Laurie Garrett: What can we learn from the 1918 flu?

199,329 views ・ 2009-04-30

TED


Please double-click on the English subtitles below to play the video.

00:12
So the first question is, why do we need to
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even worry about a pandemic threat?
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What is it that we're concerned about?
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When I say "we," I'm at the Council on Foreign Relations.
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We're concerned in the national security community,
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and of course in the biology community and the public health community.
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While globalization has increased travel,
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it's made it necessary that everybody be everywhere,
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all the time, all over the world.
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And that means that your microbial hitchhikers are moving with you.
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So a plague outbreak in Surat, India
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becomes not an obscure event, but a globalized event --
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a globalized concern that has changed the risk equation.
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Katrina showed us
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that we cannot completely depend on government
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to have readiness in hand, to be capable of handling things.
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Indeed, an outbreak would be multiple Katrinas at once.
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Our big concern at the moment is a virus called H5N1 flu --
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some of you call it bird flu --
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which first emerged in southern China, in the mid-1990s,
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but we didn't know about it until 1997.
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At the end of last Christmas only 13 countries had seen H5N1.
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But we're now up to 55 countries in the world,
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have had this virus emerge,
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in either birds, or people or both.
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In the bird outbreaks we now can see
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that pretty much the whole world has seen this virus
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except the Americas.
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And I'll get into why we've so far been spared in a moment.
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In domestic birds, especially chickens,
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it's 100 percent lethal.
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It's one of the most lethal things we've seen
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in circulation in the world
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in any recent centuries.
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And we've dealt with it by killing off lots and lots and lots of chickens,
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and unfortunately often not reimbursing the peasant farmers
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with the result that there's cover-up.
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It's also carried on migration patterns
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of wild migratory aquatic birds.
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There has been this centralized event
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in a place called Lake Chenghai, China.
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Two years ago the migrating birds
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had a multiple event
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where thousands died because of a mutation occurring
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in the virus,
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which made the species range broaden dramatically.
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So that birds going to Siberia, to Europe, and to Africa
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carried the virus, which had not previously been possible.
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We're now seeing outbreaks in human populations --
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so far, fortunately, small events,
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tiny outbreaks, occasional clusters.
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The virus has mutated dramatically in the last two years
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to form two distinct families, if you will,
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of the H5N1 viral tree
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with branches in them,
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and with different attributes that are worrying.
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So what's concerning us? Well, first of all,
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at no time in history have we succeeded in making
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in a timely fashion, a specific vaccine
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for more than 260 million people.
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It's not going to do us very much good in a global pandemic.
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You've heard about the vaccine we're stockpiling.
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But nobody believes it will actually be particularly effective
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if we have a real outbreak.
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So one thought is:
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after 9/11, when the airports closed,
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our flu season was delayed by two weeks.
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So the thought is, hey, maybe what we should do is just
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immediately -- we hear there is H5N1 spreading from human to human,
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the virus has mutated to be a human-to-human transmitter --
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let's shut down the airports.
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However, huge supercomputer analyses,
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done of the likely effectiveness of this,
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show that it won't buy us much time at all.
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And of course it will be hugely disruptive in preparation plans.
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For example, all masks are made in China.
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How do you get them mobilized around the world
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if you've shut all the airports down?
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How do you get the vaccines moved around the world
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and the drugs moved, and whatever may or not be available that would work.
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So it turns out that shutting down the airports is counterproductive.
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We're worried because this virus, unlike any other flu
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we've ever studied, can be transmitted by eating raw meat
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of the infected animals.
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We've seen transmission to wild cats and domestic cats,
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and now also domestic pet dogs.
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And in experimental feedings to rodents and ferrets,
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we found that the animals exhibit symptoms never seen with flu:
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seizures, central nervous system disorders, partial paralysis.
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This is not your normal garden-variety flu.
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It mimics what we now understand
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about reconstructing the 1918 flu virus,
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the last great pandemic,
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in that it also jumped directly from birds to people.
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We had evolution over time,
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and this unbelievable mortality rate in human beings:
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55 percent of people who have become infected
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with H5N1 have, in fact, succumbed.
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And we don't have a huge number of people
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who got infected and never developed disease.
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In experimental feeding in monkeys
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you can see that it actually downregulates
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a specific immune system modulator.
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The result is that what kills you
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is not the virus directly, but your own immune system overreacting, saying,
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"Whatever this is so foreign I'm going berserk."
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The result: most of the deaths
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have been in people under 30 years of age,
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robustly healthy young adults.
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We have seen human-to-human transmission
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in at least three clusters --
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fortunately involving very intimate contact,
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still not putting the world at large at any kind of risk.
