So the first question is, why do we need to even worry about a pandemic threat? What is it that we're concerned about? When I say "we," I'm at the Council on Foreign Relations. We're concerned in the national security community, and of course in the biology community and the public health community. While globalization has increased travel, it's made it necessary that everybody be everywhere, all the time, all over the world. And that means that your microbial hitchhikers are moving with you. So a plague outbreak in Surat, India becomes not an obscure event, but a globalized event -- a globalized concern that has changed the risk equation. Katrina showed us that we cannot completely depend on government to have readiness in hand, to be capable of handling things. Indeed, an outbreak would be multiple Katrinas at once.
Prvo pitanje je, zašto se uopće moramo brinuti o opasnosti od pandemije? Što nas to zabrinjava? Kad kažem „mi“, ja sam u vijeću za vanjske odnose. Mi smo uključeni u nacionalnu sigurnost zajednice, i, naravno, u biologiju zajednice i javno zdravstvo zajednice. Kako je globalizacija povećala putovanje, učinila je potrebnim da svatko bude svagdje, stalno i diljem svijeta. I to znači da se vaši bakterijski autostoperi pokreću s vama. Stoga početak kuge u Suratu u Indiji ne postaje neprimjetan slučaj, nego globalni slučaj – globalna briga koja je promijenila jednadžbu rizika. Katrina nam je pokazala da ne možemo u potpunosti ovisiti o vladinoj spremnosti na rješavanje stvari. Zaista, pojava pandemije bila bi višestruka Katrina.
Our big concern at the moment is a virus called H5N1 flu -- some of you call it bird flu -- which first emerged in southern China, in the mid-1990s, but we didn't know about it until 1997. At the end of last Christmas only 13 countries had seen H5N1. But we're now up to 55 countries in the world, have had this virus emerge, in either birds, or people or both. In the bird outbreaks we now can see that pretty much the whole world has seen this virus except the Americas. And I'll get into why we've so far been spared in a moment.
Trenutno je naša velika briga virus nazvan H5N1 gripa. Neki je od vas zovu ptičja gripa. Ona je prvo izbila u južnoj Kini, sredinom devedesetih. Ali nismo znali za nju do 1997. Krajem prošlog Božića samo je trinaest zemalja vidjelo H5N1. Ali sada imamo 55 zemalja diljem svijeta gdje je virus izbio ili u ptica, ili u ljudi, ili oboje. U izbijanjima kod ptica, možemo vidjeti da je gotovo cijeli svijet vidio ovaj virus, osim Amerika. I doći ću do toga zašto smo dosada bili pošteđeni.
In domestic birds, especially chickens, it's 100 percent lethal. It's one of the most lethal things we've seen in circulation in the world in any recent centuries. And we've dealt with it by killing off lots and lots and lots of chickens, and unfortunately often not reimbursing the peasant farmers with the result that there's cover-up. It's also carried on migration patterns of wild migratory aquatic birds. There has been this centralized event in a place called Lake Chenghai, China. Two years ago the migrating birds had a multiple event where thousands died because of a mutation occurring in the virus, which made the species range broaden dramatically. So that birds going to Siberia, to Europe, and to Africa carried the virus, which had not previously been possible.
Kod domaćih ptica, pogotovo kokoši, virus je 100 posto smrtonosan. To je jedna od najsmrtonosnijih stvari koje smo vidjeli na djelu u svijetu posljednjih stoljeća. I suočavali smo se s time tako što smo ubijali strahovito puno pilića i nažalost, često bez naknade seljacima koja bi pokrila te troškove. Ubijanje je također provođeno na migracijskim uzorcima divljih vodenih ptica selica. Bio je centralizirani slučaj u mjestu po imenu jezero Chenghai u Kini. Prije dvije godine ptice selice su doživjele višestruki slučaj kada su tisuće umrle zbog mutacija u virusu, što je drastično proširilo raspon vrsta. Te ptice koje idu u Sibir, Europu i Afriku prenijele su virus, što prije nije bilo moguće.
We're now seeing outbreaks in human populations -- so far, fortunately, small events, tiny outbreaks, occasional clusters. The virus has mutated dramatically in the last two years to form two distinct families, if you will, of the H5N1 viral tree with branches in them, and with different attributes that are worrying. So what's concerning us? Well, first of all, at no time in history have we succeeded in making in a timely fashion, a specific vaccine for more than 260 million people. It's not going to do us very much good in a global pandemic. You've heard about the vaccine we're stockpiling. But nobody believes it will actually be particularly effective if we have a real outbreak.
Sada vidimo izbijanja u ljudskoj populaciji. Dosad, srećom, mali slučajevi, sitna izbijanja, povremeno grupe. Virus je dramatično mutirao u zadnje dvije godine i oblikovao dvije posebne „obitelji“, može se reći, H5N1 virusnog drveta s granama na njemu i s različitim zabrinjavajućim svojstvima. Dakle, što nas zabrinjava? Pa, kao prvo, ni u jednom vremenu u povijesti nismo uspjeli pravovremeno napraviti posebno cjepivo za više od 260 milijuna ljudi. Neće nam pomoći jako puno u svjetskoj pandemiji. Čuli ste o cjepivu koje skladištimo. Ali nitko zapravo ne vjeruje da će biti osobito djelotvorno ako budemo imali pravo izbijanje.
