Transition 2021 Series: Ending the COVID-19 Pandemic

Panelists discuss the challenges of ending the COVID-19 pandemic and what steps the Biden administration should take to curb the spread, including increased and improved testing and an equitable and efficient vaccine distribution.

The Transition 2021 series examines the major issues confronting the administration in the foreign policy arena.

FREIRE: Thank you very much and welcome to today’s Council on Foreign Relations Transition 2021 Series. This meeting is on “Ending the COVID-19 Pandemic.” I’m Maria Freire. I’m president and executive director of the Foundation for the National Institutes of Health. And this meeting is part of the CFR’s Transition 2021 Series, as I said, which examines major issues confronting the Biden-Harris administration in the foreign policy arena.

So today with us we have a wonderful panel: The honorable Sylvia Mathews Burwell, president of American University and former secretary of health and human services; with us today is also Jennifer Nuzzo, senior fellow for global health for the Council; and then Rajeev Venkayya, president of the Global Vaccine Business, Takeda Pharmaceuticals. He’s also a board member of CEPI, which is the Coalition for Epidemic Preparedness Innovations.

Sylvia and Rajeev were part of the CFR independent taskforce on preparing for the next pandemic. This is a very important report that was issued in August this year. So, Sylvia, I know you’ve given a lot of thought to this issue, the issue of preparedness for pandemic and what steps we need to take, particularly what we would say to the Biden-Harris administration as to what needs to be done. So I want to start with you.

BURWELL: Thank you so much, Maria. And I think as we think about where we are in the pandemic right now, I tend to think about it in terms of the issues for execution and the issues for more discovery or thought. And right now, in terms of where we are in the pandemic, we are in a high percentage of execution. We have many solutions. We have vaccines. We know the public health measures that we need to take. And if I were advising the administration, the new administration right now, I would say that clear and important execution right now—in terms of get the vaccines out, do the public health measures that we know, work on making sure that equity exists as we’re doing the vaccine. The problems that we’ve seen, that we know, and have solutions to, work on. And I’d say that’s probably in about the 80 percent.

Twenty percent, we need to continue on the path of discovery and making sure that we’re tracking things that aren’t just about execution. Whether that’s the variants that we’re seeing and making sure that we’re appropriately tracking the variants. Whether we’re making sure that—we used emergency use authorization for the vaccines, and the follow-up that’s needed there. Therapeutics and continuing to track and prepare, which is what our taskforce report, much of it, was about, for the next thing that’s going to come. But right now, deep focus on execution.

And I think that’s what we’ve actually seen in terms of the work of the administration—immediately coming out with what is a national approach with flexibility, is how I would articulate what I think we’ve seen to date, is a national approach on things like testing, things like approaches to vaccines, things like issues of communicating about public health. Because from a perspective—the government’s role at this point in time, in terms of what the Biden administration part of the government they’re leading—they’re not leading states, they’re not leading locals. But that part, they’re responsible for making sure that the public has tools, and the public means everybody from each of us as citizens, to the states, to the hospitals, all the way up and down the chain in terms of tools and communication.

And communication I think gets forgotten in pandemics. And it was one of our most important learnings in Ebola, is the importance of communication. And it’s extremely important because this is a crisis. And when we are in wars that are wars that we fight abroad, we have set people that are doing it. When we are fighting a pandemic, everyone is fighting—from individual citizens all the way through our international relationships. So that communication is important for that reason. It’s also important because information is moving and changing. The information we’ve gotten about the variants, that’s new information. We need to be ready to respond and tell people what we know and what we don’t know.

FREIRE: So it’s kind of scary, because we have to do this at three levels. We have to do it at the level of the here and now, what we’re faced with and what we have to do. We have to do it at the level of preparedness for the next pandemic, which as you say in your report will come. And then we also have to worry about what is it—how we communicate and how we deal with not only the pandemic in the United States, but also abroad. The U.S. has had a leadership role in this issue for many, many years.

So, Rajeev, you see this not only from the perspective of the report, but also from the perspective of vaccines. And, you know, amazing technological developments. But, as Sylvia just said, we have to get it to people. Give me some thoughts on that. What do we need to do? What’s your recommendation?

VENKAYYA: Well, I was very happy to see the COVID-19 strategy that has come from the Biden-Harris administration. It is comprehensive and there is a major focus on vaccines and also a major focus on equity, which I’m sure we’ll talk more about. In terms of vaccines, we’re in an extraordinary position that few of us could have predicted that we could be in so quickly. We have multiple vaccines that have been shown to be efficacious. Not just efficacious, but almost as good as they could possibly be against preventing severe disease and death. And that is really what people care most about and what’s being lost in the debate over vaccine efficacy between one vaccine and another. And I’m not just talking about the Moderna, the Pfizer, the AstraZeneca vaccines. What we’re seeing through public reporting about vaccines that are being developed in other countries beyond the U.K. and the U.S. is that most of the vaccines do have high degrees of efficacy against severe disease. And that’s very good news for the world, for global access.

Now, in terms of global access, there has been an effort underway led by CEPI and Gavi and World Health Organization called COVAX, which is working to ensure that we minimize the gap in availability of vaccines between wealthy countries and middle-income countries and low-middle income countries. That effort has been successful in getting off the ground, and it’s been pretty successful in raising the money, and it’s also been pretty successful in securing reservations of supply to get to those countries. But it’s not as far along as we’d like it to be. We saw some encouraging news in the past couple of days from Pfizer and from AstraZeneca about volume commitments that will help to address this issue. But I would say that this is a major priority for the world, and I’m very happy to see that it was prominently featured in the strategy that was announced by the administration—this recommitment to WHO but also the global organizations that are going to work to ensure that there is equity in vaccine distribution.

