World Health Organization (WHO) Personal Profile Senior Policy Advisor to the Director General of the United Nations			Amid growing concern about the outbreak of an influenza pandemic, Dr. David Nabarro of the World Health Organization (WHO) provided us with his insight into the likelihood of such a pandemic and what should be done before it occurs. By 29 September 2005, WHO had confirmed 116 cases of avian influenza (across four nations), 60 of which had already resulted in death. On the same day, the Secretary General of the United Nations (U.N.) appointed Dr. David Nabarro to "lead the coordination of the U.N.'s response to avian influenza and a possible human influenza pandemic." As of the first week of 2006, the number of nations reporting confirmed cases of avian influenza had risen to six, the number of people who had contracted the disease had risen to 144 and the death toll was at 76. Our interview with Dr. Nabarro took place on December 22, 2005. Ken McGee: Dr. Nabarro, is human-to-human transmission of the avian influenza virus a certainty? David Nabarro: At the moment, we have animal-to-animal transmission and animal-to-human sporadic transmission between, 130 and 140 definite cases. There has sort of been on one or two occasions human-to-human transmission since the virus was first discovered in 1997, but in no case has this been sustained. And the thing that we worried about is sustained human-to-human transmission, that's the very difficult one. So, the direct human-to-human, as I say, it has never been found to have been sustained. And it's only going to be of extreme severity as far as capacity to case a pandemic when it's a sustained human-to-human transmission. McGee: That said, is an avian influenza pandemic among humans-to-humans a certainty? Nabarro: An influenza pandemic among humans through human-to-human transmission is a certainty sometime, and that's simply based on the fact that these things happen. It's a certainty that we get from studying history and recognizing that, over the last 200 years, there have been pandemics at intervals of every 30 to 40 years, on average. And we're about due for one now. So, unless something extraordinary has happened to human immune systems, influenza virus behavior or whatever, another pandemic is definitely going to happen. I just cannot tell you when. McGee: Last month in Geneva, the Director General of the World Health Organization, Dr. Lee Jong-wook, said, "It is only a matter of time before an avian flu virus, most likely H5N1, acquires the ability to be transmitted from human to human, sparking the outbreak of human pandemic influenza. We don't know when this will happen. But we do know that it will happen." My question is, to what extent, if any, are you finding government officials treating the issues being raised by WHO as being unfounded, overblown or hype? Are you detecting any of that? Nabarro: Well, I think that there will be officials in every government who question what Dr. Lee said at the beginning of that meeting. And I find that they often take a deep breath and ask you, "Really?" And you say to them, "Yes, it's going to happen; it's only a matter of time." You also stress to them that it will almost certainly - and we can't ever be completely certain - be an avian influenza virus that will develop the capacity to be transmitted from human to human. After a time, we find that they do start to realize not only that it will happen, but also that it would be rather foolhardy not to prepare for it, given the enormous human, economic and other consequences. On my most recent visit to Cambodia, Indonesia and India, the ministers, some of them very senior ministers, or the deputy prime ministers and others that I saw, very much grasped the importance of this. And they were not telling me that they thought what Dr. Lee or I were saying was overblown. The only time I've heard comments about it being overblown are hearsay regarding what some officials in certain governments - often more junior officials - have said in situations where they've been talking privately. But I've never heard anybody say this is an overrated issue. McGee: How would you classify the manner in which the Centers for Disease Control and Prevention (CDC) in Atlanta are viewing all this? There are indications that they are not as convinced, given quotes and articles that we've read. Are they on the same page as the World Health Organization about the likelihood of a pandemic? Nabarro: Well, I've seen nothing from CDC that says there won't be a pandemic. There is quite a lot of debate as to whether H5N1 will be the cause of the next pandemic, which I could talk about. But nobody I've met from CDC says there won't be one. The only other difference that I've noticed is there are people in CDC who are being very cautious about modeling the numbers of deaths from the next pandemic. And that's fair enough, because none of us can predict how many people are going to die from the next pandemic. Those kinds of models are a bit of a waste of time. McGee: Why? Nabarro: Modeling the total number of deaths is a waste of time. What the absolutely key thing to have is models and simulations of the progression of the virus, as well as the way in which the virus and society will interact. We actually need those sorts of simulations very, very badly at the moment. McGee: If it is H5N1, then will the human genome transmission take place more or less rapidly than with other influenza viruses? How do you view that spreading at this point in time? Nabarro: The biology colleagues that I speak with tell me that if the pathogenic characteristics of H5N1 were to be taken forward as it mutates into having a human-to-human transmission capacity, then we would have a virus with high pathogenicity. So, we really have to hope that if it's a mutant of H5N1 that causes the next pandemic, it sheds some of the pathogenicity that this current virus has during its mutation. McGee: I see. Assuming it is a rather deadly strain, how long would it take to reach a - I don't even know how you'd define - a worldwide...? Nabarro: A pandemic, we're quite simple on that. McGee: But does that mean every nation in the world? Nabarro: No, pandemic means a lot of people, not all people. McGee: I didn't know if you had a more specific definition. Nabarro: No, there is not, as far as I know. I don't believe we are required to say that a pandemic has affected a certain number of countries or people before it's called a pandemic. An epidemic is a thing with a fairly defined start and end, and it's usually fairly tightly located geographically. A