So one thought is: after 9/11, when the airports closed, our flu season was delayed by two weeks. So the thought is, hey, maybe what we should do is just immediately -- we hear there is H5N1 spreading from human to human, the virus has mutated to be a human-to-human transmitter -- let's shut down the airports. However, huge supercomputer analyses, done of the likely effectiveness of this, show that it won't buy us much time at all. And of course it will be hugely disruptive in preparation plans. For example, all masks are made in China. How do you get them mobilized around the world if you've shut all the airports down? How do you get the vaccines moved around the world and the drugs moved, and whatever may or not be available that would work. So it turns out that shutting down the airports is counterproductive.
Zato je jedna misao: poslije 11. rujna zatvaranje je zračnih luka odgodilo sezonu gripe za dva tjedna. Stoga, pomisao je: hej možda ono što trebamo napraviti jest da samo smjesta – čuli smo da se H5N1 širi sa čovjeka na čovjeka, virus je mutirao da bude prenosilac sa čovjeka na čovjeka – zatvorimo zračne luke. Međutim, ogromna analiza superračunala, načinjena prema mogućoj učinkovitosti ovoga, pokazuje da nam to uopće neće dati puno vremena. I naravno, da će iznimno remetiti pripremu planova. Na primjer, sve maske izrađuju se u Kini. Kako ćete ih dijeliti diljem svijeta ako ste zatvorili sve zračne luke? Kako ćete raznijeti cjepiva diljem svijeta, i lijekove, i štogod bude ili ne bude dostupno i djelotvorno. Dakle, ispada da je zatvaranje zračnih luka kontraproduktivno.
We're worried because this virus, unlike any other flu we've ever studied, can be transmitted by eating raw meat of the infected animals. We've seen transmission to wild cats and domestic cats, and now also domestic pet dogs. And in experimental feedings to rodents and ferrets, we found that the animals exhibit symptoms never seen with flu: seizures, central nervous system disorders, partial paralysis. This is not your normal garden-variety flu. It mimics what we now understand about reconstructing the 1918 flu virus, the last great pandemic, in that it also jumped directly from birds to people. We had evolution over time, and this unbelievable mortality rate in human beings: 55 percent of people who have become infected with H5N1 have, in fact, succumbed. And we don't have a huge number of people who got infected and never developed disease.
Zabrinuti smo zato što ovaj virus, za razliku od bilo koje gripe koju smo ikada proučavali, može biti prenošen jedenjem sirovog mesa zaraženih životinja. Vidjeli smo prijenos na divlje mačke i domaće mačke, a sada i na domaće pse. I u eksperimentalnom hranjenju glodavaca i lasica otkrili smo da životinje pokazuju simptome nikad viđene kod gripe, napadaje, poremećaje središnjeg živčanog sustava, djelomičnu paralizu. Ovo nije uobičajena raznolikost gripe. To oponaša ono što danas znamo o rekonstrukciji virusa gripe iz 1918. godine, posljednju veliku pandemiju, koja je također prešla izravno s ptica na ljude. Imali smo evoluciju tijekom vremena, i ova nevjerojatna stopa smrtnosti u ljudi. 55 posto ljudi koji su bili zaraženi H5N1 su, u stvari, podlegli. I nemamo veliki broj ljudi koji se zarazio i nikad nije razvio bolest.
In experimental feeding in monkeys you can see that it actually downregulates a specific immune system modulator. The result is that what kills you is not the virus directly, but your own immune system overreacting, saying, "Whatever this is so foreign I'm going berserk." The result: most of the deaths have been in people under 30 years of age, robustly healthy young adults. We have seen human-to-human transmission in at least three clusters -- fortunately involving very intimate contact, still not putting the world at large at any kind of risk.
U eksperimentalnom hranjenju majmuna može se vidjeti da virus zapravo potpomaže razvoj posebnog oblika imunološkog sustava. Rezultat je da vas zapravo ubije, ne virus izravno, već vlastiti imunološki sustav koje pretjerano reagira govoreći: „Štogod da je ovo strano, poludjet ću.“ Rezultat, većina preminulih imali su manje od trideset godina, izrazito zdrave mlade odrasle osobe. Vidjeli smo prijenos sa čovjeka na čovjeka u barem tri slučaja – na sreću, uključivali su vrlo intiman kontakt te nisu ugrozili ljudsku populaciju.
Alright, so I've got you nervous. Now you probably assume, well the governments are going to do something. And we have spent a lot of money. Most of the spending in the Bush administration has actually been more related to the anthrax results and bio-terrorism threat. But a lot of money has been thrown out at the local level and at the federal level to look at infectious diseases. End result: only 15 states have been certified to be able to do mass distribution of vaccine and drugs in a pandemic. Half the states would run out of hospital beds in the first week, maybe two weeks. And 40 states already have an acute nursing shortage. Add on pandemic threat, you're in big trouble.