Just a quick word on the variants. These are—the information is coming at us in real time. The promising news is that it looks like vaccines will have some efficacy, potentially most of the efficacy preserved. But it’s a warning sign. It’s basically a sign that new variants could emerge overnight due to evolutionary pressure. And the speed with which we develop the first vaccines is going to have to be applied to these new variants as they emerge. And I’m optimistic that that’ll be the case.

FREIRE: So before I go to Jennifer, I did want to follow up on that. Because there’s a number of people that say, well, maybe I need to wait to be vaccinated in order to get—you know, if these variants are going to get up, maybe I need the next-generation vaccine. And I think that’s problematic, right, because the more—the less people are vaccinated, the more chances there are of new variants developing. So can you—can you address that for me?

VENKAYYA: Yeah, just very briefly let me say that we don’t know for certain that the vaccines that are currently being introduced prevent transmission. But we have good reason to expect that they will. And they will play a critical role in stopping this virus in communities once we get to a certain level of uptake in the population. In terms of advice to anybody anywhere in the world, once your name comes up or once your category comes up, take the vaccine. Because if the vaccine has been authorized for use, that means it’s been deemed to be safe and effective in your country. And it almost certainly will significantly, if not completely, reduce your risk of severe disease. And so irrespective of what’s being offered to you, I would advise people to take it as soon as they have access—but not cut in line. Take it when you’re being given your turn. And also, if it’s a two-dose vaccine, we can talk about the timing of the second dose. But make sure you take the second dose.

FREIRE: Thank you. Much appreciated. So let’s disabuse people of the notion of waiting. Get it done. Get it done fast.

Jennifer, you’re my guru with numbers here with the epidemiology and all the information. You’ve been looking at this. Give us your perspective of what you see happening, what you see evolving. And there’s something that Sylvia touched upon that I want to come back to, which is disinformation and misinformation. It goes back to the question that Rajeev—that I just asked Rajeev. So give us a sense of the numbers, where we are, what you’re seeing.

NUZZO: Sure. So one of the efforts I have—not just sort of as an epidemiologist with a fascination for the numbers—is I’m involved with the Johns Hopkins Coronavirus Resource Center, which houses the global map, which has had billions of views. It’s now a year—we just passed the year anniversary. But we also have other data visualizations. And so one of the things I’ve been spending a tremendous amount of time tracking is testing. We started tracking vaccinations, hospitalizations, a variety of other things. And looking not just at policy interventions in states, but also globally.

So where we are right now? Just starting with the United States, we’re at about twenty-five million cases to date. We keep passing hideous milestones in terms of deaths. There’s a little bit of good news on the horizon—sort of cautious good news, in the sense that the number of new cases being reported nationally seems to have slowed as of late. But when I say slowed, what we are coming off of are very high highs, likely tied to the holidays. And so we shouldn’t necessarily interpret from that that the virus is on its way out, though obviously fewer cases reported each day is good news.

There are, though, some signs that I’m particularly worried about in the numbers. I spend a lot of time tracking testing. And as of late, testing has really plateaued in the U.S. So we saw for a very long time a very steep curve in terms of the number of new tests being performed each day, and that was good because we had to keep up with the ever-escalating case numbers. But really since Thanksgiving, it’s been more of a plateau. And you know, given that we have continued to see increasing case numbers, we really want to see more tests being done to make sure we’re casting a wide enough net to find the infections that are out there.

One of the metrics that I look at very closely is positivity. And so it’s either the percentage of people tested or the percentage of tests done that come back positive. What positivity tells us is if we’re doing enough testing. And our national positivity, while decreasing now, is still too high. So what that means is that we are likely missing infections, and we need to understand why.

There are a few possible reasons for this. One is that there have been anecdotal reports that as states are gearing up to roll out the vaccines, it’s the same people who have been trying to fix testing, who have been trying to protect nursing homes, who have been trying to expand, you know, protections at hospitals. And so there’s just only so much a very limited and underfunded infrastructure can do at any one time. So it would stand to reason that they’ve had to pivot their attentions.

But the rollout of vaccine in no way, you know, negates the need to continue to test and to continue to find infections, and to isolate anybody who tests positive. Ideally we would be doing some level of contact tracing to find the people who have been exposed to known cases and make sure they stay home until we know for sure that they’re not infected. That has basically fallen by the wayside with our case numbers being as high as they have been. But it is really worrisome that testing has plateaued.

The other worry that I have, and I think this is something that I am heartened to see being addressed in the Biden-Harris plan, is that there are deep disincentives to going out and getting tested for people. If you are an essential worker and you do not have paid sick leave and getting—testing positive might mean that you have to stay home for a number of weeks and will not earn an income during that time. It might also mean that you could lose your job because you’re no longer seen as a reliable employee. And so we have rolled out the technologies with some success, but have not addressed the sort of societal and structural barriers that do prevent people—who may very well want to comply with public health actions—from being able to do that.

So I was really pleased to see the plan addressing some of these economic disincentives, trying to support people who may have to stay home to isolate because they’re sick, or to stay home because they’re a contact of a case. That is a really important, pragmatic public health intervention, addressing and removing those economic barriers to compliance. And it has so far been missing in our response to the pandemic.

