Rx for Survival — A Global Health Challenge

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Ask the Experts

Discussion: The Next Pandemic?

Global pandemics are not new. An influenza pandemic in the early 20th century caused an estimated 50 million deaths worldwide. Although health care has improved in the last decades, a pandemic today could result in a significant number of deaths, both in developing countries with already strained health care resources and in developed countries like the United States. With avian flu spreading beyond its stronghold in Asia, should we now be preparing for the next pandemic? If so, how?

1. More new diseases, or more ways to spread and report them?

LARRY KLEIN, MODERATOR: Throughout the television series, there was mention of the emergence of many new and emergent diseases, and people have picked up on that. Several people have asked questions like, "Why are there so many new diseases in recent years? Where are diseases like Ebola and HIV and avian flu [H5N1] coming from, and are we somehow responsible in any way for this new emergence?"

DR. NILS DAULAIRE: First of all, there are always, have always been, and will always be new diseases emerging, because the nature of nature is that there's constant selective pressure and evolution of microbes looking for ecological niches where they can survive and thrive. That's really not new by itself. What is new are two particular phenomena.

One is that we are increasingly in direct juxtaposition with some of the biologically richest areas of the world, the rainforests. A big part of that is in Central Africa, where diseases like HIV and Ebola have emerged over the past decades. And those areas were areas where there was relatively limited contact between nature, you could say, and humankind up until the last 40 or 50 years, as the population grew and humans made increasing inroads into those biologically rich parts of the world. So there's basically more opportunity for species-to-species contact and transmission of microbes.

The second one is, we've gotten a whole lot better at identifying them, so things that might have gone undetected and unnoticed just as some unexplainable illness we can now identify as a new virus or microbe, and it gets reported. So it's largely a reporting function.

Then finally, because in the past these diseases, when they emerged, were often slow to spread and often very limited in their area. We lived in a world of sailing ships and then steamships, and only in the past 50 years have we been in a world of jet planes, so things tended to stay much more localized, whereas now they can travel globally much more quickly, and people therefore come into contact with them. At the same time, we have far better reporting than we ever did, so that the things that do appear wind up in the international media.

MODERATOR: Howard, as a historian, I would like to ask you, were there other periods in history — I'm thinking primarily about 1348 and the rise of the plague as a time when there was perhaps the first great globalization of commerce and travel on ships. Is there a parallel between this period today and other periods in the past?

HOWARD MARKEL: Actually, the global world and its attendant spread of germs began many centuries earlier, as various nations began to explore and conquer other regions of the world. But what you're referring to in the 1340s, the black plague of Europe, which killed a third of Western Europe's population and was probably caused by Yersinia pestis, the etiologic agent of bubonic plague — but there's been a lot of argument among historical epidemiologists as to the exact bacterial entity that killed all those people.

Nevertheless, you had people doing imperialistic things back then, countries taking over new lands and traveling by boat, but also by foot and horse, farther and farther. And when you mentioned 1348, it's interesting, because it's not only the period that witnessed the terrible black plague; it's also when the institution of quarantine was invented, and that was done in Venice.

The term "quarantine" literally comes from the Italian words for "40 days." The Venetian authorities closed the port for 40 days from outsiders, ships, people, goods, with the hopes that the bubonic plague epidemic that was raging there would burn itself out. At the time, Venice was as international a center of commerce, culture, and everything else as New York City is today.

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2. Distinguishing between pandemics and epidemics

MODERATOR: We hear a lot lately the word "pandemic" used as opposed to "epidemic." What is the difference between an epidemic and a pandemic, and where did the word 'pandemic' come from?

MARKEL: It has its roots, not only from epidemic, which is an ancient Greek term for an infectious disease or seemingly contagious disease that spreads, but contains the root pan, which literally means "throughout the world." There are specific definitions that public health people use for both the term "epidemic" and "pandemic" that vary from disease to disease, by the way.

Mention the word "epidemic" to most people, and they likely think of hundreds or thousands of cases of a particular malady. But if there was, say, one case of bubonic plague in Ann Arbor, Michigan, where I live, that's technically an epidemic of bubonic plague, because you don't expect to diagnose that disease in Ann Arbor in 2005.

But generally, "pandemic" means many, many, many nations are involved. We say that term, for example, for the influenza pandemic of 1918, which literally circled the globe in a matter of weeks.

DAULAIRE: The key issue with pandemics is, as Howard just said, that they are worldwide. A pandemic is an epidemic that covers the entire globe, virtually all the continents. I suppose you don't have to reach Antarctica to [have] a pandemic, but it's one that's a global epidemic.

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3. Health risks posed by air travel

MODERATOR: There has been a lot of news within the last several years about diseases that "sweep around the world," even if they don't become classically a pandemic like 1918 or HIV-AIDS. There are a lot of people in the air at any one period of time. We had several questions from people who fly a lot — flight attendants, pilots, frequent travelers — who wanted to know if there is a definite epidemic beginning to go global, like SARS a few years ago. People also wonder, whether airlines be issuing masks? Should those people continue to fly, even if they knew that they were potentially being exposed to one of these new diseases? What would you say to people who are traveling around quite a bit, and there's a disease like a SARS, or even an avian flu, although we'll get a little more into that, circling the world?

DR. REX ARCHER: When we talk about travel restrictions or various types of protective measures, we're balancing the benefits from economic development versus the risk. It's very difficult to be too general on this. You almost have to know a specific situation and a specific organism and how contagious is it and how pathogenic, how dangerous is that organism, in trying to make those decisions.

Given the world that we are in, it probably is reasonably prudent for most travelers to be thinking about having at least a simple surgical mask as part of their travel baggage, or even N95s, which is a particular type of mask that's a little bit higher-grade than just a surgical mask, if nothing else, for hygiene and courtesy; that if you develop a cough or a regular cold, that you could put that on so that you don't expose the person sitting next to you in the same seat. And washing your hands and paying particular attention to those kinds of public health hygiene measures is equally important. I doubt we will ever get to the point of going to certain kinds of UV lights and other kinds of ways to control the air within an airplane, like we do in our negative-air-pressure TB treatment facilities where we see those patients.

MODERATOR: Howard, you were obviously a big voice in the TB story that was in the television series. What if you were flying somewhere and then you came home, and then a week or so later, you were informed that someone on your flight had a bad strain of TB? What would you do?

MARKEL: Actually, I wrote a story about this in my book [When Germs Travel: Six Major Epidemics and the Fears They Have Unleashed], and TB is kind of an interesting disease, because it's contagious. Or it's infectious, I should say, because "contagious" means you catch it generally by touch; "infectious" means it's transmitted by other means such as respiratory droplets. But with tuberculosis, you have to be in the room, breathing the same air with someone for several hours, like eight or more hours. Well, that sort of describes an airplane ride, especially if you're going across the ocean.

