 Good morning. Thank you all for being with us. I'm Steve Morse from CSIS, both health analysis center. We're here today to have an informal and interactive roundtable-style discussion around some of the key dimensions of the swine flu influenza pandemic. And we realize this is very much a story that's still unfolding. So this is meant to be somewhat of a mid-course sort of view of where are things. And we've picked three terrific speakers. Brink, who I'll introduce in a moment to talk to three special dimensions of this. What do we see and what do we know? I'll ask each one of them to open up with six-day intensive-focused comments in that particular area. And then we'll have more of a roundtable-style discussion. Ron Waldman at the far end here is a professor at Columbia University of the Mailman School and works at USAID on the pandemic influenza, has a long career working with CDC, with WHO, with the Mailman School, with the US government on humanitarian crises and humanitarian crisis response. And on infectious disease control efforts, has worked on many different walks over the course of his career and has been, for us, a very valuable source of perspective over the last several years, particularly with respect to the avian influenza, where he's played a lead role in thinking about that design programmatic responses. We're going to ask Ron to open up with some commentary about the course that this pandemic has taken. What have we seen in terms of levels of preparedness and response? What are some of the early lessons? And looking forward, how is the US government beginning to think about its the next phase of response? Steve Schrage, who is the sole chair here at CSIS, comes with a very long and distinguished background, predominantly focused upon international economic policy issues. He has served at the Department of State, US Trade Representative's Office, in the congressional leadership offices of many key figures up on the hill, advising on these matters. And we've asked Steve, really, to reflect on the economic impacts, the fact that an emerging threat to our own national economy and its recovery suddenly surfaced as one very important side story to this. And how has that played itself through? And what kind of insights has that generated? Next to me is Catherine Bliss, who's the deputy director of the America's Program. She is forthcoming to CSIS, was at the Ocean's Environment Sciences Bureau at State Department, working on a number of global health and biodefense issues there for a five-year period. Previous to that had a career as a senior professor, as an associate professor at the University of Massachusetts. In Amherst, she started her career looking at the history of the health sector within Mexico. She's written, as if you haven't seen already, a very insightful piece on the CSIS website, the critical questions around that. About a week back, as this was first breaking in the news, questions around the Mexican response. We've asked her to provide us a bit of an update around the way this is all playing itself through within Mexico. And beyond that, comment a bit about how the swine flu is playing in other parts of the Americas. So we've got a lot of ground to cover in that. I just want to offer just a couple of key comments around why this is somewhat of a special and unusual moment. First of all, we came out suddenly from a period of relative lull of interest in this type of pandemic threat. The shock value that was experienced around SARS, around the anthrax scares and the immediate aftermath of 9-11, avian influenza. Over time, the pattern is that there is a perception of a diminished threat. As more time elapses, and just look at the G20 statement from just a few weeks ago in London, or look at the last G8 statements or talk to folks who were involved until very recently in preparations for the G8 summit this summer. These issues were not front and center. They will be now, I expect. So we've been sort of pulled back rapidly to put new interest on this after this period of a sort of steady, slow disengagement and to some degree disinvestment in this. The second feature of this that's so profound is that it is in our neighborhood. It is US-centered. It is Mexico-centered. It puts a spotlight on a very acutely sensitive interface between the US and Mexico. And this interface had already been elevated in importance by the President, by the Secretary of State, by others, by discussions around the arms trafficking, by the hypersensitivity around the immigration debate and the economic relationships. And suddenly you add in this very new powerful element to that picture. And that, by in and of itself, makes it quite interesting in teasing it, teasing out the consequences of this. We're also in a period of a very sensitive economic downturn. And I think prior to this most recent outbreak, people wouldn't have been quite as compelled by the argument that these types of pathogens pose a direct threat to US economic security. I think folks would have said earlier that that was an overstate or that was to be proven. Suddenly this proposition is front and center in much of the discussion around that. We'll hear more from Steve and others. We're also in a period of transition of power here at home, the team, interestingly, in the response by Washington, in the evolution of response, in the creation of the interagency. It's a period where our Secretary of HHS ascends into that position right in the midst of this and goes to work immediately. Other key positions still not filled. And so that's another wrinkle and another dimension to this that further complicates the US response and tells us a little bit about, I believe, how some of these issues will be managed looking forward. This is also turning out to be a very important moment for testing the value of the achievements of the investments that were made in surveillance and protection and response capacities in those infrastructures, going back earlier in this decade. And we do know that this was a serious priority and this is something that the previous administration put considerable effort and resources into it. The question is that these investments were made on a relatively quiet basis, their infrastructure, their by definition capacities that are not front and center invisible on a day to day basis but become exceedingly important when you enter a moment like this. And so now we're facing the question of are they working well? Are they not working well? Are there gaps? We haven't, however, I think, seen the full tests of these simply because this is turning out to be a relatively mild pandemic or up to now. It may be that we don't know exactly what the future will look like. But up to now, the fact that it has not been terribly virulent in its impacts here in the United States and elsewhere has meant that the degree to which the surveillance and response capacity has been tested has been somewhat modest. We have not gotten into high volume confrontational discussions, for instance, about the ability to produce and distribute the volumes of vaccines and antivirals that will be needed under a major pandemic. For instance, that debate, we've not hit that debate. We would have hit that debate had this been more severe. Fairly rapid, we would have hit the debate around where are the key gaps in the surveillance and detection and what do we know when and where and why and the response and the measured response times and the like. Some of that is out there, but I would argue that some of it is a little less than what would have been the case if it had come on with greater speed and severity and urgency. So let me just turn now to our three speakers. They'll each speak for about six to eight minutes and then we'll make it a more round table and we'll open it up to you for comments and questions. When we do that, we'll have microphones. Folks will come around with those microphones and we just ask you all to be very succinct. One minute, one question, identify yourself and we can sort of keep things rolling. So Ron, would you, would you care to kick things up? Yeah, sure. Is it better if I hold it away from you, some? Maybe that's the problem. I told you it would be, didn't I? All right, thanks Steve. I'm always amazed by the way you can lay out an