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05:03
Alright, so I've got you nervous.
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Now you probably assume, well the governments are going to do something.
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And we have spent a lot of money.
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Most of the spending in the Bush administration
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has actually been more related to the anthrax results
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and bio-terrorism threat.
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But a lot of money has been thrown out at the local level and at the federal level
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to look at infectious diseases.
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End result: only 15 states
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have been certified to be able to do mass distribution
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of vaccine and drugs in a pandemic.
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Half the states would run out of hospital beds
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in the first week, maybe two weeks.
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And 40 states already have an acute nursing shortage.
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Add on pandemic threat, you're in big trouble.
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So what have people been doing with this money?
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Exercises, drills, all over the world.
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Let's pretend there's a pandemic.
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Let's everybody run around and play your role.
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Main result is that there is tremendous confusion.
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Most of these people don't actually know what their job will be.
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And the bottom line, major thing that has come through
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in every single drill: nobody knows who's in charge.
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Nobody knows the chain of command.
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If it were Los Angeles, is it the mayor, the governor,
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the President of the United States, the head of Homeland Security?
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In fact, the federal government says it's a guy called
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the Principle Federal Officer,
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who happens to be with TSA.
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The government says
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the federal responsibility will basically be
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about trying to keep the virus out, which we all know is impossible,
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and then to mitigate the impact
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primarily on our economy.
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The rest is up to your local community.
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Everything is about your town, where you live.
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Well how good a city council you have,
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how good a mayor you have -- that's who's going to be in charge.
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Most local facilities would all be competing
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to try and get their hands on their piece
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of the federal stockpile of a drug called Tamiflu,
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which may or may not be helpful -- I'll get into that --
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of available vaccines, and any other treatments,
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and masks, and anything that's been stockpiled.
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And you'll have massive competition.
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Now we did purchase a vaccine, you've probably all heard about it,
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made by Sanofi-Aventis.
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Unfortunately it's made against the current form of H5N1.
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We know the virus will mutate. It will be a different virus.
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The vaccine will probably be useless.
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So here's where the decisions come in.
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You're the mayor of your local town.
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Let's see, should we order that all pets be kept indoors?
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Germany did that when H5N1 appeared in Germany last year,
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in order to minimize the spread
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between households by household cats, dogs and so on.
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What do we do when we don't have any containment rooms
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with reverse air that will allow the healthcare workers
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to take care of patients?
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These are in Hong Kong; we have nothing like that here.
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What about quarantine?
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During the SARS epidemic in Beijing quarantine did seem to help.
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We have no uniform policies
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regarding quarantine across the United States.
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And some states have differential policies, county by county.
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But what about the no-brainer things? Should we close all the schools?
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Well then what about all the workers? They won't go to work
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if their kids aren't in school.
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Encouraging telecommuting? What works?
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Well the British government did a model of telecommuting.
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Six weeks they had all people in the banking industry
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pretend a pandemic was underway.
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What they found was, the core functions --
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you know you still sort of had banks,
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but you couldn't get people to put money in the ATM machines.
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Nobody was processing the credit cards.
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Your insurance payments didn't go through.
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And basically the economy would be in a disaster state of affairs.
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And that's just office workers, bankers.
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We don't know how important hand washing is for flu --
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shocking. One assumes it's a good idea to wash your hands a lot.
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But actually in scientific community there is great debate
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about what percentage of flu transmission between people
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is from sneezing and coughing
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and what percentage is on your hands.
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The Institute of Medicine tried to look at the masking question.
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Can we figure out a way, since we know we won't have enough masks
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because we don't make them in America anymore,
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they're all made in China --
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do we need N95? A state-of-the-art, top-of-the-line,
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must-be-fitted-to-your-face mask?
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Or can we get away with some different kinds of masks?
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In the SARS epidemic, we learned in Hong Kong
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that most of transmission was because
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people were removing their masks improperly.
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And their hand got contaminated with the outside of the mask,
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and then they rubbed their nose. Bingo! They got SARS.
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It wasn't flying microbes.
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If you go online right now, you'll get so much phony-baloney information.
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You'll end up buying -- this is called an N95 mask. Ridiculous.
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We don't actually have a standard
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for what should be the protective gear for the first responders,
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the people who will actually be there on the front lines.
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And Tamiflu. You've probably heard of this drug,
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made by Hoffmann-La Roche, patented drug.
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There is some indication
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that it may buy you some time in the midst of an outbreak.
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Should you take Tamiflu for a long period of time,
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well, one of the side effects is suicidal ideations.
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A public health survey analyzed the effect
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that large-scale Tamiflu use would have,
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actually shows it counteractive
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to public health measures, making matters worse.