The other thing about airplanes is that they have re-circulated air. It's a pressurized cabin because you're flying so high and so on, and the air is re-circulated. So there's a risk that you're re-breathing infection even after it's carried away by the vents, because then it comes back again. That is quite frightening. By the way, the CDC [Centers for Disease Control and Prevention], the WHO [World Health Organization], and other public health agencies have been reporting that this is a potential risk since the mid-1990s, so it's not exactly a new concern.

Back in 1996, there was a widely reported case of a woman from Korea who thought she was cured of TB — she was treated a couple of times during her teenage years. This woman decided to visit some family in Baltimore. She traveled from Seoul, Korea, to Honolulu then for a brief stopover, then in Chicago, and finally in Baltimore.

When she got to Baltimore, she became very ill, according to her friends. She was coughing a lot, and she appeared to be losing quite a bit of weight and was always very tired. She had what's called "night sweats," where she had to change her [sheets]; … she kept dousing her bed with her own perspiration. All these symptoms are classic for terrible pulmonary tuberculosis. She decided she didn't want to get treated in Baltimore, and she'd fly back.

She did so, but she became sicker and sicker on the various legs of the journey back. Passengers who were flying with her noticed that her handkerchiefs were turning from a snowy white to red. She was coughing up blood, which is one of the final signs of terrible TB: the germ actually erodes the vessels that are there, the arteries. By the time she got to Honolulu, she was morbidly sick, and indeed she had not only tuberculosis; she had multidrug-resistant tuberculosis [MDR-TB].

Well, the scenario you just gave me isn't so hypothetical. In the case of this woman, the CDC microbe hunters who had to track this down afterwards found out that she had probably infected 29 other passengers on these four legs of the journey. So TB is very contagious, and if you're on a long flight with somebody and they're sick — that sick, meaning they're coughing up blood and so on — that's a decided health risk. You might argue that someone that ill should never be on a commercial jet with other people.

The more likely scenario is something like influenza, whether it's regular influenza or, God forbid, bird flu, which has not yet gone human to human, as you know. But the idea that you're sitting next to someone on a flight from New York to California and they're sneezing and they're coughing, and you're flying coach — (laughter) — you are at high risk, even if they have good hygiene and courtesy. So a real lesson is not just to have courtesy; you probably shouldn't be flying if you're really sick. I don't mean deathly sick necessarily, but if you have a cold, you're likely to infect other people.

MODERATOR: Nils, you probably travel more than most people I know, and you know more about various health and disease issues than most people I know. What do you do when you go on some seriously long flights? Do you prepare yourself any differently these days than when you used to?

DAULAIRE: Keep in mind that I go from place to place and immerse myself in health issues in the places that I go to. So for me, the airplane is actually no riskier than where it is I'm going or where it is I'm coming from, and I don't take any extra precautions.

You have to remember that airplanes pose two kinds of risk in terms of infectious diseases. One of them is simply the passive movement of an infectious microbe from point A to point B, that we're getting them there much faster. And in fact, most diseases that are carried by airplane, they're in their latency or incubation period; they're not infectious during the time that people are on the plane, because not always, but generally, people who are in the infectious phase of an illness are feeling sick, and they're not really feeling like getting on an airplane and flying. Someone may even have enough sense to follow Rex's recommendation and not get on the plane to begin with, because they recognize they're posing a risk to others, so there's simply this passive transmission side.

Then there's the issue of people who are infectious on the airplane. One of the sad realities, though, is that for the most part, the kinds of masks that people can get, the pore size of a mask is much larger than the size of a virus. And while the mask may stop droplets, by the time something is re-circulated through the airplane's air re-circulation system several times, it's broken down droplets into such tiny size that I would think it's unlikely that masks are going to do much good.

MODERATOR: And it's especially a problem for flight attendants.

DAULAIRE: It's less of a problem for them than it is for health providers, who are spending all of their time in wards and in contact with people who come to see them because they're sick. I would say that the overall risk to a flight attendant of getting something very serious on a long flight is probably lower than their risk of getting seriously injured on their drive to or from the airport, at this point.

MODERATOR: And I guess, Howard, there's no chance that we will be quarantining every flight that comes in for 30 days.

MARKEL: No, you couldn't even do it. Think about the delays incurred from just stopping traffic because of a storm. Just closing down a single large airport because of a storm, an epidemic, a flood or whatever causes so much economic and social disruption.

But on the other hand, just let me throw this out, since you brought that up. You could have sort of a voluntary closure of all the airports for 30 days, a friendly boycott if you will, because people would just not want to fly if indeed we're talking about something as terrible as the 1918 pandemic coming again.

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4. Is an avian flu outbreak inevitable?

MODERATOR: Without question, the vast majority of questions that were asked revolved around bird flu. Is an outbreak inevitable? And how would we know it actually had begun?

DAULAIRE: First of all, an influenza outbreak is inevitable. We had three pandemics in the 20th century. It's been almost 40 years since the last one. These things, their nature is to evolve and change and finally get to a form where our immune systems don't recognize the new form, and they become much more readily transmitted from person to person.

That's not the same thing as saying that a bird flu pandemic is inevitable. At this point, we've had very limited human infections, and they've been almost entirely bird to human. That does not pose, by itself, a serious risk to humankind.

The challenge is knowing what kinds of mutations may take place as the H5N1 continues to evolve, and whether those mutations may make human-to-human transmission and infectiousness more likely or not, and whether that level of infectiousness is one that's going to result in a disease as severe as we're currently worried about, or whether the ultimate disease ends up being much milder.

There's a whole range of unknowns. But we do know from history and from the laws of probability that a global influenza pandemic will happen. And while no one can predict that any more than they can predict the next big California earthquake, it's likely to be in the next 10 to 20 years.

ARCHER: I don't think there's any question that we will face another pandemic. Whether it is this particular novel strain or another one, I don't think any of us can predict that. Certainly this strain has its challenges and concerns us, so all these issues that we've been talking about in regard to becoming better prepared are things that we should have done in scaling up at least five years ago on. It's better late than never.

How will we know? There are some concerns that there are still parts of the world where we may not have the trust and relationships, and their government doesn't understand yet the importance of reporting this and being on top of it and being open with the rest of the world, and that is a concern. Certainly our labs' testing ability and rapid diagnosis and awareness continue to improve. As we expand that capability and work with the World Health Organization and all the partners, I think we'll pick this up more rapidly.

DAULAIRE: I'd like to get back to the question of how will we know? We will know by the classic tools of epidemiology, which is, first of all, detecting cases of respiratory infections that are severe, and we can begin to trace a connection from person to person, from community to community.

