11 October 2006

How Should Asia Prepare for the Next Great Pandemic?

Andrew S. Erickson, “How Should Asia Prepare for the Next Great Pandemic?,” participated in panel discussion, Asia Society, New York, NY, 10 October 2006.

On October 10, 2006, the Asia Society and Pfizer, Inc. co-sponsored a panel discussion at the Asia Society headquarters in New York City: “How Should Asia Prepare for the Next Great Pandemic.” The speakers at the discussion include members of the private and public sector, offering their expert opinion with regard to preparedness in the event of a pandemic. The topic is particularly relevant with the prevalence of the deadly H5N1 subtype of Avian Influenza, spanning the regions of Europe, Africa, the Middle East, and Asia. Although the discussion focuses on Asia’s role in the next pandemic, the panel recognizes the global implications of a regionalized public health threat.

Panelists included Donald G. Ainslie, a Principal at Deloitte & Touche, Andrew Erickson, a research fellow at the Naval War College and Dr. David Nabarro,  Senior UN System Coordinator for Avian and Human Influenza at the United Nations Headquarters. The discussion was moderated by Elisabeth Rosenthal, reporter for the International Herald Tribune.

Avian Flu in Asia

An Agriculture Ministry worker sprays disinfectant at cages at a bird farm in Jakarta, Indonesia, Monday, Sept. 26, 2005. (quiplash/flickr)

The government sector is another stakeholder: In a recent Council on Foreign Relations meeting titled “The Global Health Challenge,” global health expert Laurie Garrett commends the work of the United States Navy for their response to the 2004 tsunami. Garrett states that the U.S. Navy was the most successful emergency responder, providing the ground with physicians, doctors, and logistics/supply personal. The U.S. Pacific Command supervises more than 300,000 troops in the pacific region, and if properly trained, these forces can play an effective role in both the preparedness and response to a pandemic.

The economic costs of the SARS outbreak should indicate the urgency for a comprehensive preparedness plan. A great deal of money has been allocated for preparedness with regard to other national security threats such as terrorist attacks and natural disasters. However, the lack of preparedness in the event of a pandemic is ominous judging from its reported inevitability. If more money is spent on preparedness plans and response strategies, it could shield stakeholders from expected economic costs and possible human losses. This inaugural program in the Global Health Series at the Asia Society underscores the relevancy of cooperation to secure preparedness policies, advance global surveillance, and formulate effective response strategies.

Richard Holbrooke: Good afternoon and welcome to Asia Society. My name is Richard Holbrooke, and I am chairman of the board of Asia Society. I am just delighted to see so many people here, and particularly those of you that don’t often come to Asia Society because our health programs area very important and a new emerging part of what we do—started under our former president Nick Platt, who is here today and continued with our current president Vishakha Desai. For those of you who haven’t been here before, the Asia Society is now 50 years old. We are celebrating our 50th anniversary. Because it is a complicated, hybrid organization people aren’t always sure what we do because our museum is so world famous that sometimes people are not aware of our other programs: policy, business, and education. In fact we have two fantastic shows on the second and third floors right now that I hope you will see. Both received very glowing reviews from the art critics in the New York Times and so on: one modern Asian American art and the other an extraordinary show of never before seen treasures from an ancient Chinese civilization, which is little know in the west. But we also do education and policy programs. The policy programs range from Asian Leaders to American Political Leaders. We have a series of all the national political figures: Governor Vilsack and Senator Edwards will both be year within the next month. Senator Brown Back and Governor Warner have been here and almost all the other national figures you’ve heard mentioned for higher office have accepted to speak sometime next year. We have emergency programs on major issues. When the tsunami hit and the Pakistani earthquake hit, we assembled in this room to discuss it. We had live interactive TV with tsunami victims, school children, and Sri Lanka talking to New York City school children. We’ve had major policy discussions and we invite you to participate. One of the things that we initiated a few years ago was a health program focused on HIV/AIDS with a grant from the Gates Foundation. Betsy Williams who is standing at the door there came over from Columbia School of Public Health to run it. She has now been running it for several years with great success. Building on that success, we have decided to expand it into health in general. Obviously AIDS is a forerunner of modern kinds of diseases, which are unprecedented and create enormous dangers for everyone. That is what we are here to discuss today. How should Asia prepare for the next great pandemic? We will talk about Avian Flu, but also malaria fever and tuberculosis, and I will let other people talk about this in detail. I also wear another hat as President and CEO of the Global Business Coalition against HIV/AIDS. That is an organization of over 220 corporate members all over the world who have committed that their companies will fight AIDS—some by very active involvement through their work and others through public activacy. Several companies in this room today are members. The one I want to single out is Pfizer because Pfizer links both the global business coalition and Asia Society. Barbara Duboino—who is here today, will be on the panel, and used to be commissioner for public health for the state of New York—will address more in a moment about Pfizer. Barbara, I want to thank you and through you Jeff Kindler and the whole Pfizer Corporation for your support and leadership in this area. So, without any further ado, I want to ask the panel to come up here. As they come up, I will then turn it over to the moderator. The moderator is Elisabeth Rosenthal, who is well known to all of you who are Asia Society extended family because she won the first Osborne Elliot prize for outstanding journalism in Asia when she was Beijing Bureau Chief of the New York Times. We are very proud of Elisabeth, and she now works at New York Times International Herald Tribune. I didn’t know there was much difference, but it turns out that something about the expense accounts. Elisabeth, if you want to come up and then bring the other three members of the panel up here and introduce them, that would be great.

