[Paleopsych] Foreign Affairs: Michael T. Osterholm: Preparing for the Next Pandemic

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Michael T. Osterholm: Preparing for the Next Pandemic

First, the summary from CHE:

The Chronicle of Higher Education: Magazine & journal reader
                                                  Wednesday, June 29, 2005

    A glance at the July/August issue of Foreign Affairs: Coping with the
    coming pandemic

    An influenza pandemic is coming, writes Michael T. Osterholm, director
    of the Center for Infectious Disease Research and Policy and a
    professor in the School of Public Health at the University of
    Minnesota at Minneapolis.

    "The signs are alarming," he says, as the number of human and animal
    infections caused by a virulent strain of bird flu known as H5N1 "has
    been increasing; small clusters of cases have been documented,
    suggesting that the virus may have come close to sustained
    human-to-human transmission; and H5N1 continues to evolve in the
    virtual genetic-reassortment laboratory provided by the unprecedented
    number of people, pigs, and poultry in Asia."

    If a pandemic struck today, it would probably kill hundreds of
    millions of people and ravage the world economy. International borders
    would close, and there would be severe worldwide shortages of
    influenza vaccine, other medicines, and a wide range of commodities,
    "including food, soap, paper, light bulbs, gasoline," Mr. Osterholm

    In short, he says, panic would ensue. It's urgent that world leaders
    develop an "initiative to provide vaccine for the entire world,"
    stockpile "critical health-care and consumer products and
    commodities," and assess "the vulnerability of the global economy to
    ensure that surges in demand can be met," he writes.

    "Time is running out to prepare for the next pandemic," Mr. Osterholm
    warns . We can't stop it from hitting, he says, but if we act now, we
    may be able to reduce its impact.

    The article, "Preparing for the Next Pandemic," is online at

    --Gabriela Montell

    Background article from The Chronicle:
      * [55]Taking Aim at Bird Flu (3/18/2005)


   55. http://chronicle.com/weekly/v51/i28/28a01401.htm

E-mail me if you have problems getting the referenced article.


    From Foreign Affairs, July/August 2005

    Summary: If an influenza pandemic struck today, borders would close,
    the global economy would shut down, international vaccine supplies and
    health-care systems would be overwhelmed, and panic would reign. To
    limit the fallout, the industrialized world must create a detailed
    response strategy involving the public and private sectors.

    Michael T. Osterholm is Director of the Center for Infectious Disease
    Research and Policy, Associate Director of the Department of Homeland
    Security's National Center for Food Protection and Defense, and
    Professor at the University of Minnesota's School of Public Health.


    Dating back to antiquity, influenza pandemics have posed the greatest
    threat of a worldwide calamity caused by infectious disease. Over the
    past 300 years, ten influenza pandemics have occurred among humans.
    The most recent came in 1957-58 and 1968-69, and although several tens
    of thousands of Americans died in each one, these were considered mild
    compared to others. The 1918-19 pandemic was not. According to recent
    analysis, it killed 50 to 100 million people globally. Today, with a
    population of 6.5 billion, more than three times that of 1918, even a
    "mild" pandemic could kill many millions of people.

    A number of recent events and factors have significantly heightened
    concern that a specific near-term pandemic may be imminent. It could
    be caused by H5N1, the avian influenza strain currently circulating in
    Asia. At this juncture scientists cannot be certain. Nor can they know
    exactly when a pandemic will hit, or whether it will rival the
    experience of 1918-19 or be more muted like 1957-58 and 1968-69. The
    reality of a coming pandemic, however, cannot be avoided. Only its
    impact can be lessened. Some important preparatory efforts are under
    way, but much more needs to be done by institutions at many levels of


    Of the three types of influenza virus, influenza type A infects and
    kills the greatest number of people each year and is the only type
    that causes pandemics. It originates in wild aquatic birds. The virus
    does not cause illness in these birds, and although it is widely
    transmitted among them, it does not undergo any significant genetic

    Direct transmission from the birds to humans has not been
    demonstrated, but when a virus is transmitted from wild birds to
    domesticated birds such as chickens, it undergoes changes that allow
    it to infect humans, pigs, and potentially other mammals. Once in the
    lung cells of a mammalian host, the virus can "reassort," or mix
    genes, with human influenza viruses that are also present. This
    process can lead to an entirely new viral strain, capable of sustained
    human-to-human transmission. If such a virus has not circulated in
    humans before, the entire population will be susceptible. If the virus
    has not circulated in the human population for a number of years, most
    people will lack residual immunity from previous infection.