The challenge is that while in many countries of the world there are reasonable to good surveillance systems in which early cases will be recorded, and the first few associated cases will also be recorded so that you'll get an early warning, the countries of the world that are the poorest and have the weakest health systems could go for weeks or longer without cases actually becoming apparent through the epidemiology service. That's why it's so important that we build up the surveillance and detection capability in every country in the world, because the earlier we know, the better we're going to be able to respond.

MODERATOR: Howard, you've done a lot of looking at 1918, and several people now have the sequence of that particular flu virus. Do you think that this one, this H5N1 virus, has a chance to go to the human-to-human route that made 1918 so deadly?

MARKEL: Sure, it has a chance, and that's the multibillion-dollar question — or, as the WHO said the other day, the $800 million question. I have been getting a lot of calls from reporters over the past few weeks and months. Just the other day, a reporter asked me, "Look, what do you think the future will be?" I have been asked this question so often lately. I said, "Well, I don't know; no one really knows." Anyone who does, as I said very bluntly — too bluntly, perhaps — either he's a liar or an idiot. I probably shouldn't have said that! (Laughter.) But in a deep sense, that is the historical truth: we don't know for sure exactly what is going to happen.

But that's not what we're dealing with, uncertainties; we're dealing with risks and benefits and predictions. And certainly if H5N1 were to become human to human, which is a possibility, then the elements of a so-called perfect storm could be lining up very quickly.

Then there's a lot of work we need to be doing, as both Nils and Rex have already said, and we're already behind the eight ball in terms of looking at both domestic flocks of poultry and migratory birds, surveillance and modeling; taking care of a crumbling infrastructure of public health, not only in the United States but around the world, and communication systems, and on and on and on. So yeah, it really is frightening.

Now, the sky's not falling yet. And from my perspective as a historian of epidemics, this is a really odd thing to say, but there's never been a better time in human history to have a pandemic than today. The only time I'll be refuted by that is tomorrow, because things have been getting better and better in terms of our technologies and abilities.

But of course, that's only one part of the equation. We have the technologies; we have the abilities. Some of the tools are very, very old, in fact; some are not. But we have to fund them and put them to work in a timely manner. That's the other thing that history shows time and time again: that communities that prepare for epidemics do far better in their management and containment than those who get caught off guard by them.

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5. The 1918 influenza pandemic

MODERATOR: I assume that we will have our — and I use this word in quotes — "normal" contingent of flus this coming year. Those that will sweep the world will be dangerous, especially to the very young and the very old. But 1918 seemed to be particularly deadly to those in the prime of life. Have we ever figured out why that particular flu seemed to like to become very severe in people who should have had the constitution to resist it best?

MARKEL: If you would have asked me this question when you were filming the documentary, I would not have been able to really answer it as well, just speculating. We have a lot better evidence now with Jeffrey Taubenberger's study that links that 1918 strain with some genetic components of an avian flu.

What we know, and as you described, it was a lot of young, healthy, strapping men. In America, it was a lot of soldiers. You had 1.5 million young men, 18- to 22-year-old men, mobilizing for what we now call World War I. They were traveling and living cheek to jowl together on trains, camps, boats, and foxholes. But you have all those people traveling and moving, and they're all young, and they don't generally die of influenza, and yet they are.

As one physician said — he was in the autopsy room in Camp Devens in Boston, and he said, "We were stacking up corpses as if it were cordwood." What a frightening concept. And the pathologists who did the autopsies were struck when they opened up the chest and they looked at the lungs. They were not the frothy, bubbly kind of tissue you expect from a lung. Generally, if you feel a lung, it's sort of like that plastic bubble packing material that we all love to pop. The thing that you would "pop" in the lung would be the alveoli.

But in this case, they were so filled with fluid, blood, pus, and so on that they were almost solid tissues, and the doctors were struck by that. What we're finding out from the new science, looking at the historical data, is that this particular virus settles far deeper into the actual alveoli and lung cells of the infection, creating an even more, if you will, immunologic storm, a pneumonitis, an inflammation and infection of the lungs, than the garden variety forms of influenza. All influenza strains have the potential to be deadly for certain people. You mentioned very young, immunocompromised and so on. But the 1918 virus produced a much more virulent, deeper infection of the lungs, and the results were, these young men suffocated; their lungs basically filled with fluid.

MODERATOR: So what you're saying is that actually, people with a very strong immune response, this hurt them in a way; that their immune systems —

MARKEL: You're hearing that, but I don't want to overlabor that. Indeed, it's a strong immune system response that's gone awry and that the body's losing this one. So it's not as if they have a hyperimmune response to it, which is a different kind of set of diseases. Basically the infection is so virulent and affecting so deep into the lung tissue that it's causing a greater amount of inflammation, a greater level of pneumonitis, which is literally inflammation of the lungs.

MODERATOR: The flu killed the young and the old, just like a "normal" flu did. But it also killed healthy people because it infected the lungs so deeply.

MARKEL: Exactly. Usually you see a U-shaped curve of morbidity on a flu epidemic. So the very, very young and the very, very old are the two tips of the U, with the exceptions now of immunocompromised, oncology, and AIDS patients and so on. Anyway, in the 1918 epidemic, you had a W-shaped curve. That middle spike were the young people that we're talking about.

ARCHER: It's important to understand that we have a number of nonspecific types of immune functions that work in general, which are different than the more specific types of increases in immunity that occur under vaccination. And with influenza, the people with generally strong immune systems, there did seem to be a process where that strong response caused additional cellular damage that is different than if we had had a vaccine at that time, if they had been able to produce a specific response to this virus; that particularly, if they could have gotten to it before it had reached quite as deep into the lungs — there was the problem with the damage that actually occurred to the inside systems of the lungs.

And part of our responses in regards to protecting against lung infections is that we have hair cells, cilia. It's like trying to go down an escalator that's coming up, and that system helps to keep things out of deep in the lungs. This virus attacked that system so that, in a sense, it "stops the escalator," or maybe even made it go the other direction because of gravity, and then the organism could get down deeper into the lungs more rapidly.

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6. Where we stand with an avian flu vaccine

MODERATOR: You mentioned that "if we had a vaccine…" We do now, as I understand it — at least that there have been in clinical trials — a successful vaccine for H5N1. Where are we at with that now? Is this vaccine available right now? If I went to the doctor and said, "I want an H5N1 flu vaccine shot," could he give me one?

ARCHER: No, it's not available right now. My understanding is that there have been trials with different categories of individuals at different age groups, and so far, those trials seem to be showing some success.

DAULAIRE: I believe we've gone through Phase 1 and Phase 2 trials. Here's the challenge, though: because we already know that if avian influenza becomes human-to-human-transmissible, it will be because it's gone through some set of mutations and shifted its genetic composition. We don't know whether the vaccine that we have now will be the right key for that particular immunological lock, if and when the avian flu becomes a human pandemic.