Barbara A. DeBuono, MD, MPH (Pfizer): I am just going to say a couple of words from Pfizer, and Libby has graciously agreed to just wait a couple of seconds while I say hello from Pfizer. Libby is going to give me that good will because we knew each other years ago when I was working in New York as the commissioner, and she reporter on the health beat for the New York Times. I remember when she was up here in 1996 or 1997. It is great to see you. We are delighted to sponsor this event. I have been privileged to be at Pfizer for 6 years running public health and policy. My colleagues who work every day in and with the Asia markets, asked me to come here today and say a few words. It is really their leadership that has lead to the sponsorship of this event because they are so committed to a successful enterprise in the region. I have to tell you that we—as a company, as a multi-national global company—are incredibly committed to addressing this issue of pandemic planning. It has really been an experience for me personally as well as my colleagues in not only learning what all the complex issues are that we need to address, but we have actually learned about resources and assets within the company that we never knew were there. So I have gotten to meet people in IT, people in business continuity, and people in Human Resources, all of whom are going to need to be mobilized. We are planning to mobilize when this happens. I say when this happens because despite the words of my sixteen year old over the weekend when he saw that I was coming here and said, ‘Mom, enough already with this pandemic thing. Is it happening or not?’ I think you will here more from our panelists about whether or not we can actually anticipate a month or year, two years or six months. This kind of thing goes in waves and cycles in terms of the attention that the U.S. media plays to this. Right now it is a little bit quiet, but it will cycle back up again, probably as soon as the domestic flu season starts to take hold. I just want to say a word about why this is so important to Pfizer. It is really the health of our colleagues throughout the world that is so important to us. The health and the well-being of our colleagues is certainly what we care most about. We would not be company, we would not be developing and discovering new products, new therapies, without the people that work in our organization. It is because of their health and their safety and their well-being that we feel it is important to have a pandemic planning team, a business continuity team, a global security team, IT, and human resources and public health all working together to address this potential medical crisis along with so many other catastrophes. It might not necessarily be infectious disease crises, but maybe chemical, maybe terrorist, maybe environmental. So with that I just want to thank the Asia Society for hosting this. I think this is terrific. It is going to be a terrific panel. Again, Pfizer is delighted to be here and has the privilege to sponsor this.

Richard Holbrooke: Before Elisabeth comes up here, I should add two things. I mentioned the Asia Society earlier. For those of you that are not members, there should be a membership form somewhere on your chair or outside, and I hope you will consider joining. We are open to everybody. It is not expensive to join. If you want to give us more money, we will accept it. And we would love to see you on all the issues, not just health. But I welcome you all here, and I will ask Elisabeth to come up and start the discussion.

Elisabeth Rosenthal: Will all the panelists come up, and we will do this all together. I want to thank Ambassador Holbrooke and former commissioner Deboino for making this possible and the Asia Society. It is a topic that is near and dear to my heart. I was on vacation in 1997 in Hong Kong when the first bird flu outbreak occurred there. I was suddenly pulled away from my mother and told to go to chicken markets and watch a million chickens being killed. So I feel like I was there at the start and have been there ever since. Let me first introduce our panel, and we are really lucky to have all the different perspectives represented here. In the end, Dr. David Nabarro, who is the UN System Coordinator for Avian and Human Influenza who really represents the kind of global health perspective on this. It is his job to convince the world that this is a problem and to keep it in perspective. There is next to him, Donald Ainslie, who is a principle at Deloitte & Touche, who specializes in security issues, and he kind of represents the other end of the spectrum: what individual companies do to prepare for a pandemic whether Avian Influenza or otherwise. His company is fairly unusual and has done a lot of thinking and consulting on this issue. Finally, Andrew Erickson, from the Naval War College, who represents the intergovernmental perspective on Avian Influenza and what it means as an issue of international politics and global security. Is that fair enough? I have to say, I feel privileged to be the moderator here and to be a journalist because in this position I get to ask questions about what is a very very difficult issue without having to come up with answers. I would not want to have to find the answer to this one. Because I think it is very difficult to know what to do for pandemic preparedness, how to handle it, how to strike the right balance between alarmism and rational planning, how to get people energized, and how to prepare. I guess we all share questions. My first question and kind of basic question: How can you prepare for something like this? What do we mean by preparedness? What are our goals? I am king of the guinea pig in this situation. I was in Hong Kong in 1997. I lived in Beijing during the whole SARS epidemic. More recently, I covered Avian Influenza. I was in Turkey, and was there for the first outbreak. I guess I am going to be kind of provocative on this and tell you a couple of brief anecdotes to show how difficult I think this is and why we really need to think in advance and be very realistic. The first thing I want to remember is going to Turkey last January to do a story on a family of four children who were the first human victims of Avian Influenza out of South East Asia. I went to the village, and it was a snowy day, and it was a holiday in Turkey. We spun off the road before we got to the village and got rescued by these four men from another village who brought us into the village. We said, ‘Have you had any issues with Avian Influenza here?’ They said, ‘not really, but all the birds in this village died last month.’ This is a rural Kurdish village, and we said, ‘Well, what did you do?’ He said, ‘We ate them.’ This is a big village with tens of thousands of birds. I said, ‘Have you hear of Avian Influenza?’ They said, ‘Sure, we have heard of Avian Influenza, but this is dinner.’ Avian Influenza to us is a theoretical problem, and dinner is a real problem. That was first issue: How do you deal with that kind of preparedness? How do you prepare for that? The second issue was that this was an unreported epidemic. How do you get people in that setting to report? Second part of the story is coming back to my base, which was in Paris as the time. I came down with a really nasty viral infection. Now I had been in the home of this family with the four kids who had died. It had been disinfected, and I was thinking, how should Avian Influenza guidelines apply to me? Here I am: I have a runny nose, a cough, a little bit of a fever. Should I go into quarantine? And my reaction, ‘it actually started—I think—before I went to his house.’ Anyway, I want to get back and see my kids. I don’t think this is bird flu. But you have to realize that I am one traveler. I have a medical background. I can maybe make a more rational choice, but people don’t make rational choices. So how do you prepare for that? The last thing that I wanted to say, we talk about preparing companies and government. Living in China during the SARS outbreak, schools were closed down. Business was closed down. We talk as a solution. Most companies when you say ‘what are you going to do about bird flu?’ they say ‘telecommuting.’ Then I think, would that have worked with SARS in Beijing. People did that to some extent; you want to telecommute, that is fine, but your kid’s school is closed down. So your kids are at home. The supermarkets tend not to be getting that much in goods. I was lucky; I had a car. I could drive around to find what I needed, but a lot of people couldn’t. Every step of the way was difficult. They said wear a mask if you are in public. Do you think you could find a mask to bye in Beijing? No. That was not there. So basically, in a very short time, even though some companies had done what they thought of as a little planning, most of the ex-pats got on planes and left, leaving most companies severely understaffed. So again, how do we prepare for that? So let’s start. Why don’t we start with each of the panelists saying a little bit about their particular take on this subject. I guess Dr. Nabarro, the obvious question. How do you get people to be conscious of this and worry about it without being alarmed? How do you get them to take it seriously without thinking you are saying ‘the sky is falling, the sky is falling’ because the sky may not fall anytime soon.

