 Good afternoon. It is my pleasure to introduce to you our next speaker Dr. Michael Osterholm. Osterholm, a good Swedish name from an island east of Stockholm. Known as one of this country's most outspoken advocates, Dr. Osterholm is a crusader for the development of national preparedness for biological weapon attacks and pandemics. Not exactly feel-good topics. I have heard him speak at national public health conventions and he has a dynamic unforgettable speaker. There's always sort of a rustling in the crowd as he takes the podium. Minnesotans sitting up straight nudging each other with pride. He's one of our guys. He's famous. He's from Minnesota. Iowans doing the same thing because he was born there. Everyone proud to have a connection with Dr. Osterholm even though he has a hard and difficult message that he delivers. Recently Dr. Osterholm has become internationally known as the bird flu guy. I asked him last night at dinner how we ever got into this bug business. He said it was easy. He knew from the time he was eight what he wanted to do. So to prepare he went to loser college and double majored in political science and biology. A perfect background of study for his graduate work in environmental health and epidemiology. He received his PhD from the University of Minnesota and environmental health. And I also asked him how do you go on every day advocating to preserve the world. Demanding that we get ready and year after year we sit on our hands and and are doing nothing sometimes. How do you keep on doing what you're doing tirelessly saying what you are saying to paralyzed crowds. He said that part is not so easy. Dr. Osterholm is no stranger to this campus. He has spoken here before and even taught a few Gustavus January term courses in the past on public health issues. He was here in St. Peter the day after the tornado in 1998 when it ripped through the city of St. Peter and devastated this campus. The people of Mankato will never forget him for all the help he gave them during the 1995 meningitis outbreak. Last night Tim Robinson said that Michael Osterholm is so beloved around here that for all of the work he has done that he could run for political office and everyone would vote for him. He's trusted as someone who cares and he's down to earth easy to be around. So what does he do to relax while he's building a log home in Iowa next to three trout streams in Iowa. And just for fun he sometimes jumps into a lake and swims across it. At one point he was training to swim across the English Channel but then he got a little busy. He serves on editorial boards of five journals. He's a reviewer of 24 journals. He's a frequent consultant for the World Health Organization even doing some work for them last night. He's a consultant for the National Institute of Health and the Food and Drug Administration. He's the director for the Center for Infectious Disease Research and Policy a professor of public health at the University of Minnesota. The associate director of the Department of Homeland Security's National Center for Food Protection and Defense. Ladies and gentlemen Dr. Michael Osterholm. Thank you Barbara. I must admit the many introductions I've had I will never forget that one. I just wish my mother could have been here. Ladies and gentlemen distinguished guests. It's a true honor to be here today to share with you a message that has already in a sense been laid out for you. Before I begin though I want to acknowledge two specific groups of individuals who are in the audience today. First I have to acknowledge the many soulmates I have in this room today who lived with me through what was one of Mother Nature's very worst curveballs the meningitis outbreak in this area some years ago. It also was the very best of the human spirit and I know there are a number of you in here today and I must tell you that every day that I live I carry that experience with me. Grants you it took a few years of my life expectancy off I'm not sure genetic manipulation will get back but at the same time I have used that experience over and over and over again for reminding me why it is we do what we do. Second of all my remarks are aimed very specifically at the students in the audience today. I will tell you at the outset that I am not proud to be part of a generation that is turning the world over to you much in much worse shape than we received it. The issues I'm going to talk about today are part of that. It's about what we can do about it what we must do about it and what are some of the consequences if we don't. We will talk a bit about the fact that hope and despair are not strategies that issues before us are in fact workable solution situations but we are going to talk about what I would consider to be some very tough times. Now I last count had about 9500 slides in my repertoire of slides that I keep and if someone asked me and said Mike you know you got to get rid of all your slides but want to tell a story what would that slide be. This is it. This is the world we live in today. On the bottom you see the last 150 years. On the left vertical bar you see days to certainly navigate the globe what you see on the right vertical bar is population of the world. 150 years ago it took us a year to get around the world even on fast sailboats. By 1950 with the advent of the jet plane we had that down to a little over 40 hours. Not much has changed in terms of the speed to get around the world since that time but what has changed is even more dramatic. We now live in a global just-in-time economy where many of the critical products and services that you count on every day right here in St. Peter wherever you're at in the United States originates in an offshore location. Last year 1.4 billion people 1.4 billion people physically crossed an international border by airplane by boat by four-wheel vehicle by walking by any number of different ways. We live in a mobile world that moves around in a way that has tremendous implications for infectious diseases and then I look at that blue line and I remain stunned. This month we are quote-unquote acknowledging we have just reached the 300 millionth American to be alive. At the same time we've just surpassed 6.5 billion people on the face of the year. One out of every nine people who's ever lived since the caves is now in the face of the year. That has tremendous implications also for infectious diseases. The point being today in many of the developing world countries we have situations that if Charles Dickens were alive today he would be aghast at how things had gone downhill not improved from the time that he wrote about the terrible conditions of Europe. In addition I will add there are a whole lot of other problems with that blue line. At what point are we going to realize Mother Earth has only so much capacity that in fact we are challenging the very essence of our ability to live on this planet. Note that infectious diseases will play a part in that whole discussion. Now we came up with a term almost some 14 years ago called emerging infections. It was a way to describe the concept of new reemerging or drug resistant infections whose incidence in humans has increased in the past two decades or whose incidence threatens to increase in the near future. So it's brand new ones ones that we had never heard of before or at least recognized old ones that are finding ways to come back because of changes in our everyday living conditions. And of course that issue of drug resistance. This morning in what I consider one of the most elegant talks I've ever heard in my career on the genetics of our life. We also understand that microbes have the genetics and the ability to change also as we just talked about. The difference is they go through more changes in one year of 20 minute generations than we may go through dating back to the caves. So the point being is they can accommodate, they can acclimate, they can adjust to everything that's thrown at them and drug resistance that what relatively almost short-lived phenomena of drug susceptibility is something we have to understand. Now if you look at this map you see for the last few years any number of new