So our best guess right now is certainly closer than the standard flu vaccine, but even if it were broadly available, we can't tell, until and unless those evolutionary changes in the influenza virus take place, just how protective the vaccine was actually going to be.

MODERATOR: I've heard that at least currently, they feel that right now it would be effective, but — and this is far beyond my grasp — that in its present state, one needs a vast amount of it; that they have to figure out how to get higher antigen levels out of the vaccine they produce. Had you heard that?

DAULAIRE: I'm not familiar enough with it.

MARKEL: No, nor am I.

ARCHER: Yeah, I am actually familiar there. They are talking about significantly higher antigen levels to get the same response. Now, our normal vaccine has three different antigens in there, so you automatically can, in a sense, get three times the antigen if you make a vaccine that is just a one-antigen vaccine. But that does not appear to be strong enough yet. They are looking at various adjuvants to try to see if they can't strengthen the response without having to produce so much antigen.

MODERATOR: In other words, right now, if one were to take this vaccine, you would need three times as much of it for it to be protective against avian flu, or H5N1 avian flu, than a normal vaccine, meaning that whatever stockpiles we had would be used up three times as quickly. Is that correct?

ARCHER: That's close, basically because we need more antigen for a novel virus. Our present capacity to provide 60 million seasonal flu doses would only be enough to vaccinate 15 million people. Certainly the production capability will be challenged, because at this point, unless we can get these extenders — you can kind of think of them like Hamburger Helper. That's kind of how an adjuvant works: that you can get the body to recognize and build antibody and immunity against that organism with less of that particular marker of an organism.

Probably suffice it to say for the general public that obviously this is important, and a lot of research is being done on it. It's nothing that we have right now, and as Nils has said, there is likely to be additional shifts. Probably at best the current vaccine might be able to be the initial shot, and then you would have to have the booster of the more specific vaccine that has been adjusted to whatever actually is moving from person to person to get a real strong effect.

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7. Why aren't we better prepared for an avian flu outbreak?

MODERATOR: Rex, both you and Howard alluded to the fact that preparing for this avian flu is something we should have known about and should have done a better job with earlier. What could we have done earlier that would have made it a little less precarious today?

MARKEL: To begin with, when avian flu was detected in Hong Kong in 1997, the Public Health Ministry there acted swiftly and rather with great transparency. They killed every domestic chicken in Hong Kong. Apparently there has been migratory avian flu for some time, but that's a harder thing to keep a handle on because of the nature of migratory birds.

But in Indonesia, at least two years ago they were said to have detected a problem as well with avian flu among their domestic chicken flocks, and yet that information was suppressed. There was quite a bit of controversy going on in Indonesia. The poultry industry was adamant not to announce this for fear that the prices of their goods would plummet.

And you also have an even greater problem in that Indonesia is an exquisitely poor country, and a lot of people there raise their own chickens and live in close proximity with them. If the public health department were to kill these chickens or come to these individuals' homes, they're not likely to give these people money in exchange for those birds that they use for their subsistence, so there's even more complicated social dynamics there as well.

Long story short, it wasn't until June of this year that the Indonesian government actually admitted that there was indeed a problem two years after they knew it and asked for help from the WHO and other nations that are helping in terms of veterinary surveillance and so on and so forth. That's two years that more birds, migratory or domestic, could have been infected.

And what we really worry about, with the rainy season beginning and so on, and the migratory birds that may have been in Indonesia and may have had contact with some of these chickens, will now fly to places like Africa, where their public health infrastructure is even worse and more impoverished. So this scenario is really quite frightening.

And you always want to be as early as you can. You're always a few steps behind an epidemic because we don't have this little sensor device that tells us up to the minute where an epidemic is brewing. But we probably wasted a good couple of years on this particular problem that we're facing today.

MODERATOR: What about in the U.S.? What could we have done more proactively to be prepared for the possibility of the emergence of such a disease? I've heard many, many discussions about the fact that we are behind the eight ball here, that we should have started various preparations earlier. What would that have meant?

ARCHER: I'll run through a few of the important ones, although there is a long list. Obviously an easy or simple one is the failure of the free-market system to address and fix domestic vaccine production.

People don't understand that if we made cars, and had to make cars the same way that we deal with vaccine, we'd have some real challenges there. If a car manufacturer had to decide about six to eight months ahead of time what its line speed was going to be, how many cars it was producing today, and every car that it produced today it had to sell within three months or crush and destroy, and it had to change its model every year, we'd understand that it would be a different ball game.

Those are the kinds of dynamics that we're dealing with here. We need to and should have fixed this several years ago. Vaccines are for the public good, not just for the individual. Most of us get our shots as much to protect loved ones, friends, co-workers, and patients, etc., as to protect ourselves. There is a total public good on this, and we should be investing on that.

The problem is not liability or threats of lawsuits; the problem is if they overproduce, will somebody buy their overproduction because they guessed wrong on demand? There is a chance, like with [British pharmaceutical company] Chiron apparently, where you can spend all the money to produce the vaccine and then have failures close to the last step and then not be able to sell it.

We need to have an insurance pool or a mechanism to offset those kinds of catastrophic losses that a company can have it if has failed production. There are a lot of things that we can do to fix that, and we need that domestic supply, and we need it very rapidly.

The second issue is, we just don't have a "prevention culture" in this country. There used to be a test for insanity where you would sit somebody down in front of a bucket, turn on the faucet, give them a spoon and ask them to empty the bucket. If they spooned away and eventually got up and got a bigger spoon, or even a mop, but never turned down the flow into the bucket, they were considered insane.

That's our kind of approach in this country. We spend more on illness care than any other country in the world, and yet there are 20 other countries in the world where they live longer than we do because we don't focus on prevention. We don't have the infrastructure at the federal, state, or local level; don't have the relationship with our communities. There's not the trust that we need at every level to get people to even take control of regular seasonal influenza.

We're failing to control that. How are we going to handle a pandemic when we can't handle the yearly carnage that occurs with 30,000-plus deaths each year and all those distribution issues and challenges that we have?

DAULAIRE: About what should we have done, we got a real clear signal when the Institute of Medicine issued a report — I think it was in 1992 — called Emerging Infectious Diseases. It laid out the problem, it laid out the consequences of not taking action, and it laid out the steps that ought to be taken at that point. We've lost 13 years in the process. Our hope is that we're not responding too late. We are finally responding.

But there are a number of things that we needed to have done and we need to do, and we are now finally beginning to do. First of all, there's the issue of forward deployment, dealing with diseases at their point of emergence rather than, once they've become global, dealing with them here in the United States. The key there, as we've talked about, is having the capability to detect and quickly respond to disease, which can only be done by the local, indigenous health systems which are greatly under-resourced in today's world.

