Foreign Affairs September/October Issue Launch: What Happens When We Have the Vaccine?

Foreign Affairs Executive Editor Daniel Kurtz-Phelan moderates a virtual panel discussion with Thomas J. Bollyky, Senior Fellow at the Council on Foreign Relations, Ngozi Okonjo-Iweala, Chair of the Board of the Global Alliance for Vaccines and Immunization, and Michael T. Osterholm, Director of the Center for Infectious Disease Research and Policy on these questions and more.

The closer the world gets to the day when the first proven vaccines emerge, the less time there is to set up an equitable, enforceable system for allocating them. 

For further reading please see the September/October issue of Foreign Affairs, "The World ​Trump Made," including the article "The Tragedy of Vaccine Nationalism" by Thomas Bollyky and Chad Bown. Please also see the Foreign Affairs articles "Finding a Vaccine Is Only the First Step" by Ngozi Okonjo-Iweala and "Chronicle of a Pandemic Foretold" by Michael T. Osterholm and Mark Olshaker.

KURTZ-PHELAN: Good morning. Hope everyone is doing okay and staying healthy and safe and sane. Thanks to all of you for kicking off your post-Labor Day with us for this Council on Foreign Relations meeting launching the September/October issue of Foreign Affairs. I'm Dan Kurtz-Phelan. I'm the executive editor of the magazine. The cover package of the September/October issue is not on the pandemic or the topic of vaccines, as you all should know by now, having gotten the issue in your mailbox or your inbox. The cover package is an assessment of the past four years of the Trump administration's foreign policy with fantastic essays by historian Margaret MacMillan; one by Trump deputy national security advisor, Nadia Schadlow; and former Obama national deputy national advisor, Ben Rhodes; and another by CFR's own Richard Haass. We wanted to use this occasion to bring together a few of the authors who have done some of the best and most important work on the pandemic on our website and in our pages over the past few months for discussion on the effort to develop and deploy a COVID-19 vaccine, and especially how this effort intersects with global politics. Let me quote a line from the Foreign Affairs piece by one of our speakers today, Ngozi Okonjo-Iweala, who wrote: "Never before have so many lives, livelihoods, and economies depended so much on a single health intervention." So, on a day in which our presidential candidates are sparring over vaccines, we'll seek to have a slightly more congenial discussion here. Thanks to all three of our speakers for joining us. It's been an incredibly busy 2020 for all of them. They're all facing enormous demands from policymakers and the public and the media to shed light on these issues and help guide the public response. So, we're incredibly grateful that they're taking the time to be with us and for the important work they've done in Foreign Affairs in recent months. I will very quickly introduce them before we go to questions—go to the discussion.

Tom Bollyky is the director of the global health program here at the Council on Foreign Relations. And he is the author, with Chad Bown, of a really important essay in the new issue on the tragedy of vaccine nationalism. Ngozi Okonjo-Iweala has a bio that is too remarkable to give justice to in a quick summary, but it includes two stints as finance minister of Nigeria and twenty-five years as a development economist at the World Bank, including as a managing director. She is now the African Union's special envoy on global collaboration to fight COVID-19 and board chair of Gavi, the global Vaccine Alliance. She wrote an important early piece on the topic for Foreign Affairs way back in April, which was called, "Finding a Vaccine is Only the First Step." And then finally, we have Michael Osterholm, who has a long list of affiliations with the University of Minnesota where he is director of the Center for Infectious Disease. He's really one of the country's foremost experts on pandemic and pandemic response. His recent piece for Foreign Affairs was co-written with Mark Olshaker. It's called, "Chronicle of a Pandemic Foretold." I should stress that we editors gave it that title, not Mike, but it would not be immodest if he had claimed it himself since he wrote a piece in 2006 called, "Preparing for the Next Pandemic" in Foreign Affairs. And going back and reading that piece, which I recommend everyone does, is both a chilling and infuriating experience when you see, you know, the prescience of people in the public health community and all that decision-makers should have been doing in the years since to prepare for what we're entering now. Again, I will ask questions of our three speakers for the first chunk of time and then go to all of you for questions. And we'll get to as many of those as we possibly can.