    Once the novel strain better adapts to humans and is easily
    transmitted from person to person, it is capable of causing a new
    pandemic. As the virus passes repeatedly from one human to the next,
    it eventually becomes less virulent and joins the other influenza
    viruses that circulate the globe each year. This cycle continues until
    another new influenza virus emerges from wild birds and the process
    begins again.

    Some pandemics result in much higher rates of infection and death than
    others. Scientists now understand that this variation is a result of
    the genetic makeup of each specific virus and the presence of certain
    virulence factors. That is why the 1918-19 pandemic killed many more
    people than either the 1957-58 or the 1968-69 pandemic.


    Infectious diseases remain the number one killer of humans worldwide.
    Currently, more than 39 million people live with HIV, and last year
    about 2.9 million people died of AIDS, bringing the cumulative total
    of deaths from AIDS to approximately 25 million. Tuberculosis (TB) and
    malaria also remain major causes of death. In 2003, about 8.8 million
    people became infected with TB, and the disease killed more than 2
    million. Each year, malaria causes more than 1 million deaths and
    close to 5 billion episodes of clinical illness. In addition, newly
    emerging infections, diarrheal and other vector-borne diseases, and
    agents resistant to antibiotics pose a serious and growing public
    health concern.

    Given so many other significant infectious diseases, why does another
    influenza pandemic merit unique and urgent attention? First, of the
    more than 1,500 microbes known to cause disease in humans, influenza
    continues to be the king in terms of overall mortality. Even in a year
    when only the garden-variety strains circulate, an estimated 1-1.5
    million people worldwide die from influenza infections or related
    complications. In a pandemic lasting 12 to 36 months, the number of
    cases and deaths would rise dramatically.

    Recent clinical, epidemiological, and laboratory evidence suggests
    that the impact of a pandemic caused by the current H5N1 strain would
    be similar to that of the 1918-19 pandemic. More than half of the
    people killed in that pandemic were 18 to 40 years old and largely
    healthy. If 1918-19 mortality data are extrapolated to the current
    U.S. population, 1.7 million people could die, half of them between
    the ages of 18 and 40. Globally, those same estimates yield 180-360
    million deaths, more than five times the cumulative number of
    documented AIDS deaths. In 1918-19, most deaths were caused by a
    virus-induced response of the victim's immune system -- a cytokine
    storm -- which led to acute respiratory distress syndrome (ARDS). In
    other words, in the process of fighting the disease, a person's immune
    system severely damaged the lungs, resulting in death. Victims of H5N1
    have also suffered from cytokine storms, and the world is not much
    better prepared to treat millions of cases of ARDS today than it was
    85 years ago. In the 1957-58 and 1968-69 pandemics, the primary cause
    of death was secondary bacterial pneumonias that infected lungs
    weakened by influenza. Although such bacterial infections can often be
    treated by antibiotics, these drugs would be either unavailable or in
    short supply for much of the global population during a pandemic.

    The arrival of a pandemic influenza would trigger a reaction that
    would change the world overnight. A vaccine would not be available for
    a number of months after the pandemic started, and there are very
    limited stockpiles of antiviral drugs. Plus, only a few privileged
    areas of the world have access to vaccine-production facilities.
    Foreign trade and travel would be reduced or even ended in an attempt
    to stop the virus from entering new countries -- even though such
    efforts would probably fail given the infectiousness of influenza and
    the volume of illegal crossings that occur at most borders. It is
    likely that transportation would also be significantly curtailed
    domestically, as smaller communities sought to keep the disease
    contained. The world relies on the speedy distribution of products
    such as food and replacement parts for equipment. Global, regional,
    and national economies would come to an abrupt halt -- something that
    has never happened due to HIV, malaria, or TB despite their dramatic
    impact on the developing world.

    The closest the world has come to this scenario in modern times was
    the SARS (severe acute respiratory syndrome) crisis of 2003. Over a
    period of five months, about 8,000 people were infected by a novel
    human coronavirus. About ten percent of them died. The virus
    apparently spread to humans when infected animals were sold and
    slaughtered in unsanitary and crowded markets in China's Guangdong
    Province. Although the transmission rate of SARS paled in comparison
    to that of influenza, it demonstrated how quickly such an infectious
    agent can circle the globe, given the ease and frequency of
    international travel. Once SARS emerged in rural China, it spread to
    five countries within 24 hours and to 30 countries on six continents
    within several months.

