybe the state level even. That’s a diversified stockpile that might be as part Tamiflu, might be part Zofluza, or Baloxavir. So we have at least options, if we saw resistance developing to the other. And, of course, we need to think about vaccination and how we can invest in technologies that would scale more rapidly so we can have more doses quickly that are independent of eggs. I talked about the recombinant-based vaccine that we built with protein sciences. That technology has been acquired by Sanofi Pasteur, and basically offshored and moved to—out of the U.S. So in the U.S. we don’t have that capability any longer.  We do have a stockpile, a surge capacity of eggs. We can surge to from 600,000 to 900,000 eggs a day pretty rapidly. But I’ve already described the vulnerabilities. So I think it goes back to, number one, what you’re thinking is, how do I tell people now—or, how do I reduce the chances of getting infected with this virus, while we figure out some of this other stuff that may not be directly in your hands? And, as Jennifer noted, I mean, the greatest risk are to those who are in close contact to the virus. That means those who are in close contact to infected animals. That might be an infected dairy cow. Might be infected cats, or birds, or raccoons, or skunks, or alpacas now. So if you see a sick animal, just stay away from it. Call animal control and let them handle the sick animal or dead animal. Avoiding contact with that is going to help reduce your risk.  Of course, we know that the milk coming from infected cows has very high titers of H5N1 virus in it, if it’s not pasteurized. So raw milk has super high virus titers, some of the highest titers of virus I’ve seen in any substrate. When we have this quantitative PCR analysis and you get a three, that means there’s a lot of virus in that milk. So discouraging raw milk consumption and raw meat, or undercooked meat, from potentially infected animals is primarily important. Keeping a distance from infected animals, staying off and the dairy farms, et cetera. If you have people in your states and areas that work on dairy farms, the CDC has put out some really important guidance on how to protect themselves working on those farms.  I know it looks uncomfortable. I can’t imagine working on a dairy farm and having to really gown up. The instructions that came out today look almost as if they’re protecting themselves from an Ebola outbreak, other than the hood. But they’re—the head-to-toe clothing and protection, head covers, the right type of respirators, eye covers, gloves—this is really important if they are working in environments that have infected animals, because you don’t want them to be the test cased that this virus infects and then have further opportunity for adaptation in the human population. But those are primarily simple things to do, sometimes complex to implement.  But right now, the general population, if they can stay away from infected animals and products, they’re pretty safe. But I do think it’s a ticking clock. I do think we’re about to hit midnight. I’ve never seen this virus take hold in mammals, so far—so broadly distributed in such a sustained way. And we are not doing the testing. We have not done serology studies. And maybe you can do that at the state level to start getting a baseline of human immunology, who is exposed, what level exposure there is among the general population, high risk individuals. Imagine if a lot of the infected dairy cows are going to slaughter, which they are, and if there is infected meat product going to your fast-food restaurants where a lot of this dairy cow meat goes. It goes into pink slime and it goes into fast food burgers, a lot of it.  And, of course, the FDA says if you cook that meat to 140 and 160 degrees it removes the virus. However, if you handle that meat in the process of it being cooked, you’re at high risk. So it’s really important to think about the entire chain of transmission, potential exposure, and protecting all people on the farm all the way through the market to the slaughterhouse and processing plants. So, I’ll stop there. Again, to remind you, this is an evolving situation. What we know today will change tomorrow. More crops—more animals are exposed. So pay attention. FASKIANOS: Thank you very much for that. And now we’re going to go to all of your questions and comments. Please use this forum to share best practices as well as what you’re doing in your own communities. (Gives queuing instructions.) And so with that, I’m going to go first to Renee Yarbough-Williams, who is the chief of staff and the office of Maryland Delaware (sic; Delegate) Cheryl Pasteur. Basically: Can the virus live in pasteurized milk? And how do—how will we know which farms are infected? Is there any tracking system that’s happening now? Or is it really as it gets reported out? BRIGHT: I think either of us can do that—Jen, do you want to do that first, and then I’ll take the next? Or either way? But, yes, why don’t we do that? NUZZO: So they have found genetic material of the virus in pasteurized milk. They have so far, from the tests done to see if you can grow the virus from milk, have not been able to. I’m reassured by that. I haven’t worried about drinking milk. My