even worry about a pandemic threat?

What is it that we're concerned about?

When I say "we," I'm at the Council on Foreign Relations.

We're concerned in the national security community,

and of course in the biology community and the public health community.

While globalization has increased travel,

it's made it necessary that everybody be everywhere,

all the time, all over the world.

And that means that your microbial hitchhikers are moving with you.

So a plague outbreak in Surat, India

becomes not an obscure event, but a globalized event --

a globalized concern that has changed the risk equation.

Katrina showed us

that we cannot completely depend on government

to have readiness in hand, to be capable of handling things.

Indeed, an outbreak would be multiple Katrinas at once.

Our big concern at the moment is a virus called H5N1 flu --

some of you call it bird flu --

which first emerged in southern China, in the mid-1990s,

but we didn't know about it until 1997.

At the end of last Christmas only 13 countries had seen H5N1.

But we're now up to 55 countries in the world,

have had this virus emerge,

in either birds, or people or both.

In the bird outbreaks we now can see

that pretty much the whole world has seen this virus

except the Americas.

And I'll get into why we've so far been spared in a moment.

In domestic birds, especially chickens,

it's 100 percent lethal.

It's one of the most lethal things we've seen

in circulation in the world

in any recent centuries.

And we've dealt with it by killing off lots and lots and lots of chickens,

and unfortunately often not reimbursing the peasant farmers

with the result that there's cover-up.

It's also carried on migration patterns

of wild migratory aquatic birds.

There has been this centralized event

in a place called Lake Chenghai, China.

Two years ago the migrating birds

had a multiple event

where thousands died because of a mutation occurring

in the virus,

which made the species range broaden dramatically.

So that birds going to Siberia, to Europe, and to Africa

carried the virus, which had not previously been possible.

We're now seeing outbreaks in human populations --

so far, fortunately, small events,

tiny outbreaks, occasional clusters.

The virus has mutated dramatically in the last two years

to form two distinct families, if you will,

of the H5N1 viral tree

with branches in them,

and with different attributes that are worrying.

So what's concerning us? Well, first of all,

at no time in history have we succeeded in making

in a timely fashion, a specific vaccine

for more than 260 million people.

It's not going to do us very much good in a global pandemic.

You've heard about the vaccine we're stockpiling.

But nobody believes it will actually be particularly effective

if we have a real outbreak.

So one thought is:

after 9/11, when the airports closed,

our flu season was delayed by two weeks.

So the thought is, hey, maybe what we should do is just

immediately -- we hear there is H5N1 spreading from human to human,

the virus has mutated to be a human-to-human transmitter --

let's shut down the airports.

However, huge supercomputer analyses,

done of the likely effectiveness of this,

show that it won't buy us much time at all.

And of course it will be hugely disruptive in preparation plans.

For example, all masks are made in China.

How do you get them mobilized around the world

if you've shut all the airports down?

How do you get the vaccines moved around the world

and the drugs moved, and whatever may or not be available that would work.

So it turns out that shutting down the airports is counterproductive.

We're worried because this virus, unlike any other flu

we've ever studied, can be transmitted by eating raw meat

of the infected animals.

We've seen transmission to wild cats and domestic cats,

and now also domestic pet dogs.

And in experimental feedings to rodents and ferrets,

we found that the animals exhibit symptoms never seen with flu:

seizures, central nervous system disorders, partial paralysis.

This is not your normal garden-variety flu.

It mimics what we now understand

about reconstructing the 1918 flu virus,

the last great pandemic,

in that it also jumped directly from birds to people.

We had evolution over time,

and this unbelievable mortality rate in human beings:

55 percent of people who have become infected

with H5N1 have, in fact, succumbed.

And we don't have a huge number of people

who got infected and never developed disease.

In experimental feeding in monkeys

you can see that it actually downregulates

a specific immune system modulator.

The result is that what kills you

is not the virus directly, but your own immune system overreacting, saying,

"Whatever this is so foreign I'm going berserk."

The result: most of the deaths

have been in people under 30 years of age,

robustly healthy young adults.

We have seen human-to-human transmission

in at least three clusters --

fortunately involving very intimate contact,

still not putting the world at large at any kind of risk.

Alright, so I've got you nervous.

Now you probably assume, well the governments are going to do something.

And we have spent a lot of money.

Most of the spending in the Bush administration

has actually been more related to the anthrax results

and bio-terrorism threat.

But a lot of money has been thrown out at the local level and at the federal level

to look at infectious diseases.