Dobro, sada ste postali nervozni. Vjerojatno pretpostavljate da će vlada nešto napraviti. I potrošili smo mnogo novca. Većina troškova Busheve administracije zapravo je bila vezana za proučavanje antraksa i prijetnje bio-terorizma. I mnogo je novca bačeno na lokalnoj razini i na federalnoj razini da bi se proučavalo zarazne bolesti. Završni rezultat: za samo 15 država potvrđeno je da su sposobne za masovnu distribuciju cjepiva i lijekova u slučaju pandemije. Pola država ostat će bez bolničkih kreveta u prvom tjednu, možda u dva tjedna. I 40 država već ima kronični nedostatak njegovatelja. Dodajte još i pandemijsku prijetnju i u velikoj ste nevolji.
So what have people been doing with this money? Exercises, drills, all over the world. Let's pretend there's a pandemic. Let's everybody run around and play your role. Main result is that there is tremendous confusion. Most of these people don't actually know what their job will be. And the bottom line, major thing that has come through in every single drill: nobody knows who's in charge. Nobody knows the chain of command. If it were Los Angeles, is it the mayor, the governor, the President of the United States, the head of Homeland Security? In fact, the federal government says it's a guy called the Principle Federal Officer, who happens to be with TSA.
Što su ljudi radili s tim novcem? Vježbe, treninzi, diljem svijeta. Pretvarajmo se da je pandemija. Neka svi trče uokolo i igraju svoju ulogu. Glavni rezultat je da postoji ogromna zbunjenost. Većina ovih ljudi zapravo ne zna što će biti njihov posao. Na kraju krajeva, glavna stvar koja se očitovala u svakoj vježbi jest da nitko ne zna tko je glavni zaduženi. Nitko ne zna zapovjedni lanac. Ako je u Los Angelesu, je li gradonačelnik, guverner, predsjednik SAD-a, vođa Domovinske sigurnosti? Zapravo, savezna vlada kaže da je to momak s titulom Principle Federal Officer, koji je u TSA-u.
The government says the federal responsibility will basically be about trying to keep the virus out, which we all know is impossible, and then to mitigate the impact primarily on our economy. The rest is up to your local community. Everything is about your town, where you live. Well how good a city council you have, how good a mayor you have -- that's who's going to be in charge. Most local facilities would all be competing to try and get their hands on their piece of the federal stockpile of a drug called Tamiflu, which may or may not be helpful -- I'll get into that -- of available vaccines, and any other treatments, and masks, and anything that's been stockpiled. And you'll have massive competition. Now we did purchase a vaccine, you've probably all heard about it, made by Sanofi-Aventis. Unfortunately it's made against the current form of H5N1. We know the virus will mutate. It will be a different virus. The vaccine will probably be useless. So here's where the decisions come in.
Vlada kaže da će savezna odgovornost u principu biti u pokušaju da se zadrži virus vani, što svi znamo da je nemoguće, i onda da ublaži utjecaj na naše gospodarstvo. Ostalo je mjesnoj zajednici. Sve ovisi o tvom gradu, o mjestu gdje živiš. Pa koliko je dobro gradsko vijeće koje imate? Koliko dobrog gradonačelnika imate; on će biti glavni zaduženi. Većina će se mjesnih postrojenja natjecati da dobiju dio saveznih rezervi lijeka po imenu Tamiflu, koji može a i ne mora biti od pomoći – doći ću do toga – dostupnih cjepiva, ili bilo kojeg drugog tretmana, maski, i svega što će biti uskladišteno. I imat ćete ogromnu konkurenciju. Mi jesmo kupili cjepivo, sigurno ste čuli o tome, napravio ga je Sanofi-Aventis. Nažalost, napravljeno je protiv trenutačnog oblika H5N1. Znamo da će virus mutirati. Bit će drugačiji virus. Cjepivo će vjerojatno biti beskorisno. Dakle ovdje dolazi do odluke.
You're the mayor of your local town. Let's see, should we order that all pets be kept indoors? Germany did that when H5N1 appeared in Germany last year, in order to minimize the spread between households by household cats, dogs and so on. What do we do when we don't have any containment rooms with reverse air that will allow the healthcare workers to take care of patients? These are in Hong Kong; we have nothing like that here. What about quarantine? During the SARS epidemic in Beijing quarantine did seem to help. We have no uniform policies regarding quarantine across the United States. And some states have differential policies, county by county. But what about the no-brainer things? Should we close all the schools? Well then what about all the workers? They won't go to work if their kids aren't in school. Encouraging telecommuting? What works?