kids drink it a lot of times. I am not currently worried about that. I am worried for people who, as Rick said, are exposed to raw milk prior to pasteurization, because of the level of the exposure and because the process of pasteurization has not been able to render that virus incapable of infecting us. So that’s my concern. Regarding tracking, as I said, we’re not doing a lot of testing. So I wouldn’t assume that because you see it in some—know that it’s in some places, it doesn’t mean that it’s not in other places. BRIGHT: Yeah. And I’ll add to because—and this is where we can learn more from the states, and local levels, and others directly dealing with this. And I will agree that the limited experiments that have been done to show that heat can inactivate H5N1 in milk in a simulated pasteurization process does seem to be effective, if the amount of virus going into that process is low to moderate. And so my concern is the way we consolidate milk from various farms and take it to a pasteurization facility, it involves picking up milk—maybe one truck or a few trucks—picking up milk from various farms. If the ratio of milk from infected farms going into one tanker truck is low—so if you’re picking up milk from ten farms and two of those farms have infected cattle and eight are unaffected you’ve diluted that virus out quite a bit. And I think that pasteurization can handle it.  But as we continue to see this outbreak spread broaden and spread out across the country and farms, the ratio of infected milk will go up in that tanker, in that—in that batch going through pasteurization. So we don’t yet have data on the effectiveness of pasteurization as that viral titer gets higher going through that process. So that’s why it’s important to pay attention. And if there is anything noted that changes, and the pasteurization is not completely effective, that’s what we need to be completely aware of and be able to respond quickly. FASKIANOS: Thank you. I’m going to take the next question from Sean Murphy. Has a written question, but let me just see—oh, also a raised hand. If you can say who you are, that would be great. And unmute yourself, please.  Q: Hi, there. Can you hear me?  FASKIANOS: We can. Q: My name is Sean Murphy. I’m the mayor pro tem for a small town in Colorado.  My question is, what would you advocate on the local level for getting prepared for a pandemic like this? Thank you.  BRIGHT: I think that was— NUZZO: So—go ahead. BRIGHT: On the—on the basic level we know how this virus spreads. So I think it’s going to be—it sounds simple, but I know it’s going to be a very difficult conversation coming through COVID, what we know is hand hygiene can rid the virus—if you come in contact with it, you touch it, washing your hands actually can prevent you from getting infected and transferring that to your eyes, your nose, or your mouth. We also know that respirators—N95 respirators—are quite effective at managing the spread of influenza. So it could already be at the basic level in the community just awareness of hygiene, once again. No one needs to start wearing a mask right now, or being extra overly conscious for H5N1. But now’s a good time to reinforce just general hand hygiene and the concept that if this were to spread, we might have to wear respirators to protect ourselves again. NUZZO: And I would maybe just add, I think in the short term the thing that I’m most worried about is protecting these farmworkers. I’m quite concerned that there are a number of reasons why infections in this population may not be—might not be found as much as we would like to be able to find them. One, just to understand what’s going on with this virus but, two, really to protect these farmworkers. And so I think really outreach to providers who, particularly in farming communities, that these farmworkers may rely on, just what the symptoms are. You know, these—so far, the two known cases, publicly known cases, have had eye infections. And that might not be what clinicians think to try to test. It’s unfortunately a little cumbersome to test that right now, but nonetheless it would be important to think H5N1 if there were a farmworker with an eye infection.  So just in the short term, just doing outreach for the purposes of protecting farm workers. In the longer term, agree with the list that Rick gave. I will just also queue that this virus—we don’t yet know what a pandemic strain of H5N1 would look like, and if it will be the same as what we’ve seen so far. Again, the data that we have on H5N1 is quite limited. But the data that we have are enough to be concerning. We do typically know that influenza may be different than the SARS-CoV-2 virus that causes COVID-19. And one key difference could be that influenza viruses often are hard on kids. And there was a lot of debate about schools and whether kids should be in schools. I will tell you, I was on the side of keep the schools open.  