pandemic moves around - across countries and across communities. The reason why we're particularly at risk is our world population is so massively mobile at the moment. How long do we have before the situation is an established pandemic? The modelers are telling us that it may be as few as 21 days from the initial appearance of a virus to it being a full-blown pandemic. That particular part of modeling is, again, hedged with uncertainties. But having that lower-end 21-day value is quite useful, because it concentrates the mind a bit. McGee: What do you say when presidents and prime ministers ask, "What's the likelihood of a pandemic in one year?" Nabarro: There, we can get into trouble. We don't know the likelihood of a pandemic in one year. I can't speak for other people, but I say, "I don't know." I say that pandemic influenza will happen at some point in time and that I believe it's more likely now than three years ago, because this virus is alongside us in large amounts, and that increases the likelihood of the mutation. I say that the pandemic could be mild, severe, extremely severe ? we just don't know. So, I will not say how severe it will be. I also say we do not know when it will start. McGee: I now want to move on to what should be done. What is your sense of the state of readiness, not of governments, but of global corporations? Do you have any feel for that? Nabarro: Corporations that work in agriculture, particularly in production of meat, are very concerned about this, because the influenza virus could well affect their trade directly. I think that the health-sector companies are getting more engaged for obvious reasons - again, because they're directly involved - whether they're concerned with protective clothing and masks, or with production of medicines and vaccines. I think there's still more work to be done in that group just to make sure that they are best using their production capacity. We're always slightly nervous about antitrust laws and things like that for reducing the willingness of companies to work well together. I've seen evidence that a number of other groups are getting quite well prepared. Judging from informal contacts I've had with the tourism and travel industry, airlines, hotel groups and the like (which I'll be meeting more formally with in January) are seeing this as a serious risk area and getting engaged. McGee: Would you go so far as to say the same thing to corporate CEOs that you say to cabinet-level ministers? Should corporate CEOs assign senior executives to coordinate their response to avian flu? Nabarro: I don't know enough about how corporations work to come out with a prescription like that. However, I do know enough about governments, and in particular about the tussles that can occur when you have two different government ministers directly involved, like agriculture and health. This recommendation was definitely made for governments, not for corporations. My request to corporations is that they do all that is necessary for themselves to get prepared for how influenza could affect the continuity of their businesses. McGee: The World Health Organization has given a large number of things for governments to consider. But what steps would you suggest that corporate executives take? Nabarro: Start by looking at the frailty of your business and consider where you might be in big trouble if you had to lose an arm of your supply or distribution chain. I think that business continuity is pretty important - that's their business, not mine - so companies surely ought to do that. The second thing I would say to companies is that we have a huge amount to do to bring health services, vet services and our relief services in many countries up to the kind of standards that they're expected to display in the 21st century. We who work in government or the public sector can't do this on our own. We can do this only if we work with others who have the expertise. You in the private sector have not only expertise in terms of strategizing and programming at your high levels, but also huge workforces of motivated people who can themselves become advocates and activists in the influenza arena. McGee: Governments look to your organization and similar organizations for some guidance. It doesn't seem that there are any such parallels in the private sector. Are there? Nabarro: I attended a meeting in Bangkok with representatives from 60 companies to look at how companies can work with the U.N. and governments to share their expertise, with a particular focus on South Asia and the bird flu. It was a really great meeting, and we came out of it with some very concrete plans on how to move forward on that. The other place where I think we're going to get some traction is through the World Economic Forum, where there will be quite a lot of activities on pandemics. McGee: It occurs to us that aside from the obvious - the healthcare industry - the information technology industry will be called on for "work-arounds" in the event of a pandemic to assist governments and businesses as much as possible. Nabarro: Yes, some IT company officials have been in touch with me about this specifically. McGee: In closing, if you were on stage in the U.N. General Assembly and the world's cameras were on you, and you had only three minutes to address the world, what would you say? Nabarro: Well, the messages are very clear. We have an awful lot more to do with the current bird flu epidemic. It is really not under control at all, and that means we have to build up vet service quickly to get on top of it. The longer it's there, the longer we have a virus close to humans that is capable of mutating and causing a pandemic. And the situation is very, very serious indeed. Number two, we've got to be ready to contain the pandemic when it starts. And that's done through rehearsals and other drills, clear command and control. It requires a level of planning and preparation that's much, much greater than the majority of countries are showing so far. Number three, the pandemic will kill when it comes. But more seriously perhaps, it will do massive economic and social damage, because our systems of trade, finance and governance are interconnected and will not survive the impact of a pandemic on workforces. We need to be able to deal with both the human consequences and the economic, social and governance consequences if we're going to survive it. And believe me, the pandemic could start tomorrow. By the time the pandemic starts, preparation will be too late. So, you should be doing this now, and that's my message. McGee: Dr. Nabarro, thank you very much.