Vi ste gradonačelnik vašeg grada. Da vidimo, da zapovjedimo da se svi ljubimci drže u zatvorenom? Njemačka je to napravila kad se H5N1 pojavio u Njemačkoj prošle godine, kako bi smanjili širenje između kućanstava, preko kućnih mačaka, pasa i slično. Što radimo kada nemamo zatvorenih soba s izmjenom zraka, koje će omogućiti zdravstvenim djelatnicima da se pobrinu za pacijente? One su u Hong Kongu. Nemamo ništa tome slično ovdje. Što s karantenama? Tijekom epidemije SARS-a u Beijingu karantene nisu pomogle. Nemamo ujednačenu politiku koja se odnosi na karantene diljem SAD-a. Neke države imaju različitu politiku od okruga do okruga. Što je s očitim stvarima? Trebam li zatvoriti sve škole? Što sa svim radnicima? Oni neće otići na posao ako njihova djeca nisu u školi. Poticanje telekomunikacija? Što djeluje?
Well the British government did a model of telecommuting. Six weeks they had all people in the banking industry pretend a pandemic was underway. What they found was, the core functions -- you know you still sort of had banks, but you couldn't get people to put money in the ATM machines. Nobody was processing the credit cards. Your insurance payments didn't go through. And basically the economy would be in a disaster state of affairs. And that's just office workers, bankers.
Britanska vlada napravila je model telekomunikacija. Šest tjedana svi ljudi u bankarskoj industriji pretvarali su se da je pandemija u tijeku. Ono što su otkrili jesu osnovne funkcije, znate još uvijek ste imali banke, ali niste mogli dovesti ljude da stave novac u bankomate. Nitko nije obrađivao kreditne kartice. Vaše uplate za osiguranje nisu prolazile. I u osnovi, gospodarstvo bi bilo u katastrofalnom stanju. A to je samo što se tiče uredskih radnika, bankara.
We don't know how important hand washing is for flu -- shocking. One assumes it's a good idea to wash your hands a lot. But actually in scientific community there is great debate about what percentage of flu transmission between people is from sneezing and coughing and what percentage is on your hands. The Institute of Medicine tried to look at the masking question. Can we figure out a way, since we know we won't have enough masks because we don't make them in America anymore, they're all made in China -- do we need N95? A state-of-the-art, top-of-the-line, must-be-fitted-to-your-face mask? Or can we get away with some different kinds of masks? In the SARS epidemic, we learned in Hong Kong that most of transmission was because people were removing their masks improperly. And their hand got contaminated with the outside of the mask, and then they rubbed their nose. Bingo! They got SARS. It wasn't flying microbes. If you go online right now, you'll get so much phony-baloney information. You'll end up buying -- this is called an N95 mask. Ridiculous. We don't actually have a standard for what should be the protective gear for the first responders, the people who will actually be there on the front lines.
Ne znamo koliko je pranje ruku važno za gripu – šokantno. Za pretpostaviti je da je dobra zamisao često prati ruke. No zapravo, u znanstvenoj zajednici velika je debata o tome koliki postotak prijenosa gripe između ljudi je od kihanja i kašljanja a koliki postotak je na vašim rukama. Medicinski Institut je pokušao razmotriti pitanje maski. Možemo li smisliti način, s obzirom da nećemo imati dovoljno maski jer ih više ne pravimo u Americi. Sve se prave u Kini. Trebamo li N95? Posljednje dostignuće, vrhunski izum, maska koja mora pristajati vašem licu? Ili možemo proći s nekom drugačijom vrstom maski? Tijekom epidemije SARS -a, naučili smo u Hong Kongu da je većina prijenosa gripe bila zbog nepravilnog skidanja maski. Njihove su ruke bile kontaminirane s vanjske strane maske, nakon čega su protrljali nos. Bingo! Dobili su SARS. To nije bio leteći mikrob. Ako sada odete na internet, dobit ćete mnoštvo lažnih i glupih informacija. Na kraju ćete kupiti -- ovo se zove N95 maska. Smiješno. Zapravo nemamo standard o tome što bi trebala biti zaštitna oprema za one koji će se prvi suočiti s time, ljude koji će zapravo biti na prvim linijama obrane.
And Tamiflu. You've probably heard of this drug, made by Hoffmann-La Roche, patented drug. There is some indication that it may buy you some time in the midst of an outbreak. Should you take Tamiflu for a long period of time, well, one of the side effects is suicidal ideations. A public health survey analyzed the effect that large-scale Tamiflu use would have, actually shows it counteractive to public health measures, making matters worse. And here is the other interesting thing: when a human being ingests Tamiflu, only 20 percent is metabolized appropriately to be an active compound in the human being. The rest turns into a stable compound, which survives filtration into the water systems, thereby exposing the very aquatic birds that would carry flu and providing them a chance to breed resistant strains. And we now have seen Tamiflu-resistant strains in both Vietnam in person-to-person transmission, and in Egypt in person-to-person transmission. So I personally think that our life expectancy for Tamiflu as an effective drug is very limited -- very limited indeed.
