Elisabeth Rosenthal: Do you have a sense of what fraction—I am not asking for 18 percent versus 54 percent—what portion of companies have thought about this?
Donald G. Ainslie: Unfortunately I am not overly optimistic, and the reason being is that I think the folks I have been working with in trying to advise is a lot of folks are looking at the government. The government is going to take care of them. As I have described with the adjust in time economy, that is not going to be there. The government is not going to build or provide you help in this pandemic. It is important that the companies prepare. To answer your question, I think it is a very small percentage.
Elisabeth Rosenthal: We talk a lot about surveillance. Obviously we saw with SARS, one person with the virus gets sick, gets on a plane, goes to Hong Kong, gets in an elevator with some people, and in this time of global travel, your virus is spread to I think half a dozen different countries in that case. And that was with a virus that was not particularly contagious. To Dr. Nabarro, how do you get surveillance and detection refined? Let's not even talk about getting someone flying from Guangzhou to Hong Kong. But in rural Indonesia, how do you get surveillance to the point where a guy with a runny nose and a cough thinks 'Could I have bird flu?'
David Nabarro: So in rural Thailand in early 2005, when they were starting to have human cases, the Thai's entire authorities made use of the million village health volunteers that exist in their country who were trained very rapidly to identify individuals with flu like symptoms and to make sure that they were followed up and that necessary specimens were taken. An interesting case, they did turn out to be human cases of avian influenza. They were detected and then managed. When you engage communities in that kind of surveillance—we have seen it also in Vietnam and China to perhaps a lesser extent Indonesia—when you engage the community in a participatory way you will get certain people identified as sick who have not actually turned out to have got any kind of unpleasant bug. So there is a degree of false positivity, but it is the only way to do is to have communities engaged. For example, from the bird flu reporting in Indonesia, the technique that people use is their cell phones, and they send text messages to central points which then lead to action which is then undertaken fairly rapidly in order to bring the issue under control. So there will be much more use of modern reporting techniques like cell phones. China for example has invested hugely in building a more efficient and streamlined reporting system from provinces to headquarters to try and make sure that information comes through. It is then reported to the World Health Organization in the case of human sickness or the World Organization for Animal Health in the case of bird illness. I think Asia is better prepared to do this kind of thing than just about anywhere else. They've had the experience of SARS; they have been living with Avian Influenza for a number of years and with human cases. There are other parts of the world that are much less well prepared. So the world Health Organization and the other organizations with whom I work are investing massively in making sure that the international regulations on disease reporting whether for animals or for humans are being properly implemented. Are we doing it well enough? Well, we never do things as well as we would like to, but I think we have the architecture there. We have the frameworks there. What remains is the political will to ensure that this kind of reporting is done properly and is done transparently. I think that there are people in the audience who may have views whether or not we have actually reached the point where we can be confident that we will all know when untoward incidences occur. Personally I think we have some way to go.
Elisabeth Rosenthal: Are you getting enough cooperation at the very local level. It is very easy for a government to say we have a good surveillance system, we have fifty-five surveillance points throughout the country, but as we have seen again and again, in Turkey I say and certainly in China we see re-introductions over the boarder into Vietnam. There is clearly bird flu going on out there that UN agencies—whether it is FAO or WHO—are not hearing about very quickly.
David Nabarro: I think it is very difficult. One of the real challenges in some of the cases that you have identified is that people who are poor and are depending on chickens, ducks, turkeys, quail for their livelihoods, when they find them getting sick, are not going to start rushing to the nearest government employee and saying, 'my chickens are sick' because they know that not only will they lose their birds, but the whole village and near by village will lose their birds as well. They feel very anxious that they are going to be stigmatized for being the snitch that went and told the story. So they usually rather keep these things quiet. The result is that we don't get full reporting. Unless we can get really effective compensation programs in place so that when farmers report the fact they have sick birds, they will get immediate compensation. Unless we can make sure that if humans are sick, that the villages are treated not only with respect but also treated as heroes if they have reported what they have got going on to the authorities. Unless we move to that kind of positive incentive for communication reporting, people will go on hiding things. We just heard a bit about clustering in northern Sumatra in April or May this year, and the truth is that the villages were really very scared of telling authorities that they were sick because they were worried that then bad things would happen to the village. So the business of creating trust between authorities and village people who are experiencing these kind of diseases have still got some way to go. I think that is probably the area where I am most preoccupied at the moment is building that relationship so that we won't get disease incidents hidden.
Elisabeth Rosenthal: One more question for Andrew Ericson. Why should the U.S. be concerned with Avian Influenza? Here we are, there has been no animal cases in the U.S., there is clearly no human cases. Why is it in the U.S.'s interests to worry about this far away disease in Asia and what can we do?
Andrew Erickson: Well first of all I would say it is not a far away disease. I am myself not an expert on infectious diseases, but every time I talk to my friends and contacts who are, I am continually reminded just what a risk this is in this era of unprecedented global connectivity, especially of people over airlines. We really do face the same threat nearly at the same time. My understanding is that over the past three centuries we've had roughly ten global pandemics. If—god forbid—we have number eleven, it would occur in this climate. This brings up some personal memories on my part. I know you were in Beijing during SARS. I was hoping to be studying Chinese in Beijing. Instead I had to stick on the Princeton University campus for the whole summer. But I think it gave a false sense of security about where things are located. I later became more educated about this when my sister was teaching in Thailand and there were some concerns about the H5N1 strain increasing in its incidents. So I got on the phone with my father, and we looked up on the internet, how do we send her Tamiflu. I did all these things, and then I realized that I had been to the airport in providence Rhode Island earlier that day. So what I was seeing as this artificial construct of some risk being far far away was completely inaccurate. The speed with which this can and will travel is extremely disturbing. That alone should be the reason why the U.S. is trying to prepare and help others prepare as well as possible. I think it is absolutely a no brainer.