David Nabbaro: Well thank you, and first of all, I would just like to say how pleased I am to be here and to be working with this group on such an important issue. You have all come, so you are all—at some level at least—aware that pandemics are a reality of modern life. You are also I suspect aware that without preparing as Elisabeth said, all sorts of problem arise. Heads of States of most of the world’s countries have committed themselves to acting to both try to prevent the next pandemic and also to respond to it. It is not difficult at the moment to engage them in this issue because they are aware of the catastrophic economic and social and governance consequences that could come as a result. They just need to look at SARS: less than a thousand people died in what is generally thought to be a public health success. But the economic cost was at least 50 billion dollars for the kind of reasons that Elisabeth has described. Further analysis of the economic and social costs of HIV and other pandemics, which are still with us obviously, show that unless we do anticipate well in advance what might happen we are not going to be able to limit the consequences, and there are a very clear set of techniques that can be used that I and my team at the United Nations are responsible for working with governments on. Whether or not people in the wider world are yet convinced is of course another matter, and what I am hoping is that instead of creating messages that cause real high level of fear and possible paralysis. Instead, what we are working towards—and I believe it is happening in this country—is an indication that government, private sector, and others are aware that there will be an influenza pandemic sooner or later and are taking preparatory action. Therefore, perhaps there is not a need for people to say this is something about which I need to be frightened because nobody else is taking it seriously. Instead hopefully they are saying this is something I need to be concerned but I am pleased to see that my government and institutions like the Red Cross are taking it seriously and therefore, I don’t need to panic about it.

Elisabeth Rosenthal: I think maybe we will just go through the three panelists first and come back to each one.

Donald G. Ainslie: Yes, I think a lot of discussion has been taken place. We’ve been working on this since December 2004. There has been a lot of discussion about what is avian influenza, what is bird flu, and my god, there is 50 million people could die and there are all those reports that 300 million people could die. Part of the problem that we have is that there is too much discussion going on trying to quantify the likelihood of this event occurring. And I think we need to get passed that discussion and start the planning because the reality is that there is a high risk. If the high risk is 1 percent or 3 percent, I consider that high because the impact that would have to the global economy would obviously be significant. You talk about international trade; that would essentially shut down. There would be shortages of food medicines. The whole health care system that we have in these countries in the U.S. and others would be swamped and overwhelmed. So I think it is important considering the magnitude and the impact that could have on us from a personal standpoint and from a business standpoint is to get passed those discussions and start the planning. What I try to tell folks, we are made up of multiple partnerships and about eighty different partnerships in one partnership. We are in about 150 countries, and so it is a monumental task here. But it is important that we start to really look at planning and how we can get a really fundamental base. We have a lot of organizations that put together large plans that are 150 or 200 pages. We need to make it really simple—some blocking and tackling. Let’s face and address the basics: What do you do with stranded employees? We have fifteen to twenty-five thousand people that travel any given day on a plane, remotely, or on site with a client. So if there is going to be a boarder closure, how are we going to get those people out or how are we going to support them? And we know that there are cases in the Ukraine and cases in Romania where they actually quarantined a city there just based on incidences in birds, where they actually brought in constantina wire and soldiers not allowing individuals to go in and out. They realize they overreacted there, but that is just the case of it being in birds. We also know that in June of this last year there was a cluster in Indonesia where there was numerous mutations, person to person, about eight or nine people there. That was actually identified by a Bloomberg reporter not by the World Health Organization. But the interesting thing is that this is happening in June. I happen to have a meeting in Singapore taking place with 400 of my partners there. And I am thinking to myself, the World Health Organization, I have gotten word, is considering raising it to three to four. If they go to four, we know certain governments have already stipulated that they would shut boarders down immediately, and this is before pandemic. We know there are certain companies that have stated that they will start to evacuate their ex-pats. There I am with 400 or so partners in Singapore. Fortunately, I had a contingency plan in place, where I had some aircraft available, just in case I needed to get them out because what would happen is that the airline would be overloaded. The point here is that I can go through a number of other instances, is that we need to make it very basic and very simple and not a big book. We need to educate our people. We have put together an e-learning module that really kind of educates our individuals, partners, and practitioners, and what they need to do from a personal standpoint because at the end of the day, it is going to come down to that individual taking care of his or her family, whether they are going to come to the office or not. You also need to have HR policies in place that are modified that allow that individual to make that decision so that they can feel comfortable in not coming to the office so that they are not going to get laid off. So you also have strategies in place. You have strategies in place that allow from a technology standpoint that people can still serve clients, bill clients, and do that all from the home. One of the things we are concerned about is the fact that everybody talks about working remotely everywhere. Now what is the capacity of the internet? Nobody knows that. What is the ability of the ISPs when we have 30 to 50 percent of the workforce not going to show up because that is what we are being told out of fear to taking care of their family members, that ISP can’t get you to the backbone or can’t get you to the internet. There are some things that you can plan. There are assumptions that you got to make: If the internet is not there, you have bigger problems.

