fourth and third groups, both of them touched on something that I thought was incredibly important, and in some ways I wish they had gone further with it.

The third group talked about operational infrastructure research. And the fourth group talked about animals, the need for surveys of knowledge, attitude and practice among people who raise poultry, the development of economic incentives, and the development of educational programs all of which are subject to research. I think that as part of our long-term research strategy, we should be putting much more effort than we have into the non-biologic aspects of a pandemic, because there are factors that strongly influence the spread of a virus, and the ability to control the spread of a virus that really have very little to do with pathogenicity and with hosts and molecules and all those areas that we, as scientists, drawn to. I also think that if a pandemic emerges, we will not lose so many people to Tamiflu resistance as we will to the fact that they did not understand the importance of basic hygiene or they did not have access to personal protective equipment. I think those are factors that determine how a pandemic flows.

I also think that the type of research that we need to do will have to draw much more heavily on some people who we do not usually partner with. We need to talk to the people who know about immune modulators, but also the people who know about health education, and the people who know about international trade law, the people who know about organizational dynamics, some of the factors in getting these drugs out to the field, getting the supply chain, which we heard about earlier today.

Those are issues that we have not spent the time researching. It is a much more basic set of questions that we have. In contrast, we have gone very, very far with research on some of the biologic questions.

PARTICIPANT: I would like to return to the previous discussion, if we could, and maybe ask the group if there is any information that we can glean from historical perspectives of pandemics. Over the past few months I have been trying to understand the future of the pandemics, and have gone back and pulled out a lot of the original work or writing that have been done. But I think there has been a lot of what I would call also folklore around previous pandemics. And when you really start to peel the onion and look at what’s there, it is clear that 1918 was not unique. It looks like 1830-1832 had a very similar picture of deaths primarily between 20 and 35 year olds, and a very classic W shaped curve again, just like we saw in 1918. Whereas, if you get into the 1880, you get into the other ones, there are at least 10 in the last 300 years; they really fall into two camps, those that had the classic accelerated or exaggerated Y shaped curve, and those that had the W shaped curve. Which would suggest to me, that there are several mechanisms for pandemics to occur?

The underlying necessary cause of a pandemic is a new virus for which there is a lack of overall population-based immunity. Pathogenicity is by definition, the virus’ ability to cause disease. Virulence defines the virus’ ability to cause severe disease. The virulence factors may determine which type of pandemic it is.

In other words, is it one of the W shaped curve, or the accelerated or exaggerated Y shaped curve? The answer has tremendous implications for how we deal with it, because one is probably more of a secondary bacterial pneumonia type picture and the other not. I think that this area needs a lot more research because we have artificially lumped all pandemics under one category, when in fact they may be of a common origin, but not of common outcome or cause. Perhaps an historian in this area could comment on it.

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