To start, I wanted to actually step back from the topic of vaccines and get some sense of how the three of you see the state of the pandemic and global cooperation responding to it before we get to question this specific intervention.  So, Mike let me start with you for some focus on the United States. How do you see where we are in the U.S. right now? Are we in a kind of purgatory where we're going to stay at 40,000 cases a day? Do you worry about a new surge? Just give us a sense of where things stand.

OSTERHOLM: Well, first of all, thank you Dan for having me here with you today. And I'm very honored to be with my two copresenters also—two people who have made major contributions to this whole area. We're on a journey. From the time that this first emerged in Wuhan, and the Hubei Province in China back in November-December of last year to now. It's been a journey. People have likened this because it's a pandemic to waves, where that's what we've often talked about with influenza, where in fact, a true wave exists where you will see case numbers increase substantially in a first wave and without any human intervention. Suddenly, the wave gives way to a trough, for which we have no explanation why that happens, and then several months later comes in another wave. This is acting very differently. This is a coronavirus that basically is acting, to me, like a super forest fire coronavirus that will burn wherever there is human wood to burn. And only when we suppress it, do we actually see the fire go down. But as we don't put it all the way out, it comes back. And we're surely seen that not only the United States but around the world. If you think about where we've been in the United States, we had house on fire in late March, early April, where we were up to 32 to 33 thousand cases a day. At that point, it seems it couldn't get worse. And then intervention efforts, distancing in particular, had a big impact in reducing transmission in some of those hot areas. And the case numbers came down. But by Memorial Day, we were about twenty-two thousand cases. And at that point, somehow, we sensed we were done—we had pretty much accomplished victory here. And you saw what happened. We reopened the economy, people begin to experience pandemic fatigue, release where they actually came out of their homes and locations. They had been sequestered in great numbers. And then we saw the protests, which I must add, that I think that was a psychological issue bringing people together relative to this virus, but we actually saw very little impact in terms of transmission because of outdoor air, largely outdoor air. And then we kind of went into summer and you saw what happened by late July, early August, we were up to sixty-five thousand cases a day, surely, much greater than that original 32 to 33 thousand cases a day. Same thing happened again—the hotspots Florida, Texas, Georgia, and California. Major emphasis placed on distancing. ICU's overrun, up to a quarter to a third of them in those states. And basically, cases came back down again. But now what we're seeing is hitting this level of forty thousand cases, a much higher plateau than the original twenty-two thousand cases. And what's happening? Well, we're seeing the upper Midwest on fire, case numbers going up substantially here. Yes, lower population density, so lower numbers of overall cases than you might see in California or Florida. But nonetheless, the rate of transmission is substantial. And of course, we're seeing the opening of colleges, universities and schools, something we predicted would be a big challenge. I think this forty thousand case number will quickly go up by the thousands over the course of the next three to five weeks, as we see more students coming back to school. One of the challenges will be how accurate our numbers are anymore, because we're seeing more and more people deferring from being tested. They don't want to be tested. We're having major challenges right now in our college campuses, up to two-thirds of the students refuse to do contact tracing or be tested, unless it's mandatory. And so, I think we're going to see numbers increase clearly but not even nearly as much as we might have seen if people were complying with that. I think with the fall indoor heating season coming upon us, we're going to see more and more people inside, indoor air clearly is an enhanced risk for transmission. I think we're going to see a very sizeable increase in cases. So, this kind of step up from, you know, twenty-two thousand, down, up, down, up, down kind of thing, but the ups are getting higher and higher each time.

KURTZ-PHELAN: Tom, does that, if you zoom out and look at the global picture, could you apply a similar kind of analysis to the international scene? Or do you see a different picture if you step back and look at the world as a whole?