It’s harder to argue in the context of a virus that is disproportionately affecting kids, a virus, influenza, we know is often seeded to the community from kids. And so that, I think, creates another scenario. So if I were a local leader, one of the things I would be doing is if there were a pandemic, what actions would we as a community be willing to take to stop the spread of this? What are the red lines for us as a community? What would make us shift our feelings on those red lines? Think about if we did need to start vaccinating again, how would we do it? Could we build on the infrastructure that we just used for COVID? Does that infrastructure still exist?  So I would be kind of going through those scenarios, again, hoping we never, ever need to act on them. But that if we did, that we would, you know, be able to hit the ground running, instead of trying to figure it out de novo. FASKIANOS: Thank you very much. The next question from Steven O’Connor, who’s an attorney: Is there an mRNA H5N1 vaccine in the pipeline? BRIGHT: That’s a great question. And a good answer is there are multiple H5N1 mRNA vaccine candidates in development. And Moderna has started a clinical trial. And also, BioNTech and Pfizer are also in clinical studies with H5N1 mRNA-based vaccines. Also, caveat to say that we’ve had—they’ve had many years of work in developing an mRNA-based vaccine for influenza. And there have been some technical challenges to address in that process. So we’re still learning. So even though they have a candidate in the clinic for H5N1, we still may need to optimize that in some ways. But the good news is that they are moving forward. They’re doing this at risk. And we should have some clinical data read out in a matter of months, I would say. FASKIANOS: Great. I’m going to go next, an oral question from Patrick Jordan, if you can accept the unmute prompt and tell us who you are. There we go. I see you’re unmuted. Nothing. OK, waiting. I’m going to go next to—there are a couple of questions in the chat about unpasteurized products. So one question about pasteurized eggs are not readily available. And then there’s another question from Deirdre Goins about, does this warrant a state pulling unpasteurized dairy products from shelves? Because this—you know, the outbreak. And how can states begin testing farms? What policies would you recommend, you know, putting into place at the subnational level? NUZZO: So in terms of unpasteurized products, first of all, there’s long been reasons to avoid unpasteurized products. Eggs, obviously, can be cooked. So that’s—you know, but eating raw eggs has long not been recommended. So I personally, you know, fall in the position that this has long been public health guidance and it should continue to be. I worry about the sort of rise in sort of, you know, fashion, I guess, of raw milk as a product that some people perceive to be beneficial. I quite worry about raw milk, not just the consumption but also, as Rick said, touching it and other exposure. So, yes, unpasteurized products represent a risk.  I will say, though, in terms of testing, I think one of the things—there is a notable difference in terms of our approach to handling H5N1 chicken farms versus cattle farms. Sorry, if you call them cattle farms. And the difference is that this virus has typically killed the chickens. And so the response to H5N1 in chicken farms has been much more aggressive, in part, because of the risk to the industry. So while I worry a lot that this virus is circulating on cattle farms and we are unaware because, you know, the cows are not being killed and because we know that asymptomatic cows can be infected. We don’t fully understand their abilities to transmit it, but we have to assume that that’s possible, in chicken farms it’s different.  Another key difference also is that there are financial incentives for identification and reporting of infections in poultry farms that don’t exist yet for cattle farms. And so I worry—my worry is focused right now on the cattle farms, because I think that the incentives are really, really important. We obviously have to balance multiple priorities here. The objective isn’t to put our farmers out of business. The objective is to be able to produce these products safely in a way that won’t harm the general public, but also won’t harm the workers who are involved in their production. And I think the incentives are key to that.  This is why I’m so interested in making sure we have available tools that can protect workers on these farms, such as personal protective equipment, but ultimately vaccines because it is—well, as Rick said, it’s hard to wear these personal protective equipment in the context of these farms. And, you know, we want to make sure if we have a tool that can protect humans, we should be using it on these high-risk individuals.  FASKIANOS: Rick? BRIGHT: No, I mean, that’s exactly right. I mean, and the does bring up a question, maybe some things to think about at state-level policies. There could be discussions and considerations to making the vaccines that we have in the stockpile available to vaccinate high-risk individuals, those working on farms—dairy farms, or in the slaughterhouses, or milk processing. And so even though the vaccines that we have in the stockpile may not be exact match of what could circulate if this were to become an efficient human-to-human transmitting virus, we’ve done a number of clinical trials through the years with our stockpile and what we call prime-boost studies or mix and match studies. And there’s a number of published data that show if we were to give the first dose of vaccine now, with what we have in the stockpile, it would prime the immunity of those of the highest risk.  