Not just here. I'm talking about in places like Indonesia and sub-Saharan Africa, where many of these diseases are most likely to emerge because they are areas of high endemnicity of a whole range of diseases and a lot of contact between animals and people because of farming practices. So for our own protection, we need to really help to strengthen the health systems that are dealing with basic public health in those countries.

We also need to look at this as sort of a global insurance scheme, that countries should not be punished economically for doing the right thing. As Howard said, that was the concern in Indonesia. They were afraid that they were going to lose economic productivity in a country that's already very poor if they announced that they had avian influenza, so they tried to keep a lid on it — the same thing that happened in the early stages with SARS in China; the same thing that happened in the early stages with the emergence of plague in India in the 1990s.

There needs to be a global system in which countries will, in a sense, be insured for their losses so that there's not this perverse incentive on their part to try to cover up problems and hope that it goes away because dealing with it at the national level would be so costly for them. We're all benefiting from that.

Secondly, as Rex said, there has been a failure of the free-market system, but I'll take a little bit of issue with what he said. There are a couple of parts of the free-market system that need attention. In order to develop a new vaccine, we're talking about probably hundreds of millions of dollars. If we're going to develop a whole new technology for a rapid vaccine production, a surge capacity, then we're probably talking about investments in the billions of dollars.

We cannot expect the private market, raising capital through equity and through the standard private mechanisms, to be doing this "just for the good of the world." They have to do it on the basis of a rational economic model, which means on one side an investment from the public sector, from the U.S. government, in some of the key areas of technology. And I'm very pleased that this is an important part of the administration's new initiative on avian influenza, developing a cell culture approach to vaccine production rather than staying with the 1950s technology of growing virus and developing vaccine from chicken eggs.

That infusion of cash is necessary, but secondly, because we don't have a better system in the world at this point for bringing vaccines in high quality and high quantities to market other than the private sector, we have to look to see what it is that will encourage that to happen. There are two parts to that. One, as Rex said, is the market uncertainty. If you spend $500 million on developing the latest strain of influenza vaccine, and you get it out there and it's sitting on all the pharmacy shelves, and then the epidemic doesn't happen, who takes the hit?

Well, it's the private company that developed that vaccine, and they go under pretty quickly, and these are with high investments, a risk-averse group. So we have to have a guaranteed purchase arrangement so that for our common protection, there's a certainty that there are going to be enough buyers for it. And then we have to have some market flexibility for an even greater capacity.

But the other side of this is the liability issue. And I would disagree with Rex that liability isn't a big issue. I've had a lot of conversations with reasonable and responsible people in the pharmaceutical industry, and this worries them a great deal. There are issues like the red herring of autism, which has been clearly and scientifically proven not to be connected with vaccines, but that still in the United States is widely believed to have a vaccine relationship. Cases go to trial by jury, and all of a sudden you've got a multi-tens or hundreds of millions of dollars lawsuit to settle.

These things make it not very attractive for drug companies to want to get into the game. There need to be some very clear rules and regulations set up around this, but there also needs to be some sort of protection for those kinds of risks, both for the companies and the individuals, because we do recognize that absolutely any drug, any vaccine, anything that you put in your body in some cases is going to have an adverse effect.

I don't think that individuals should take all that risk upon themselves and companies should be protected. Again, this is a matter of the common good, where the government actually ought to take on the issues of compensation for people who have suffered injury, but that the companies should have reasonable protection against liability.

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8. Hand washing is essential to stopping the spread of disease

MODERATOR: Just to move it to a different level for a moment, right now we have, in terms of avian flu, a disease that hasn't yet, as far as we know, moved to a human-to-human phase. But in its current state, we had several people write in who are themselves or have family members about to visit Indonesia or Thailand, where the flu has been lingering for several years now among the flocks of birds and chickens. And they ask whether there anything they should do when they go over there? Should they take Tamiflu with them? Should they not eat chicken? Can you get bird flu from eating chicken?

MARKEL: No, unless it's completely undercooked, but that's very rare.

DAULAIRE: This is actually a directly pertinent question for me, because my wife has just flown to Bangkok, and we had this conversation before she went. My recommendation, which she followed, foolishly or not, was [first], there is no benefit in taking Tamiflu or bringing Tamiflu along, because to the best of our knowledge you have to have taken it before you get infected with avian flu for it to have any real effect, and you don't know if or when you're going to get infected; you're simply dosing yourself with a potentially toxic drug.

Secondly, the likelihood of someone coming into casual contact with avian influenza if they're visiting is very low. Again, their risk is far higher driving in a car from the airport to the downtown hotel in Bangkok or in Jakarta than it is that they would actually come in contact with and then get sick from avian influenza. It's not that one shouldn't be paying attention, but I think the risks have been somewhat overblown.

MODERATOR: So just to pull this apart for a second, people should not, anywhere for that matter, where there have been reports of avian flu, should not be afraid of eating chicken or duck, but should make sure it was well cooked?

DAULAIRE: I would presume that anyone eating anything in the developing world understands that everything they eat, whether it's fowl or beef or pork, better be well cooked, or they're setting themselves up for a high probability of one sort or another of infection, absolutely.

ARCHER: I'd like to add that [the problem affects] not just the developing world; the same problem is here domestically. People need to be prepared, carefully washing their hands, doing all the right things in food preparation and cooking for those kinds of products regardless. And if they do that, then there shouldn't be a problem if it ever did come into our domestic market.

MARKEL: Eating meats or poultry or fish that are well cooked is an absolutely perfect and wise piece of medical advice. But you also have a much, much, much greater risk of contracting a gastrointestinal infection in developing parts of the world if the food you are about to eat is undercooked or if someone who's preparing it hasn't washed their hands and happens to have dysentery, shigella, cholera, and many other gastrointestinal infections.

So on all levels, when you're eating meals in developing countries, you have to keep your eyes and ears about you, and really be over-careful not [to get] an infection or a wide variety of infectious diseases.

DAULAIRE: And probably at some point, there will be a report of some migratory bird having avian flu here in the U.S.

MARKEL: That's going to be like the biggest news day. All of us will be on the phone to somebody that day.

MODERATOR: Can U.S. farmers do anything now?

MARKEL: I looked into this, and I called some people in the United States Department of Agriculture. Actually, we're very well blessed in this country with having a pretty good bird surveillance of domestic birds, for example. The migratory bird situation in the U.S. is not dire at present, by the way. A lot of universities, including a program at the University of Washington, are looking at migratory ducks and birds to make sure there is no importation of avian flu.

More important, the USDA has a superb reporting system that has put reports out to the various poultry farmers in the United States of what to look for, what the symptoms of bird flu are, so on and so forth. I'm very confident that if it does happen, it will be reported very quickly and, hopefully, contained.