I Tamiflu. Vjerojatno ste čuli za ovaj lijek, napravljen od strane Hoffman – La Roche, patentiran lijek. Postoje neke naznake da vam može kupiti nešto vremena usred izbijanja epidemije. Ako uzimate Tamiflu duže vrijeme, jedna od nuspojava su suicidalne misli. Istraživanje javnog zdravstva analiziralo je učinak koji bi imao uzimanje velikih količina Tamiflua, pokazujući zapravo da je suprotan mjerama javnog zdravstva, pogoršava stanje. Također jedna zanimljiva stvar: kada čovjek proguta Tamiflu, samo 20 posto je probavljeno pravilno, tako da bude aktivna tvar u ljudskom organizmu. Ostatak se pretvara u stabilnu smjesu, koja preživljava filtraciju u vodene sustave, time se izlažući vodenim pticama koje će prenijeti gripu i pružiti im priliku da razviju otporne vrste. Do sada smo vidjeli vrste otporne na Tamiflu u Vijetnamu, u prijenosu sa čovjeka na čovjeka, i u Egiptu u prijenosu sa čovjeku na čovjeka. Tako da osobno mislim da je očekivano trajanje Tamiflua kao učinkovitog lijeka vrlo ograničeno – zaista vrlo ograničeno.
Nevertheless most of the governments have based their whole flu policies on building stockpiles of Tamiflu. Russia has actually stockpiled enough for 95 percent of all Russians. We've stockpiled enough for 30 percent. When I say enough, that's two weeks worth. And then you're on your own because the pandemic is going to last for 18 to 24 months. Some of the poorer countries that have had the most experience with H5N1 have built up stockpiles; they're already expired. They are already out of date. What do we know from 1918, the last great pandemic? The federal government abdicated most responsibility. And so we ended up with this wild patchwork of regulations all over America. Every city, county, state did their own thing. And the rules and the belief systems were wildly disparate. In some cases all schools, all churches, all public venues were closed.
Ipak, većina je vlada utemeljila cijelu svoju politiku borbe protiv gripe na nagomilavanju zaliha Tamiflua. Rusija je skupila zalihe dovoljne za 95 posto ukupnog stanovništva. Mi smo skupili zalihe dovoljne za 30 posto stanovništva. Kad kažem „dovoljne“, mislim na zalihe u trajanju od dva tjedna. A nakon toga ste prepušteni sami sebi jer će pandemija trajati od 18 do 24 mjeseca. Neke od siromašnijih zemalja koje su imale najviše iskustva s virusom H5N1 skupile su zalihe kojima je sada već istekao rok trajanja. Što znamo iz 1918.godine, vremena zadnje velike pandemije? Federalna se vlada odrekla većine odgovornosti. I tako smo završili s ovom ludom mješavinom propisa širom cijele Amerike. Svaki grad, okrug, svaka je država radila po svome. I zakoni, kao i sustavi vjerovanja, bili su u najvećoj mjeri različiti. U nekim su slučajevima sve škole, sve crkve, sva javna mjesta bila zatvorena.
The pandemic circulated three times in 18 months in the absence of commercial air travel. The second wave was the mutated, super-killer wave. And in the first wave we had enough healthcare workers. But by the time the second wave hit it took such a toll among the healthcare workers that we lost most of our doctors and nurses that were on the front lines. Overall we lost 700,000 people. The virus was 100 percent lethal to pregnant women and we don't actually know why. Most of the death toll was 15 to 40 year-olds -- robustly healthy young adults. It was likened to the plague. We don't actually know how many people died. The low-ball estimate is 35 million. This was based on European and North American data.
Pandemija je kružila tri puta u 18 mjeseci u odsutnosti komercijalnog zračnog prijevoza. Drugi je val bio mutirani, superubojiti val. U prvom smo valu imali dovoljno zdravstvenih radnika. Ali, do trenutka kada je došao drugi val, uzet je toliki danak među zdravstvenim radnicima da smo izgubili većinu naših liječnika i medicinskih sestra koji su bili na prvim linijama bojišnice. Sveukupno smo izgubili 700 tisuća ljudi. Virus je bio 100 posto smrtonosan za trudnice. I dalje, zapravo, ne znamo zašto. Većina je umrlih bila u dobi od 15 do 40 godina – to su bile snažne, mlade osobe. Bilo je to nalik kugi. Mi zapravo i ne znamo koliko je točno ljudi umrlo. Niska je procjena oko 35 milijuna. Ovo je temeljeno na europskim i sjevernoameričkim podacima.
A new study by Chris Murray at Harvard shows that if you look at the databases that were kept by the Brits in India, there was a 31-fold greater death rate among the Indians. So there is a strong belief that in places of poverty the death toll was far higher. And that a more likely toll is somewhere in the neighborhood of 80 to 100 million people before we had commercial air travel. So are we ready? As a nation, no we're not. And I think even those in the leadership would say that is the case, that we still have a long ways to go.
Nova studija Chrisa Murraya s Harvarda pokazuje da, ako pogledate baze podataka koje su Britanci vodili u Indiji – tamo je bila 31 posto veća stopa smrtnosti među Indijcima. Zato postoji čvrsto uvjerenje da je u siromašnim mjestima broj umrlih bio znatno veći. I da je vjerojatnija brojka umrlih negdje oko 80 do 100 milijuna ljudi, prije nego što smo imali komercijalni zračni promet. Stoga, jesmo li spremni? Kao nacija, ne nismo. I mislim da bi čak i vodstvo naše zemlje priznalo da je, u ovom slučaju, pred nama još dug put.