FREIRE: So what you’re saying is that you have several levels—again, we’re talking about the levels of intervention. And one of them is we seem to be lacking the manpower to be able to do all of these things together effectively. Since we can’t possibly get people trained in the next two months in order to do what we need to do, I mean, how do we tackle this? And the economic stress and the societal stress that you just mentioned is not only in the United States, of course. We see it globally even more acutely. So, Sylvia, I don’t know if you have any thoughts on how we do this.

BURWELL: So I think that we use all the tools at hand. And it is a problem. You know, in West Virginia, my home state, where right now it’s one of the leading states with regard to vaccination—per capita vaccination—it is the same people, because they used the pharmacies—they used the local pharmacies and local community health centers. And so those were the people doing the testing. And now they’re doing the vaccination. It’s further complicated by the fact that the vaccination—you have to do it two times. So if it’s two weeks from the day that I first gave the 250 in the school, I need to do the second 250. I can’t do additional people because I’m doing the second vaccine. So because it’s a two-dose vaccine, the burdens on the system are great.

But what you need to do—and that’s why I focus so much on execution—is figure out—use all the resources at hand. And you see that in the plan in terms of turning to federally qualified health centers, in terms of turning to the public health service commission—the corps. You know, redeploying people. Making sure that you are very clear. Having just gone and gotten my test on my campus right now, you know, we are using parts of our public health students who can do the initial—with regard to testing. A lot of testing, and even some of the vaccination pieces, have to do with forms and making sure that things match and giving people instructions, not an actual thing that a person needs to be certified to do in terms of giving an injection.

So making sure that we understand what the needs are, and then planning for that, and using all the tools that we have at our ability. And I think that’s what you start to see in the plan. And different states may need to do—they may have different pieces and parts, but having an overarching way to do that, I think, is essential and how we will get through using—you know, using all the tools at hand to get to the execution. Because we know—and I’m so glad Jennifer mentioned the testing.

While the vaccine is coming on and we’re getting to that place we need to get to, we got to accelerate the vaccine. We need to do the testing. We need to get to the place where contact tracing is a possibility. That’s how we’re going to continue to move those case counts down. And practice the basic public health measures that we know we can. And that’s masks, distance, and making sure that you behave the way you would—you should when you’re sick. And many of us—you know, I think we’re all guilty of maybe having gone in when you had a little bit of a fever, or you didn’t feel well. That is just not what we can do during these times.

VENKAYYA: And if I could just add to that.

FREIRE: Yeah, Rajeev.

VENKAYYA: One of the challenges we could be facing with the new variants as they expand their presence here in the U.S. is the consequences of having more transmissible virus, which really puts pressure on every layer of your public health suite of interventions. Which means you have to be better about masking. You might even need to use better masks, or better mask strategies. You can’t afford the leakage, as we might say, in terms of people that are continuing to congregate without appropriate protections I place. And so that, I think, is really the biggest concern that we have here, but not just here, everywhere in the world.

That, you know, there are three questions we ask with these new variants. One, is it more transmissible? Probably. Two, is it more lethal? Possibly. The latest is that it might be 30 percent more lethal but, frankly, the transmissibility, from a public health standpoint, is the much bigger problem because it drives many more cases. And, thirdly, does it affect vaccine protection? And the promising news there is that it looks like there probably will be preserved vaccine protection. But in a country where we have not had a well-coordinated national public health response, the urgency of implementing the Biden-Harris strategy to get to that national response and have people be compliant can’t be overstated. That is critically important. It’s a race against time.

So there’s an issue with the public health infrastructure that we’ve seen is not as robust as we thought it was. And I don’t—I would like to hear, Jennifer, your view because this is critically important. Had we been building on a robust infrastructure perhaps we would have been at a better place. So how do we ensure and how do we not repeat this story where we become complacent? What are the issues that you see on the ground that perhaps we ought to be thinking about?

NUZZO: Sure. So, you know, I started my career working in local public health in New York City after 2001, and really just saw the whole field change with the recognition that public health was an essential component of our national defense. And you know, we went from a time where computers were few and far between, and health departments and people weren’t available on the weekends to take calls if there were an emergency, to what I think was a fairly robust preparedness posture. And, Rajeev, you were in the White House at the time and oversaw many of those efforts to really expand and provide resources to health departments.

But I think what we failed to realize is that when we’re talking about preparedness it is not just about buying some computers and leaving it there. I mean, mostly we’re talking about a workforce that is to be used day to day, but also marshalled in an emergency. And that requires sustainment. And so while we saw, I think, probably the peak of preparedness was 2004 to sort of 2006, really I think robust, you know, personnel levels and planning efforts. Really, I think it all took a turn with 2008 and the economic downturn, where, you know, globally this was a problem, but certainly here in the U.S. where state budgets got cut, federal budgets got cut. And there was a hemorrhaging—a hemorrhaging of staff as a result.

You know, when you’re asked to kind of tighten the belt, there’s only so many places you look. And unfortunately, preparedness is an easy target because it’s a resource that you hope to not have to use in full. So it’s the easy thing to cut. And, you know, I led a team that did a study just before COVID asking local health departments: If you needed to vaccinate a large portion of your population in a short period of time, could you? This was before COVID. We didn’t even know about the virus. And the answer was largely: No. And in part, because they didn’t have the plans. Many had referenced that the health department had been involved in vaccination efforts in 2009, but many of the places we spoke to—the people that we spoke to who would be the ones responsible for that job today were not in their positions in 2009. That those staff who were familiar with those plans were gone.