issue. I think that you touched on so many of the important points regarding this pandemic. I guess by way of introduction, I wanna say a little bit about the detection of the pandemic and what we know to date about its spread and I do wanna hit on a couple of issues, some of which you alluded to. Let me just say for now, I'm sorry. No, I'm fine, this is okay with you. You know, we've been concerned for a long time with the possible evolution of the avian influenza virus, the H5N1 virus in particular, into one that would be capable of sustained human-to-human transmission. Whenever we worry about a pandemic of viral origin, it's that we're really looking out for three characteristics of that virus. One is that we're worried about viruses that undergo genetic transformation into a kind of virus that we don't have experience with as human beings because our immune systems, once they see something are capable of mounting a response that's able to protect us in the future. When something new comes along to which we're totally defenseless, there's a real threat of a major disaster occurring. The second thing characteristic of the virus is that it needs to be shown to be able to produce disease in human beings and serious disease. Otherwise, it's a substantially less concern and the third and most important element, we've had those two things circulating out there for a long time in the form of the avian influenza virus, which is new and which we know can cause serious disease and result in the death of people and we've had around the world about 400 deaths, which people who have come in close contact with the primary source of that virus, namely the domestic poultry in most cases. But the third factor that these viruses can develop is the ability to develop sustained human to human transmission at the community level and we haven't had that in some time, although pandemics occur periodically. We had three during the last century, the most damaging of which was the first one, the 1918, 1919 so-called Spanish flu epidemic and I'll come back to some of its characteristics in the past but there were two other influenza epidemics, one in the 1960s, one in the 1970s and many of you will remember the swine flu scare that never actually developed into a pandemic but did have major political consequences for those who were involved. So what we have now is a new virus, one that we know is capable at least at times and in ways we don't understand causing really important lethal disease in human beings and which we now know is capable as well of human to human transmission, albeit perhaps as not as rapid transmission to the extent that we originally feared. Nevertheless, I'll come back to why we still can't just all go back to our day jobs. Although for me this is my day job and that's what Steve was saying is that there has been quite a lot of silence sort of below the radar preparation going on which is really important. Let me just say for those of you who didn't see the latest reports, WHO now has reported 1,124 confirmed cases around the world in 11 countries. Those countries are situated on all continents except Africa which has yet to report a confirmed case. In all through this whole scene as it's developed so far, there have been 26 confirmed deaths from this virus, 25 of them in Mexico, one in the United States in Texas which I really count as a Mexican death because the child, the 23-year-old toddler came over after falling ill with his family and died in an American hospital. So it's sort of strange that all the deaths seem to have been of Mexican origin. So then with 1,000 cases and 25 deaths, 26 deaths, why is this such a big deal? I think that's an important question to ask and well part of the answer is for all the reasons I gave regarding the characteristics of this virus. But so far I would say that our ideas regarding the severity of the virus are very incomplete. We know that it's capable of causing death at least in Mexico and we were certainly afraid of a similar pattern developing in the United States and then in other countries around the world but as Steve said in fact it seems to be much less severe now and spreading much more slowly than we would initially have thought. CDC has told us that they've done a genetic analysis of the virus and that the virulence markers that were on the 1918 virus which was also an H1N1 virus as this one is are not present on the currently circulating virus. That's okay but it doesn't really allow us to rest because the 1918 pandemic interestingly enough was odd in that it began in the Northern Hemisphere at the end of the influenza season in the springtime just as this one is. And perhaps more importantly it also had a very mild beginning and in fact the 1918 pandemic occurred in three waves that virus circled the globe three times. The first wave was quite mild just like we're seeing now and there's very little doubt but that this virus also will make its way into country after country each of which will report a few cases. In fact of the 21 cases of the 20 or so countries that have reported confirmed cases so far in 14 of those countries they're reporting fewer than five cases so there doesn't seem to be that much but we don't know for sure what the real denominator is because not everyone who gets sick with mild cold like symptoms is going to a doctor or having themselves tested. But the first wave in 1918 was quite mild and it was really only at the beginning of the next fall season that the beginning of the influenza season that it hit with tremendous impact so of course we're concerned about that to the extent that we have some time to prepare for that it would be really great but when it's the end of our influenza season in North America it's the beginning of the influenza season in the southern hemisphere so we may in fact not have all that time available and our information about how exactly the 1918 pandemic played out is incomplete so we may not have quite as much time as we like if we're concerned about what is going to happen at the beginning of the flu season in the southern hemisphere. What we've been doing to a large extent now we'll have plenty of time to talk about the response in Mexico and the United States and in other places but I do want to make the point very clearly that in addition to mounting influenza surveillance which is at a reasonably sophisticated stage and in addition to the plans that have been made to try to identify an outbreak such as this one as rapidly as possible and to try to encircle it to try to contain those initial cases to keep the virus from spreading which obviously was not done in this instance we identified it too late after it had already spread which is why there are no recommendations regarding travel restrictions and so on and so forth because it's already out of the bag but in addition to that there have been a lot of preparations made in developing countries as well as developed countries for how to deal with a full-fledged pandemic should one occur. How to deliver humanitarian assistance should a major catastrophe occur and this is really the most important point that I think deserves our attention and Steve will be talking about the economic consequences of this but the consequences are in fact more than economic of a full-fledged pandemic. So we have a situation now where United Nations has designated the Director General of the World Health Organization to be in charge of this situation which is absolutely appropriate. Here in the US the Department of Health and Human Services Centers for Disease Control and Prevention have taken the lead on the situation to date which is entirely appropriate but should this continue to spread and should we get into a situation where we begin to see large illnesses at a much larger scale than we have now that would provoke absences from all walks of life where schools all over need to be closed where transportation comes to a halt where all commerce can come to a halt then we're looking at a very different situation that's referred to as a whole of society event. There it becomes much more than a health problem and the kinds of preparations that need to be made are those that ensure the economic viability of nations, security and the prevention or moderation of civil strife which