So what does that mean for you? Well the first thing is, I wouldn't start building up personal stockpiles of anything -- for yourself, your family, or your employees -- unless you've really done your homework. What mask works, what mask doesn't work. How many masks do you need? The Institute of Medicine study felt that you could not recycle masks. Well if you think it's going to last 18 months, are you going to buy 18 months worth of masks for every single person in your family?
Što to znači za vas? Prije svega, ja ne bih započela s izgradnjom osobne zalihe ičega – za sebe, svoju obitelj ili svoje zaposlenike, osim ako niste temeljito proučili svoju zadaću. Koja je maska djelotvorna? Koja maska nije djelotvorna. Koliko maski trebate? Institut za medicinu smatra da ne biste trebali reciklirati maske. Pa ako mislite da će pandemija trajati 18 mjeseci, hoćete li kupiti maski za 18 mjeseci, za svakog člana svoje obitelji?
We don't know -- again with Tamiflu, the number one side effect of Tamiflu is flu-like symptoms. So then how can you tell who in your family has the flu if everybody is taking Tamiflu? If you expand that out to think of a whole community, or all your employees in your company, you begin to realize how limited the Tamiflu option might be. Everybody has come up to me and said, well I'll stockpile water or, I'll stockpile food, or what have you. But really? Do you really have a place to stockpile 18 months worth of food? Twenty-four months worth of food? Do you want to view the pandemic threat the way back in the 1950s people viewed the civil defense issue, and build your own little bomb shelter for pandemic flu? I don't think that's rational.
S Tamifluom, opet, ne znamo, jer su prva nuspojava Tamiflua simptomi slični onima kod gripe. Kako onda možete znati tko u vašoj obitelji ima gripu, ako svi uzimaju Tamiflu? Ako proširite ovo razmišljanje na cijelu zajednicu ili na sve zaposlenike u vašoj kompaniji počinjete shvaćati koliko bi zapravo opcija s Tamifluom mogla biti ograničena. Svi su mi došli i rekli da će nakupiti zalihe vode ili zalihe hrane. Ali, ozbiljno? Imate li, zaista, mjesta za zalihe hrane za 18 mjeseci? Ili zalihe hrane za 24 mjeseca? Želite li pristupiti opasnosti od pandemije na isti način kao što su 1950-ih ljudi pristupili problemu civilne obrane i izgraditi svoja malena atomska skloništa za pandemiju gripe? Ne smatram to racionalnim.
I think it's about having to be prepared as communities, not as individuals -- being prepared as nation, being prepared as state, being prepared as town. And right now most of the preparedness is deeply flawed. And I hope I've convinced you of that, which means that the real job is go out and say to your local leaders, and your national leaders, "Why haven't you solved these problems? Why are you still thinking that the lessons of Katrina do not apply to flu?" And put the pressure where the pressure needs to be put. But I guess the other thing to add is, if you do have employees, and you do have a company, I think you have certain responsibilities to demonstrate that you are thinking ahead for them, and you are trying to plan. At a minimum the British banking plan showed that telecommuting can be helpful. It probably does reduce exposure because people are not coming into the office and coughing on each other, or touching common objects and sharing things via their hands. But can you sustain your company that way? Well if you have a dot-com, maybe you can. Otherwise you're in trouble. Happy to take your questions. (Applause)
Mislim da moramo biti spremni kao zajednica, a ne kao pojedinci, spremni kao nacija, kao država, kao grad. A trenutna je pripravnost najvećim dijelom prilično slaba. I nadam se da sam vas sada uvjerila u to, što znači da je sada pravi zadatak izaći van i reći svojim lokalnim vođama, reći svojim državnim vođama, "Zašto niste riješili ove probleme? Zašto još uvijek mislite da se lekcije dobivene od uragana Katrine ne odnose na gripu?" I vršiti pritisak tamo gdje pritisak treba biti nametnut. Ali pretpostavljam da trebam dodati da ako imate svoje zaposlenike ili kompaniju, tada imate određenu odgovornost pokazati im da razmišljate unaprijed za njih i da pokušavate nešto isplanirati. Plan britanskih banki pokazao je da rad od kuće, putem računala, može biti prilično koristan. Na taj način smanjuje se izloženost gripi jer ljudi ne dolaze u ured i ne kašlju jedni po drugima, ne diraju zajedničke predmete i ne dijele stvari iz ruke u ruku. Ali možete li radom na takav način održati svoju kompaniju? Ako imate računalnu firmu, vjerojatno možete. Inače ste u nevolji. Rado ću odgovoriti na vaša pitanja. (Pljesak)
Audience member: What factors determine the duration of a pandemic?
Publika: Koji čimbenici određuju trajanje pandemije?
Laurie Garret: What factors determine the duration of a pandemic, we don't really know. I could give you a bunch of flip, this, that, and the other. But I would say that honestly we don't know. Clearly the bottom line is the virus eventually attenuates, and ceases to be a lethal virus to humanity, and finds other hosts. But we don't really know how and why that happens. It's a very complicated ecology.