emerging infectious disease issues that have come forward. And note that they are all over the world. It's not just the developing world or the developed world. It varies from multi-drug resistant organisms to E. coli infection to intentional events such as anthrax and what it means for the future potential events. You'll see today I'll talk about a few of these in the context of examples of why systematically we have to understand and respond to this issue of infectious diseases. Now the National Academy of Sciences Institute of Medicine put together a group in 1991 that not only coined the term emerging infections but on that left side of the book really laid out a clarion call to all of civilization, not just the public health community, not just medicine, not even just governments, that you had to wake up that that era of infectious diseases being gone and eliminated was not true. We had that very, very short respite where we thought we had infectious diseases in control. But in fact we didn't. The point being is that today we recognize that these infections are coming back. So the point being is that now we have a second group that's looked at this issue that published in a document in 2003 of which I was part of that group and we which went back and looked at the fact that if we understand emerging infections from 1992 we didn't really even understand them compared to today because all the things that we said would happen that were horrible bad happened and a lot of things we hadn't anticipated. So today we have to understand that nothing looks bright in terms of the advances we're making but it doesn't mean it has to be that way. Unlike some things it is not inevitable that we have to live in this world of infectious diseases as we do. Now there were a number of factors that we put forward that really contribute to that whole what I'd call perfect storm, a term that's unfortunately often overused for the emergence of infectious diseases, human demographics and behavior. We obviously understand from the world population standpoint what we're talking about. But with human demographics you got to feed people. When you got to feed people you have to have a lot of domestic animals. You start challenging water systems for water, things like that, all the things that you don't think about that contribute. The issue of behavior, issues of sexual behavior, issues of IV drug use, a behavior that virtually didn't exist 100 years ago because the advent of the needle was not yet there for people to routinely do intervenious drug abuse. The issue of technology and industry today we have created all kinds of new things that add actually to the risk of infectious diseases we hadn't thought about. I never thought back in 1980 when our group first discovered the relationship between tampons and toxic shock syndrome that the oxygen capacity of a tampon might have a lot to do with how Staph aureus grows or how it produces toxin. And in fact it did because as we thought more and more absorbent tampons we just basically jacked up the risk of toxic shock syndrome. I could go through a long endless line of examples of industrial related activities that have increased our risk. Economic development and land use. Today we are basically changing the face of the earth. We happen to live in an area right now. I don't know if you know this or not but the upper Midwest is a single most quote unquote ecologically devastated location in the world. We devastated 98% of the native prairie in this area 150 years ago to make way for the bread basket, which you would argue is a good thing. But the point is the rainforest no other area of the world has been as ecologically changed in modern history as where we sit right now. But today, how many of you know that there are more forests, there are more trees in the eastern part of the United States today than there ever was when the first white man set foot on this continent. As a result of that, we see major changes in animals. Which wildlife are there? We see major changes in vectors. I could go through a laundry list of issues. Economic development and land use with dams. Today you can't build a dam anywhere in the world and not create a major water borne related and mosquito other vector related crisis. International travel and commerce I've already hit on that one, the microbial adaption and change. You know, the bugs don't wake up in the morning, go read the paper and try to figure out, okay, what are we going to do today? Who are we going to get? They have a much more powerful guide that of evolution. And as I pointed out earlier, they are using it very well. The breakdown of public health measures. I always get a little nervous on this one because most people in the room say, What are you talking about? Today, the basic support for public health in this country has eroded dramatically even with recent reinvestments. It is not anything to what it was 30 to 40 years ago. We are so focused on curative medicine that last minute miracle, the prevention constantly takes a back seat. You're going to hear later about health care costs in this country. Last year to give you a perspective, the increase in health care, disease care costs in this country exceeded the entire revenue from the entertainment industry. Meanwhile, the investment in public health was measured in nanometers. That is obviously a problem. If we look at the human susceptibility to infection, as we heard this morning, we grow older, but as we grow older, it doesn't mean we stay young longer. Today we see many more people living with debilitating conditions, not just HIV, cancers, etc. that predispose them to infections we never heard of 25 years ago. Is it safe to drink municipal water supply? Well, for the vast majority it is, but there may be microbes in that water supply today that are not pathogens or disease causing bugs to most of us, but to those very few that are immune deficient. It can be a real problem. Climate and weather. You know, let's just wake up and acknowledge climate changes here, and it's coming quickly. The point being, though, is weather is important. Some 15 years ago, we got a glimpse of that when we started seeing an El Nino bring the rains to southern part of the Southwestern United States. Now, you can't call that climate, but as a result of a massive greening of the desert, we saw a massive burst in rodent populations, which we then saw a massive burst in an infectious agent we hadn't previously recognized called Hontavirus. As a result of this burgeoning rodent population, they sought refuge wherever they could. They left their territories and went into homes, and with that rodent, came rodent urine, and with that rodent urine came the virus. And if you swept up a floor that, frankly, a mouse had peed on, you were in trouble. Today, we are wondering about that because we have predictions for a major El Nino coming back into the Southwestern United States this winter. That kind of thing is weather related. It's not just climate. Poverty and social inequality, infectious diseases, as you'll see, are largely tied to the world's poverty status. As goes our well-being, as goes infectious diseases. War and famine. I'm going to talk more about, particularly the famine case, but suffice it to say today, there are very few people who are aware that every time we have a war, what makes the front cover of the magazine or the front, the first story in the evening news is the bloody dead bodies that are lying there in a battlefield or today in a result of terrorism. What they don't realize that there are many more people who die every day from infectious diseases because they can't get the vaccines, they can't get safe water, they can't get the kinds of basic infrastructure protections. Eight times as many people died in Kosovo from infectious diseases has ever died from a bullet or a knife. But we never heard about those. Lack of political will. As I was state epidemiologist, I served two Democratic governors, two Republican governors, one independent Rassler. And I've served in the last three presidential administrations and I can tell you, quite honestly, my own family cannot tell