Elisabeth Rosenthal: How about the international perspective and global security issue.

Andrew Erickson: Absolutely, first of all I would like to thank the Asia Society for this opportunity. It is a wonderful chance and a very important issue that really affects us all. Before saying anything further, I better state the usual disclaimer that what I am going to say is solely my personal opinion and does not represent the policy or analyses of the U.S. Naval War College, the U.S. Navy, or any other branch of the U.S. Government. That being said, I would like to discuss a few things that give me optimism. This is being taken very seriously at all levels of the U.S. Government and other governments. Measures have already been taken that are moving us ahead here. As many of you know in the U.S., the Department of Homeland Security has overall responsibility for issues involving a possible pandemic of Avian Influenza. The department of Health and Human Services handles domestic efforts and medical issues. The State Department handles public diplomacy and would be involved extensively in international issues. The department of Agriculture handles animal-related issues. Now that said, the U.S. Pacific Command, I think, also has an important role to play here, partially because of its scope of operations. It has under the hospices of the U.S. Pacific Command; there are roughly 300,000 troops in the Asia-Pacific region. Five out of seven of the U.S. mutual defense treaties are in that region. 35 percent of U.S. trade or over 550 billion dollars goes through that region. So clearly the possibility of an outbreak of Avian Influenza or related issues is being taken very seriously in the U.S. pacific command. I would like to call your attention to a landmark speech that our chief of naval operations, Admiral Michael Mullen, made at the U.S. Naval War College on September 21, 2005. It certainly got my attention at the time. The quote I would most like to share with you is when the Admiral said, ‘In today’s interconnected world, acting in the global interest is likely to mean acting in one’s national interest as well. Exercising sovereignty and contributing global security are no longer mutually exclusive events.’ I think this is a key concept for us to understand in the 21st century, and that is why I was so happy to also hear this sentiment echoed by PRC [People’s Republic of China] Vice Foreign Minister, when he said that our destinies are interconnected. In the fight against Avian Influenza, no country can stay safe by looking the other way. I know that time is short in this panel, so I won’t go into all the initiatives, but I think if you look at what the U.S. Pacific Command has done to prepare, the signs are extremely encouraging. In October 2005, U.S. Pacific Commander sponsored a public health emergency, officer influenza seminar. Pacific Command continues to discuss and shares plenty of ideas with foreign governments and military leaders in ASEAN, Chiefs of Defense, or COD, meetings, and also operations planning meetings concerning non-combatant evacuations. I can go into a little more detail on some of these, but these are some of things that make me think people are getting this. And yes there is the possibility to plan; there is the possibility to prepare. We need to build on this but we have already started, and I think it is encouraging. We can’t afford to do less.

Elisabeth: Thank you. I think I would like to ask all the panelists a question. We are all here in New York—a center of the developed world. We hear about governments, companies, on millions if not billions to buy drugs to prepare their citizens for the event of a possible pandemic. Are we doing enough for the poorer parts of South East Asia, which are having particularly serious problems with the bird flu now? When I trained in medicine, we always said that prevention is better than treatment as the most effective treatment. Compared to the money that goes into preparedness in the developed world, very little is going into try and address this disease in animals in places like Indonesia where it has become a significant and very out of control problem.

Donald G. Ainslie: I think all I would like to say here is that part of the issue that I see is that a lot of the developing countries’ companies located there, the bottom line has been drawn and everything. Everything is now is outsourced and offshore. The reality is that I think the bigger risk is for the developing countries because what is going to happen, they are going to shut the boarders, close the boarders. You have prescription drugs; in the U.S. for example, more than 50 percent come from outside the U.S. You talk about the adjust time economy. Back in the 60’s, a jolly green giant had a can of corn that from the time it was harvested from the time that it was on the shelves was twelve months. Today it is within weeks. Within the U.S. for example during Katrina there are concerns about bodies floating in the water. They thought they were going to have a large body count. So the FEMA director asked all the truckers with refrigerated trucks to come down there and load the bodies. What they found there though is that the fact that they were there, the produce was not being delivered to the grocery stores. My point here is I think that is an issue. I think we are going to find that we are going to have a bigger problem than those developing countries because the boarders are going to be shut down. Everything that we have off shored and outsourced is there. I don’t think we are doing enough to invest in getting ourselves ready and certainly I don’t believe we are doing enough to educate and get other parts of the world ready.