So we have not only hemorrhaged numbers of people, but we have hemorrhaged expertise. And so when COVID hit, we were left with a public health infrastructure that really hadn’t been improved upon since the early 2000s, a staff that was a fraction of what it had been a few years earlier, people without expertise. And a number of things that we’re asking health departments to do now, I mean, we were talking about contact tracing before. You know, that’s often described as something routine that public health departments do. But the reality is that health departments haven’t been doing contact tracing in a serious way for, you know, tuberculosis or measles—routine threats that they have been dealing with over the years—in part, because they just haven’t had the staff or the resources to do it.

So we have some work to do. But as we do the work—and I’m really worried, I think, looking ahead. Although it’s hard for me to imagine people can come out of COVID and think it’s not worth to invest in preparedness, I am very worried about the economics and whether we will see a return to austerity budgets following the economic downturn that COVID is causing. But, you know, my hope is that we will invest in preparedness, but recognize that it is a capacity that will have to be maintained for as long as we’re worried about threats occurring. And we can’t just kind of assume that next year’s not going to be the year that it’s going to hit.

FREIRE: Well, we—you know, it’s the proverbial example of the fire department. You know, why are we—why do we keep fire departments? Well, you want them when the house burns down, right? So, Sylvia, you are ideally placed to tackle that question. How do you do that? (Laughs.)

BURWELL: As a former director of the Office of Management and Budget, in terms. And I actually think about it as I would when I was the director of OMB, with all the many requests from many departments and many important needs across the entire country. And I think what we need to do at this particular moment—and the taskforce report that we worked on—Rajeev and I worked on—I think comes to this. We need to have a fundamental shift in how we think about this issue. When we think about our military preparedness—that, you know, it is the pride of our nation. It is such an important part to defending our values, our democracy, and all the things that we hold dear, and the investments that we do there.

When you think about the damage that this pandemic has done, both on a morality—and compare that relative to some of our losses in wars—and economically. And so we need to treat the issue of a pandemic like we treat these other issues. It needs to move to a different category. We’re in a different world, where the threats to our own homeland, our own national and economic security, are coming from different places. And what we need to do is shift our mind in how we think about the things that we need to protect ourselves from, and therefore invest in it in the ways that we invest in other things.

And that is an important—I think we have to tactically get the funding, as an OMB director, to the state and local communities for those health centers to do that kind of preparedness that they need to do, in terms of public health departments. But we also—that needs to be led by a mind shift in terms of how we think about what this is. And I think that’s an important first step that then follows with that. And as Jennifer said, I mean, I had to try out how good those systems were, because that’s how we tracked Ebola—people who had potentially been exposed or came from places where they could have had exposure to Ebola.

It actually was those public health departments that were calling people every day for twenty-one days and checking on them. Do you have a fever? Asking all the questions. And so having had to use that system—and not at the level of scale that we’re using it now—we are going to continue to use it. But change the mindset, then do the investments. And do the investments in ways that we get added benefits. Your public health system is also an incredibly important part of community health, whether that has to do with obesity, whether that has to do with opioids, whether that has to do with heart disease. Make it so that we’re building an infrastructure that helps use every day that we can then depend on when we have a crisis.

FREIRE: I think that’s absolutely critical.

Rajeev, before—we have, like, two more minutes before we go into the Q&A section. But I wanted to ask you the tricky question of the role of the private sector, since you’re sitting there in the private sector. I, in my career, have seldom seen this coalition of the public and private and not-for-profit sectors come together, gratefully, for this pandemic. But what do you see the role of the private sector in the next, you know, let’s say, hundred days?

VENKAYYA: Well, it’s absolutely critical. You know, the creation of CEPI was prescient, I would say. And you were involved in—Maria—in the—in creating the—putting forward the ideas that led to the creation of CEPI in 2017. So CEPI began investing in platforms and vaccine candidates that set the stage for accelerated development. I mean, CEPI doesn’t get the credit, of course, but it was a contributor to the revolution that has happened in vaccine development that we’re seeing now.

The mRNA vaccines would not have been a reality were it not for private sector investment in the face of significant odds and other opportunities for capital deployment inside companies. Some companies decided to take the chance. Now, granted, they were focused not just on infectious diseases. They were focused other very attractive therapeutic areas from a business standpoint. But at the end of the day, these vaccines were ready to go. And they won the race. And what’s increasingly becoming apparent is that it’s not that this was an easy target.

It turns out that this isn’t that easy a target. We just saw yesterday another company announce that it’ll be pulling out of vaccine development, which illustrates some of the challenges that we’re dealing with here. So now we absolutely need the private sector to continue to deliver. And the biggest challenge ahead of us right now is going to be on manufacturing scale up and scale out. Scale up meaning the high volumes at any given facility. Scale out meaning that you’re not just using one facility to manufacture your vaccine, you’re using many facilities to do it because you absolutely have to leverage that kind of capacity to get to the kinds of volumes that the world needs. And time is of the essence.

Now, what people rarely talk about—because the people that work in manufacturing are not really available to give interviews; they’re very busy—is manufacturing vaccines is extraordinarily complex. And so you routinely will see batches fail. You’ll see delays in manufacturing. And we’re seeing that right now as we speak. This is a big part of the reason that we’re not getting the volumes that we had expected. And so the private sector needs to use all of its talents to focus on those issues, managing that risk, the quality issues to deliver the supply that we’re counting on. And then obviously we’re counting on the private sector to develop the platforms to be prepared for the next pandemic, and potentially to even help us to prevent the next pandemic from happening.

FREIRE: Thank you.