BOLLYKY: So, if you look at the world as a whole, the picture is similarly dismal. I would think in the sense that many of the countries that had been adversely affected early—on fire—to extend Mike's metaphor, continue to be on fire, and that's particularly true in the Americas. So, leaving aside just for a moment the United States, Brazil continues to have a high number of cases. Like us, they have largely stayed within a range flat for months now—cases. There have also been increases in Colombia, Peru and Argentina, as well. On an individual national basis, India is very much on fire with setting records with ninety thousand new cases per day. They have now overtaken Brazil as the country with the second most cases worldwide. It will be a matter of time, if they continue at this pace, that they will overtake the United States. Now India is a populous country, but they really are creeping up even on population-adjusted numbers as well, so it's been quite high. Some of the places which had been smoldering and we had seen as more successes in Europe, are unfortunately, have reignited to some extent. So, we've seen that in Spain and France in particular, a lesser extent in the U.K. So, you're seeing increases coming up as we're moving into flu season. The one thing I will say, a little more on the positive side on flu, is in terms of the Southern Hemisphere where they're, of course, emerging from flu, some of what countries are doing to suppress the spread of the coronavirus has helped in terms of keeping it from being as bad of a flu season as you might see. So, if you're looking for a little bit of hope, there's something there. But my fear is, and this will tie to our later conversation around vaccines, is as we're heading into the winter, as you will see candidates start to emerge, a number of countries are going to be under enormous pressure given how high their infection burden is, to seek interventions that don't involve suppressing the entire economy to move forward. So, there's going to be a lot of pressure on countries like India, some European nations, Russia, of course the United States, with regard to medical interventions that might alleviate what they're currently undergoing.

KURTZ-PHELAN: Ngozi, before we return to the topic of vaccines, let's talk a bit about the state of international cooperation. More generally, you've in many ways been at the center of the effort to wrangle a slightly more cooperative global response. There was, of course, in the early months of the pandemic, a lot of controversy of the role of the WHO and lots of geopolitical tension. Do you see improvements in the state of global cooperation? Do you see any prospect for a more cooperative approach going forward?

OKONJO-IWEALA: Well, thank you. Just before I get into that, I just want to quickly say that it's interesting that in Africa, we have a pattern that mirrors what I'm hearing described for the rest of the world. You know, the continent has about 1.3 million cases and about forty thousand deaths, but it's very variable within the continent. There are countries like Mauritius and Morocco where it's all under control. There are countries like Ethiopia where it's rising. And South Africa where we are yet to reach the peak. But, you know, it's interesting that it's concentrated in a handful of countries—South Africa, Egypt, Nigeria, and Ghana. But the big issue on the continent is testing. Only twelve countries out of the total fifty-four on the continent have tested up to ten percent of their population. So, this is an issue. But moving on to the status of global cooperation, I think things look a bit more solidary, if I may use that word, now than they were a few months ago in the sense that there has been an attempt to develop what we are calling the ACT [Access to COVID-19 Tools] Accelerator. It's an effort to put together the international community to try and accelerate the tools like vaccines, therapeutics, and diagnostics, in an effort to find solutions to the problem of the COVID pandemic. And it's a partnership. Many countries are involved. It was launched with the European Union, participating fully and many countries from around the world. And as of now, it has WHO. It has CEPI—the Coalition for Epidemic Preparedness Innovations—which is dealing with modern research and development. It has Gavi, whose board I chair, looking at the delivery and distribution arm and procurement when these things become finally available. And that's the international effort coming together, there are about, I would say almost 117 countries involved in what we call the COVAX facility. Because out of this effort, we've also developed a facility to try and be able to get equitable access to vaccines when they become available. And we've got ninety-two countries that will benefit low-income countries, under what we call the AMC [advance market commitments] will come to vaccines. And then we have high income countries, about seventy-eight of them participating. And I'm giving you these numbers to say that, look there's been a big partnership, you know, led by WHO, Gavi, and CEPI, and internationally by many countries, and there's an effort to ensure that whatever happens there's equitable and affordable access to all these medicines, therapeutics, diagnostics, and vaccines. So, the international community is coming together much more than we thought would be the case.

KURTZ-PHELAN: Is the United States participating in that?

OKONJO-IWEALA: The U.S. is not participating. But I think we're very much in touch with companies—U.S. companies—and scientists, who are also, you know, collaborating with us. So, in a way, yes, we've got the U.S. but not as an official body.

KURTZ-PHELAN: Thank you. So that sets up the vaccine stage of this conversation really well. Mike, I wanted to start with you on this to give us, let's say, cautiously optimistic but plausible scenario for a timeline of vaccine development and deployment. What are the kind of key steps to come and what worries you in this process—is politicization a worry, is inadequate testing to worry? Just give us a sense of where we are.