David Nabarro: There are different elements of work in which countries have to be engaged right now: The first thing is that they have got to be doing what they can to deal with the current episodic of highly pathogenic avian influenza. The reason why this is a big worry is that this is the most unpleasant avian influenza virus that has ever been known. It kills birds within hours, and if it gets into a chicken farm, it will kill three quarters of the birds within a day. Now this Avian Influenza virus is not only very profound in South East Asia, but it has also moved in to west Asia, Eastern Europe, Africa, and Western Europe. The movement was very dramatic in the early part of 2006. This virus is already mutating at quite a speed and it can cause disease in humans thus far. Only a few over 240 humans have been infected that we know. More than half have died. Each time a human gets infected, the selective pressure for further mutation to the point where the virus could be transmitted in a sustained way from human to human increases. So the first job is to stamp out the Avian Influenza virus at source. Indonesia has moved very rapidly in the last two or three weeks to take forward its operations, and I was there just ten days ago. I am very impressed with the new moves that have taken place in that country. Avian Influenza is in more than 260 out of the 440 districts in Indonesia, more than thirty out of the thirty-three provinces. In order to get on top of it, it needs significant amount of cash: probably between 100 and 150 million dollars per a year. Extra investment is needed to help the Indonesians deal with this. There are other countries in the region that also continue to need significant amounts of money. We have had a reasonable amount of external assistance pledged for this. The U.S. is one of the leading countries in providing that assistance. But this is not a problem that is going to go away tomorrow. It is going to take years to deal with Avian Influenza, years to transform poultry production systems so that they are safe. And we are going to need to have significant investment at the country level in countries that are affected by the problem over the next ten years. I think I need all of your help to try and make the case that in order to prevent the likely emergence of the next Influenza pandemic coming from this particular very unpleasant bird flu virus, we need to maintain international investment. It is much greater than it is at the moment. Please don’t imagine that simply by closing borders here that we are going to be able to keep America safe. Safe America depends on a safe world.

Elisabeth Rosenthal: Can I ask a question? There was a big pledging conference in Beijing earlier this year to try and address some of this problem. How much of that money actually came through in the end.

David Nabarro: We got a pledge of 1.9 billion dollars, which was 1 billion dollars of grant money and .9 billion of loan money. That money has virtually all been committed, which means it legally has to be spent. The disbursement rate is pretty good for what normally happens in these kinds of things. The reality is that we are going to need to see considerably more international investment in this in order to get the right level of response to avian influenza and pandemic preparedness. At the World Bank IMF meetings in Singapore just last month, the World Bank estimate for the potential cost of the next influenza pandemic is between 1 and 2 trillion dollars. So to be investing say 2 or 3 billion dollars even a year in preparedness is not unreasonable. When you consider the scale of the threat of an influenza pandemic, compared with the threat of some other sources of risk that we are engaged in, the amounts of money we are talking about here are relatively small, even when talked about naked they sound like an awful lot.

Andrew Erickson: Elisabeth, you have raised an excellent question here. Obviously there is a tremendous moral concern here: how safe is the world in its entirety, not just regions that happen to be more fortunate in terms of what resources they have available. But it is really also a practical question. When you are talking about infectious diseases, as we know, they know no borders. If one region is at risk, the weak link, if you will, where people are suffering the most with this sort of threat inevitably, it will pour over into other more fortunate areas. That is why, among other things, I was particularly encouraged to hear in the U.S. Chief of Naval Operations Admiral Michael Mullen’s speech—a huge emphasis on humanitarian operations. I think there is a growing understanding of the globalized nature of security in the 21st century in terms of concrete issues. My understanding is that the U.S. is in the process of establishing a pacific regional coordination center for rapid communications coordination and information sharing among forty three pacific nations to facilitate mutual efforts that could be positive. The U.S. is also heavily involved in the military medical labs syndromic surveillance network which monitors over 30 sites in Southeast Asia. So trying to create a full picture of where the greatest risks of people may be and working accordingly. I would also say that I am very happy that the U.S. is committing these resources. But I should also say that the U.S. needs to be humble and learn from people who have had to deal with these infectious diseases such as avian influenza directly. Some other nations policies and systems have been tested much more than that of the U.S., which has fortunately not fully been tested at this point. I think the U.S. is in the process of talking with its partners and learning better so that we can all fight this collective threat more effectively.

Elisabeth Rosenthal:
 Thank you. I wanted to ask Donald Ainslie about the issue of personal protection versus the global fight, which often is not synchronous. Protecting your employees and your company and making sure that your company can continue to function may or may not. You want medication or vaccine for your employees first and then it is a second issue how the government gets it for its programs. How do you deal with the conflicts that will inevitably arise for scarce resources and what do you tell companies?

Donald G. Ainslie: First of all I think this is something that we cannot do in a vacuum. What I tell our member firms and what I tell clients when I talk to them, the planning needs to start in house, but the planning also needs to bridge the gap between our clients our customers, and our local communities because we are in this together. There is a good example in Katrina, where a local brewery instead of brewing beer decided to brew water by bottled water to the Katrina victims. My point here is if we can pull together good plans so people understand what they need to do, that they should have a two month supply of food and water. We should have the ability that we can do remote access and all that other. But we have a social responsibility, and that social responsibility starts with our local communities and work with the local governments.

Elisabeth Rosenthal: What do you tell people when you talk about a simple plan, that plans need to be simple beyond telecommuting? You want to give us five basics about what a simple plan involves.

Donald G. Ainslie:
 First of all, it all starts with your HR policies that make sure that they are flexible enough to allow the people and the organization to feel that they don’t have to come to the office and that the work is structured in such a way that they can work remotely. Communication is critical. You need to have a concise communication plan so that you can communicate with your employees, your partners, your customers, your clients. Education awareness—as I have mentioned, we have rolled out a e-learning module. It is important that you get the word out there. What it is? What is Avian Influenza? What can the individual do personally? I had a phone call a few months back from an operation in India, and the folks were concerned about eating chicken. So I think the concern that I would have is the fact that these rumors will start to fly, and you need to power your people. The other thing is from a regulatory standpoint. What would the regulatory market look like in a pandemic? Would the government require companies to start the monitoring report in individuals that have a virus or individuals that have been recovered, or individuals that have vital skills that can provide good services in the recovery effort? So that is just a sampling of what I feel is important. The most important thing is that you communicate with your people.