can arise as we've seen in many other situations of the past. I sometimes when I ask people to picture a pandemic just to make sure that everyone's on the same page I like to explain to people that what we're preparing for in terms of a phase six event where humanitarian assistance needs to be provided looks a lot more like what might have happened than what did happen say in Kenya during the post-election period a couple of years ago when violence broke out. There the health sector was certainly impacted and many, many people who for example were on antiretroviral treatment for age were lost the follow up. A third of the patients who were on antiretrovirals were cut off from the health system during the post-election violence. Two thirds of the patients were cut off from anti tuberculosis drugs who had been receiving them at the time. So it has an impact on this health sector that goes far beyond just influenza itself. We don't have much right now. We have antivirals, we have means of accomplishing social distancing, personal protective measures, but if it becomes really a bad situation and health facilities are overrun with people seeking care, then we have to think also what about those people who would normally die of malaria? What about those people who would normally die of other common diseases? So we've been preparing for that eventuality as well. And in the other sectors, education, commerce as well, there are a lot of contingency plans in place that take an extraordinary amount of cooperation to implement. We haven't begun that process yet, but we hopefully will have this window of opportunity with which to put those plans into place. And I think that it's worth thinking about the future of this. So Steve asked me to mention what has been done. So I'll just end my remarks by saying, yeah, we hope that this will remain mild now. Obviously it may fizzle out and nothing will happen, but we are quite concerned, everyone is quite concerned about the next flu season in North America, the upcoming season in Southern Hemisphere, North American Europe. And a tremendous amount of planning that had begun and was going on by the World Health Organization, its regional offices, the US government, which has been spending a lot of money on this. USAID has spent close to a billion dollars in the past three years in preparing for a pandemic like this, under the radar, all under the radar screen. That now becomes a lot more visible. Steve has said all of those systems have not yet been tested by a major event, but people are now moving into very high gear because of the imminent threat that's being posed by this pandemic. I don't know if the extent that people have heard me speak before, interacted with me before, I tend to be a little bit cynical and critical at times. And I'm happy to talk about some of the things that might not go so well, but I have to say that the data been really encouraged by the degree of coordination that has been achieved, not only throughout the US government, but on the international scene as well. All that time and all that effort we put into place trying to get people to work together, to work as a single entity, rather than protecting the interests of their individual agencies. That seems to have really paid off and we can go into more of the details during the general discussion. Right, thank you very much, Ron. Steve. Great, thank you for, I thought that was an excellent overview and I really thank Steve Morrison for pulling this together and what I think is such kind of a comprehensive way of looking at all the different angles of this. As was mentioned, I'll cover some of the economic aspects and I think one of the things that's been very interesting is over the last 18 months, the economic crisis has kind of caused this 180 degree turn where everyone's been focused on banking and financial issues, but I think the pandemic threat has really shown that there's many of these enduring issues that are out there that are important in their own right far apart from economics, but also are very much influenced by the economic crisis in the situation we face and in turn could have a very significant impact on that crisis, either worsening it or helping it depending on how they all play out. So I'm gonna address three main aspects of that today. First of all, kind of what's the situation we're in now? Have we escaped the worst of the short-term impacts of what's out there? Second, kind of what are the longer-term economic risk and interconnections where I think you can see some risk scenarios that are far more troubling. And then third, kind of what does this raise in terms of the broader questions about how the economic crisis is influencing this and are we prepared to deal with, you know, walking and chewing gum at the same time and dealing with this and a lot of the other threats we have that are out there and it's encouraging to hear that some of the legwork that's been done before is playing out and I think, you know, it'll be interesting to kind of delve deeper and see how this, you know, how those interactions will work. Excuse me. First of all, I think economically, the general perception is we've avoided some of the worst of the short-term outcomes. You know, I think as was mentioned, you know, we're, it was disturbing to see how quickly it spread in this kind of global, interconnected environment, but it doesn't seem to be having kind of the deeper impact that many feared. Mexico canceled many of its sporting events. It took a very aggressive response. You know, some of the estimates in Mexico City were that it was costing them 55 million a day. There's some broader estimates in terms of what it was costing Mexico a day that, you know, were more towards a one to two billion dollar impact. Estimates have ranged pretty widely. The peso fell 5.5% against the dollar as markets reacted sharply in the early days. And Citibank had already estimated that Mexico's economy was gonna contract 3.5%. The finance minister has said that this situation could add an additional 0.3 to 0.5% of GDP and others have estimated that its budget deficit could increase by 0.7% of GDP. And those sound like pretty small numbers, but GDP numbers are so huge that that can have a fairly significant impact. In terms of U.S. and global markets, it's always hard to make correlations because there's so many different things that play in the market. But if you look at a certain specific things that are linked to this challenge, they took hard hits early. Carnival cruise ride, Delta Airlines fell by 14%. Tyson's Foods, which has a large, obviously pork position, fell 12%. But overall, stocks have rebounded. There are some of the highest levels in months of this year, towards the end of this week. Another dynamic in the short term has been an excuse for protectionism. You've seen Russia, China impose these limitations on pork exports, even though the vast majority of science, at least from my understanding, shows no correlation at all in terms of threat. But it may feed into some of these broader concerns about protectionism spiraling out of control in the wake of this economic crisis and everyone turning inward. So in the short term, it seems like the greatest impact was the fear that spread rapidly through the economy and reacted, it may have been justified, again, given that we didn't know the information that was out there. But things seem to be stabilizing and getting better. And again, a lot of that's dependent on the expert's analysis of where this is going. But in the longer term, I think, this has kind of raised an issue that has dramatic economic risk over time, at least based on the estimates that we've seen. Harvard economist Robert Barrow had a piece that was out today and had been doing some work on this, said that other than wars and financial crisis, these kind of health shocks have been associated more with kind of these great depression type situations in countries, declines of GDP of 10% or more more than any other factor. If you look at the 1918 flu, there was a World Bank estimate that said that, overall world growth GDP could fall by 3 trillion. You could have a 4.8% contraction, which is a huge amount. Now again, these were done before the economic crisis, which may have lowered that number a bit