Well, we’re at the witching hour where I’d like to open it for questions. But before I open the questions, I want to leave one dangling, which is this issue that all of you touched upon, which is information, disinformation, or bad information, and the role of social media. You’ve equated some of this to this being a war and treating this pandemic as we would a national security issue, which it is. And I think disinformation is one of these big national security problems. So I’m just going to let that dangle. And I’m going to ask our colleagues at the CFR to open the floor for questions. And hopefully there’ll be one coming along that way.

MODERATOR: Thank you so much.

(Gives queuing instructions.)

Our first question will be from Christopher Isham. Please don’t forget to say your affiliation.

FREIRE: Christopher Isham, there—yeah, I’m going to remind you that we are on the record, just for everybody to remember. Yeah.

Q: Thank you. How high a priority is it to determine the origin of COVID-19? Are you confident that the WHO, with their team in China right now, will get to the bottom of it?

FREIRE: I’m going to hand that question over to the entire panel. But, Sylvia, you looked at that in the—in the report.

BURWELL: So what I think is important about the question is understanding the origins so that we can do the preparedness that we need to do. I think some of the conversation about origins have been connected to issues of blame and other things. And so I think what we need to do is we do need to know how did this virus, which is highly transmissible, understanding that part of it I think will help us with a number of things. It will help us understand better about the virus in terms of transmissibility. I think it will also help us understand in terms of the variant issues that we’re talking about, in terms of its evolution, where it came from, and that sort of thing. And those are the questions that I think we need to focus on as we think about it.

With regard to the work of the WHO, as the report indicates, the WHO’s strength comes from its members. And that’s its support from its members and its participation by its members. And so I think those are the keys to WHO being able to do anything from help implement solutions and move information quickly. It is very much about the members.

FREIRE: So, Rajeev, thoughts? How important is this?

VENKAYYA: Well, OK. I think—so, first of all, I have not seen any scientific suggestion that there was deliberate engineering of a virus, just to get that out there. Now, that doesn’t mean that that’s—that it didn’t happen, but so far a lot of people have looked hard at this and they haven’t found that evidence. Could it have been a laboratory escape? Certainly a possibility. We need to investigate that and understand whether that happened. That’s the point.

The meta-point, though, is that we have proof of concept. We’ve seen it with SARS, we’ve seen it with MERS, we’ve seen it with countless flu viruses that when you have an almost infinite animal reservoir of viruses that are constantly testing the system to see if they can mutate into something that can cross over to humans and then be transmitted from person to person, we know that that can happen. And we now know that coronaviruses are probably equal or even a greater threat than influenza viruses as the cause—the probable cause of the next pandemic.

And so we do need to understand how this emerged. We have pretty good hypotheses as to how it happened. And from my standpoint, that’s enough to justify a moonshot or a Mars-shot, investing in tools so that we can prevent the next pandemic from happening or, if it does happen, that we’re prepared to massively limit the human suffering that will result.

FREIRE: Jennifer, would you like to add anything to that? Should we go to the next question?

NUZZO: Well, I think it’s important to understand the drivers of pathogen emergence and spillover, but I view that as a research agenda. As a priority right now—I mean, for me, the priority is dealing with the fact that we have about a hundred million cases happening worldwide, and we need to make sure it doesn’t get much larger than that. So, you know, these questions flared up also in 2009, about what the origin of the virus that caused the global flu pandemic was. The fact that it was first detected in the United States possibly tamped down some of those questions. But these things will always happen. We didn’t come up with answers then. I think it’s a difficult thing to do scientifically. But I think the more we can understand the science, the better. But right now, the priority for me is containing the pandemic.

FREIRE: Thank you. Next question, please.

MODERATOR: Our next question is from Katherine Hagen. If you could please unmute your microphone and state your affiliation.

Q: Thank you. And I’m affiliated with a group that works a lot in Geneva with the WHO, Global Social Observatory, and with multistakeholder engagement. We were very, very pleased with the COVAX facility establishment.

This session has been very, very good in terms of understanding where to go next on addressing the pandemic in the United States. And I found this very valuable for that reason. I would like to talk—you know, have you talk a bit about where it’s going globally and what the U.S. should be doing in that context, because when Dr. Fauci appeared at the WHO this week to reinstate American active involvement with the WHO, he also said that the U.S. would be joining the COVAX facility and would be providing resources, as long as there is a surplus of vaccines from the United States.

In other words, things have to be in the U.S. first, and then look at what is to be done globally. I think the COVAX facility was intending to get everyone to pool for a global priority first. The question is, how do you distinguish between a strategy that is focused on the U.S. with a strategy of getting the United States more actively involved in a global support for this COVAX facility, and overall effort to fight the pandemic globally?

FREIRE: Well, thank you very much. That’s certainly very important. And I can’t tell you that I personally—I am so happy that we’re back engaging the WHO. Critically important. So thank you for your question.

Rajeev, I’m going to hand this one to you, please.

VENKAYYA: Sure. Sure. And I had the opportunity to be involved in some of the early design of COVAX, and I think it’s come a long way in putting forward an arrangement that works towards equity but also address—tries to address individual government priorities. So the idea behind COVAX that you’re alluding to, Katherine, is that everyone can get up to 20 percent, but nobody goes beyond 20 percent in terms of vaccine acquired through COVAX or procured through COVAX until everybody gets there. Now, that looks—that’s good on paper. The reality is that since the beginning of the pandemic bilateral deals have been put in place between governments and vaccine manufacturers to reserve supply for populations.