Elisabeth Rosenthal: Do you have a sense of what fraction—I am not asking for 18 percent versus 54 percent—what portion of companies have thought about this?

Donald G. Ainslie: Unfortunately I am not overly optimistic, and the reason being is that I think the folks I have been working with in trying to advise is a lot of folks are looking at the government. The government is going to take care of them. As I have described with the adjust in time economy, that is not going to be there. The government is not going to build or provide you help in this pandemic. It is important that the companies prepare. To answer your question, I think it is a very small percentage.

Elisabeth Rosenthal: We talk a lot about surveillance. Obviously we saw with SARS, one person with the virus gets sick, gets on a plane, goes to Hong Kong, gets in an elevator with some people, and in this time of global travel, your virus is spread to I think half a dozen different countries in that case. And that was with a virus that was not particularly contagious. To Dr. Nabarro, how do you get surveillance and detection refined? Let’s not even talk about getting someone flying from Guangzhou to Hong Kong. But in rural Indonesia, how do you get surveillance to the point where a guy with a runny nose and a cough thinks ‘Could I have bird flu?’

David Nabarro: So in rural Thailand in early 2005, when they were starting to have human cases, the Thai’s entire authorities made use of the million village health volunteers that exist in their country who were trained very rapidly to identify individuals with flu like symptoms and to make sure that they were followed up and that necessary specimens were taken. An interesting case, they did turn out to be human cases of avian influenza. They were detected and then managed. When you engage communities in that kind of surveillance—we have seen it also in Vietnam and China to perhaps a lesser extent Indonesia—when you engage the community in a participatory way you will get certain people identified as sick who have not actually turned out to have got any kind of unpleasant bug. So there is a degree of false positivity, but it is the only way to do is to have communities engaged. For example, from the bird flu reporting in Indonesia, the technique that people use is their cell phones, and they send text messages to central points which then lead to action which is then undertaken fairly rapidly in order to bring the issue under control. So there will be much more use of modern reporting techniques like cell phones. China for example has invested hugely in building a more efficient and streamlined reporting system from provinces to headquarters to try and make sure that information comes through. It is then reported to the World Health Organization in the case of human sickness or the World Organization for Animal Health in the case of bird illness. I think Asia is better prepared to do this kind of thing than just about anywhere else. They’ve had the experience of SARS; they have been living with Avian Influenza for a number of years and with human cases. There are other parts of the world that are much less well prepared. So the world Health Organization and the other organizations with whom I work are investing massively in making sure that the international regulations on disease reporting whether for animals or for humans are being properly implemented. Are we doing it well enough? Well, we never do things as well as we would like to, but I think we have the architecture there. We have the frameworks there. What remains is the political will to ensure that this kind of reporting is done properly and is done transparently. I think that there are people in the audience who may have views whether or not we have actually reached the point where we can be confident that we will all know when untoward incidences occur. Personally I think we have some way to go.

Elisabeth Rosenthal:
 Are you getting enough cooperation at the very local level. It is very easy for a government to say we have a good surveillance system, we have fifty-five surveillance points throughout the country, but as we have seen again and again, in Turkey I say and certainly in China we see re-introductions over the boarder into Vietnam. There is clearly bird flu going on out there that UN agencies—whether it is FAO or WHO—are not hearing about very quickly.

David Nabarro: I think it is very difficult. One of the real challenges in some of the cases that you have identified is that people who are poor and are depending on chickens, ducks, turkeys, quail for their livelihoods, when they find them getting sick, are not going to start rushing to the nearest government employee and saying, ‘my chickens are sick’ because they know that not only will they lose their birds, but the whole village and near by village will lose their birds as well. They feel very anxious that they are going to be stigmatized for being the snitch that went and told the story. So they usually rather keep these things quiet. The result is that we don’t get full reporting. Unless we can get really effective compensation programs in place so that when farmers report the fact they have sick birds, they will get immediate compensation. Unless we can make sure that if humans are sick, that the villages are treated not only with respect but also treated as heroes if they have reported what they have got going on to the authorities. Unless we move to that kind of positive incentive for communication reporting, people will go on hiding things. We just heard a bit about clustering in northern Sumatra in April or May this year, and the truth is that the villages were really very scared of telling authorities that they were sick because they were worried that then bad things would happen to the village. So the business of creating trust between authorities and village people who are experiencing these kind of diseases have still got some way to go. I think that is probably the area where I am most preoccupied at the moment is building that relationship so that we won’t get disease incidents hidden.

Elisabeth Rosenthal: One more question for Andrew Ericson. Why should the U.S. be concerned with Avian Influenza? Here we are, there has been no animal cases in the U.S., there is clearly no human cases. Why is it in the U.S.’s interests to worry about this far away disease in Asia and what can we do?