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And here is the other interesting thing:
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when a human being ingests Tamiflu, only 20 percent
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is metabolized appropriately
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to be an active compound in the human being.
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The rest turns into a stable compound,
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which survives filtration into the water systems,
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thereby exposing the very aquatic birds that would carry flu
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and providing them a chance
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to breed resistant strains.
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And we now have seen Tamiflu-resistant strains
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in both Vietnam in person-to-person transmission,
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and in Egypt in person-to-person transmission.
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So I personally think that our life expectancy
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for Tamiflu as an effective drug
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is very limited -- very limited indeed.
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Nevertheless most of the governments
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have based their whole flu policies
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on building stockpiles of Tamiflu.
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Russia has actually stockpiled enough
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for 95 percent of all Russians.
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We've stockpiled enough for 30 percent.
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When I say enough, that's two weeks worth.
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And then you're on your own because
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the pandemic is going to last for 18 to 24 months.
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Some of the poorer countries
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that have had the most experience with H5N1 have built up stockpiles;
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they're already expired. They are already out of date.
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What do we know from 1918,
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the last great pandemic?
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The federal government abdicated most responsibility.
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And so we ended up with this wild patchwork of regulations
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all over America.
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Every city, county, state did their own thing.
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And the rules
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and the belief systems were wildly disparate.
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In some cases all schools, all churches,
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all public venues were closed.
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The pandemic circulated three times in 18 months
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in the absence of commercial air travel.
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The second wave was the mutated, super-killer wave.
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And in the first wave we had enough healthcare workers.
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But by the time the second wave hit
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it took such a toll among the healthcare workers
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that we lost most of our doctors and nurses that were on the front lines.
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Overall we lost 700,000 people.
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The virus was 100 percent lethal to pregnant women
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and we don't actually know why.
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Most of the death toll was 15 to 40 year-olds --
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robustly healthy young adults.
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It was likened to the plague.
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We don't actually know how many people died.
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The low-ball estimate is 35 million.
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This was based on European and North American data.
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A new study by Chris Murray at Harvard
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shows that if you look at the databases that were kept
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by the Brits in India,
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there was a 31-fold greater death rate among the Indians.
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So there is a strong belief that in places of poverty
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the death toll was far higher.
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And that a more likely toll
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is somewhere in the neighborhood of 80 to 100 million people
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before we had commercial air travel.
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So are we ready?
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As a nation, no we're not.
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And I think even those in the leadership
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would say that is the case,
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that we still have a long ways to go.
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So what does that mean for you? Well the first thing is,
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I wouldn't start building up personal stockpiles of anything --
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for yourself, your family, or your employees --
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unless you've really done your homework.
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What mask works, what mask doesn't work.
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How many masks do you need?
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The Institute of Medicine study felt that
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you could not recycle masks.
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Well if you think it's going to last 18 months,
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are you going to buy 18 months worth of masks
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for every single person in your family?
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We don't know -- again with Tamiflu,
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the number one side effect of Tamiflu is
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flu-like symptoms.
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So then how can you tell
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who in your family has the flu
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if everybody is taking Tamiflu?
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If you expand that out to think of a whole community,
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or all your employees in your company,
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you begin to realize how limited
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the Tamiflu option might be.
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Everybody has come up to me and said,
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well I'll stockpile water or, I'll stockpile food, or what have you.
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But really? Do you really have a place
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to stockpile 18 months worth of food? Twenty-four months worth of food?
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Do you want to view the pandemic threat
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the way back in the 1950s
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people viewed the civil defense issue,
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and build your own little bomb shelter for pandemic flu?
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I don't think that's rational.
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I think it's about having to be prepared
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as communities, not as individuals --
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being prepared as nation,
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being prepared as state, being prepared as town.
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And right now most of the preparedness
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is deeply flawed.
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And I hope I've convinced you of that,
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which means that the real job is go out and
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say to your local leaders,
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and your national leaders,
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"Why haven't you solved these problems?
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Why are you still thinking that
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the lessons of Katrina do not apply to flu?"
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And put the pressure where the pressure needs to be put.
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But I guess the other thing to add is,
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if you do have employees, and you do have a company,
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I think you have certain responsibilities
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to demonstrate that you are thinking ahead for them,
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and you are trying to plan.
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At a minimum the British banking plan showed that
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telecommuting can be helpful.
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It probably does reduce exposure
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because people are not coming into the office and coughing on each other,
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or touching common objects
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and sharing things via their hands.
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But can you sustain your company that way?
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Well if you have a dot-com, maybe you can.
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Otherwise you're in trouble.
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Happy to take your questions.
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(Applause)
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Audience member: What factors determine the duration of a pandemic?
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Laurie Garret: What factors determine the duration of a pandemic, we don't really know.