already. So it may be a little bit of apples to oranges, but you can see the overall impacts are quite huge. CBO economists have said this could lower real GDP. Again, a worst case scenario may be kind of 1918 flu by 5% of GDP growth. Lower estimates could be 1.5%. And again, the SARS experience, Southeast Asia and East Asia were hit by 18 billion, 0.6% of GDP, Hong Kong fell 2.6%. So you're seeing some pretty significant economic impacts and risk of a lot more. Again, overall, the impacts may be muted in some case in terms of supply contraction because if you've already had this fall through to the economic crisis, so the overall numbers may seem less, but when you're adding to what's a really serious risk of what's called the Great Recession or even a Depression, this could be very magnified in terms of the actual impact they have on the real world and could combine with other disturbing behavior in terms of the protectionism, in terms of the nationalism, the closing of borders. I mean, things we've already seen kind of brewing at a low level globally in this period of economic contraction could gain new life or gain new excuses for moving forward. And combined impacts on particular countries could be very profound. I'm very much looking forward to some of the analysis on Mexico from the strategic standpoint. Tourism is something, obviously our estimates are 8% of the Mexico economy. And you kind of overlay that with the existing contraction. Tourism was $13 billion a year. It's the third largest source of foreign currency. You've got drug war concerns and the overall economic crisis, the contraction of trade. How are these gonna impact certain key countries and the overall dynamics going forward? So I think we've got a lot of serious long-term concerns. And then when you step back from that one step further, what are kind of the broader serious questions that this raises? You know, again, with the economic crisis in the 1930s, countries turned in where they looked primarily in the economic measures. So is this gonna dry up the ability to make investments in these critical long-term challenges and threats, particularly from our massive debt load that's being piled up in terms of economic efforts to address the direct impact of the crisis? In the developing world, is this gonna be a serious challenge in terms of increasing aid, early warning capacities? You know, some of these countries that have initially impacted have very fairly sophisticated health system. If this happened in some countries in Asia or sub-Saharan Africa where that's not the case, could this spiral out of control more quickly? And what would be the security and political impacts? And I guess overall is this gonna be kind of a wake-up call in terms of some of these dynamics? Or will it kind of be a boy who cried wolf scenario? Where I don't know the history precisely of the 1918 flu, but you could see where people pulled their kids out of school. You know, you can even see on some of the things like the drudge report, did they overreact? Were they pushing this too hard? And then if it comes back with a vengeance, later we'll be prepared to address this. Or will we use this time to build up the stocks of the equipment needed, the capacity, the coordination to move forward? And then finally, I think from this focus that we've had on the economic crisis, of talking about banking regulation and all these different challenges, it's easy to forget that the greatest lesson of the Great Depression may have been that we focused in on these economic issues and domestically and avoided these larger problems that spread across Europe in terms of authoritarianism or in Japan. Are there other threats and shocks that we may be missing over time, both in terms of pandemics, but the broader security issues that are gonna have this impact? So I think this will be a really fascinating group to discuss these with, and I look forward to all your different comments. Thanks, thank you. Make sure I get the phone. So I think the numbers that I saw before I came down here were that Mexico had about 800 confirmed cases and 25 deaths, and then Ron said 26th of you, if you consider the infant who came from Mexico and died in the United States. Just to provide a little bit of background, the right to health is part of the Mexican Constitution of 1917. Mexico has made significant progress in strengthening its health system and reaching underserved communities in recent years through conditional cash transfer programs, popular insurance for people not covered by private insurance or people who are working in the public sector. But gaps remain, especially in remote and marginal or underserved areas, making surveillance a challenge in some places. After the outbreak was announced on April 24th, President Felipe Calderón invoked emergency powers, which authorized the government to scale up its quarantine and isolation measures and to go into homes and other private spaces to conduct inspections as necessary. On April 26th, the government closed schools in Mexico City. On April 27th, it closed schools across the nation, affecting about 33 million children and university students in classes altogether. Federal offices or non-essential federal services were closed between the 1st and the 5th of May, but that's also a long holiday in Mexico, encompassing Labor Day from May 1st until Cinco de Mayo today. In Mexico City, which has borne the brunt of the epidemic, where the concentration of cases have been reported, cultural events, sports events, public gatherings have been canceled, restaurants were ordered to provide takeout service only, discos, bars, and nightclubs were closed until further notice. The health ministry has stepped up communications, instructing people how to protect themselves to practice appropriate hygiene, stay at home and seek medical help if they're sick. Mobile clinics have been mobilized to provide access to people in remote or underserved areas in rural as well as urban settings, and the Army has been mobilized to distribute face masks. I think six million or more was the last number I had heard. Just to place some, and that's just some of the basics of the response. I know we can go more into that, but just to provide a bit of the larger political context, as Steve mentioned, and Steve also mentioned, the Mexican government is currently waging a very intense campaign against drug trafficking organizations and other organized crime, especially in states in the northern part of the country along the US-Mexico border, where so much of that takes place. This has been a violent campaign with over 7,000 deaths attributed to the drug cartels since January of 2008. In this context, the government has mobilized the military to contribute to the struggle against the cartels, so basically to bolster the activities of civil police, but in some cases in the north, the Army has been brought in to maintain order where the struggle has been most intense. So there's already this larger mobilization underway. Also, Mexico has midterm congressional elections on July 5th, and the political campaigns are just now getting underway as well. So the outbreak and the sanitary alert in Mexico imposed some restrictions on public gatherings, not only in Mexico City, but across the country. In some cases that forced candidates to cancel the launches of their campaigns. One of the political parties, the Partido de la Revolución Democrática, canceled its 20-year anniversary celebration because of the sanitary alert. Some political candidates in this context are using the outbreak as a way to sort of critique the current situation and advance their own campaigns, but in Congress, the sitting Congress right now, there have also been calls for investigating what could be done better in the context of the outbreak. Does Mexico need a new national security agency to oversee these kinds of threats? Talk of bolstering the capacity of some of the agencies within the larger secretariat of health to improve response. With respect to the economic context, I know Steve has already talked a great deal about this, but before the outbreak, Mexico was already hard hit by the global economic crisis. Demand for Mexican produced consumer products was down, remittances from migrants were down. At the same