Andrew Erickson: Well first of all I would say it is not a far away disease. I am myself not an expert on infectious diseases, but every time I talk to my friends and contacts who are, I am continually reminded just what a risk this is in this era of unprecedented global connectivity, especially of people over airlines. We really do face the same threat nearly at the same time. My understanding is that over the past three centuries we’ve had roughly ten global pandemics. If—god forbid—we have number eleven, it would occur in this climate. This brings up some personal memories on my part. I know you were in Beijing during SARS. I was hoping to be studying Chinese in Beijing. Instead I had to stick on the Princeton University campus for the whole summer. But I think it gave a false sense of security about where things are located. I later became more educated about this when my sister was teaching in Thailand and there were some concerns about the H5N1 strain increasing in its incidents. So I got on the phone with my father, and we looked up on the internet, how do we send her Tamiflu. I did all these things, and then I realized that I had been to the airport in providence Rhode Island earlier that day. So what I was seeing as this artificial construct of some risk being far far away was completely inaccurate. The speed with which this can and will travel is extremely disturbing. That alone should be the reason why the U.S. is trying to prepare and help others prepare as well as possible. I think it is absolutely a no brainer.

Elisabeth Rosenthal: Can I ask you one quick question? I realize you are talking for yourself and not the Naval War College or the U.S. government. Will the U.S. Government be as willing to invest in paying for chickens in Indonesia as it is for purchasing Tamiflu or vaccines for Americans here on Park Avenue?

Andrew Erickson: Well, I am not involved in the formulation of the policies so I really can’t speak.

Elisabeth Rosenthal: Is it a harder sell?

Andrew Erickson: I think we still have a mission to educate Americans, American voters, and people around the world about this threat. But when I see funding already coming forth and policies already being laid down and exercises being engaged in and centers being set up, I see enough proactively here to convince me that positive things are happening. We can’t let up; we have to only double the pace. I think things are looking good in that respect.

Elisabeth Rosenthal: Dr. Nabarro, did you have something to say?

David Nabarro: I do think that the role played by the U.S. government in Indonesia and particularly in relation to trying to help the Indonesian authorities, particularly at the local government level, to get on top of bird flu is pretty remarkable. There have been strong involvements of USAID, a much loved organization I understand in the U.S. administration. Also, Tuffs University working with them and the U.S. Ambassador to Indonesia, Lynn Pasco, have been very focused on working with Indonesian camp parts in a thing call Comnass, which is the national influenza commission. It is something which every American citizen ought to be amazingly proud because it is being consistent, good, and it looks like being long term. I actually wish that every other international donor could have shown that kind of leadership. It is a really good model.

Elisabeth Rosenthal: Does anyone in the audience have questions they would like to ask? Please identify yourself before you speak.

Question: My name is Ralim Cambel with the National Bureau of Asian Research, the Pacific Health Summit. I wanted to ask real quickly, someone alluded to the internet surge capacity, and I wanted to ask about unintended consequences of putting preparedness plans into place such as over use of the internet and different actions that are taken that might have consequences that might result in other problems.

Donald G Ainslie:
 I think that when we are doing the planning, there are certain assumptions that we have to make. For example, the internet is something that we are relying on but we have to make the assumption that the internet might not be there because you can’t segment the internet. You can’t say that you want this much capacity and this person has that much capacity. There is no one out there directing traffic. I think from a business standpoint, you need processes in place. I don’t know what they are, so that you can work without the internet. It is not the end all answer.

Question: I want to ask the panelist, to what extent do you seriously believe that the pandemic poses a real immediate threat to us because while it is true that I agree the pandemic is going to happen sooner or later, it seems that this itself is not scientifically informed because how it is going to be different from saying that we are all going to die sometime in the future. Secondly, while I agree that those impacts of the pandemic will be negative in terms of economies, society, and governance, so far all these predictions and estimates seem to be based on the 1918 Spanish Flu, which seems that it is rather exceptional in terms that it is one of the most lethal threats. It seems harder to make this exceptional case a standard scenario.

David Nabarro: I would like to start with a reminder to everybody that the estimates done by CDC [Center for Disease Control] colleague Lonny King suggest that 70 percent of the new infections that are going to effect human kind will come from the animal kingdom. HIV, the current pandemic we are living with, came from the animal kingdom. SARS, which we were worried about when it appeared, possibly being a pandemic disease, came from the animal kingdom. Yellow fever, Marburg, Ebola, all came from the animal kingdom. What we are actually primarily talking about is defending the human race against pathogens that come from animals. We have put a lot of effort, time, cash, and thinking into protecting ourselves against risks associated with violence—bombings, shootings, kidnappings, and the like. We have put a lot of time and energy into protecting ourselves against natural disasters like hurricanes and such. We put virtually no time or energy into protecting ourselves against diseases, particularly those that come from the animal kingdom, that can effect the human race, i.e. the pandemics. I would like to come back to Andrew Wang and say what we are simply talking about here is a part of human security that is going to be missing in international discourse and national planning for a very long time. We are simply trying to readdress the balance. Our particular focus is on Influenza because we have this H5N1 virus roaming around the world at the moment. If it does become sustained human to human transmissible virus—it is already mutating away—but if the mutation leads to sustained transmission, if that that virus maintains its current pathogenicity, we will have a very unpleasant situation. We will also be asking ourselves, why on earth didn’t we do more to get ready?

Donald G. Ainslie: If I could just interject, you are the expert from a medical standpoint, but my understanding is that they were able to exhume a body that had the 1918 strain, and the analysis in layman’s terms is that this strain is a kissing cousin of that strain. I think that being the father of six children and being responsibility for 130 thousand people in my organization from a security standpoint the fact that we are even discussing the percentage of the risk and the impact of this pandemic, we wouldn’t be doing ourselves service by not planning. I think the other thing that gets lost is that by planning for a pandemic it will allow you to be in a better position for terrorism attack, natural disasters, or whatever they will be. We need to get past trying to quantify what is the likelihood of a risk and agree that there is a risk. The realization that if it does hit, it is not going to be like anything we have seen before.