Laurie Garret: Mi zapravo ne znamo koji čimbenici određuju trajanje pandemije. Mogla bih vam dati hrpu pretpostavki. Ali, umjesto toga, reći ću vam da iskreno ne znamo. Jasno je da virus s vremenom slabi i prestaje biti smrtonosan za čovječanstvo te pronalazi druge domaćine. Ali mi zapravo ne znamo kako i zašto se to događa. To je vrlo komplicirana ekologija.
Audience member: What kind of triggers are you looking for? You know way more than any of us. To say ahh, if this happens then we are going to have a pandemic?
Publika: Kakvu vrstu aktivatora tražite? Vi znate puno više nego bilo tko od nas. Zbog čega ćete reći: "Ah, ako se ovo dogodi - doći će do pandemije?"
LG: The moment that you see any evidence of serious human-to-human to transmission. Not just intimately between family members who took care of an ailing sister or brother, but a community infected -- spread within a school, spread within a dormitory, something of that nature. Then I think that there is universal agreement now, at WHO all the way down: Send out the alert.
LG: Onog trenutka kad vidite ozbiljan dokaz prijenosa sa čovjeka na čovjeka. Ne samo intimno, između članova obitelji koji su se brinuli o bolesnoj sestri ili bratu, već kad vidite zaraženu zajednicu - širenja unutar škola, unutar studentskih domova, nešto te prirode. Smatram da sada postoji opće slaganje sada u Svjetskoj zdravstvenoj organizaciji do kraja. Pošaljite upozorenje.
Audience member: Some research has indicated that statins can be helpful. Can you talk about that?
Publika: Neka su istraživanja pokazala da uzimanje lijekova za smanjenje razine lipida u krvi može biti korisno. Možete li reći nešto o tome?
LG: Yeah. There is some evidence that taking Lipitor and other common statins for cholesterol control may decrease your vulnerability to influenza. But we do not completely understand why. The mechanism isn't clear. And I don't know that there is any way responsibly for someone to start medicating their children with their personal supply of Lipitor or something of that nature. We have absolutely no idea what that would do. You might be causing some very dangerous outcomes in your children, doing such a thing.
LG: Da. Postoje neki dokazi da uzimanje Lipitora i nekih sličnih lijekova za kontrolu kolesterola može smanjiti vašu osjetljivost na gripu. Ali ne razumijemo, u potpunosti, zašto. Taj mehanizam nam nije jasan. I smatram da, ni na koji način, nitko ne bi trebao osjećati potrebu da počne liječiti svoju djecu s osobnom zalihom Lipitora ili nečeg sličnog. Nemamo ni ideje do čega bi to moglo dovesti. Time bi mogli prouzročiti opasne nuspojave kod svoje djece.
Audience member: How far along are we in being able to determine whether someone is actually carrying, whether somebody has this before the symptoms are full-blown?
Publika: Koliko smo napredovali u sposobnosti da zaključimo da netko ima gripu, prije nego što su simptomi u punom cvatu?
LG: Right. So I have for a long time said that what we really needed was a rapid diagnostic. And our Centers for Disease Control has labeled a test they developed a rapid diagnostic. It takes 24 hours in a very highly developed laboratory, in highly skilled hands. I'm thinking dipstick. You could do it to your own kid. It changes color. It tells you if you have H5N1. In terms of where we are in science with DNA identification capacities and so on, it's not that far off. But we're not there. And there hasn't been the kind of investment to get us there.
LG: Već sam prije dugo vremena rekla da je ono što zapravo trebamo brza dijagnoza. I naši centri za kontrolu zaraze razvili su test za brzu dijagnozu. On traje 24 sata u visoko opremljenom laboratoriju, u vrhunski vještim rukama. Ja razmišljam o mjernim štapićima. To biste mogli napraviti svome djetetu osobno. Oni mijenjaju boju. Kažu vam ako imate H5N1. U uvjetima u kojima je trenutno znanost glede identifikacije pomoću DNK kapaciteta i slično, to i nije tako nemoguće. Ali mi to nemamo. I ne postoje ulaganja bilo koje vrste koja bi nam to omogućila.
Audience member: In the 1918 flu I understand that they theorized that there was some attenuation of the virus when it made the leap into humans. Is that likely, do you think, here? I mean 100 percent death rate is pretty severe.
Publika: Koliko sam shvatio, kod gripe iz 1918. postojale su neke teorije da je virus oslabio u trenutku kada je prešao na ljude. Smatrate li da je to moguće i sada? Mislim, stopostotna stopa smrtnosti je prilično ozbiljna.