time, reduced oil production led to lower levels of funding for social programs that were in the budget in Mexico. But in response to the outbreak, some countries have banned travel to Mexico or suspended it, and that includes Argentina, Cuba, China, and Ecuador. Other people are canceling travel plans on their own, and this has brought tourism to a significant slowdown, and I think I saw some estimates of cancellations that nine major conferences had been canceled, another 15 had been postponed, 10% of tours had been canceled, and 5,500 visitors per day were estimated to be lost over the course of this process. At the state level, a group of governors has now sort of vanted together and called for an action plan to stimulate the economy in the context of the outbreak and to repair Mexico's image, especially in high tourism areas, and I know Steve mentioned the considerable impact that that's estimated to have caused. At the same time, the closure of restaurants in the federal district, the closure of some offices, I think Bridgeport Tires closed its production in Mexico and other workplaces, means that many people have had to stay home either to take care of school-age children who are out of school or because their workplaces have been closed and the estimates are about, I think, seven billion pesos in the first week. I think that correlates with what was said before. On the social side, there have been a number of interesting developments. On the one hand, restaurant operators in Mexico City were deeply upset about this restriction to provide takeout service only, and there were a number of protests around the Angel of Independence on reforma in Mexico to raise the tension to the issue. They perhaps felt they were being stigmatized by food production. On the religious side, churches are keeping their doors open and available for prayer, but masses have been canceled not only in the federal district over the last week, but in other affected areas as well. With respect to popular culture and the popular sort of commenting on and responding to the outbreak, there's a video going around on YouTube which is the Cumbia della Influenza, which is sort of a dance song that talks about the Gripe Perfecta, the perfect flu, and I think invokes Indiana Jones somehow coming in and getting involved in the flu somehow. At the same time, television shows have canceled, talk shows, and with the telenovelas, they've had the so-propos, they've had to come in and re-script some of the soap operas to sort of eliminate the more passionate activity that might be portrayed, and so people are having to kind of speak their passions instead. And I think probably everyone has seen the cartoons highlighting the economic impact of the outbreak with images of pigs dressed as bank robbers running off with the bags of cash. In terms of preparedness though, to kind of take this to the larger question of preparedness, the Pan-American Health Organization has worked over the past three years not just with Mexico, but with countries throughout the region to develop and exercise national pandemic preparedness plans, that's hard to say, national pandemic preparedness plans, through the Security and Prosperity Partnership, the United States, Mexico, and Canada worked together to refine their plans to share information about them and to develop procedures for assistance. In addition, Mexico participated through Asia-Pacific Economic Cooperation activities focused on pandemic planning among the countries, not only on the Pacific in the Americas, but also in the larger Asia-Pacific context. Within the region, the United States government has undertaken a number of activities through USAID and other agencies, which we can talk about. Just to kind of talk a little bit about the response that has gone to Mexico and then to just say a few things about some of the other cases that have been reported in the region. PAHO reports that it has sent 27 experts to Mexico to help the Ministry of Health forecast demand for resources and vaccines and craft communications and messaging. The World Bank has offered Mexico emergency funds of about $205 million, not only to respond to the outbreak, but also to assess the economic impact of the outbreak. The USAID has offered Mexico $5 million in this current context, as has China, I think 1 million in cash support, but also 4 million in gear and other technical assistance. And there's a global task force working on vaccine development, which is of course involving Mexican experts as well as others in the region. I think as of this morning, in terms of cases reported, there was a confirmed case in Costa Rica, another confirmed case in Colombia, and two in El Salvador, with an additional eight suspected in Costa Rica, an additional three suspected in El Salvador, and I saw reports of sort of 12 to 20 suspected in Colombia. The context is that those are associated with people so far, they seem to be associated, according to reports with people who had traveled to Mexico. The reports in the press in those countries, the reports about the flu seem to focus more generally on the global outbreak. There are newspapers across the region have special segments focused on what's happening in North America or what the global response has been, but as more cases are reported in this particular context, there will no doubt be additional reporting and efforts for increased disease surveillance and of course cooperation throughout the Americas. So I'll stop there. Thank you very much. I wanna add just a couple of other impressions that came up in the course of listening to these three excellent presentations. One is just about the nature of the administration's response. I think that with the exception of the comment made by Vice President Biden, it was a relatively free of stumbles and it was a fairly smooth period over the last week and that traces back to President Obama's own statement during his 100 day press statement and Q&A in which he offered, I thought, a very deaf sort of statement of reassurance, of exhortation towards some basic measures of protection and it kept, was walking that delicate line of being vigilant, being careful, taking control of things as you could in terms of hand washing a little bit of social distancing but not panicking and that was, I think, terribly important in retrospect that you had that kind of message that also included acknowledgments in a very positive way of the investments that have been made by the prior administration and that we are building on this. The interaction among CDC Acting Director Besser, Secretary Napolitano and HHS Secretary Sebelius has also been, I think, quite noteworthy. When you've seen them in multiple occasions made available for extended discussions, there's been quite a bit of consistency, I thought, in terms of the messaging and so that style of outreach and engagement, I think, in retrospect, I mean, as we look back in the coming weeks at this particular moment, that proved to be terribly valuable as an aggressive, multiple media steps at a very senior level with a strong consistency of message backed by the president's own statement and I would include in that same grouping Tony Fauci and others who were there contributing to this at hearings, at public affairs shows, at special press conferences, special internet access outlets and the like. There were multiple channels that were used and that was quite interesting and I think that it did help within the American context to raise confidence and the survey work that we've seen a surface in the last week about American opinion showed that confidence was remaining reasonably strong. There are, there remains a certain levels of ignorance around the nature of transmission and kind of steps to be taken and there's more work that can be done there but basically the polling data shows that this kind of response and engagement pays off in terms of keeping people feeling reasonably comfortable about what they face and how to go ahead with this. The other thing that's been quite remarkable, I mean, Catherine's statement shows the extraordinary scale of response and complexity of response by the Mexican government and in a way we owe a great debt to the Mexicans for having been committed to undertake those multiple complex measures which were not without pain and controversy, I expect, in putting them in force. I think by comparison, getting those sorts of measures in place in the United States would have been very difficult to do and in that period in which those measures were put into place, the U.S.