And this group, more than any, understands the political economy at stake here. If you are a leader of a country, your responsibility is first and foremost to your population. And they will expect you to do everything you can to protect them, from a national security standpoint, an economic standpoint, a health standpoint. And vaccine is definitely a part of that. Now, what COVAX is trying to do is create—allow space for those bilateral arrangements, but also in parallel have supply go to—go to the rest of the world. And there’s no two ways about it, there is a bit of a competition that we’re dealing with here. So there is already a time lag between when the wealthy countries are getting vaccine and the less wealthy countries are getting vaccine. And that is an equity issue to begin with. The hope is that that time window will be collapsed as much as possible, minimized as much as possible, in the spirit of equity.

The last point I’ll make is that COVAX has had to raise money to put these reservations in place for vaccine supply with manufacturers and was facing about a $4 billion or so gap for 2021. It looks like most of that gap is going to be closed, at least as far as I can tell based on the most recent U.S. announcement of committing $4 billion to countermeasure procurement, primarily. And then we saw the more recent announcement from the Biden administration of a very substantial financial commitment. I believe it’s over $10 billion to global COVAX response efforts. And I think a big portion of that will go toward—I believe—toward vaccines and therapeutics. So my hope is that the financial resources are there to be able to work toward this goal of equity. But we’ll see what happens.

FREIRE: Thank you. Thank you very much. Thank you, Katherine.

Can we have the next question, please?

MODERATOR: Our next question is from Fred Hochberg.

Q: Hi, Sylvia. (Laughs.) Part of this is a communications question. I as in the Obama administration, I do some consulting now. Some of the communication that’s now clear, from what I understand—for example, the measles vaccine has about a 98 percent effectiveness rate. When I talk to people, when they hear that COVID-19 is 94-95, that makes them nervous because they don’t understand the best there is is 98. None of us, I believe, really worry about getting measles. So that percentage is just confusing to people. And it seems that we need to—and then, compounding that, we may be able to pass the virus if we have the vaccine, also makes people confused because they don’t understand it stops you from getting it, but it doesn’t stop you necessarily from passing it. So part one is, how do we address that in a thoughtful way? Because we’re only a month or so into vaccinations and we have these kind of questions.

And the last question maybe is a scientific one. I was told that part of the reason for the 94-95 percent is people who might have contracted the virus within the first twelve days, before it’s actually effective. And that once the virus—once the vaccine’s been effective, it’s much closer to 100 percent. And I don’t know if that’s true, but partly it’s just the communication. There’s a lot of misinformation and it is not easy to get good information now. So I’d like anybody who would like to tackle those to please respond. Thank you.

FREIRE: OK. So let’s talk the—(audio break)—question, Sylvia and maybe Jennifer. And I’m going to hand you the wonky question, Rajeev, on the vaccine issue. So, Sylvia, would you like to address the issue of—

BURWELL: Hi, Fred. And I think that what is important—this is why I said communications is so important. And I also think it’s very important that our scientists are out there setting the stage on a consistent basis and helping us understand the context in which we’re doing it. And so it is absolutely right. What we need to talk about is all the other vaccinations. (Laughs.) Let’s not even talk about, you know, the flu vaccine. We can talk about the flu, and what percentage effectiveness, and how it varies year to year. But helping get people the information that they need, that when you get to that level in terms of when we’re in the 90s like this, it’s very effective. I think being honest with people about part of the reason measles is so effective is you don’t want great spread.

This is why it’s really important that what we do at the same time that we’re all getting vaccines is we’re doing these other practices that get that case count down. The effectiveness of the vaccine also has to do, you know, with the context in which it’s operating. And so explaining those things from a scientific perspective, this is a very high effective rate. Giving other people examples so they know that is, I think, a very important question. And, Fred, I think we just need to talk honestly about—I think people understand what was most important about the vaccine is we know it’s safe and we know it’s effective. The transmission question is being examined right now, but we weren’t going to wait for the answer to that to get it out.

I think when people understand that basic logic of: What did we need? The vaccine is a really important tool in the toolkit to fight what is something that we’ve seen unheard of numbers of deaths in our country. And so make sure it’s safe, make sure it’s effective, and we’re finding out the answer to that. But this is why constant, consistent, clear communication is important. The thing about pandemics that I think we should have started the whole conversation with, back in March, is, the pandemic evolves and changes. Our knowledge evolves and changes. And setting people’s expectation.

Uncertainty’s a hard thing for all of us. We don’t like it. It’s really hard. But setting the expectation that that’s the way this works, but our job—and that’s why I say communications is such an important part of the government’s role, is because the job is to say: Here’s what we know. Here’s what we don’t know. And explain these kinds of questions that you’re talking about.

FREIRE: So, Jennifer had a very interesting and insightful comment when we were discussing some of this. And that is that we tend to communicate as scientists or we tend to communicate as policy people at a particular level, but that there is actually a very well-organized disinformation campaign against vaccines in general. And this proves the perfect breeding ground to continue with disinformation and create chaos. So, Jennifer, you have thought about this quite a bit.

NUZZO: Sure. And, you know, it’s not an area of my particular expertise, but I’ve been seeing it. You know, I’ve been the recipient of the information and seeing it in various forms. And I have been so incredibly struck by how much more that there is than at any other point—you know, of any other public health crisis I’ve seen. And now there have been reports that have looked at the disinformation campaigns that are being waged and find that, you know, these are highly organized groups that are coordinating. They are organizing. They see COVID-19 as a historic opportunity to seed doubt about vaccines in general. And they are approaching it in two prongs—one, by seeding doubt about the vaccines, but also seeding doubt about the virus and the risks that the virus poses.