And we know that takes two doses of an H5N1 vaccine to make a sufficient level of immunity in a person, because this is a virus we’ve never seen before in people. But the data show that we published in our prime-boost studies, that if we do the first dose with what we have now on the stockpile when that virus takes off, and we have the match to vaccine, we can give that second dose and it will actually make that immune response really robust to match what was circulating even before that virus took off, and then the circulating strain that became a pandemic. So there’s a lot of data to support discussions and considerations for perhaps immunizing at least a first priming dose in individuals at a high risk. FASKIANOS: Great. And just to say that that question from Deirdre Goins, works in the office of Representative Andrew Gray in Alaska.  So Patrick Jordan, who was unable to unmute or we were having technical difficulties, wrote something I want to just read out loud: Getting back to the mayor pro tem from Colorado, here in Ionia County in Michigan, we’re at ground zero for avian flu. Our health department is working closely with the state. We’ve tested twelve to fifteen dairy farm workers with zero positive. But the critical thing here, with the migrant farmworkers, is building relationships with the organizations that serve migrant families, that migrant families trust and are used to working with. So I just wanted to read that because I think that is a good contribution to the discussion. BRIGHT: Irina, can I say— FASKIANOS: Yeah, please go ahead. BRIGHT: I’d say that we should make a poster with that statement on it, because that is crucial. I mean, and we’re learning that much of the workforce across the U.S. at highest risk are likely to be migrant workers. And there are so many issues with getting health care and tracking or monitoring for infection or sickness, or treatment and recovery in this population. And the relationships that are built now around trust and trying to help and make things available are critically important, because in the context of an outbreak and something really devastating it’s that much harder to build trust and work on those communication lines. NUZZO: And just to add that that’s likely to be a durable benefit. Meaning that it’s not just an avian flu benefit to doing that. I mean, this was critical for the H1N1 pandemic in 2009, which didn’t involve avian—an avian influenza virus, but nonetheless this was a vulnerable group. And there was some stigma because the virus was thought to, you know, have started in Mexico. So there was—there was really to do that. There was a mumps outbreak on mushroom farms. So, anyway, this is something that I think public health would benefit from, just regardless, because I think the overarching lesson from all of these events is that, you know, outbreaks, epidemics, pandemics, they expose our vulnerabilities. And that remains a highly vulnerable population and worthy of having strong relationships and, as Rick said, a high degree of trust. BRIGHT: And, Irina, as you get the next question, I’m going to add one more, because that was such a good comment. It was loaded. I loved it. You should have the next panel—he can be on the next panel. But he also mentioned the fact that they’re testing some exposed individuals, monitoring. One of the biggest gaps that we have right now in this outbreak, in the animals as it adapts to humans potentially, we don’t have access to those data. So we have no data in serology, or the virus, and the things that are happening in people or the animals. And we understand that there are jurisdictional challenges. There are database challenges. So many issues, even in the United States, between the federal level and the state level, the state and local, local and the farm, and et cetera.  And it’s so important at the non-federal level—wherever you fall in the local, state, wherever it might be—sharing data in real-time, as real-time as possible, is the only way we’re going to understand what’s happening and be able to sharpen our tools that we have and be able to get in front of this virus. If the data aren’t shared for whatever reason, made publicly available for whatever reason, then we will be caught flatfooted. We won’t know that this is taking off and spreading and killing a lot of people until so many people are infected and dying that we can’t stop it any longer. The key is held right now in the sampling that Patrick just described. FASKIANOS: Thank you. Next question from Jonathan Olvera in Lacy Lakeview, Texas: What season do you believe will be the highest risk for transmission? Or what season should we be aiming for our preparation? NUZZO: I don’t know that we know this answer. I mean, there’s a couple of ways of looking at it. Typically, respiratory flu viruses, we see a higher activity in the months that we go inside where there’s not a lot of humidity. So that’s the kind of late fall, early winter, early spring. Why we’re seeing these infections now, don’t know. Maybe tied to bird migration. But we’re still learning about this virus. And I would say that’s one of the concerns that I have—and I’m just going to—I’ve been looking at the questions in the box and there’s a lot of questions about where. And I would say we can’t answer where because the type of testing that we’re doing is—we’re only finding cases where we are shining a light. And we are not shining a light in enough places to know for sure.  