-Mexican bilateral dialogue seemed to stay pretty stable. I didn't, maybe I'm missing something but I don't think there was any breakdown in that period or any recriminations or any great misunderstandings along that key bilateral channel which is another thing that deserves special mention. Last thing is the, you contrast that with the confrontation between China and Mexico around the forced detentions and removals that were covered in the last day or two as against what I think has been a fairly sensitive and close dialogue between the United States and Mexico at each sort of step along the way. No one's mentioned the fact that at the scientific network level there was rather remarkable speed, it seemed to me, among the Mexican-American, Canadian and WHO-based networks at gathering the data, comparing notes, doing the sort of testing to confirm what we were dealing with across multiple test cases in a way that helped clarify the nature of this pathogen and that it was, in fact, spreading. That seems to me, the speed and quality of that seems to me relatively new. There's debates around the response time as against the discovery time or the detection time and those will go on. But overall, I think when you look back, there are some very positive stories growing out of this experience that do deserve, do deserve a mention. Why don't we open things up? What I'd like to do is take three, we'll take three quick comments or questions. Please identify yourselves and be rapid and we'll come back to our speakers and we have three right here. We'll start with, yes, right there. Judith, sorry. Hi, I'm Judith Govman. I have two quick questions. I know you said one minute, one question, but they're really very quick. If it's in one minute, it's okay. Modeling in the past has shown a reluctance to share stockpiles of countermeasures, camouflage in this case. Do we know whether there is any sharing going on or any attempt? Did Mexico request it? Are there other countries that might need it and what's the response been? And secondly, this is really the first big test for the international health regulations and there's been some question about whether WHO did or did not know early enough, tell the world early enough. I have the feeling that they did it about as quickly as it could be done. But do any of you have any comments on how the IHR actually worked in this case? Thank you. Hold for a second in the front here. There's your mic. Ed Berger, the Eurasian Medical Education Program, the Catherine Flitz, the Mexican government, as we all know, mobilized the army, as you alluded to on the issue of the drug problem. Mm-hmm. Has the assessment to mobilize it again for the health issue to compromise the drug war? Sir? I'm Stan Salad of the EA Foundation and designer of avianfluidsearch.net. My question to each of you is, how do you get your information on pandemic flu? And how would you compare your information sources to the information available to the general public? We'll come back to our other questioners in a moment. Ron, you wanna start off? Sure, let me start. In regard to the stockpile, yes, the U.S. is sharing from its national stockpile and has accommodated Mexico's request for the amount of tamiflu. It's a little bit, you know, it's always hard to sort out and that's what we're in the process of doing now is making sure that requests are compiled because frequently requests can go to different places or different requests can be made at the same place. But in regards to both tamiflu and personal protective equipment, the U.S. government's been pretty quick in providing to Mexico the amounts it did ask for pretty much. There's a lot of countries begin to ask for a lot of things and I think the most important thing in providing assistance to other countries is going to be to adopt the strategic approach because once you start responding to requests in chronological order as they come in then that throws you into a very reactive mode. And it really doesn't serve anyone very well. We have to get on top, we have to be ahead of the curve in responding to this. Obviously Mexico has very real and very concrete needs now and they are being met by U.S. government but by the international community as well. WHO has also responded to Mexican requests and WHO also has a stockpile of tamiflu and they pushed substantial amounts of their stockpile out to their regional offices for further distribution to countries when the time becomes appropriate. So it's working well. The international health regulations have worked well. What happened? Explain what that means. Yeah well, a couple of years ago there's always been a body of law called the international health regulations of which the World Health Organization has been the custodian and enforcer and it really, that's why you have for example, well, it just hasn't been very good. A couple of years ago, those international health regulations were reformed and became a big undertaking of WHO. It was approved by the General Assembly and so on and so forth. It calls now for all countries to develop the capacity to identify public health emergencies of international concern as quickly as possible and to report them through WHO to the international community. Even if they don't, WHO is empowered to kind of be more aggressive in their identification of these events when they do occur and there are three or four diseases that are stipulated in the international health regulations of which pandemic influenza is one. That's why countries are reporting as much as they are and we know about them. It's a testament to the compliance with the international health regulations which is something new. You can understand why countries might be reluctant to comply because you mentioned the sanctions that have been put on Mexico and not only for travel but for, in terms of purchase of their economic goods. I know that I was in charge of the cholera control program at WHO when cholera first came to the Americas and cholera at that time was one of those diseases mentioned by the international health regulations that were enforced at that time. The first cases of cholera occurred in Peru and the economic impact on Peru was just extraordinary due to sanctions put on them by the Economic Union or the importation of their fish products and seafood products. So it's always a little bit difficult to get countries to act in a way that might not conform to their best interests but with these new international health regulations there are incentives built into countries to do that and for the time being at least they seem to have worked. Margot Chandrick, WHO has spoken out in praise of the way the international health regulations have worked to date. I was just going to answer the other question regarding the information sources that we use or that I use, CDC's website is great, WHO's website is great. I don't think we have any information that's not out in full availability to the public. I'll put in a plug for another website that we've developed called www.pandemicpreparedness.org. It's not an epidemiological website so we're not reporting on cases there but if you do visit that site you can get an idea for what's been going on in the past in regard to preparedness. Over the last few years it's a website that's sponsored by USAID but also by WHO by the National Federation of Red Cross and societies by a number of other civil society organizations by the United Nations as well and it contains a large number of documents, guidance documents, policy documents, informational documents that have been developed, viewed, vetted through all of those organizations and put up there again in an attempt to have all of those major organizations that would be involved in the pandemic response speaking with a single voice. That's what's been so encouraging to me about the response so far. You put your finger on it Steve. There hasn't been much deviation from the policies that have been discussed and debated and developed over the past few years by