    The SARS experience teaches a critical lesson about the potential
    global response to a pandemic influenza. Even with the relatively low
    number of deaths it caused compared to other infectious diseases, SARS
    had a powerful negative psychological impact on the populations of
    many countries. In a recent analysis of the epidemic, the National
    Academy of Science's Institute of Medicine concluded: "The relatively
    high case-fatality rate, the identification of super-spreaders, the
    newness of the disease, the speed of its global spread, and public
    uncertainty about the ability to control its spread may have
    contributed to the public's alarm. This alarm, in turn, may have led
    to the behavior that exacerbated the economic blows to the travel and
    tourism industries of the countries with the highest number of cases."

    SARS provided a taste of the impact a killer influenza pandemic would
    have on the global economy. Jong-Wha Lee, of Korea University, and
    Warwick McKibbin, of the Australian National University, estimated the
    economic impact of the six-month SARS epidemic on the Asia-Pacific
    region at about $40 billion. In Canada, 438 people were infected and
    43 died after an infected person traveled from Hong Kong to Toronto,
    and the Canadian Tourism Commission estimated that the epidemic cost
    the nation's economy $419 million. The Ontario health minister
    estimated that SARS cost the province's health-care system about $763
    million, money that was spent, in part, on special SARS clinics and
    supplies to protect health-care workers. The SARS outbreak also had a
    substantial impact on the global airline industry. After the disease
    hit in 2003, flights in the Asia-Pacific area decreased by 45 percent
    from the year before. During the outbreak, the number of flights
    between Hong Kong and the United States fell 69 percent. And this
    impact would pale in comparison to that of a 12- to 36-month worldwide
    influenza pandemic.

    The SARS epidemic also raises questions about how prepared governments
    are to address a prolonged infectious-disease crisis -- particularly
    governments that are already unstable. Seton Hall University's
    Yanzhong Huang concluded that the SARS epidemic created the most
    severe social or political crisis encountered by China's leadership
    since the 1989 Tiananmen crackdown. China's problems probably resulted
    less from SARS' public health impact than from the government's failed
    effort to allay panic by withholding information about the disease
    from the Chinese people. The effort backfired. During the crisis,
    Chinese Premier Wen Jiabao pointed out in a cabinet meeting on the
    epidemic that "the health and security of the people, overall state of
    reform, development, and stability, and China's national interest and
    image are at stake." But Huang believes that "a fatal period of
    hesitation regarding information-sharing and action spawned anxiety,
    panic, and rumor-mongering across the country and undermined the
    government's efforts to create a milder image of itself in the
    international arena."

    Widespread infection and economic collapse can destabilize a
    government; blame for failing to deal effectively with a pandemic can
    cripple a government. This holds even more for an influenza pandemic.
    In the event of a pandemic influenza, the level of panic witnessed
    during the SARS crisis could spiral out of control as illnesses and
    deaths continued to mount over months and months. Unfortunately, the
    public is often indifferent to initial warnings about impending
    infectious-disease crises -- as with HIV, for example. Indifference
    becomes fear only after the catastrophe hits, when it is already too
    late to implement preventive or control measures.


    What should the industrialized world be doing to prepare for the next
    pandemic? The simple answer: far more. So far, the World Health
    Organization and several countries have finalized or drafted useful
    but overly general plans. The U.S. Department of Health and Human
    Services has increased research on influenza-vaccine production and
    availability. These efforts are commendable, but what is needed is a
    detailed operational blueprint for how to get a population through one
    to three years of a pandemic. Such a plan must involve all the key
    components of society. In the private sector, the plan must coordinate
    the responses of the medical community, medical suppliers, food
    providers, and the transportation system. In the government sector,
    the plan should take into account officials from public health, law
    enforcement, and emergency management at the international, federal,
    state, and local levels.