you my partisan politics. I believe it is my job to serve as a fair, honest, and hopefully informed voice of science. Don't think it's not hard sometimes. But today I will make comments about some of the political issues out there and please take it in that context. Suffice it to say I've had about as much as I can stand of Washington, D.C. right now. I have seen inaction based upon inaction. We worry more about the political issues of division than we do about the collective good of our world. Infectious diseases represent that as much as I know. Finally, the intent to harm. This is one that's tough for me because I have every reason to believe it's coming back. As many of you know in the room, I wrote a book on 9-11 and 2,000 called Living Terries one year to the day before the event. It was painful because in that book I did talk about why the World Trade Center Towers would still stay the number one target for the Elkite and why they wanted to bring it down. I also talked about what would happen if a very limited anthrax had occurred which we saw. That one was really just a wake up to what could happen. Today we have to know that there are people who want to hurt us who will have the ability with infectious agents to do catastrophic things. That's hard to think about and plan for. Now in terms of some of the examples, let me point out to you why I say these things and what they mean. Here's the example of the SARS epidemic that occurred several years ago. We quickly discovered this was caused by a thing called the coronavirus as a possible cause of the severe acute respiratory syndrome. Clearly caught everybody off guard. But I must tell you from the standpoint of the big picture it was really just a minor blip. 8,000 cases, 774 deaths. On an everyday public health basis, not big. But I will tell you that in fact, what it did to the individual locations where it occurred was devastating. 80% of the flights in and out of Singapore and Hong Kong were canceled for more than 12 weeks. The city of Toronto lost billions of billions of dollars in revenue and income. By the eighth week of the problem in Toronto, 25% of healthy healthcare workers were too afraid to come to work. This is the kind of thing we'll talk more about. But I want to point out to you what I mean today about these factors. We live in a world of loose connections that are all connected. This is the chain of transmission that really got that SARS epidemic started and it should serve as a model for a lot of the other infectious agents we're going to talk about. What happened was in that red bar right here, we had a business man from the Guangdong province of China who became infected as a result of exposure to animals in his own local city. He then traveled overnight to the Metropolitan Hotel in Hong Kong and stayed there for three days. While he was there, he infected 10 different people who then all left, well at the time that they left. They went to Canada, they went to Ireland, they went to the United States, they went to Singapore, which then went on to Germany, they went to Vietnam, they went to Hong Kong. Very quickly, within a matter of days, that particular infectious agent was around the world. That's that connection I talked about with time and the ability to actually intervene is limited. This kind of situation is real for all the infectious disease we have today where this kind of transmission can and will occur. This is the old days of public health when you could do things that were basically a little bit, should you say, more in control of and less considering the implications of. We now know that this is not necessarily a wise way to quote unquote disinfect or disinfest your airplane, but let me tell you the next slide may be the saddest slide I have in my entire repertoire of slides I'll show you today. It shows you where we've been, where we're at, and I fear where we're going. 80s the gypti is a type of mosquito that vectors several very important infectious disease concerns of humans. Yellow fever and dinghy, for example. It's what we call the household mosquito. It loves to be with people. It loves to breed in little containers of water. Even a discarded McDonald's wrapper in the ditch where a drop of water will collect for more than a day or two, it will lay its eggs and do a very fine thank you. This mosquito was in retreat. When in the 1930s the Rockefeller Foundation, a number of other groups said we're going after this thing and we're going to get it. We're going to eliminate the breeding sites. And look what they did from 1930 where the green reflects where 80s Egypti was in the Americas to 1970. And I might add that part of the United States was almost absent of the 80s Egypti, hardly any there. And then we got complacent. We removed resources. We realized, you know, we had won well before we had won. Now ladies and gentlemen, look at the distribution of 80s Egypti today. And I will tell you, per location, it is much, much, much more in numbers and locations within any one country than it ever was in 1930. We've lost all that ground because we didn't continue the job. We got complacent. We gave up on public health. Why is that important? Well this is a disease that I think is one of the most fascinating of all diseases because in part it's a man-made concoction. Dinge fever is a viral disease caused by mosquitoes, that's what arthropod means. Basically this disease lived in humans with humans for centuries and centuries and was relatively not a big public health issue. It had the nickname of break bone fever because if you got it, you thought you were going to die for two or three days. Your bones felt like you were breaking. But you recovered. Well today we have a brand new component to Dinge fever we never ever realized. It turns out that there were four to sync serotypes of Dinge, all located in four different parts of the world. Two different ones and two different parts of Asia, one in the Americas and one in Africa. Basically following World War II and through that time we begin to move the mosquitoes around in all the transportation we did whether in cargo holds, in you know old military vehicles, tires, whatever. Before 1970 only nine countries had experienced hemorrhagic fever. Why did hemorrhagic fever occur? It was because once the one serotype occurred in an area and a second third and fourth got introduced. It turned out that if you got reinfected the first time with one serotype and then infected a second time later with a second one and particularly certain second ones, you then developed a whole new illness we'd never seen called Dinge hemorrhagic fever, which for the lack of a better description is like any Ebola like illness. Basically it's horrible. A case fatality rate approaching 30 to 50 percent. We created that disease because today everywhere Dinge ever existed all four serotypes now exist. All within the last 50 years. That's a huge issue. So when you have students going abroad to one of these areas and they get Dinge the first time I would be nervous as hell. I was going to send a student back a second time because the second time could be a very different outcome. Today the WHO estimates 50 million infections, 500,000 hemorrhagic fever cases and 12,000 deaths annually. If you look at the global burden of Dinge we now estimate that it could be a significant as malaria and tuberculosis combined. The world impact will likely continue to grow dramatically due to the potential population change in the 80s Egyptite. Everywhere you see in the developing world inner city jump. The deplorable conditions in inner cities those are all rich breeding grounds for 80s Egyptite. Dinge has to be considered the classic emergent infection and today we have virtually no control programs throughout most of the world for this. If you look at the belt where Dinge exists if you also overlay population with the exception of China we really are where the heaviest populations are. I might also add for all of you Minnesota snowbirds who enjoy going to the Caribbean I would suggest you begin to take more note of where you're going as we're beginning to see much more widespread transmission of Dinge through all the Caribbean vacation locations. Factors associated Dinge increase include world population, conditions favoring 80s Egyptite include the rural urban migration. As we have these big cities we live in junk piles literally all holding water again one little plastic wrapper is a wonderful breeding ground. If you don't have a running water in your house you have containers. 