DR. FINEBERG: This and the previous question raise important ethical aspects of research as well as preparedness strategy.

DR. GELLIN: While I cannot give you a comprehensive and definitive answer regarding what would be done in a given situation, the comment highlights the importance of on-the-ground surveillance. If we look only under the street lamp, we may miss important developments.

DR. GOODMAN: We could well argue that the appropriate use of interventions on a global level will benefit both U.S. citizens and residents of other countries. We need to consider global response plans rather than pitting one country versus another. Maybe we can help our policymakers to come to the same conclusion.

DR. GERBERDING: We need to emphasize economic as well as international health motives. Multinational corporate interests are likely to be more involved in addressing these problems than in the past.

DR. STOHR: The question has a political as well as a technical component. The political component must be addressed at a relatively high level: we are talking about multinational treaties and agreements between heads of states. We should continue raising the issues at that level. At the same time, we need to continue to invest in technical solutions like antigen-sparing strategies that will give countries without production capacity access to vaccines and antivirals as well as knowledge when they are most needed. We should not put all our eggs in one basket.

DR. FAUCI: If ever there were a need for international agreements on what countries will do if and when a crisis occurs, this is certainly one such situation, because if individual countries make conflicting policy decisions, we will have chaos. We need an international agreement before we get into a crisis.

PARTICIPANT: We are talking about the availability of new technologies and new approaches. While on the science side that makes a great deal of sense, we are overlooking the supply side. Can we actually provide the new technologies, and what is the surge capacity per item? Given all the orders for antivirals, it’s going to be years before they are actually going to be filled. Today two companies own 80 percent of the market for N95 masks and have no surge capacity. The United States also lacks surge capacity for mechanical ventilators. The country has 105,000 ventilators, and in any one day 70,000 are in use; during flu season 100,000 are in use. Unless we are prepared to spend money to create capacity that will not be used except during a crisis, we can develop all the technologies we want, but our actual ability to bring a stockpile to market is going to be limited.

During the anthrax situation, the biggest problem many of us in the states faced concerned reagents for testing for bacillus anthracis—they just did not exist. We couldn’t make them fast enough. Even though scientists might come up with wonderful diagnostics for influenza, I question how many will be available during a crisis. Wonderful new technology tools may have little applicability if they are not available.

DR. GERBERDING: I agree but this also speaks to the need for communication, because we have to make hard decisions about how to spend our dollars. Business figured out a long time ago that just-in-time delivery was the most cost-effective approach. We are moving in the opposite direction by stockpiling and investing large quantities of resources in items we might never use. But that’s the role of leadership and the federal government.

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