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I could give you a bunch of flip, this, that, and the other.
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But I would say that honestly we don't know.
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Clearly the bottom line is
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the virus eventually attenuates,
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and ceases to be a lethal virus to humanity,
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and finds other hosts.
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But we don't really know how and why that happens.
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It's a very complicated ecology.
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Audience member: What kind of triggers are you looking for?
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You know way more than any of us.
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To say ahh, if this happens then we are going to have a pandemic?
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LG: The moment that you see any evidence
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of serious human-to-human to transmission.
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Not just intimately between family members
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who took care of an ailing sister or brother,
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but a community infected --
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spread within a school,
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spread within a dormitory, something of that nature.
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Then I think that there is universal agreement
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now, at WHO all the way down:
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Send out the alert.
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Audience member: Some research has indicated that statins can be helpful.
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Can you talk about that?
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LG: Yeah. There is some evidence that taking Lipitor
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and other common statins for cholesterol control
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may decrease your vulnerability
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to influenza.
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But we do not completely understand why.
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The mechanism isn't clear.
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And I don't know that there is any way
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responsibly for someone to start
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medicating their children
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with their personal supply of Lipitor or something of that nature.
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We have absolutely no idea what that would do.
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You might be causing some very dangerous outcomes
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in your children, doing such a thing.
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Audience member: How far along are we in being able to determine
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whether someone is actually carrying, whether somebody has this
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before the symptoms are full-blown?
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LG: Right. So I have for a long time said
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that what we really needed was a rapid diagnostic.
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And our Centers for Disease Control
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has labeled a test they developed
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a rapid diagnostic.
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It takes 24 hours in a very highly developed laboratory,
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in highly skilled hands.
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I'm thinking dipstick.
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You could do it to your own kid. It changes color.
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It tells you if you have H5N1.
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17:28
In terms of where we are in science
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with DNA identification capacities and so on,
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it's not that far off.
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But we're not there. And there hasn't been the kind of investment to get us there.
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17:43
Audience member: In the 1918 flu I understand that
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they theorized that there was some attenuation
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of the virus when it made the leap into humans.
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Is that likely, do you think, here?
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I mean 100 percent death rate
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is pretty severe.
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LG: Um yeah. So we don't actually know
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what the lethality was
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of the 1918 strain to wild birds
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before it jumped from birds to humans.
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It's curious that there is no evidence
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of mass die-offs of chickens
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or household birds across America
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before the human pandemic happened.
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That may be because those events
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were occurring on the other side of the world
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where nobody was paying attention.
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But the virus clearly
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went through one round around the world
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in a mild enough form
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that the British army in World War I
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actually certified that it was not a threat
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and would not affect the outcome of the war.
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And after circulating around the world
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came back in a form that was tremendously lethal.
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What percentage of infected people were killed by it?
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Again we don't really know for sure.
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It's clear that if you were malnourished to begin with,
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you had a weakened immune system,
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you lived in poverty in India or Africa,
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your likelihood of dying was far greater.
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But we don't really know.
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Audience member: One of the things I've heard is that
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the real death cause when you get a flu is the associated pneumonia,
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and that a pneumonia vaccine
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may offer you 50 percent better chance of survival.
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LG: For a long time, researchers in emerging diseases
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were kind of dismissive of the pandemic flu threat
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on the grounds that
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back in 1918 they didn't have antibiotics.
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And that most people who die of regular flu --
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which in regular flu years
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is about 360,000 people worldwide,
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most of them senior citizens --
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and they die not of the flu but because the flu gives an assault to their immune system.
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And along comes pneumococcus
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or another bacteria, streptococcus
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and boom, they get a bacterial pneumonia.
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But it turns out that in 1918 that was not the case at all.
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And so far in the H5N1 cases in people,
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similarly bacterial infection
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has not been an issue at all.
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It's this absolutely phenomenal disruption of the immune system
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that is the key to why people die of this virus.
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And I would just add
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we saw the same thing with SARS.
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So what's going on here is your body says,
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your immune system sends out all its sentinels and says,
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"I don't know what the heck this is.
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We've never seen anything even remotely like this before."
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It won't do any good to bring in the sharpshooters
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because those antibodies aren't here.
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And it won't do any good to bring in the tanks and the artillery
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because those T-cells don't recognize it either.
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So we're going to have to go all-out thermonuclear response,
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stimulate the total cytokine cascade.
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The whole immune system swarms into the lungs.
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And yes they die, drowning in their own fluids, of pneumonia.
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But it's not bacterial pneumonia.
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And it's not a pneumonia that would respond to a vaccine.
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And I think my time is up. I thank you all for your attention.
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(Applause)
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