80s Egyptite love to breed in there. That unreliable water source is huge. Solid waste as I pointed out we think we got solid waste problems in this country much the developing world has solid waste also but they just don't deal with it just stays there. Again breeding grounds for 80s Egyptite. Our infrastructure support has eroded and I don't go to any place that people sit there and go raw yay hot dinghy fever prevention they don't think about it it's one of many that are orphaned from any constituency out there because it occurs among the least of us. In fact it's just another developing world disease. West Nile virus this is one that changed on a submit this this turned out this was one that we had said the same thing about for quite some time. This was a viral infection was first isolated in the West Nile district of Uganda in 1937 hey no big problems over there. Today we know it's commonly found in humans and birds and other vertebrates in Africa Eastern Europe West Asia Middle East but until very recently it was not documented in the Western Hemisphere it was moving it was spreading the mosquitoes and the birds that actually are part of this feeding cycle. What happens is an infected bird bird gets infected from an infected mosquito an uninfected mosquito also takes a blood meal and that bird that now is infected and it's just a vicious cycle infected mosquitoes then transmit the West Nile West Nile virus to us when they take a blood meal. You can see it was documented as I mentioned before throughout the world Israel had outbreaks in 51 and 54 and then the virus appeared to change someone in 1957 we saw the first outbreaks of severe disease with meningitis mortality rates approaching 10 to 20 percent. France South Africa Romania Italy Russia all those them countries and then in 1999 it all changed. In the summer of 1999 we had an introduction of this virus ironically during a serious drought in the Northeast just so you understand in the land of mosquitoes you know we all know that unofficially it's our state bird a mosquito is not just a mosquito there are those mosquitoes that do very well in those containers I talked about there is mosquitoes that need floodplains there are mosquitoes that do well in dry years because of the way they actually where they grow their mosquitoes that do well in tree holes in tires their treat as a mosquito that do very well in wet years what so happened in the Northeast where you would think mosquito populations would be way down there was several selected types of mosquitoes were way up why because first of all everyone was banned from filling their swimming pools so that old stagnant water and there were certain mosquitoes love that there are certain mosquitoes that lived in the sewers and because water never rushed through the sewers with rainfall they never got cleaned out as such flushed out and we had little pockets of water sitting down underneath those drains six feet down in that cool nice area all were competent vectors for West Nile how it got here we don't know did it come in mosquitoes in a plane did it come in wild birds that were brought over illegally we know that we as you'll see in a moment we have all kinds of animal importations could do it but look what happened with the spread it followed basically the migratory routes of the birds infected birds moved down the east eastern flyway the Atlantic Coast flyway by 2001 it had moved back up from the Gulf states coming up now the Mississippi flyway and by 2002 we had both human and bird activity in most of the country if we look at that activity today there have been over 2,900 cases of West Nile virus so far this year over 85 deaths there have been upwards of a third of those cases had severe neurologic disease last year that number was over 3,000 cases it's now here there's not much we can do about it because we let it in we let our guard down we didn't deal with it when it was other areas of the world were control would have meant a big impact and just to give you a wake up all the farmers in the room if nothing else you better pay attention to this slide because just as West Nile came and ironically I was actually at a meeting of vector control people just the year before in which I made a prediction that we would see some novel new arbol virus into the country they couldn't understand why they'd stay out I mean we're bringing them in airplanes every day I predict this one I think could be our next one and this is going to be a doozy it's riff valley fever it's a hemorrhagic fever virus it causes disease in both humans and animals it's mosquito-borne disease or at least 11 species native in North America that are very well capable of moving this including the back black flies of north northern Minnesota human diseases have up to 10% a case of 10% have hemorrhagic fever a 1% case fatality rate even higher than West Nile virus and among the animal diseases cattle calves have a 10 to 70% case fatality risk adults 4 to 10% sheep and goats less in one week of age 100% case fatality rate others 20 to 30% we have no vaccine for it we don't really care about this disease because it's not us it's a developing world but we need to get here we'll care we'll care big time but it'll be too late we should be caring now even if we're not all churistic we should just be smart now in terms of back up here in terms of that animal importation I talked about I mentioned her I'm going to get one more just one if you look at the issue of animal importation these are data that came out of that investigation of West Nile in 1998 99 these are the animal importations in New York alone and in this very dark lavender area what you'll see these are countries where over 350,000 animals came through just the port of New York through the legally for importation in the United States that year in New York City was one of the smallest ports of entry we have the point being today we're moving everything around the world including animals this is an example of what happened with that movement of animals for those who don't recognize this this is a disease you shouldn't on the out of hand recognize this is monkey pox a distant but very important relative to the smallpox virus this is a viral infection with about 1% case fatality rate it has occurred in Africa for years we've never seen it in the Americas and then one day low and behold we suddenly had an outbreak in this country and it turned out that we ultimately had estimated about 70 cases of monkey pox in the summer of 2003 37 were laboratory confirmed this was just an incredible situation what happened well what we saw was up here rodent shipment from Ghana today you can't be a pet store in this country and make it by selling puppies and kitties you got to have the latest most exotic designer animal I know that very well because my son today who's 25 when he was in high school he said dad I got to have an African dwarf hedgehog anybody who's cool has one I got to have a sonic I said no way well after about six months of this discussion I finally relented night knowledge I gave in but I said only under one condition we're going to test that thing when it gets in our house the first three turds out of that animal were in the Minnesota Department of Health medical laboratory within a matter of one hour within two weeks we identified three new strains of salmonella had never been seen in Minnesota before needless to say I won't say more about the African dwarf hedgehog or my son's disposition of it but the point being is today that we basically are bring animals and so what happens this importer imported 50 Gambian giant rats 53 rope squirrels to brush tail porcupines 47 tree squirrels 100 striped mice and 410 dormas these are all animals you and I would never recognize