We should be shining a light so we can answer these questions. So we don’t fully know why it is now. I worry, though, that we are looking at the numbers and looking at where the cases are and drawing the conclusions on not only incredibly limited data, but possibly highly biased data. So one of the concerns I have is if you look at the USDA map of which farms—which states have infected farms, that map has remained unchanged for weeks, despite the fact that they keep finding more and more farms in the states that have already identified outbreaks. So this virus is moving around. We’re finding it in wastewater. It may be from wild birds. We don’t know. But the number of states reporting outbreaks hasn’t changed.  So that that makes me highly suspicious that what we’re seeing is an artifact of our surveillance and not an indication of the viral activity. So I worry that some people think that this is on the nadir because we just haven’t found more and more states, and that this is just on the way out. I would love that to be true. But I cannot tell you that, based on the data that I’m seeing. So that’s my overarching, like, take home for everyone today, is don’t assume evidence of absence is evidence—you know, that the absence of evidence is evidence of absence. We really don’t know where this is. We need to be much more proactive in our testing to get ahead of it.  One way—you know, people have asked me, well, if we’ve only had two human cases in dairy workers, and those cases have been mild, does that mean this virus may be much more mild than we think? If we did serology studies that told us that, like, 90 percent of the population had already had this virus, that would change my opinion about it. But we haven’t done that and we don’t know. I would like to see us do much more testing to better answer these questions. I think the fact that in the 1997 outbreak when they tested healthcare workers, they did serologic studies, they looked for evidence of prior infection, they found that these workers likely were infected and that many of them didn’t have symptoms. That was that virus, not this one. But that’s interesting and important to know. But we haven’t done the kinds of studies that would allow us to better answer some of these questions. And that’s to our peril. BRIGHT: Yeah. I’ll just add too H1N1 started in April, went through May, June, the summer is when we had the waves. 1918 H1N1 pandemic also burned through the summers. So it started in the spring and burned through the summer. So it’s unusual that we don’t see—when we see these pandemic flu virus outbreaks really take off in the spring and go through the summer. This is unusual, non-seasonal influenza virus. I worry that we might—if it abates in this summer, that we might think it’s under control or under management. And it will cloak itself within the seasonal winter respiratory viruses because we don’t have test monitoring for H5. We’ll just think is influenza A and we’ll miss it. And it will adapt during that time, and then when the spring hits next year, it’s really six weeks—six months after that when we could see this resurgence. So we could be blessed with a window of time to prepare, but I would not relax if I did see—if I saw the reporting drop in cases lower or the next month. I would intensify preparation for the spring. FASKIANOS: So there’s a question from Mayor James Fahey of Corrales Village in New Mexico: Do you know if anything is being done on swine surveillance, as it is my understanding that they both have the Alpha 26 23 receptors? BRIGHT: There is some surveillance in swine. I mean, again, when we think about the ratio of testing for human influenza viruses versus swine surveillance or, you know, cattle surveillance, or other animals, it’s very limited. But, I mean, the infections that we see in pigs historically aren’t that harmful to the pig. So the pigs can be coinfected with a seasonal influenza virus, human strain, and a H5N1 avian strain. It really is in the combination of those two viruses in that mixing vessel that we see things that can emerge. And we see actually an unusual triple reassort, we call it, strain that emerges most years lately around the state fair time. And so we constantly see this unusual reassort – (inaudible) – come out of pigs around state fairs. And it’s affected several states for many years.  