And I was so struck by the level of organization and coordination of groups who are in some cases sponsored by unknown sources—possibly including state sponsors—and thinking: This is not something we can just risk communicate our way out of. Like, we can’t just leave this up to the doctors and nurses on the frontlines who have to talk to their patients in the midst of everything else that they’re doing, or the already overtaxed public health departments. In many cases, I see my colleagues, experts who are trying to respond to it online, by doing things that actually accelerate the spread of the disinformation. So sharing the messages and trying to put the edits on top of it—which, you know, the people who are experts in online information flows will say that all that does is just amplify the disinformation.

So I just—it really strikes me that there’s an asymmetry here in terms of our approach that requires, I think, a concerted strategy. And, you know, I think the scale of the interventions are so great, and the tools that are being used to propagate the disinformation—you know, they’re unique in terms of history, and their ability to reach. And, you know, the burden for medical and public health workers is that we have to, you know, convince people. But all that the groups that are spreading the disinformation need to do are just to raise questions. And so it much—a harder job on our end. And we need more of a strategy and more of a real approach. And, you know, if groups are using information as warfare, it just seems crazy to me that we’re just leaving it up to, you know, people who aren’t particularly skilled or trained in communications to try to combat it.

FREIRE: So that may be a very good recommendation for the Biden-Harris team, is to really put a different level or scale.

Rajeev, anything you want to say on this before we go to the next question?

VENKAYYA: Well, I mean, just on the disinformation issue, I mean, we have to admit that there were some very high-level enablers of this environment. And I’ll—my expectation is that that’s going to change, but the damage has been done. And it’s very, very hard to rewind the movie on this one. In terms of the scientific communication, this is the latest example of where we probably got it wrong in communicating about the vaccines. The primary end point in the clinical trials was: Can you prevent any COVID infection with any symptoms? It could be as simple as a fever. And that’s the number that we talk about, the 94-95 percent efficacy. That’s a phenomenal level of efficacy in preventing any kind of illness. I never expected us to see that with the mRNA vaccines. If anything, over 60 percent we would have been breaking out the champagne. And so that’s—and we did a bad job of communicating that. And the corollary to that is that it almost completely prevents severe disease and death, which is what people care about. And as I said, most of the vaccines will do that.

In terms of transmissibility, we don’t have the data. But what I now realize is we should have told people: Based on our experience these probably will have an impact on transmission. Because we don’t know how much, you need to keep wearing your mask to protect those people who are vulnerable or who have not yet received the vaccine. But we expect that over time as more people are vaccinated, that these vaccines will impact transmission. We just need the data to prove that.

FREIRE: Thank you, Rajeev.

Next question.

MODERATOR: Our next question is from Nina Schwalbe.

Q: Hi. Thanks so much for this. And, Sylvia, I guess my question is primarily to you. My name is Nina and I’m at Columbia University. I’m on the faculty at Columbia.

My question is around the systemic racism and determinants of health. So we’ve seen that COVID has really disproportionately affected Black and brown populations, and that is tied one-to-one with the comorbidities that make people more susceptible to severe COVID. I’d like to talk a little bit about, in your report, and actually in the Biden plan, about why you think that didn’t come across a little bit more strongly. In your report, there was a dissenting view which gets at that, but can you talk about what led you to sort of prioritize other issues around that for the report itself?

BURWELL: So I think that when we did the report I think we felt that we had included it. The question of including it more, which was the dissenting report, but I think we felt it was included in terms of a priority issue that must be taken on. With regard to the specifics of the recommendations around how to solve structural racism, I think that we didn’t go to that length because, as a Council on Foreign Relations report, felt that those were areas where perhaps the group that we had brought together didn’t have as much expertise. But felt it was essential that it be a core part of what the report recommended in terms of a place for greater focus and recognition that it is a very large problem in terms of how it impacted during the pandemic.

But I think if you look at the language, it also is about what you just said, which is some of those comorbidities that exist because structural racism in our health care system has led to situations where people have, you know, the things that we know are particularly challenging. So I think what we were trying to indicate in the report through that language is both that it needs to be taken care of from a pandemic perspective, but the underlying health disparities that exist must be addressed not just because of the pandemic, but what they—the fact that they exist in the first place.

FREIRE: So, Rajeev, I know you have some thoughts on that. And, Nina, hello. It’s been a long time. So one of the issues here also is even in the clinical trials we saw that the populations for the clinical trials were not as representative as they should have been. And they were at the end, but it was an uphill battle. So, Rajeev, any thoughts on Nina’s question?

VENKAYYA: Well, I’m very—I’m delighted to see equity is prominently featured throughout the Biden administration’s strategy. I mean, you read it, it just comes up time and time again, which is really great to see. We have to accept that there is a history in the U.S. that has led people to mistrust the medical system. It has not served them well. And there have been terrible examples of even experimentation on Black populations in the U.S. And I’ve participated in a number of conversations with colleagues and people who are Black or African American who are very upfront about how this is a major impediment for people enrolling in clinical trials.

So I—you know, fortunately we had a greater representation of Black and brown populations in the mRNA vaccine trials than we would have expected otherwise. That was deliberate. And fortunately, it looks like the performance is pretty comparable of the vaccine in those populations from a safety and efficacy standpoint. But we can’t just look at this in the clinical trial context. We’ve got a whole health care system that needs a careful examination. And I’m very hopeful that that in fact is what’s going to happen now with true leadership specifically on that issue within the administration.