but they're all being sold in pet stores was so happened that one of the Gambian rats actually had monkey pox they then were brought into an area a holding area in the upper Midwest here that were being held with prairie dogs because little prairie dog pups are really cute little things when they're young when they get older they get mean they get basically don't like to live with humans they weren't basically raised that way and what happened though is people acquire these they went out and today we actually have companies that have machines look like the size of this podium they stick over whole holes of prairie dog colonies out in the western states and suck up all the prairie dogs in the hole they kill the adults take the pups and go sell them in pet stores well these pups and these Gambian giant rats from the same building they spread them the door of the pups were then sold at what was based called boot fairs and low and behold this happened just so you understand that this is not just a one-way problem either for the up and tell this time we were exporting 70 to 80,000 prairie dog pups annually to Tokyo for sale in pet stores there and as they would get older they would get out and they would get loose prairie dogs also happen to be a very good vector for plague and we I'm convinced that now that these prairie dogs have started to take over the sewers of Tokyo which they literally have they're now beating Norwegian radicals out for space it wouldn't surprise me one day to see a plague outbreak in Tokyo totally related the prairie dogs of North America now taking over the sewers of Tokyo this slide is one that should be a sober wake up to all of us because it's a very simple slide with a very powerful message this is the correlation of infant mortality and total fertility in selected countries and areas of the world what you see on this left bar is infant mortality per hundred thousand live births what you see in the bottom is total fertility rate in other words number of children per hundred women 700 here down to 100 here zero to 125 we have known for some time that there is an inverse relationship between fertility and infant mortality if families do not have to keep having babies because they die they won't why do they die they die because of infectious diseases they die from a very simplest of issues not having clean water clean food when you bring the overall sanitation level up of any community you greatly lower the overall infant the total fertility rate look at New York City in 1900 123 per hundred thousand in terms of total fertility I'm sorry 650 per total fertility rate look at their infant mortality rate look at it today all we did is bring safe water in 1900 the number one cause of death in kids under age nine in Minneapolis St. Paul was typhoid fever related to an unsafe water supply that's a hundred seven years ago today that's gone well why do I talk about this with infectious diseases because I think first of all it has a lot to do with world population you know just handing out more condoms or telling people just say no is never going to completely solve this problem there are social cultural issues that are far deeper and this is one of them well because I think there are other issues around infectious diseases are key ladies and gentlemen we are obviously aware of losing one resource called petroleum but we are missing the point that we're losing even more quickly a more vital one called fresh water this is a chart showing the actual relative development of population growth versus blue water withdrawals over the last century blue water is that water either in the ground or in the surface that we can use for fresh water it's not salt water it's the water that's available to us what you see here is population growth and it's projected you see the projection of blue water withdrawals when you look at those withdrawals you see where it's going it's going to irrigation why to feed our population ladies and gentlemen we're in a collision course with famine now I'm sure some people would not agree with this issue none the least I think that we are also been very blessed to have people who've worked hard to make this not happen I remember reading Paul Ehrlich's book the time bomb back some 40 years ago in which we said in 20 to 30 years we run out of food well then we had wonderful people like I think Minnesota's native saint Norman Borlaug who helped green the world with genetic manipulation of crops was able to grow greatly greatly increased production but that was predicated on there's a place to grow it what grows patrol food today two things one is water the second thing is petroleum where does your fertilizers come from where is your insecticides come from your pesticides where does your harvest capability come from it's from petroleum we won't go into petroleum today you understand that look at the water issue we are running out of fresh water even right here in places in Minnesota this is a map showing how irrigation and groundwater withdrawals are beginning to have a major impact what you see in the burgundy for places like India and even in parts of the western United States high overdraft where we're mining the water the recharge is much less than the actual water we're taking out in some parts of the world we have 20 to 30 years of fresh water left and then all that food's going but equally so is the water itself and we know water is one of the most critical important pieces of a public health infectious disease control program I would urge all of you to read a absolutely spellbinding factually very very well researched series of articles this past week in the New York Times you can see from these articles in teaming India water prices means dry pipes and fall sludge India digs deeper but wells are drying up often parts India struggles to tap them on soon we are seeing this around the world when we lose our water will lose food which will predispose us even more to infectious diseases and we lose water will lose basic hygiene and we have any at all predisposing it's much more to infectious diseases I swear to guy that if the 1800s look bad when you look at some of these issues they look much worse I can't do any talk without talking about this issue the area of HIV this is an area that I have been very involved with having attended the very first meeting at CDC on June 4th of 1981 when at that time we had 37 cases that we call KSOLI Kaposi Sarcoma Opportunistic Infections later than called a grid gay related infectious diseases during that time I have lost many many dear dear dear people in my life including my aunt 63 oh Catholic none who is the first blood transfusion recipient in this country to die of AIDS and a very very dear high school friend of mine who is the first health care worker to die as a result of an occupational exposure I know aids it hurts and ladies and gentlemen as much as we have talked about all the wonderful new things with the Gates Foundation and the Clinton Foundation and these are wonderful things I can't begin to say how much those gentlemen and those foundations are doing but we must face the reality of what HIV means if you look at this slide you can see sub-Saharan Africa yet what more can you say if you look at this number is it's very sobering 68 million people infected 25 million people have died in the last 25 years five million infected this past year the rate of new infections continues to rise in it is not lovely no it's getting more about 14,000 new HIV infections each day 13,000 persons 15 to 49 a person is infected about every six seconds now in this country we've taken a step back and said well we can treat it with drugs it's become more of a manageable chronic disease some of that's true but we are now be also beginning to see the long term impact of being on anti-retro therapy over time and how long this wonderful gift of these drugs will mean also high quality of life or improve quality of life is questionable but for much of the world that's not even a point of discussion 8200 days related deaths of courage day a person dies every nine seconds six seconds nine seconds more people are becoming infected