the international community. Captain, can you speak to the issue that Ed knows with respect to drug war and consequences of putting new responsibilities forward with respect to the response? This is not something I've followed to a huge extent but my understanding is the Army was mobilized to distribute the face masks sort of in and around Mexico City where the brunt of the sort of the concentration of the cases have been. The mobilization of military troops in the context of the larger campaign against organized crime has in many ways been more in the north of the country. I don't know if there was any need to pull people away from one thing for another so I couldn't say for sure on that but the military does have the mandate to undertake work in emergencies and disasters so that I think is consistent with the larger mandate. Thank you. One issue that this next round that I was hoping perhaps Ron you could comment on question of how we organize ourselves in situations like this. There's been a lot of debate the Institute of Medicine is about to issue their report on US global health. They delivered a letter or version of this in December with one of their lead recommendations the appointment of a senior coordinator within the White House who would pull together the inner agency and deal with situations like this. My question is does this set of demands and the likelihood that they will continue in some form does this push forward the idea internally around better organizing the inner agency with some sort of designated senior level oversight. So we can hold on that issue just if you can comment a little bit on this. This gentleman right here and then we'll take a couple of others. George. This is a question I'm decked with Dalrymple and social question for Dr. Walden. If you were President Obama and Secretary Sebelius and as they're developing a seed strain for a vaccine during the next month or so with CDC and St. Jude's if in let's say the end of June or July it still looked like a mild attack rate. Same mortality rate perhaps which seemed pretty high 2% or so in Mexico based upon of course there are probably a lot of under reported cases but nevertheless would you make the same decision they made in 1976 knowing the 1918 history and knowing the 1976 history where in one case a mild season later was severe the following season. So you would have a vaccine. Go ahead and contract for millions of doses of vaccine to be available in October. Not knowing whether there'll be a severe case. Mortality rate in next fall. Okay, hold on. Over here. George Handy, I'm with the activity for innovation and economic growth. I'd like to ask a question that follows on from the point that Steve made. In emergencies other than pandemics and epidemics one of the key decisions is evacuation or shelter in place. It would appear that in looking at the operational concerns should the current situation worsen this fall that the decision that will be crucial will be containment or not or some other element. If I'm correct on this could you talk a little bit about what are going to be the operational considerations that will be crucial to successful containment should this crisis worsen in the fall? Thank you. Any other questions? One in the rear here. Zeng Xin from Tainin Magazine, two simple questions. One simple question. Sorry? One question please. Okay, just say if the United States and Mexico develop some, successfully develop some vaccine streams will they share that with other countries? Ron I think most of these are sort of aimed towards you. Steve maybe you can speak after Ron's or speak to the question of if we have a resurgence in the fall or there's the distinct possibility of that what should we be doing now or think about now in terms of planning for the economic consequences? Ron? I think most of the question might be aimed at me but they're not exactly aimed at my area of expertise. But in terms of vaccine development, if I had to make a decision now as you asked, yeah I think that one would have to be prepared to manufacture the vaccine in large doses for mass administration or at least to encourage people to be vaccinated. We have to remember that there's gonna be a flu season next year and we've always encouraged and promoted widespread vaccination particularly in certain age groups and those are certainly valid recommendations. The fact of the matter is that there should be full speed ahead and more development of a vaccine against this pandemic stream. There's no question about that. But one doesn't have to make the decision right now about exact administration, I mean, vaccine administration policies because it's going to take some time for that vaccine to be developed and then to be mass, before mass production can begin. But certainly the vaccine should be developed. Surveillance, monitoring of the spread of the disease and of its potential, the validity should continue and decisions can be made once one has a better handle on it as to target populations, principal target populations, secondary target populations. Certainly I think health care workers and others would be considered among the principal receivers of vaccine at this point in time but we're going to get a lot more information epidemiological and otherwise together regarding the spread of the vaccine and its clinical manifestations before specific vaccine policies have to be developed. So that's certainly an area of major ongoing work. But the first thing to do is to develop the vaccine before it becomes available for mass production that's going to be five to six months. It'll take that one. The seed virus will be available in about a month. Trials need to be undertaken to determine its safety and efficacy but mass production would take on the order of four to six months. No question about that. My question around that, I didn't see you in there. Leadership? Yeah, well I think that one in some ways can be quite happy that we've had this avian influenza threat for the past few years because although we might have been looking in the wrong direction regarding the exact cause of the pandemic, preparations have really been underway. So there is an avian influenza action group. There's an international partnership on avian and pandemic influenza. And a lot of the, as was mentioned, there's a Mexico-Canada US group that has been preparing documents, running exercises. The administration maybe is working together as well as it is because there have been pandemic response exercises that have been conducted of the assistant secretary on the secretary level in the previous administration. So this is nothing that is, sorry, I don't think this is working right now, but this isn't something that we do for people. So it used to be before that there was a call this morning. There was a call this morning that had representatives from state, from AID, from HHS, from DOD, from Treasury, and from a number of other agencies. These calls take place regularly. There are different interagency groups operating at different levels. Some of the lead actions are taken by different agencies at different phases of the pandemic. But it's been a number of years of development of policies and strategies and processes for how to achieve the best coordinated response to an event like this. Now, people have been looking towards Southeast Asia as an initiating point. People have been looking towards poultry and wild birds. The fact is that we had an event that was initiated in North America by a non-bird related virus. So there's some things that we certainly got completely, completely wrong, but nevertheless, the mechanisms that were put in place are flexible enough that they can be adapted and have been adapted and put into place to deal with the current threat. In regard to the sharing of the vaccine, internationally, absolutely, no question about it. And there are already many, many plans to do that, the World Health Organization will take charge of that as part of the preparation for avian influenza because there was no vaccine for that as well. You can't make a vaccine to a pandemic virus until the pandemic begins because you don't have that virus strain to make the vaccine against. So when the threat was the H5N1 virus, all kinds of plans put into place. Funding was given to