LG: Um yeah. So we don't actually know what the lethality was of the 1918 strain to wild birds before it jumped from birds to humans. It's curious that there is no evidence of mass die-offs of chickens or household birds across America before the human pandemic happened. That may be because those events were occurring on the other side of the world where nobody was paying attention. But the virus clearly went through one round around the world in a mild enough form that the British army in World War I actually certified that it was not a threat and would not affect the outcome of the war. And after circulating around the world came back in a form that was tremendously lethal. What percentage of infected people were killed by it? Again we don't really know for sure. It's clear that if you were malnourished to begin with, you had a weakened immune system, you lived in poverty in India or Africa, your likelihood of dying was far greater. But we don't really know.
LG: Umm, da. Mi zapravo ne znamo kolika je bila smrtnost za divlje ptice 1918. godine prije nego što je virus prešao s njih na ljude. Zagonetno je to što nema dokaza o masovnom ugibanju kokoši i ptica u kućanstvima diljem Amerike prije nego što se dogodila pandemija među ljudima. To može biti zato što su se ti događaji pojavljivali na drugoj strani svijeta, gdje nitko nije obraćao pozornost. No, virus je očito prošao jedan krug oko svijeta u blagom obliku, dovoljno blagom da britanska vojska za vrijeme Prvog svjetskog rata proglasi da on nije prijetnja i da neće utjecati na ishod rata. I nakon tog kruženja oko svijeta vratio se u obliku koji je bio strahovito smrtonosan. Koji je postotak zaraženih ljudi umro? Ponovno, nismo u potpunosti sigurni. Jasno je da ako ste bili pothranjeni, imali oslabljen imunološki sustav, živjeli u siromaštvu u Indiji ili Africi, vaša je vjerojatnost umiranja bila znatno veća. Ali mi zapravo ne znamo.
Audience member: One of the things I've heard is that the real death cause when you get a flu is the associated pneumonia, and that a pneumonia vaccine may offer you 50 percent better chance of survival.
Publika: Jedna od stvari koje sam čuo je da je pravi uzrok smrti kada dobijete gripu - upala pluća koja dođe s njom. I da vam cjepivo protiv upale pluća može osigurati 50 posto veću šansu preživljavanja.
LG: For a long time, researchers in emerging diseases were kind of dismissive of the pandemic flu threat on the grounds that back in 1918 they didn't have antibiotics. And that most people who die of regular flu -- which in regular flu years is about 360,000 people worldwide, most of them senior citizens -- and they die not of the flu but because the flu gives an assault to their immune system. And along comes pneumococcus or another bacteria, streptococcus and boom, they get a bacterial pneumonia. But it turns out that in 1918 that was not the case at all. And so far in the H5N1 cases in people, similarly bacterial infection has not been an issue at all. It's this absolutely phenomenal disruption of the immune system that is the key to why people die of this virus.
LG: Dugo su vremena istraživači nastanka bolesti, na neki način, odbacivali prijetnju od pandemije gripe na temelju toga što 1918. godine nije bilo antibiotika. I da su većina ljudi koji umru od obične gripe, što je oko 360 tisuća ljudi širom svijeta godišnje, stariji građani. I da oni ne umiru od gripe, već zato što gripa daje zadnji napad njihovom imunološkom sustavu. A usput dolazi i pneumokok, ili druga bakterija, streptokok i - bum, oni dobiju bakterijsku upalu pluća. Ali izgleda da 1918. godine to uopće nije bio slučaj. Tako i sada, u slučajevima H5N1 kod ljudi, slična bakterijska infekcija nije ključan problem. Radi se o apsolutnom poremećaju imunološkog sustava i to je ključna stvar zbog koje ljudi umiru od ovog virusa.
And I would just add we saw the same thing with SARS. So what's going on here is your body says, your immune system sends out all its sentinels and says, "I don't know what the heck this is. We've never seen anything even remotely like this before." It won't do any good to bring in the sharpshooters because those antibodies aren't here. And it won't do any good to bring in the tanks and the artillery because those T-cells don't recognize it either. So we're going to have to go all-out thermonuclear response, stimulate the total cytokine cascade. The whole immune system swarms into the lungs. And yes they die, drowning in their own fluids, of pneumonia. But it's not bacterial pneumonia. And it's not a pneumonia that would respond to a vaccine. And I think my time is up. I thank you all for your attention. (Applause)
I htjela bih dodati da smo istu stvar imali sa SARS-om. Dakle, ono što se ovdje događa je da vaše tijelo kaže, vaš imunološki sustav kaže: „Ne znam što je ovo. Nikad nismo vidjeli nešto ni približno slično ovome.“ Neće vam biti nimalo bolje ako uvedete „iskusne strijelce“ u organizam - jer tih antitijela nema ovdje. Ni uvođenje „tenkova i topništva“ neće rezultirati poboljšanjem jer ih vaši T-limfociti neće prepoznati. Zato ćemo morati ići sve do termonuklearne reakcije, stimulirati potpunu kaskadu citokina. Cijeli imunološki sustav nahrupi u pluća. I da, ljudi umiru utapajući se u vlastitoj tekućini, od upale pluća. Ali to nije bakterijska upala pluća. I to nije upala pluća koja bi reagirala na cjepivo. Mislim da mi je vrijeme isteklo. Zahvaljujem Vam svima na pozornosti. (Pljesak)