every day that are dying the number of total infected continues to increase there are 13 million orphans a child becomes an orphan every 14 seconds anybody who's ever worked in this area sees the heart tug of losing entire family units relative to the adults but leaving behind young children who are now in many instances literally on their own if you look at the current estimate there's about 43 million people living with HIV infection of the world about 4.9 million new infections in 2005 and about 3.1 million deaths due to AIDS in 2005 anti-retro therapy is getting to a very very small percentage of those and we had a major program initiative two years ago that in fact we wanted to make sure that we had large numbers of people on these drugs we've fallen far short doesn't mean we can't keep trying I'll never forget some almost 20 all more than 20 years ago when one of the esteemed speakers at this previous meeting and somebody who's a dear friend of this campus was involved with the discovery of HIV or the name of the new virus and then secretary Margaret Heckler at HHS came forward and said we will have a new AIDS vaccine within two to three years we're in good shape I was quoted the next day on the front page of your time saying I did not believe we would see an effective AIDS vaccine in my lifetime now I don't know what I knew back then but I knew enough about retrovirus is something that our very distinguished speaker this morning knows a lot about and I stand by that today I hope I live a very long productive professional career I don't know what it's ever going to take if we ever will have an effective preventive AIDS vaccine if you look at where AIDS has impacted I've already pointed out but you see Sub-Saharan Africa Asia and the very rapidly growing number of cases there this again isn't us but it's the rest of the world and what happens in the rest of the world because that global just-in-time economy does impact on us let me spend my last few minutes talking about this topic of pandemic influenza as I mentioned earlier I published in my book that was published a 9 of 11 of 2000 that the al-Qaeda wanted to take down the World Trade Center towers at that point you know I had no additional information anybody else would have had it was not already available and as a scientist who has spent his entire life basically dealing with numbers you know put it in rates put it in those things that people can interpret from a data-driven standpoint if you had asked me what the risk of a major attack again occurring in the World Trade Center towers would be I really thought about this and I would probably told you one in five thousand one in ten thousand I don't know but it's real we now know the answer from 9 11 what I'm here to tell you today is the next pandemic influenza is a one it is going to happen it is not discretionary it's not optional it is going to happen I've never said anything like that in my career before I don't know if more terrorism is going to occur for sure I think it is I don't know when the next exotic disease is going to emerge from somewhere I think it's going to but I know this is going to happen pandemics are like earthquakes hurricanes and tsunamis they occur human influenza pandemics occur when a novel influenza strain emerges from the alien population as the following features so you got a virus living a wild birds basically until recently thought they did pretty well birds mean that virus now genetically changes so it's no longer is the bird virus it can be transmitted by in two humans so it's no longer about the birds once it becomes a strain transmitted by into humans it's genetically unique meaning we don't have protective antibody we already have a problem with that I mean for what other vaccine we have in our infectious disease armatarium that we're constantly reformulating every year because the virus changes that much in one year now we're talking about a gigantic leap in change so that we now have no protection at all and finally increase virulence now flu does a job anyway every year we estimate between 28 and 50,000 people a year dying this country from flu I know at first hand my 72 year old uncle died last February from influenza the point being is that already happens what we're talking about is something way above and beyond seasonal flu throughout in history influenza pandemics have occurred but they've returned in different times of the year there's no one time the mortality rates have varied there's no one model and even the number of ways how it presents in the community has varied this is a cartoon it basically gives you the seasons of influenza on the far left side here you see the wild birds we used to think that the influenza virus resided in those birds such that there was never really any problem while the aquatic birds emerged about 150 million years ago in the evolutionary process somewhere between 150 million years ago and 100 million years ago when domestic poultry emerged 50 million years later influenza viruses took residents in the guts of those birds and they lived happily ever after we thought now if those viruses get away out of those birds and get into domestic birds you can have one of several different kinds of influenza one that's very serious one is not a serious but again that's not a big problem to humans it's clearly an issue to the birds we now know today that you also can have disease in cats we didn't know this H5N1 the Asian flu virus was a problem with cats until 46 tigers and the bingles a bingo tigers in the Bangkok zoo were fed dead H5N1 infected chickens and all of them died within 3 to 4 days after being fed the chickens now we know cats can transmit we didn't know dogs could transmit we had an outbreak in Turkey last winter and all the dogs eating the dead chickens got sick also but what we really worry about is when it moves down this line towards humans now we used to think that it only went this way a term called reassortment where basically what happened was this virus that has eight genes in it would infect a pig cell because pigs happened to be the universal lung recipient for influenza viruses at the same time a human virus would coincidentally infect that pig lung and then what would happen is the influenza virus is one of the most sloppy promiscuous viruses we have it'll swap out genes in a moment's notice and what would happen is the two viruses get together and create a third virus that's called reassortment that's what 1957 and 1968 pandemics were caused by and we now know in retrospect those are the dumbed down versions those are the best kind of pandemics to have what we're worried about is what happened in 1918 we now know because of the resurrection of this virus a couple of years ago from capturing all eight genes of the virus from old samples that in fact that virus didn't reassort it basically stayed a bird virus that genetically changed enough to become a human transmitted to transmitted agent that's where the real horsepower behind the pandemics that we believe this is where we worried today when a pandemic hits what happens then is the virus gets into the population over a period of 12 to 18 months it goes through waves of the population 12 to 16 weeks here dies down 12 to 16 more weeks and by the second or third wave it basically you get it you die you get it you get protection or it just attenuates over time and then it becomes a seasonal flu situation now the WHO came out with the document last October they'll be coming out of another one in a couple of weeks which will actually update this one and I'm not a liberty to share the data in that but let me just suffice to say this one's enough pandemic influenza is different maybe in flu yes we know that so while we're worried about this situation Asia right now it's when it becomes a pandemic that will be the real issue if it does influenza pandemic should recurring events it's going to happen the world may be in the brink another pandemic that's a very strong statement from the WHO all countries will be affected that matters to us because many of the critical products you count on come from offshore widespread illness will occur