Migratory birds are a little bit different, but as I said, there are several research groups at universities and nature conservancy groups and so on that will probably work with local public health departments to observe that situation, too. But it is inevitable, if indeed these migratory birds are migrating. I looked up migratory birds, by the way. The birds that fly over Indonesia often stay on that side of the world. They have two main paths, but eventually they're going to come from one end of the world to the other, and we're going to have a great news day of "A Downed Duck! Canadian Goose Was Found to Have Bird Flu!"

DAULAIRE: The good news is that we're getting into the very tail end of the bird migration season, so we're unlikely to see a case in North America this year. But it's certainly going to happen in one of these years.

MARKEL: And the bottom line is that we're still talking about birds and less than 120 people. That's critical, too.

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9. Can Tamiflu guard against avian flu?

MODERATOR: Nils, you mentioned something when we were talking about travel to Thailand in which you said that Tamiflu, which is the most mentioned antiviral flu medicine — not vaccine — is most effective when you take it prophylactically; that is, before you even get the flu. Are you suggesting it's not really that useful to take after you get it?

DAULAIRE: I'm talking specifically about avian influenza. Rex probably has better information on this than I do, but my understanding is that there is scant information that Tamiflu taken after the first symptoms of avian influenza in a person — and there have been over 100 bird-to-person cases reported — actually has an effect in terms of protecting the person. That would indicate that if it is effective at all in this particular instance, it would only be if you got enough of the drug on board when the virus first starts its inroads into your body that it can work at that point.

ARCHER: Well, I am unfortunately a little bit of a — pardon the term — nihilist when it comes to antivirals. Many of us have had experience with nursing home outbreaks and with the amiodarone types of antivirals where, by the end of the outbreak, it's already resistant to the antiviral. Most people don't understand that these viruses, when they invade a cell of the body, are producing over 1,000 copies of themselves, plus upwards of 10,000 copies that are slight variations to pretty significant variations of themselves. The chance is that there's already evidence that the H5N1 may be resistant, at least in some of the strains, to Tamiflu.

Even though Tamiflu works in a little different way and tends to keep the viral particles within the cell and stop them from being released, so that there may be some advantages on reducing infectivity in people — even if it doesn't necessarily save the person, it may make them a little less contagious — I'm not a real big believer that this is going to be that useful. We're going to have to slow down the outbreak with all of the voluntary measures and hand washing and avoiding contact and hoping that we've got tissue culture vaccine production.

If we make the decision, which I hope we will make this year, to go to universal influenza vaccination in this country, and set that as a standard and goal and expectation — and I've been calling for a commitment that by the year 2010, we should be vaccinating 90 percent of the U.S. population to influenza, in at least no longer than a six-week period — it would force us to be able to try to go up to scale and do this in a way that will pressure us, so that if we have other kinds of disasters, whether it's a pandemic from influenza or multiple crop dusters that hit us with another biological agent from an intentional attack, that we can gear up to scale and do something more rapidly in this country.

Speeding up vaccine production is an essential step, but it is equally important to improve our distribution system and efficiency at actually proving we can get vaccine into 50 million people per week for several weeks.

MODERATOR: So here's the takeaways: we don't have an effective vaccine right now, and the antivirals are probably not all that useful if we do get a serious epidemic or even pandemic. So I guess we're back to Venice, right?

MARKEL: Yes. Isn't it ironic?

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10. Quarantine and other methods of containment

MODERATOR: How would quarantine work in this case?

MARKEL: There are specific definitions of what the word "quarantine" means in 2005, but once it's gotten into the popular imagination, it's been used for a lot of things. Right now what it means is that you are separating those people who either you suspect of having contact with someone who is ill with a particular disease, or that they may have a disease incubating at that time. That's different than isolation, which is you're absolutely separating those people you've discovered to be ill with that infectious disease.

By the same token, though, quarantine has many meanings to people — the placard put in front of people's homes, and the "40 days and 40 nights of Venice," the few days that you would put people into quarantine just to stay away from somebody, and on and on and on and on. The United States government has come up with some very specific definitions, and these are still being worked out, and there are a variety of options.

For example, in Canada during the SARS epidemic, they tried something called voluntary quarantine; they were asking people to stay home. It was voluntary until you said, "I don't want to stay home," and then it became mandatory quarantine. So they don't like the word "voluntary" because that creates different messages. There's concepts called "snow days" you'll find in the new national flu pandemic planning report, and it's really a concept to say that you're not a suspect, you probably haven't had any contact with anybody with, say, flu, but why don't you and your family stay home from work and school, cut down on potential contact with this infectious disease? There's a whole bunch of plans to try to get the public at large to buy into an event if quarantine were to be ordered. There's also something called cordon sanitaire, where you would actually close the perimeter of a town or a county or what have you and prevent people from getting in or getting out of that area.

The thing that's most worrisome to me, as someone who's spent a lot of time looking at quarantines over the ages, is that one, they rarely work — cases generally get in and out, no matter what you do; two, people don't like them, and so often they run away or try to get out or around them, and so they inadvertently spread the disease as well; and three, they can sometimes stigmatize people if it's associated with a particular so-called socially undesirable group. So if you were to quarantine only Asian immigrants coming from Guangdong, China, you might say, well, that provides a risk that all Chinese immigrants might be stigmatized about infectious diseases. And in fact, if you look at past epidemics, that has happened rather frequently.

So for all those problems, if we're actually getting to quarantine as our best preventive method, it is way too late. We've missed a lot of cues if we've gotten to that point. Nevertheless, it will be used. If there was an outbreak of disease, some of these restrictions will be applied.

MODERATOR: I heard recently that there was developed a very rapid avian flu test. Now you don't have to wait days to find out if you're infected. If someone were confirmed, obviously they would be put in some sort of isolation ward there. That would be a good thing, unless the hospitals began to fill up with such people and didn't have any more room.

MARKEL: Right. And invariably, if it's a real pandemic, that's exactly what happens: you have far many more patients than you have beds. You bring up another very exciting and intriguing point, that the half-life between cases popping up and definitive diagnosis is continuously shrinking, so that 1,000 years ago, when you're using nearly empiric methods, there's already lots of cases of bubonic plague around when the doctor finally gets a picture: "Yeah, there's a plague epidemic."

HIV-AIDS had the record for some time between newly emerging disease and actual discovery of the etiologic agent; that was about three and a half years. That record was broken a few years ago by SARS. When the first cases were breaking out in Hong Kong — the first real, reported cases — to the time they had the genomic imprint, the genome of the coronavirus, that was about eight days.

So our technology is getting better at how to diagnose things, at how to predict things, how to model epidemics, rapid diagnosis, and so on and so forth. That's very encouraging, and that gives us an extra leg up — many extra legs up — on containing an epidemic.