And so I would say, because of that we have some decent surveillance in the swine population. It could be bolstered, probably should be, in context of what we’re seeing now. The thing we don’t have a lot of is reporting and sharing of those data. So even if farmers, and veterinarians, and others are testing in swine, there is not a lot of information about viruses that have been found in swine. They’re not sharing the sequences, necessarily, or posting them in the database, like, GISAID database where most influenza sequences are collected and analyzed. And so if there is additional testing being done in various animal populations, I can’t emphasize enough the importance of submitting and sharing that data into a database that will allow us to monitor for mutations, evolution, or recombination events in any of those animal populations to be better prepared for a human outbreak. FASKIANOS: Wonderful. And there was a question asked about is the stream readily detectable by wastewater surveillance. Jennifer just answered it in the answer thing. I’m just going to read it for the— NUZZO: I’m trying to get to these questions. I see a lot, so I’m just typing them if I can. FASKIANOS: Yeah, no, that’s great. CDC is doing a wastewater testing for influenza A. H5N1 is not—is one, but not the only. And it will soon do testing for H5 specifically. And she put in the chat the link to the CDC.gov. So you should take a look there.  We don’t have much time left. We’ve got, like, three minutes. So I wanted to just ask—this is probably a good question—how would an H5N1 outbreak compare to COVID-19, given low uptake of the most recent COVID-19 vaccine? What can be done about vaccine hesitancy in the public? And that comes from Steven O’Connor, who asked a question earlier. So if you could answer that and leave us with any final thoughts, that would be great. And I’m sorry we couldn’t get to all the questions here. NUZZO: So one key way is that, you know, I would say a blessing of COVID-19 is that it largely spared kids. It didn’t fully spare kids, but compared to influenza viruses it did. We don’t know what an H5N1 pandemic will look like. But the fact that young children, as well as older adults, could be affected—possibly young, healthy adults. You know, we just—there’s a larger age range, I think, to worry about. So that is—that is one key way. I am worried about our willingness to do what it takes to respond to a flu pandemic now, following a COVID-19 pandemic, given sort of where we are politically and where we are just from a pandemic fatigue standpoint.  I will say that it is important to note that we do regularly use influenza vaccines. But a pandemic H5N1 vaccine would not be like a regular seasonal flu vaccine, likely because, as Rick mentioned, it would use an adjuvant, which is an additive that’s meant to provoke a higher immune response. That’s not something we use that frequently in our vaccines. And I think it’s something that warrants specific conversations with the public about what adjuvants are and why we would use them and what it would mean that they might have more of a reaction than they would otherwise get, and why that potentially is beneficial. So I think there’s a lot of work that we have to do on the front end to talk to people about these vaccines, to hear their concerns about it. Anyway, I’m just—I’ll stop there so Rick can say—get some words. BRIGHT: Well, I think that’s important. I think the conversation should start now. And they just start in the high-risk communities. I think they should start—the lessons for from COVID-19 vaccination is there’s a lot of distrust. There was a lack of information and details from the federal level to the state and to the locals. And we should now use the time we have to have those conversations, build those trusted messengers and relationships—on the farms, in the communities, in the barbershops. I mean, I’ve worked with a lot of groups that taught us a lot of lessons. Now’s the time to have those conversations. And you can have them with seasonal influenza. And you can talk about the differences in how bad different influenza viruses can be and the importance of vaccination.  Jennifer has mentioned something that’s really critical in avian influenza viruses or pandemic influenza. It hits the very young and the very old hardest sometimes, and sometimes they’ll hit those with the most robust immune response. Sometimes your body’s immune response does more harm to you than the virus itself. So it’s really important to think about educating everyone for vaccination to make sure that they are protected when that time comes. And I’ll leave you the thought of we are better prepared for influenza than any other pathogen, and therein lies the rub. We can’t be complacent. We can’t think this is going to pass. We must do everything now in this window of opportunity to educate, communicate, and prepare. FASKIANOS: Wonderful. That was a great note to end on. So thank you both, Dr. Jennifer Nuzzo and Dr. Rick Bright for sharing your expertise with us today. And thanks to all of you for joining us for your questions and comments. We will send a link to the webinar recording and a transcript. Until then you can follow Jennifer Nuzzo on X at @JenniferNuzzo, and Rick Bright at @RickABright. And, as always, we encourage you to go to ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on international trends and how they’re affecting the United States—and, of course, CFR.org. And please do send us your suggestions for future webinars by emailing [email protected]. So thank you all again for being with us. And thank you to you, Jennifer and Rick, for your time. We really appreciate your expertise. BRIGHT: Thank you. Been a pleasure. (END)