    At the same time, it must be acknowledged that such master blueprints
    may have their drawbacks, too. Berkeley's Aaron Wildavsky persuasively
    argued that resilience is the real key to crisis management -- overly
    rigid plans can do more harm than good. Still, planning is enormously
    useful. It gives government officials, private-sector partners, and
    the community the opportunity to meet, think through potential
    dilemmas, purchase necessary equipment, and set up organizational
    structures for a 12- to 36-month response. A blueprint forces leaders
    to rehearse their response to a crisis, preparing emotionally and
    intellectually so that when disaster strikes the community can face

    Influenza-vaccine production deserves special attention. An initiative
    to provide vaccine for the entire world must be developed, with a
    well-defined schedule to ensure progress. It is laudable that
    countries such as the United States and Vietnam are pursuing programs
    with long-term goals to develop and produce H5N1 vaccine for their
    respective populations. But if the rest of the world lacks supplies,
    even the vaccinated will be devastated when the global economy comes
    to an abrupt halt. Pandemic-influenza preparedness is by nature an
    international issue. No one can truly be isolated from a pandemic.

    The pandemic-related collapse of worldwide trade and its ripple effect
    throughout industrialized and developing countries would represent the
    first real test of the resiliency of the modern global delivery
    system. Given the extent to which modern commerce relies on the
    precise and readily available international trade of goods and
    services, a shutdown of the global economic system would dramatically
    harm the world's ability to meet the surging demand for essential
    commodities such as food and medicine during a crisis. The business
    community can no longer afford to play a minor role in planning the
    response to a pandemic. For the world to have critical goods and
    services during a pandemic, industry heads must stockpile raw
    materials for production and preplan distribution and transportation
    support. Every company's senior managers need to be ready to respond
    rapidly to changes in the availability, production, distribution, and
    inventory management of their products. There is no model for how to
    revive the current global economy were it to be devastated.

    To truly be complete, all planning on international, regional,
    national, and local levels must consider three different scenarios:
    What if the pandemic begins tonight? What if it starts one year from
    now? What if the world is so fortunate as to have an entire decade to
    prepare? All are possible, but none is certain.


    What would happen today in the office of every nation's leader if
    several cities in Vietnam suffered from major outbreaks of H5N1
    infection, with a five percent mortality rate? First, there would be
    an immediate effort to try to sort out disparate disease-surveillance
    data from a variety of government and public health sources to
    determine which countries might have pandemic-related cases. Then, the
    decision would likely be made to close most international and even
    some state or provincial borders -- without any predetermined criteria
    for how or when those borders might be reopened. Border security would
    be made a priority, especially to protect potential supplies of
    pandemic-specific vaccines from nearby desperate countries. Military
    leaders would have to develop strategies to defend the country and
    also protect against domestic insurgency with armed forces that would
    likely be compromised by the disease. Even in unaffected countries,
    fear, panic, and chaos would spread as international media reported
    the daily advance of the disease around the world.

    In short order, the global economy would shut down. The commodities
    and services countries would need to "survive" the next 12 to 36
    months would have to be identified. Currently, most businesses'
    continuity plans account for only a localized disruption -- a single
    plant closure, for instance -- and have not planned for extensive,
    long-term outages. The private and public sectors would have to
    develop emergency plans to sustain critical domestic supply chains and
    manufacturing and agricultural production and distribution. The labor
    force would be severely affected when it was most needed. Over the
    course of the year, up to 50 percent of affected populations could
    become ill; as many as five percent could die. The disease would hit
    senior management as hard as the rest of the work force. There would
    be major shortages in all countries of a wide range of commodities,
    including food, soap, paper, light bulbs, gasoline, parts for
    repairing military equipment and municipal water pumps, and medicines,
    including vaccines unrelated to the pandemic. Many industries not
    critical to survival -- electronics, automobile, and clothing, for
    example -- would suffer or even close. Activities that require close
    human contact -- school, seeing movies in theaters, or eating at
    restaurants -- would be avoided, maybe even banned.

    Vaccine would have no impact on the course of the virus in the first
    months and would likely play an extremely limited role worldwide
    during the following 12 to 18 months of the pandemic. Despite major
    innovations in the production of most other vaccines, international
    production of influenza vaccine is based on a fragile and limited
    system that utilizes technology from the 1950s. Currently, annual
    production of influenza vaccine is limited to about 300 million
    trivalent doses -- which protect against three different influenza
    strains in one dose -- or less than one billion monovalent doses. To
    counter a new strain of pandemic influenza that has never circulated
    throughout the population, each person would likely need two doses for
    adequate protection. With today's limited production capacity, that
    means that less than 500 million people -- about 14 percent of the
    world's population -- would be vaccinated within a year of the
    pandemic. In addition, because the structure of the virus changes so
    rapidly, vaccine development could only start once the pandemic began,
    as manufacturers would have to obtain the new pandemic strain. It
    would then be at least another six months before mass production of
    the vaccine.