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11. Battling a pandemic at the community level

MODERATOR: Pandemic happens. What does the government do, or what should people do? What should state governments do?

DAULAIRE: Well, the first thing — and this goes to the heart of what we are talking about when we talk about quarantine — I completely agree that the cordon sanitaire approach to quarantine is totally unrealistic. Certainly in the case of a highly transmissible infectious agent like influenza, what we can do is try to slow it. And extra days can make a difference here. The longer we have to respond, the more likely it is that we're going to have some of the right elements in place when this emerges.

We do need the new technology, so that instead of having to wait 18 to 24 months from the time that a new influenza virus type is identified until you have enough vaccine on board to immunize a large population, you've got to get that new technology, which is certainly within our technical means at this point, to be able to do that rapid turnaround. As was done with SARS, you can do the genetic typing in now a matter of hours to days. We should be able to ramp up to produce large amounts of vaccine in a matter of weeks to months. That's the goal, and that's where we ought to be headed in the next couple of years.

But slowing the epidemic down, if you can respond in that kind of time frame, makes a huge difference. Right now, with the technology we have on hand, slowing it down doesn't do that much good. I'd say that the emergence of a highly infectious and highly fatal form of influenza, if it happens in the next year to two years, we've got a very big problem on our hands, because you can't build the levees in New Orleans three days before the hurricane strikes.

MODERATOR: Would you see a situation that occurred such as the one in SARS, where, for instance, when it was reported there were cases of SARS in Toronto, people and companies, just simply stopped going to Toronto? They just said, "We're not going there." Would you start to see a kind of self-imposed cordon sanitaire?

ARCHER: Obviously you're going to see that, and our communication priority will be to make sure that there aren't certain kinds of inappropriate prejudices going on. When the SARS outbreak occurred, there were many parts of the country where people literally stopped going to Chinese restaurants, even though there was obviously no risk in that situation. So you do have to be careful: when humans become fearful, sometimes other kinds of prejudices and other kinds of stereotypes and ways that we generalize behavior can come out in increased ways, and we have to guard against that.

I think we should talk a little bit more about the public health side, but I'd also like to go to what do individual groups and organizations, as well as individuals and their families, do and think about and be prepared for these kinds of events. From a public health standpoint, I certainly agree: whether it's a public health law or any other kind of a law, unless 95 percent of the people understand and are generally willing to comply with the law, it's very hard to enforce the law.

So you frequently will start with voluntary kinds of announcements and suggestions to get people to think about the risk and to begin to comply, or just as "the patriotic thing to do." First, you have to warn people that, in fact, fleeing an area when it's likely to be fairly contagious, you don't know that you won't be going to another area that may already have as much as where you are. Second, if you're going to another area where you have family or friends, if you already have the illness but you're still without symptoms, you may actually carry it to those other individuals.

One of the unfortunate things that's happened over the last several decades is much of our grassroots community public health workers are gone. When there was a smallpox outbreak in New York City back in 1949, there were strong relationships with the New York City health department and its various diverse communities, and when the public media program went out, they were able to reinforce it in a community-by-community, trusted way, unlike what happened back in 1894 in Milwaukee, when they got too draconian with quarantine. It was perceived as being unfair, that only poor people or particular ethnic or racial groups were being restricted where others in richer neighborhoods were not. They had riots and many more deaths, and difficulty controlling it.

So a lot of this has to do with, is there trust? Are there adequate numbers of people at the local level to make sure that that one-on-one and group reinforcement of whatever messages we put out there are going to be consistent with whatever we try to tell people through the mass media?

The next thing is, if you've heard about it, if you've thought about it ahead of time, if you know that government has at least been talking about it some, if they've come to your schools and your workplace and talked about having contingency plans, and you've thought through how are you going to manage potentially four to six months where, for significant periods of time, you may have at most half the employees there, because the other half are either ill or taking care of other ill ones and can't come in to work, do you have mechanisms to get the job done? Those are the kinds of things that we're starting to discuss at the grassroots level.

We've lost some of our social fabric in this country, and we tend to expect the magic bullet or a hospital to "save us." Well, we're going to have hundreds of times, potentially, more people ill that want a hospital bed than there will be hospital beds. So we're going to be back to what we were in 1918-19, which is family and friends are taking care of loved ones at home. Do we have the systems in place to train people rapidly over cable TV on how to do that?

If you don't have 10 or 20 friends who are willing to put their life on the line helping you with a disease that may not have treatment, you may not do well. I don't know that we've talked to people much about that in a while, but there's a lot of reasons for having social connections and being in social support groups, and this may be one of the real survival factors if we have a pandemic.

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12. Strengthening the public health system, domestically and worldwide

MODERATOR: Howard, way back when, you made the statement alluding to the fact that here in the U.S. certainly, and in many other countries, the public health system is, I think you used the phrase "in a shambles." Is it because of what Rex was alluding to, that somehow or other in the developed world, and particularly in the U.S., we tended to say, "Well, we have enough hospitals and doctors and new medicines, and what have you, that we don't really have to invest in preventive health anymore, in public health anymore"? Is that the reason we're in a shambles now? Because it seems to me that every time something comes up, whether it's an anthrax scare or SARS or now potentially avian flu, that these show us the flaws in the system, how deep those flaws are and how they need correcting. And you sit and wonder, how did we get in that position in the first place?

MARKEL: Well, all of the above, yes. It's one of the great paradoxes of public health that if it's doing its job well, it's silent, and you don't have outbreaks, and you don't have problems, and so then when it's time to reassess the budget for that public health department — local, state, national, what have you — people tend to say: "Well, why do we have to put a billion dollars into that? We don't have that problem anymore. That's conquered; that's done."

And that's particularly true of the late 20th century. We've really gotten kind of complacent, fat and lazy really, because if you were born in 1900 — 1880, let's say — as a child in America, you had a one-in-five chance of not actually making your first birthday. Everyone knew death because of contagious and infectious diseases on a level much more common than today, where less than 10 babies die per 1,000 born in the United States. That's a rather high rate for developed nations, but most of those babies die because of prematurity or congenital birth defects, not because of infectious diseases.

But we've tended to say: "There's always medicines. And oh, if those antibiotics become resistant, we'll come up with new ones," or, "The medical-industrial complex will save us; it always has in the last 50 or 60 years." But I would contend that's really been an artifact of human history; it's only been in the last 50 or 60 or 70 years that we could do things on such a definitive level in terms of antibiotics and for most vaccines.

But the thing about public health mechanisms — it's preventive maintenance. And it's not just a U.S. problem; I think it's a postmodern problem in the developed, Westernized world. We don't tend to think about problems until they're staring us in the face, and the best public health work is done well before that ever happens. That's what we have to do.