Andrew Erickson: I am a political scientist as opposed to a real scientist, so I will try to explain my beliefs of a threat from a political perspective. If this were not indeed a threat that we would have to be concerned about, I don’t think we would see the international efforts in this regard. I don’t think we see the efforts that I have mentioned from the U.S. side. There are also considerable efforts from such nations as the People’s Republic of China [PRC]. For example, in October 2005, PRC Health Minister Gao Qiang and the Department of Health and Human Services in the U.S. signed a very positive cooperative agreement on November 19, 2005. The two countries signed a joint initiative on Avian Influenza. At the ministerial pledging conference that David has referred to—he will have more up-to-date statistics than I will—but my understanding is that the U.S. pledged 334 million dollars. The PRC pledged at least 10 million dollars and that was on top of 247 million dollars that China had already allocated in its domestic budget. These are significant amounts of resources already being put on this. In April 2006, China hosted the APEC symposium on emerging infectious diseases. I think this is recognition of a significant threat. I also want to briefly say that just as I said that the U.S. military is taking this very seriously, I understand that the Chinese military, the People’s Liberation Army (PLA), is also taking this seriously. The PLA had considerable experience during the SARS epidemic. In 2004 the PLA published a practical pamphlet on techniques for dealing with Avian Influenza and is drawing on its large network of hospitals and research facilities and even cutting edge research reported at various PLA and civilian institutions. Again, I am not a scientist, but I hope that those who are in this room are closely looking into what China is doing. It appears to be cutting-edge. I think it is very positive that the U.S. Pacific Command Commander Admiral William Fallon has invited the PLA to discuss Avian Influenza. Indeed, in March of this year, Pacific Command sent a medical team to meet with leaders in the PLA to discuss pandemic influenza planning efforts. I think this has been positive, but I think it is also testimony to recognition of a very serious threat that we have to face together.

Donald G. Ainslie: I think the other reason that it is very critical that we conduct and initiate our planning activity as soon as possible is that this doom and gloom picture we are painting here is eighteen to twenty-four months. This is going to end at some point and hopefully sooner rather than later whenever it starts. But remember, the people within your organization will remember how you treated them during that episode, that pandemic. Your clients, your costumers are going to remember how you operated and conducted yourself. So it is important that you operate with dignity and there is plan in place so that you are not running down the hall with your hair on fire. That is why it is important that I think you put together a good plan.

Question: My name is Pam Kim Petra and I am with Dahlberg Global Development Advisors. My only question is it seems that everybody might be working in silos. Is there a global coordinating body? It seems that everybody at the table is representing different silos. What happened in Canada with SARS, everybody seemed to piss everyone off. There needs to be global agreements beyond bilateral that also involve private sector because now multinational companies can extract their employees and contribute to the spread of disease. It seems that there needs to be someone who works across the agencies.

Elisabeth Rosenthal: Do you all talk to each other when you make your plans?

David Nabarro:
 In today’s world, by in large, it is not possible to require people to behave in a particular way in a kind of controlling style. For example, I don’t think you would ever get companies or governments signing a pledge as to how they would behave when we move from the current phase three of pandemic alert to phase five or six. Instead, what we are trying to do is a little less precise. We try to make sure that there is a shared understanding of what the issues are, shared approaches to how we are going to react, and that there is movement that combines people together so that they try to do the same sort of thing. The case in point of what happens when the pandemic starts is tricky: Many companies have now decided that they will not evacuate their staff immediately. Instead they will have people staying at home with supplies and try to whether the storm for as long as possible. Because of that concern, they try to pull their staff out, and everybody does it together, you will end up contributing to an extremely unsatisfactory situation. For example, the UN’s coordinated response, which has been shared with a lot of other organizations and companies through the kind of movement and network I have just described, is we will stay put. We will do basic minimal tasks. So we will have a lot of people at home and we will stay put. Because we know that if we try to get out, the moment there is a rumor that pandemic has started, we will actually endanger our staff and we will also cause problems for others.

Donald G. Ainslie: I think the answer to your question is I have not seen that. Part of the frustration is that I think there is a lot of discussion taking place about if it is going to happen, if it happens, how bad will it be, do we need a plan for it. There is not that form that you are describing where the commercial companies and the government are sitting down and collaboratively working together. There is probably isolated cases of that, but unfortunately I have not seen that. I think it is opportunities like this to discuss with you all and then you all can be the champions to go out there and really educated people. This is something that we need to put at the forefront.

Question: I am Claire Coppell at the National Bureau of Asian Research in the Pacific Health Summit. I have been hearing everyone talk about investing a lot of energy and money into sophisticated surveillance efforts. A lot of them are communication and having supplies on hand, which is obviously critical. I am wondering how much of the same energy and money has gone into strengthening general health infrastructure systems and how important that is in all this.

David Nabarro:
 There are two infrastructures that are key: one is veterinary infrastructures, which are really very weak in too many countries at the moment. We need to be building them up, and that involves a combination of working with governments and working with people, and non-governmental groups. The second is basic health infrastructures so that they will be able to address the human consequences of not only avian influenza but pandemics, and not just talking about influenza pandemics but others as well. Is enough money going in? I personally remain very disappointed about the general level of investment in health infrastructures in about fifty or sixty countries out of the 192 in our world. These are the countries with relatively low gross domestic product; not very many of them are in Asia. There are some. Most of them are in Africa, and were a pandemic episode to start or even to appear to be transmitted into many sub-Saharan African countries, the consequences would be quite appalling. I think you are absolutely right to stress—as your question implies—that there must be serious investment in building up health infrastructures if we are going to be also serious about dealing with this threat.