    Even if the system functions to the best of its ability, influenza
    vaccine is produced commercially in just nine countries: Australia,
    Canada, France, Germany, Italy, Japan, the Netherlands, the United
    Kingdom, and the United States. These countries contain only 12
    percent of the world's population. In the event of an influenza
    pandemic, they would probably nationalize their domestic production
    facilities, as occurred in 1976, when the United States, anticipating
    a pandemic of swine influenza (H1N1), refused to share its vaccine.

    If a pandemic struck the world today, there would be another possible
    weapon against influenza: antiviral medicine. When taken daily during
    the time of exposure to influenza, antivirals have prevented
    individuals from becoming ill. They have also reduced the severity of
    illness and subsequent complications when taken within 48 hours of
    onset. Although there is no data for H5N1, it is assumed antivirals
    would also prevent H5N1 infection if taken before exposure. There is
    no evidence, however, that current antiviral influenza drugs would
    help if the patient developed the kind of cytokine storm that has
    characterized recent H5N1 infections. But barring this complication,
    H5N1 should be treatable with Tamiflu (oseltamivir phosphate), which
    is manufactured by the Roche pharmaceuticals company in a single plant
    in Switzerland.

    In responding to a pandemic, Tamiflu could have a measurable impact in
    the limited number of countries with sizable stockpiles, but for most
    of the world it would not be available. Although the company plans on
    opening another facility in the United States this year, annual
    production would still cover only a small percentage of the world's
    population. To date, at least 14 countries have ordered Tamiflu, but
    the amount of these orders is enough to treat only 40 million people.
    The orders take considerable time to be processed and delivered --
    manufacturing can take up to a year -- and in an emergency the
    company's ability to produce more would be limited. As with vaccines,
    countries would probably nationalize their antiviral supplies during a
    pandemic. Even if the medicine were available, most countries could
    not afford to buy it. Critical antibiotics, for treatment of secondary
    bacterial infections, would also be in short supply during a pandemic.
    Even now, supplies of eight different anti-infective agents are
    limited in the United States due to manufacturing problems.

    Aside from medication, many countries would not have the ability to
    meet the surge in the demand for health-care supplies and services
    that are normally taken for granted. In the United States, for
    example, there are 105,000 mechanical ventilators, 75,000 to 80,000 of
    which are in use at any given time for everyday medical care. During a
    routine influenza season, the number of ventilators being used shoots
    up to 100,000. In an influenza pandemic, the United States may need as
    many as several hundred thousand additional ventilators.

    A similar situation exists in all developed countries. Virtually every
    piece of medical equipment or protective gear would be in short supply
    within days of the recognition of a pandemic. Throughout the crisis,
    many of these necessities would simply be unavailable for most
    health-care institutions. Currently, two U.S.-based companies supply
    most of the respiratory protection masks for health-care workers
    around the world. Neither company would be able to meet the jump in
    demand, in part because the component parts for the masks come from
    multiple suppliers in multiple countries. With travel and
    transportation restricted, masks may not even be produced at all.

    Health-care providers and managed-care organizations are also
    unprepared for an outbreak of pandemic influenza today. There would be
    a tremendous demand for skilled health professionals. New "hospitals"
    in high school gymnasiums and community centers would have to be
    staffed for one to three years. Health-care workers would probably get
    sick and die at the same rate as the general public -- perhaps at an
    even higher rate, particularly if they lack access to protective
    equipment. If they lack such fundamental supplies, it is unclear how
    many professionals would continue to place themselves in high-risk
    situations by caring for the infected. Volunteers who are naturally
    immune as a result of having survived influenza infection would thus
    have to be found and employed. That means that the medical community's
    strong resistance to using lay volunteers, which is grounded in both
    liability concerns and professional hubris, would need to be

    Other unpleasant issues would also need to be tackled. Who would have
    priority access to the extremely limited antiviral supplies? The
    public would consider any ad hoc prioritization unfair, creating
    further dissent and disruption during a pandemic. In addition, there
    would not even be detailed plans for handling the massive number of
    dead bodies that would soon outstrip the ability to process them.
    Clearly, an influenza pandemic that struck today would demand an
    unprecedented medical and nonmedical response. This requires planning
    well beyond anything devised thus far by any of the world's countries
    and organizations.