medical supplies will be inadequate I don't have time in the sake of the day's talk but I'll mention a moment I am convinced we will have no better than 1918 medical care during the next pandemic you realize today that 80% of all the pharmaceutical products used in this country come from offshore virtually 100% of the vaccines most of all the IV bags needles syringes all the equipment parts all the things you count on every day come from some distant country where when a pandemic hit they too will be in the soup with us and borders will close I have no doubt about it and because it's just in time delivery system if your pharmacy doesn't get its drug twice a day you're out overnight there's no surge capacity there large number of deaths will occur I'll talk about that in a minute economic and social disruption will be great every country must be prepared the WHO will alert us which I wish I could say that were true today the world health organization staff around influenza for the world numbers less than 40 it's hardly an army vaccine and all drugs have limited impact on this why because today we didn't have that just in time delivery we now have a worldwide capacity to make 300 million doses of seasonal flu vaccine every year that's it and you can't make the flu vaccine until you get the strain circulating so even for a pandemic we'd have to wait until we finally got the last one that's coming out we will have no vaccine we have not invested in this because no company sees the bright bright silver dollar or light at the end yes we have 36 vaccines for H5N1 in the works right now all very early pulmonary stages nothing about big production it's years off the same thing is true with drug in the sense that we're not sure this drug will work the drugs we think of tamiflu and I don't have time to go into that today but there are big differences between seasonal flu that we currently use tamiflu for which works well and that of H5 the waves in past pandemics the first wave has been the worst one 1890 it was the third wave 1918 it was the second wave 1957-68 was the third wave when we blow our wad of supplies we have no clue from a public health perspective if you're only going to have one shot at this what are you going to do when are you going to use what you have we don't know and non-pharmaceutical interventions such as quarantine, infection control, distancing social distancing going to have a limited impact today we have just enough respirators the kind of masks that we typically think have to protect ourselves gloves again a just in time delivery product will run out overnight our hospitals are already overstressed we're going to hear more about that some additional things of global just in time economy presents a unique state of vulnerability I can't begin to I've been doing a lot of work recently with a number of economists in fact if you go read Tom Friedman's version two of the Flat Earth he and I put a whole section together in there just on this issue about why the world has this unique vulnerability now because of global just in time economy with flu because it will shut down what happens when somebody puts a rock in the gears of the just in time economy international governments who have limited opportunities to respond secretary Mike Leavitt who I did not know before he took over as the current secretary I worked for secretary Thompson but he's become a big hero of mine because he had the courage to go out to 50 states and say we won't be there for you we're not going to be there and everybody thought it was a post Katrina cover your butt statement when in fact when every town every village every city every county every state every country will be in the soup at the same time there won't be any reserve capacity so when we sent 260 people down from Minnesota to Louisiana to help out with the post Katrina hurricane we could do that we weren't affected that won't happen but hoping to spare not strategies we have to get through this we have to start planning now for this business continuity planning is not is not optional I can just tell you right now that in fact as goes the private sector we'll go our help we don't have food and water we don't have the basic services the implications will be huge imagine running out of insulin not being able to find it for months we'll get through it just like every pandemic in our history to get a sense of this pandemics have been recorded since apocrates the 1580 pandemic gives you a sense of this you just don't think that I'm talking about only severe pandemics it's a classic example it started in Asia in six weeks it afflicted all of Europe mortality was high 9,000 of 80,000 residents in Rome died in a little over a week Spanish cities were considered totally depopulated they had 10 pandemics in the last 300 years they range from 10 to 49 years between pandemics the average is 24 years now they're not normally distributed events it's not like you know the throwing of diets basically it's like 100 year floods where you have nothing for 50 years and then 4 of them in 10 years I don't know if the next one's going to occur because of the average I know because of H5 and what's a good likelihood the 1918-19 pandemic is what I talked about we know it was caused by H1N1 200 million to 1 billion people were infected 50 to 100 million people died and the highest number of deaths were in healthy people 18 to 25 to 30 years of age we now know and we were given some information that would suggest this based on studies of pregnant women which is a very precarious time immunologically where part of your immune system is trying to protect this thing that's not supposed to be there because it's not all you and that whole immune relationship is complicated when that virus got in the middle of that it was a real problem and we now confirm that it's the immune response of the healthiest people that end up killing you with not only this virus infection but also with H5N1 I would urge all of you to read this book from John Barry, a historian The Great Influenza it is, I think, both an incredible discussion of our past and very much a glimpse potentially into our future just to give you a sense of what this is like this is a letter from Dr. Roy Grist to Burt Roy Grist was a military physician at a camp outside of Boston in the fall of 1918 he wrote this to Burt after Burt died this was found by his children in his effects in the attic and submitted to the British Medical Journal these men start with what appears to be an ordinary attack on the gripper and for winds and when brought to hospital they rapidly develop the most vicious type of pneumonia that's ever been seen a few hours later you can begin to see cyanosis extending from the ears and spreading over the face until it's hard to distinguish the colored men from the white it's only a matter of a few hours in before devils dropping like flies we've been averaging about 100 deaths per day pneumonia means and about all cases death we've lost an outrageous number of doctors and nurses it takes special trains to carry away the dead for several days there were no coffins and the bodies piled up something fierce it beats any site they'd ever had in France after a battle an extra long barracks has been vacated for the use of the morgue it would make any man sit up and take notice to walk down the long lines of dead soldiers all dressed and laid out in double rows these people died quickly they died within hours in a couple of days that's not the kind of flu death we see today from secondary bacterial pneumonia but it is what we're seeing with H5N1 doctors and nurses died we ran out of things so what's the potential for this to happen all I can tell you genetically pathophysiologically and clinically H5N1 and the 1918 virus are kissing cousins it has an ongoing genetic roulette table in Asia to basically become genetically capable of being transmitted to humans and I'll show you that in one moment anybody who in the audience says it was going to happen what happened by now I remind you of H3N8 in the early 1960s H3N8 jumped from birds to horses it was basically a bird virus to jump never reassorted it's been