OSTERHOLM: Well, I think that the accomplishments that have been made to date by vaccine researchers, manufacturers, governments around the world has been nothing short of remarkable. We really, truly have had major accomplishments in this area. I think the challenge we're all experiencing right now is what's that finish line look like? What does it mean? Are we going to have safe and effective vaccines that will have well-demonstrated data to support that conclusion? Or will there be an urge to get those vaccines out before such data is available? Remember, we do have a crisis every day that we don't have a vaccine. That means another thousand people in this country die. So, we do want to get these vaccines out. There's every incentive to do that. But as you've also more or less alluded to Dan, is there surely has been a great deal of discussion about the pressure from a political perspective to get these vaccines out before November. I'm more confident today than ever that in the United States, at least, that won't happen relative to the system we have set up for FDA review. The companies today are signing a pledge that they themselves will not allow the products to go out and be used before their time. I think each company recognizes, as much as they surely have, a financial incentive to get them out, they have an altruistic incentive to get them out. They also recognize what the consequences would be if for some reason a vaccine were released and used and find out that there were incomplete data about its safety or effectiveness. That would be a big challenge, not just from this point, but for years to come. So, I think that we're going to not have that quote-unquote, "October surprise," unless there is some very unusual political decision made that would override the system itself.

Now, you asked me one of the things I'm concerned about, I think that there surely is a huge challenge in this country right now around will the population use the vaccine, even if we are able to show that it's safe and effective. Poll data showing as high as sixty-plus percent of the U.S. population wouldn't take the vaccine or might be concerned about it, in terms of its safety. And I think we do have a real job on our hands, in some ways, almost you might say ice skating the razor blade here, of making sure that we don't let a vaccine out before it is safe and effective. At the same time, while we talk about that, assuring the population it will be safe and effective when it comes to you. And this is going to be a real challenge. The last point I just want to make is, and I think this is something we have to keep in the back of our minds, which most people don't want to, but it's critical, is we still understand that coronavirus immunology, and how it affects humans and how humans might be protected against future coronavirus infections is still an area that we know little about. We already, just in the past ten days, we've seen eight different case reports of well-documented reinfections of people who had two different viruses between episode one and episode two, meaning that there wasn't long term durable immunity. How extensive this might be, whether it's through natural infection or vaccines, is going to be a huge challenge for us. So, we also want to make sure that we don't set ourselves up to say once the vaccine is here, we're done. We may be dealing with this virus in unusual ways for many years yet to come.

KURTZ-PHELAN: Ngozi and Tom, in your pieces, you both focus on the challenges that we're likely to see once we do have a viable vaccine or a number of viable vaccines, in terms of manufacturing and in terms of distribution. Ngozi, let me start with you on this topic. I know you wrote back in April, which feels like a very long time ago at this point, that we needed to think of a vaccine as a global public good with, you know, various actors from the public and private sectors and civil society collaborating in a public-spirited way. The efforts you described, give us some sense that's starting to happen. But if you could, you know, look forward a bit to the moment when there are viable vaccines, how should the process of deploying them and manufacturing and distributing them work, so that does away some of the concerns you laid out in that piece?

OKONJO-IWEALA: Thank you, Dan. I think that we are at a moment in this pandemic, and in world history, where the type of billions of doses that will be needed to meet the demand, I think is unprecedented. In the ACT Accelerator, and with the COVAX facility, we are trying to look at having two billion doses of vaccine by the end of 2021. And this scale of manufacturing is unprecedented, and I don't even know there are facilities that can do it. So, a lot of the effort has been to how to incentivize manufacturers to expand to be able to manufacture at that scale. And the Serum Institute of India, for instance, is one organization where we have had an MOU [memorandum of understanding] and they are trying to expand the facility to be able to do a billion doses, which has never been done before. But so, manufacturing is one thing, and we are getting them. Hopefully, we'll be able to incentivize.