    Even if an H5N1 pandemic is a year away, the world must plan for the
    same problems with the same fervor. Major campaigns must be initiated
    to prepare the nonmedical and medical sectors. Pandemic planning must
    be on the agenda of every school board, manufacturing plant,
    investment firm, mortuary, state legislature, and food distributor in
    the United States and beyond. There is an urgent need to reassess the
    vulnerability of the global economy to ensure that surges in demand
    can be met. Critical heath-care and consumer products and commodities
    must be stockpiled. Health professionals must learn how to better
    communicate risk and must be able to both provide the facts and
    acknowledge the unknowns to a frightened or panicked population.

    If there is a year of lead-time before an H5N1 pandemic, vaccine could
    play a more central role in the global response. Although the world
    would still have a limited capacity to manufacture influenza vaccine,
    techniques that could allow scientists to get multiple doses from a
    current single dose may increase the supply. In addition to further
    research on this issue, efforts are needed to ensure the availability
    of syringes and equipment for delivering vaccine. There must also be
    an international plan for how the vaccine would be allocated. It is
    far better to struggle with the ethical issues involved in determining
    such priorities now, in a public forum, rather than to wait until the
    crisis occurs.

    Prevention must also be improved. Priority should be placed on early
    intervention and risk assessment. And an aggressive and comprehensive
    research agenda must be launched immediately to study the ecology and
    biology of the influenza virus and the epidemiologic role of various
    animal and bird species.


    If developed countries begin to transform radically the current system
    of influenza-vaccine production, an influenza pandemic ten years from
    now could have a much less devastating outcome. The industrialized
    world must initiate an international project to develop the ability to
    produce a vaccine for the entire global population within several
    months of the start of a pandemic. The initiative must be a top
    priority of the group of seven industrialized nations plus Russia
    (G-8), because almost nothing could inflict more death and disruption
    than a pandemic influenza.

    The current BioShield law and additional legislation recently
    submitted to Congress will act to enhance the availability of vaccines
    in the United States. This aim is laudable, but it does little to
    address international needs. The ultimate goal must be to develop a
    new cell-culture vaccine or comparable vaccine technology that works
    on all influenza subtypes and that can be made available on short
    notice to all the people of the world.


    The world must form a better understanding of the potential for the
    emergence of a pandemic influenza strain. A pandemic is coming. It
    could be caused by H5N1 or by another novel strain. It could happen
    tonight, next year, or even ten years from now.

    The signs are alarming: the number of human and animal H5N1 infections
    has been increasing; small clusters of cases have been documented,
    suggesting that the virus may have come close to sustained
    human-to-human transmission; and H5N1 continues to evolve in the
    virtual genetic reassortment laboratory provided by the unprecedented
    number of people, pigs, and poultry in Asia. The population explosion
    in China and other Asian countries has created an incredible mixing
    vessel for the virus. Consider this sobering information: the most
    recent influenza pandemic, of 1968-69, emerged in China, when its
    population was 790 million; today it is 1.3 billion. In 1968, the
    number of pigs in China was 5.2 million; today it is 508 million. The
    number of poultry in China in 1968 was 12.3 million; today it is 13
    billion. Changes in other Asian countries are similar. Given these
    developments, as well as the exponential growth in foreign travel over
    the past 50 years, an influenza pandemic could be more devastating
    than ever before.

    Can disaster be avoided? The answer is a qualified yes. Although a
    coming pandemic cannot be avoided, its impact can be considerably
    lessened. It depends on how the leaders of the world -- from the heads
    of the G-8 to local officials -- decide to respond. They must
    recognize the economic, security, and health threat that the next
    influenza pandemic poses and invest accordingly. Each leader must
    realize that even if a country has enough vaccine to protect its
    citizens, the economic impact of a worldwide pandemic will inflict
    substantial pain on everyone. The resources required to prepare
    adequately will be extensive. But they must be considered in light of
    the cost of failing to invest: a global world economy that remains in
    a shambles for several years.

    This is a critical point in history. Time is running out to prepare
    for the next pandemic. We must act now with decisiveness and purpose.
    Someday, after the next pandemic has come and gone, a commission much
    like the 9/11 Commission will be charged with determining how well
    government, business, and public health leaders prepared the world for
    the catastrophe when they had clear warning. What will be the verdict?

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