a big problem in the equine since then two and a half years ago H3N8 jumped from horses to dogs we have no reason why we don't know why today it's a major problem of death in canine particularly in central Florida this past summer again basically a bird virus if H5N1 that follows this lead it could be today tomorrow next year five years from now but it could sure happen the genetic roulette table I talked about this is that changing world in 1968 the last pandemic there were 790 million people in China today there's 1.3 billion according to the FAO in annual harvest in 1968 5 million pigs were harvested in 2004 508 million pigs associated with the new social political and economic realities of China poultry 12 million harvested in 1968 15 billion in 2004 the average time from a chicken being hatched till it's eaten is about 40 days point being is we're constantly putting new fresh birds out there that are basically still susceptible to this virus we've given this virus unlimited play in these populations this is the current situation 249 laboratory confirmed cases including 146 deaths ladies and gentlemen this is not the problem what I mean by that is that if excuse me this is a public health issue with people getting it from birds but not on going transmission it's when that virus becomes capable of going person to person we're seeing it getting closer and closer and closer to that if I could tell you about the current clusters we have out there it's like listening to that old John Deer tractor get started in the middle of January in the old days boom, boom, boom, boom boom, boom, boom and about five of those and all of a sudden you heard a pop and away it went and I am convinced we are on the end stages of the John Deer tractor start-up when will it happen no one can predict if, when or where H5N1 virus will shift from an avian strain with incidental human infections to a genetically competent human to human transmitted agent we don't know Asia remains a genetic red table for this virus mutation first evidence will be on going transmission third generation cases all my science training leaves me unable to answer the question for you any better than this I wouldn't want to bet my family's life on H5N1 not becoming the next pandemic influenza strain if you look at what it could do to our country these are the numbers from the Department of Health and Human Services I might add if it's a severe or moderate like pandemic 90 million illnesses 45 outpatient visits but look at the deaths 1.9 million 742,000 people now we have 105,000 mechanical ventilators in this country and anyone given day 70,000 or in use during the flu season we get right up to 100,000 we have no capacity in our health care system to respond to this none this slide really reminds us we can easily go to either camp chicken little or rotten and dying earlier this year I was on the Oprah show for an hour talking about this with Oprah and the following day for the following week my email system choked the entire University of Minnesota system practically and the emails fell in one of two categories even though it was the same words the same ugly face the same message half of them said you know what guys like you should be hung you should be fired by your place you should just go out and shoot yourself for scaring us needlessly guys like you are really bad the other half over here saying you're part of the government cover-up we know this is going to be much worse we're all going to die why don't you just tell us that and be honest you know why we do that because that's the easy answer if you believe it's done if you don't believe it's going to happen just enjoy life it's the truth it's hard and this is where it's about you for the kids what kind of world are we going to leave you and today ladies and gentlemen we're doing almost nothing except giving lip service at the state level at the federal level we have done very little I just met last week with executives from ten of the largest trucking companies in the United States they've virtually done nothing we held a national summit in February we held the Nobel Prize in revenues we heard from the oil refinery companies all of them were there they said if we lose 20 to 30% of our workers we can't continue to run our refineries we have just time delivery but we also have enough employee delivery we've done virtually nothing to prepare for that this is going to make Katrina seem mild responding to the pandemic I mentioned the issue without it like you do if we had nothing following a Katrina. Our medical response system already is very weakened. We won't have that. I worry desperately how we're gonna get pharmaceutical drugs to you. Today, we don't have that pipeline. You can't stockpile if you wanted to. We've got to change that. But there's no economic incentive. There's nothing happening to make that happen. I worry whether you'll get your life saving drugs during a pandemic. Not for the pandemic, but for your other condition. In terms of worker patient protection, we're gonna have to figure out where our healthcare workers come to work. I mentioned earlier 25% of them wouldn't go to work in Toronto with SARS by the eighth week. If you don't have vaccine, you don't have effective drug, and you don't have masks, who's gonna come to work? Some of you may be doing it in places like this very room giving care. Corpse management, in 1968, the average time from a casket being made till it was in the ground was almost six months. Today, it's less than 30 days. Crematorium space just in time delivery. We saw in Katrina, and we saw in the tsunami when we treat our dead with disrespect, that's what takes us over the edge. We have no plans. Cities like Seattle have gone out and figured out where they can get all the indoor ice arenas they know, and they're gonna stack bodies right where you're sitting and hopefully keep them until they can process them. We've done none of that planning here. Implications, food and water, foods are just in time delivery system today. I deal with that all the time and the work I do. We have no contingency plan how to get food to people because it is just in time. Domestic international security, again, we just did a survey of prison wardens. Most of them told us if we lose 20 to 30% of workers, we don't know how we'll control our prisons. Again, where are the plans for that? We could do it now. Pandemic implications, just imagine a 12 to 18 month global blizzard with mandatory or voluntary closes in national state or even local borders. Public panic in 24 seven media coverage will rain. Governments will have limited resources. I believe at least 20 to 30% of people won't go to work. We won't close schools because parents will take their kids out of you. You won't have to close them. Even under the worst case scenario, the world's population will survive however. We have to start planning how we're gonna do that now. So what do we do? Well, it's not a matter of if it's just when and where. At a minimum, assume we will not have a vaccine for the first six months, then supplies will be limited. If it's a 1918 like scenario, 98 out of 100s will get through it, but we'll still lose 1.9 million Americans and up to 150 million people worldwide. Planning's not an option, yet we keep postponing it. So in conclusion, just let me say, emerging infections are a reality of our modern world. They are. The causes are complex and the solutions are difficult, but there is nothing here that can stop us from doing this. We invest today in things that I have to ask myself over and over again as I go to sleep at night, is this really making the world safer? When I know there are things that will, and we're doing virtually nothing. Hoping to spare not strategies, I believe that so much. Why do I do this? My whole career today can be still down in one very simple answer. I don't do it for the money. I don't do it for the 180,000 air miles I travel a year. I don't do it for my kids. It's about my kids. And it's about you students in this room. You're all that matter. We owe it to our kids to make a difference. I can't think of a more important legacy. Thank you very much.