End result: only 15 states

have been certified to be able to do mass distribution

of vaccine and drugs in a pandemic.

Half the states would run out of hospital beds

in the first week, maybe two weeks.

And 40 states already have an acute nursing shortage.

Add on pandemic threat, you're in big trouble.

So what have people been doing with this money?

Exercises, drills, all over the world.

Let's pretend there's a pandemic.

Let's everybody run around and play your role.

Main result is that there is tremendous confusion.

Most of these people don't actually know what their job will be.

And the bottom line, major thing that has come through

in every single drill: nobody knows who's in charge.

Nobody knows the chain of command.

If it were Los Angeles, is it the mayor, the governor,

the President of the United States, the head of Homeland Security?

In fact, the federal government says it's a guy called

the Principle Federal Officer,

who happens to be with TSA.

The government says

the federal responsibility will basically be

about trying to keep the virus out, which we all know is impossible,

and then to mitigate the impact

primarily on our economy.

The rest is up to your local community.

Everything is about your town, where you live.

Well how good a city council you have,

how good a mayor you have -- that's who's going to be in charge.

Most local facilities would all be competing

to try and get their hands on their piece

of the federal stockpile of a drug called Tamiflu,

which may or may not be helpful -- I'll get into that --

of available vaccines, and any other treatments,

and masks, and anything that's been stockpiled.

And you'll have massive competition.

Now we did purchase a vaccine, you've probably all heard about it,

made by Sanofi-Aventis.

Unfortunately it's made against the current form of H5N1.

We know the virus will mutate. It will be a different virus.

The vaccine will probably be useless.

So here's where the decisions come in.

You're the mayor of your local town.

Let's see, should we order that all pets be kept indoors?

Germany did that when H5N1 appeared in Germany last year,

in order to minimize the spread

between households by household cats, dogs and so on.

What do we do when we don't have any containment rooms

with reverse air that will allow the healthcare workers

to take care of patients?

These are in Hong Kong; we have nothing like that here.

What about quarantine?

During the SARS epidemic in Beijing quarantine did seem to help.

We have no uniform policies

regarding quarantine across the United States.

And some states have differential policies, county by county.

But what about the no-brainer things? Should we close all the schools?

Well then what about all the workers? They won't go to work

if their kids aren't in school.

Encouraging telecommuting? What works?

Well the British government did a model of telecommuting.

Six weeks they had all people in the banking industry

pretend a pandemic was underway.

What they found was, the core functions --

you know you still sort of had banks,

but you couldn't get people to put money in the ATM machines.

Nobody was processing the credit cards.

Your insurance payments didn't go through.

And basically the economy would be in a disaster state of affairs.

And that's just office workers, bankers.

We don't know how important hand washing is for flu --

shocking. One assumes it's a good idea to wash your hands a lot.

But actually in scientific community there is great debate

about what percentage of flu transmission between people

is from sneezing and coughing

and what percentage is on your hands.

The Institute of Medicine tried to look at the masking question.

Can we figure out a way, since we know we won't have enough masks

because we don't make them in America anymore,

they're all made in China --

do we need N95? A state-of-the-art, top-of-the-line,

must-be-fitted-to-your-face mask?

Or can we get away with some different kinds of masks?

In the SARS epidemic, we learned in Hong Kong

that most of transmission was because

people were removing their masks improperly.

And their hand got contaminated with the outside of the mask,

and then they rubbed their nose. Bingo! They got SARS.

It wasn't flying microbes.

If you go online right now, you'll get so much phony-baloney information.

You'll end up buying -- this is called an N95 mask. Ridiculous.

We don't actually have a standard

for what should be the protective gear for the first responders,

the people who will actually be there on the front lines.

And Tamiflu. You've probably heard of this drug,

made by Hoffmann-La Roche, patented drug.

There is some indication

that it may buy you some time in the midst of an outbreak.

Should you take Tamiflu for a long period of time,

well, one of the side effects is suicidal ideations.

A public health survey analyzed the effect

that large-scale Tamiflu use would have,

actually shows it counteractive

to public health measures, making matters worse.

And here is the other interesting thing:

when a human being ingests Tamiflu, only 20 percent

is metabolized appropriately

to be an active compound in the human being.

The rest turns into a stable compound,

which survives filtration into the water systems,

thereby exposing the very aquatic birds that would carry flu

and providing them a chance

to breed resistant strains.

And we now have seen Tamiflu-resistant strains

in both Vietnam in person-to-person transmission,

and in Egypt in person-to-person transmission.

So I personally think that our life expectancy