laboratories, in fact, vaccine development laboratories in developing countries. The US made a substantial contribution, $100 million to WHO to be able to build up a network of laboratories where vaccine could be developed in developing countries because the fear has been and has probably been justified that with vaccine production on a global scale, relatively limited that there would only be enough vaccine for those who could pay for it, namely the wealthier countries. And in fact, for H5N1, developing countries had already purchased all the potential production capacity for a vaccine. So other mechanisms were put in place to be able to fill the gap. It'll take a long time until there's enough vaccine for everyone in the world, which is why some sort of prioritization policies are gonna be needed, whether or not vaccines can reach countries in time and whether or not the distribution networks in more, in countries with fewer resources will be sufficient to reach the more peripheral areas of those countries. Those are things that remain to be determined, but again, for which substantial planning has taken place, and I don't know what the outcome of it would be, but from this 30,000 foot level, if you will, things are underway maybe a little bit late. It would have been great to have another three or four years to continue with this preparation and planning process, but we have the situation now. It is what it is. Yeah, and just I think to build on some of the things that Steve mentioned and we just mentioned a second ago too, I think if you look at the initial administration response, it's been very calm, coordinated, which I think is very impressive early in an administration where people are still figuring out how all these things operate and what's kind of a complex interagency effort. The longer term domestic challenge is gonna be how is this integrated into the economic planning, into the security planning, where these are kind of different channels or different silos in the White House and more generally. And I think where you didn't see as coordinated or as an effective response, particularly in the economic front, was in the international dimensions. You saw a very calm reaction by the United States, but then you saw Russia and China move on pork exports, things of that nature. So are there ways you can work, whether it's the G20 or other processes to kind of share information more quickly, have a coordinated response, not only in terms of the US interagency, but in terms of the international community to prevent this from kind of spiraling out of control or confidence-building measures in terms of increased screening in terms of some of the things that we've mentioned about reaching out to distressed areas or areas that might not have that capacity so to prevent it from, even if the United States handles it well, from other countries overreacting or not having the capacity to handle this and then having an overall negative impact on an already weak and kind of fragile economy globally. Captain, do you want to offer any closing thoughts for getting towards the end of our time here? Do you like to offer any closing thoughts? Well, just to kind of the current situation, Mexico has downgraded. It's alert from red to orange, which maintains a high level of vigilance. Restaurants are going to reopen, I think starting tomorrow in Mexico City, but they have to rearrange their tables to keep people further apart. Yeah, theaters can reopen, but patrons have to sit six feet apart. So I think some of the theater owners are saying they might wait until the outbreak is clearer and students will start going back to school at the university and secondary levels on Thursday and then at the primary level next Monday. So I think there's a lot to be learned from the origin and initial trajectory of the outbreak in terms of the outbreak itself and the response. As the flu season ramps up in the Southern Hemisphere with these initial cases in some of the countries in Central and South America, the lessons should be shared and it's time to continue to, for countries to continue to review their pandemic preparedness plans and to improve communication and ensure the lessons from what has happened so far in North America. Thank you, Ron. I just want to say that, because you remind me, we can talk about these social distancing measures of staying three feet apart or six feet apart. Yeah, I made a lot of reference and you see a lot of reference through the 1918 pandemic and how similar this has been in origin. And I say, we've got a springtime start and apparently a mild first wave. So the question arises, is this a serious problem or is it just being overhyped? Well, the answer is both. It's obviously a very serious problem and the answer is there's obviously been a lot of hype in the media. But I do want to make the point that there are three significant differences between a 1918-like event that might occur now and the event that did occur in 1918. First of all, we know about these social distancing measures and we know that they work. Whether or not we can give the messages forcefully enough, whether or not people will go along with the kinds of messages will depend a lot on the confidence they have in their governments and in the international organizations. Or in those countries where they don't have confidence in the government, appropriate messaging can come from other sources, from religious sources, from educational sources, whatever it might be. But for the extent that people implement well-appropriate technically sound policies, that will help. Secondly, there was no vaccine for the 1918 pandemic. We will have a vaccine this time around. We have that technology and we have the ability to develop one fairly quickly, not I mentioned four to six months, that's just the time it takes to do it with the current technology. And that will be available with some sort of policy that will undoubtedly be imperfect, but it's possible that many, many people around the world will be vaccinated and that will certainly take a bite out of this as well. Thirdly, the leading cause of death in the 1918 pandemic was not viral pneumonia. It was secondary bacterial pneumonia. According to three scientific papers that went back and looked and actually autopsy remaining specimens from people who had died during the 1918 pandemic, the leading cause of death seems to have been secondary bacterial pneumonia. There were no antibiotics at that time. There are antibiotics now, so that's a huge addition to our armamentarium to deal with situations like this. Fourthly, as much as the interconnectedness of people and of countries, it facilitates transmission and the rapid spread of a virus like this, so too does it facilitate our ability to monitor and to stay abreast of the events as they unfold in real time. And this information that we're able to collect and report on at six a.m. every morning and five p.m. every afternoon is just of extraordinary benefit to countries in knowing what kinds of policies to put in place and when to make their populations aware of those things that they ought to do. So I think that there are tremendous advances that we've made and I think that everyone needs to be as vigilant as possible, but I agree with the president and with the director general of WHO and others who have said that in fact we have a bad situation. It's a time to address it with the tools that we have in our possession and not to panic over it. I think that's the best advice. There's no question, I would just say in absolute one closing note. Pandemic of this nature takes a toll. It takes a toll economically. It takes a toll politically on diplomatic relations between countries and it takes a toll in the number of lives that will be lost due to this pandemic. The goal is not to have everything be a nice, clean slate. This is happening now. It's something that's beyond anyone's control. The goal is to mitigate the consequences of this outbreak of this pandemic to the greatest extent possible and that's what we're all working towards and if we manage to be as successful as we would like to be, those losses will be kept to an absolute minimum. Thank you Ron. This has been very rich. I just, please join me in thanking Catherine, Stephen and Ron. Thank you.