That's what I think is so wonderful about this show, the [Prescription] for Survival show, and the efforts of many, many, many people in the world of public health and medicine, journalism, reporting, what have you. We're all talking about this dialogue that, "You know, this is not something we can afford to take for granted." It's an issue not only of a public good, as we've discussed earlier on this discussion; it's also an issue of survival.

If we let these problems get out of hand because we've, like an ostrich, put our head in the sand, it doesn't mean the problem or the world has gone away; it just means we're not looking at it. And if we continue to not look at it, we'll look at it much more closely than we ever hoped to.

MODERATOR: If we strengthen the public health system significantly in this country, and perhaps one day even give more strength and perhaps power to global agencies, this will help across the board, won't it?

DAULAIRE: Oh, absolutely. That's one of the clear messages from Rx for Survival, is that we really are in this together, and that a public health system protects everyone, not just the people right around it, and not even just the people in that country. We are dependent on the public health system in Indonesia and China and the Republic of the Congo as much as we are on our county public health system. This really is a common investment for the protection of all of us.

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13. Resistance to penicillin and other antibiotics

MODERATOR: One question that is just personally very intriguing — "If an antibiotic such as penicillin was removed from use for an extended period of years, would bacteria that are now resistant to penicillin lose their resistance to it and make penicillin effective once again?"

DAULAIRE: To some degree. Again, this is all about natural selection and evolution of bugs. I think it was Rex who talked about the way that bugs replicate. They're sloppy replicators. They make a lot of copies that are exactly the same as them, and they make quite a few copies that are a little bit different, and those different ones that had a resistance gene had an advantage in a world awash with penicillin and other antibiotics, and so you saw more and more of those.

If you removed a particular antibiotic, whether it's penicillin or something else, from the environment — which, by the way, isn't likely to happen; [it's] conjecture — if you did that, there would no longer be a selective pressure to select for organisms that were resistant to that, so there would probably be a trend back to a more sensitive bug, because everything has a cost. If you have a gene for resistance against penicillin, it's probably costing the organism something in terms of its metabolic performance. So yes, but I guess the bottom line is yes, but so what? Because it's not ever likely to happen.

ARCHER: There's some small exceptions or potential issues, where sometimes there's a plasmid that may have several resistances on it. Unless you removed almost all of those antibiotics, then you're not going to necessarily change the selection process, other than some potential errors in replication over time. But yeah, I would agree that's not likely to be an extremely useful [hypothetical scenario]. It's probably much better to make sure that the new antibiotics that are developed are clearly held in reserve for the right times and the right situations, and that they don't end up going global in some way or being misused.

DAULAIRE: There is, though, a practical angle on this, which is the widespread use of antibiotics in animal husbandry, veterinary care, particularly in terms of industrial animal production. There's no question that that is a major contributor to the development and dissemination of antibiotic resistance, and the more that is brought under control and stopped as a growth enhancement, the better protected we will be.

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14. Investing in technology, the developing world, and early education

MODERATOR: If you all were the czars of the U.S. Public Health Service now, and you had the ability to build up or make better one thing that would help not only perhaps here but also abroad, what would you do?

DAULAIRE: I would do two things. I would focus on that forward deployment of detection and response on the front lines of disease emergence, which is in the developing world. I would make very significant commitments in that arena, recognizing that that's going to protect Americans. That's the first thing.

The second thing is, I would make a major investment in technology to give us the capability — we know that new diseases are always going to emerge; the front-line deployment will slow it down. But we also have to be ready with vaccines and possibly drugs. We've got to be able to turn around, identify a new pathogen, and have something ready to mass-produce on very short notice. That requires a whole new conceptualization of vaccine technology that I think we're scientifically able to do, but practically not, because the investments haven't been there.

MARKEL: I agree thoroughly with Nils. The one issue is, of course, focus on the developing world, because that's where a lot the emerging infections are coming up and where the most impoverished, if extant, public health systems exist. Technology also is critical.

And I would just add one other thing to those two points to a czardom. We also have to encourage young people to enter careers in medicine and public health, on the front lines, in the back lines, as researchers, and so on. We have to inspire them to do this kind of work and make sure that they can advance and take over the mantles from those who are doing it so well right now.

ARCHER: I'll go to another area that I think is a tremendous missed opportunity. We really fail to help people reach their potential in this country from preconceptual health, and appropriately even planning to bring somebody into the world to making sure that there's strong bonding occurring between the infant and mother, and that that infant sees other human beings as fellow human beings, and that they have the right-brain development and social development in that first three or four years of life.

By waiting until kindergarten for formal education, we're missing a lot of what needs to happen. I carry that scenario a little bit farther in the fact that we have a science-illiterate culture in this country. Unfortunately, as we've learned with math in many cases, elementary ed teachers maybe have had difficulty with math, and that's one of the reasons they picked elementary ed when they were in college. We've had to go to even specialty math teachers to make sure that our elementary students are being taught by people that are enthusiastic about math and understand math and love it, and can convey that to the kid.

The same thing occurs with educators in science. We haven't fixed the problem of not getting kids to understand and encourage them to love science even before they get to kindergarten. At the rate that the world's changing, if we don't do that, I think we're going to have some serious problems. Our policymakers don't have the science background to understand the issues that they're being confronted with, and to the degree that we are a world economic power, we're not taking these issues responsibly, and we don't have the knowledge to take them responsibly.

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15. Final Thoughts

ARCHER: It would be nice for people that are reading in on this, that if they've not heard the river parable in public health, it would be good to have a brief description of that, because I think it helps to get at this issue. It's part of the challenge that our capitalistic, materialistic world [faces]. For those of you that have heard it, I apologize for telling it again quickly.

You're walking along a river and you hear a cry for help, and somebody's in trouble and you tie off a rope, go out and get the person, perform artificial resuscitation and save a life. And you're about to celebrate that, but then you hear more cries for help, and you look out and now there's a dozen people, and you can only save maybe one out of 10. People are drowning before they even get to your post, and many are going by.

Now you've got a dilemma: do you go upstream and find out why people are getting in the water and work with those communities and educate them, and figure out whether you need to build a bridge or a swimming pool? Or some people are still going to get in the water, but at least you can make them wear lifejackets and helmets. Or do you stay downstream and decide to charge people for pulling them out of the water when they're more motivated, and they'll pay more money?

That's really the dilemma that we're in. Going upstream is tough work, and it's hard to make a living doing it, whereas you can stay downstream and pull people out, the few you can pull out. You can even get paid for the ones that you don't pull out a lot of times.

Expert Panel

Dr. Rex Archer

Director of Health for the City, Kansas City, MO

Dr. Nils Daulaire

President and CEO, Global Health Council

Dr. Howard Markel

Professor of the History of Medicine & Professor of Pediatrics and Communicable Diseases, University of Michigan

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