FREIRE: Thank you, Rajeev. Jennifer, any thoughts on that issue?

NUZZO: You know, I think just in talking about the disparities, just a few things. One, I noticed at the onset when the disparities were becoming quite, you know, obvious—despite the fact that, you know, a number of states weren’t reporting cases broken out by race and ethnicity—there was an inclination to kind of wave it away as a result of the underlying health risk factors. But it very later came to be the fact that the disparities were also in terms of who was infected, which is not—(laughs)—a reflection of, you know, somebody’s comorbidity. It’s about the fact that not all of us can protect ourselves equally, and that it is easy for some of us to take protective actions than others.

So I think going forward we have to be mindful of the fact, and make it such that all of us can comply with public health recommendations equally. And I think the plans that talk about the income replacement and income protection is really important. I think we have to keep this in mind when we make recommendations about masks and who can afford masks and what type of masks. There are just many places where we need to examine it. And particularly in rolling out the vaccines we have to be mindful of the mistrust, of course. We also have to be mindful of the access issues.

And right now we’re going to see a lot of tension in states as we’re trying to get the vaccines in arms as quickly as possible. That will favor those people who have easier access to health care than people who have various reasons not to be able to access health care. And so that’s going to require, I think, a multipronged approach where we are not forgetting the groups that are not easily the ones that are able to sign up and show up to get vaccinated. And that we also need to monitor our efforts through continuous data collection. And only a handful of states are showing who has gotten vaccinated with respect to race and ethnicity. And that’s something that we need to fix.

FREIRE: So thank you, because that’s a critically important question. And I think Katherine, going back to the question you raised at the very beginning, this is also very much an issue not only in the United States but across the globe. So equity and distribution and access is critically important.

Can we go to the next question, please? And I think it’s—unless we have a lightning round, it’s probably going to be the last question of the session. So please go ahead.

MODERATOR: We’ll take our last question from Cathy Taylor.

Q: Thank you. Hi. Cathy Taylor, Kentanna Group. I think I speak on behalf of all of us that all four of you are heroes and we are eternally grateful to you. So thank you very, very much for all that you’ve done.

My question is about the last mile. And I’m hoping you can provide us some additional education and even hope there. And I consider that to be manufactured stock to shots in arm. In his book, Polio, David Oshinsky details the almost obsessive role that March of Dimes played in creating an apolitical force for vaccine urgency in our society and our country, and also for the operational cap of getting those shots in arm. We’ve obviously had an absence of national strategy, and there’s not really one centralized player in this pandemic—though the private sector has stepped up so phenomenally. Is there risk in not having an apolitical centralized player? And if not, who steps up and fills those roles? And if it is the private sector, how do we ensure aggregation and consistency of data across the sector in order to bring that information back to governments, both at the state and federal level, so that we can do even better next time?

FREIRE: So many of us have thought back to the March of Dimes, and the campaigns against polio, and massive immunizations that happened. I was born and raised in Peru, and I can tell you as a little girl I remember standing in line to get my vaccinations. So, Jennifer, you think about these issues, so help us here. And then I’m going to go to Rajeev. And, Sylvia, you’re going to have the last word on this.

NUZZO: I’ll say a fast word, which is just that I think we also need a bottom-up approach where we are involving multiple groups. Obviously, private sector can be great, and I think helping out with the logistics is key. But, you know, if we’re going to advance our equity goals, that’s really going to require community partnerships and the involvement. I mean, just hearing that it’s great to offer vaccines to people who are eighty-five-plus, but they may need help getting to the vaccination sites. And that’s where community-serving organizations are going to play a key role in helping serve the people who are eligible to be vaccinated. So I think we need—we need everyone to pitch in and roll up their sleeves.

FREIRE: Rajeev.

VENKAYYA: Thanks, Cathy, who’s a former colleague from the NSC. You know, political leadership is critically important here. Governors need to own this. The federal government needs to provide an overarching framework and guidance. Ideally there would be lessons learned and best practice sharing between states. We need a clearinghouse for that kind of information to put these distribution plans in place. I think it’s really hard for the private sector to—(audio break)—on its own. You really need governments to step in and take a leadership role.

And the last thing I’ll say is that when it comes to lessons learned we should also look overseas, because there have been some very resource-poor governments, relative to the U.S., that have done a phenomenal job of—throughout the public health response, whether it’s testing, or public health measures in general and soon, hopefully, vaccination.

FREIRE: Thank you. Sylvia, you’ve got the last word.

BURWELL: I would just say that I think the question highlights what’s so important, I think, as think about pandemics and fighting pandemics. That it takes the very local all the way up through the international in terms of everyone has a piece and a part to play. And it is about getting those aligned and working together, because it is a shot in the arm that is a very local thing. But it is getting that—you know, that vaccine itself, in terms of the research. And so making sure that we work across all. And so my answer, you know, is “and.” It’s what Rajeev said it is, what Jennifer. You have to think about it that way. And I know that’s hard. We like simple things, with easy—but this is about working all the way through, the through-line in terms of everyone taking on what is their role and responsibility in making a difference to both fighting a pandemic like we’re now in and preventing the next one.

FREIRE: Well, thank you all very much. It’s a little tiny bit past 3:00, so we did our job. We did it relatively in good time. (Laughs.) I really appreciate everybody joining us today, and I especially appreciate the panel. Thank you very much. I certainly have learned a lot. And has just been said, you guys are my heroes. Thank you for being on the frontline and helping.

The audio and the transcript of today’s meeting will be on the CFR’s website. So thank you all. Goodbye. Stay safe.

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