The other issue is, once you have it, what's the allocation mechanism? The big effort within this ACT Accelerator, this international effort, is to make sure that no country is standing in the queue, whilst bigger or richer countries take the vaccine, as happened with H1N1 in the past. And that is why we say the vaccine also must be treated as a global public good. Because this pandemic hits everyone. There is no sense, you can't stay in your country and say, I'll grab all the vaccines for my people, and I'll be safe. That won't happen, because others are going to be impacted. And given the interconnectedness, there's bound to be some measure of carrying it back over to countries who'll think they're safe. So, in order for us to reach everyone and to make sure no one is left behind—because I keep saying no one is safe until everyone is safe—we must treat this vaccine as a global public good and make it accessible and available to all. So, the allocation mechanism has to be equitable, because we can't serve everyone at once and WHO has been working on this. Perhaps we have a situation where frontline health workers across the board in all countries get the first dibs when a vaccine becomes available. And then you think next of, you know, critical populations, and maybe an allocation of a certain percentage to countries to deal with these issues of critical populations. And we can think of twenty percent maybe of their population being covered and then countries can decide for themselves how do they want to distribute that. And then you go in phases, so that the allocation mechanism is equitable, you're giving it as across the board to all countries and nobody's waiting. So, these are the kinds of notions that we're struggling with.

And then, of course, you've got the distribution end of this. Countries have to be prepared to take delivery of this. Once you've sorted out the issue of how to procure, and right now it is the ACT Accelerator with the COVAX facility, we're of course trying to mobilize resources that would enable us to incentivize to do what we call an advanced market commitment, i.e., incentivize manufacture and production beforehand so that we can have enough doses—millions of doses. And, you know, once you are able to mobilize these resources, and it's about $37 billion, and please don't blink at that, because we've spent $10 trillion in fiscal stimulus, and this is a minuscule part of what the world needs in order to make this thing work. So, once you've done that, then you've got to think in countries, particularly developing countries, are they ready to receive the vaccines? What conditions do we have to deliver these [inaudible] cold chain required? What type of cold chain? At what temperature do you need to store this vaccine? And it could be, I'm hearing, minus thirty. Some temperatures that we have not dealt with for some of these vaccines before. So, what is suitable for where? All these things have to be worked out so that countries are ready to take delivery. So, even the logistics, the procurement, and delivery can be quite complicated.

KURTZ-PHELAN: Tom, if some of the efforts that Ngozi is describing that has been working on provide glimmers of hope, you know, your essay traces a much, much darker picture in many ways—the consequences of vaccine nationalism, or as you and Chad (Bown) put in the piece, a "my country first" approach to vaccine manufacturing and distribution. So, trace out the consequences here if some of the initiatives that Ngozi has described don't come together. What are we likely to see in terms of the consequences?

BOLLYKY: Great. Thank you. So, I appreciate the question—also the great remarks from my colleagues. On what I'll say on vaccine manufacturing that's important for listeners to understand, or viewers to understand, is that it's scarce. The largest vaccine manufacturer in the world as Ngozi said is the Serum Institute of India. Across all its product lines, in most years, the Serum Institute of India produces 1.8 billion vaccines. That's across all its product lines. The next largest, Sanofi, produces about a billion vaccine doses a year. So, under any scenario, early doses are going to be limited, which makes them both excludable and rivalrous, meaning one country's use of them will keep them from other people using them. So, the question is who gets those early doses first? Because we're working to ramp up that manufacturing capacity, we're not going to get there in time. The science is moving faster than building the vaccine manufacturing capacity. So, the challenge under that circumstance is how can we build up an arrangement that allows for doses to be shared equitably across countries. And many large economies are entering into advanced-purchase agreements to lock up that early capacity. So, it is rivalrous with what COVAX is ultimately doing. Then you get to all the challenges that both Mike and Ngozi alluded to, which is how are these allocated? There are a lot of uncertainty about the attributes of these vaccines. Do they prevent infection? Do they prevent disease? What will that mean? What populations will they both be most effective in? There are issues that were laid out ar-ound distribution. Then the question is with so many other countries under pressure from the current pandemic, can you even get doses out of those environments? And one thing that hasn't come up in our conversation yet, is the patterns we've seen early in this pandemic, which is more than seventy countries, plus the European Union, instituted export bans or seized local supplies of personal protective equipment, ventilators, other medical equipment. So, you have the combination of wealthy nations buying up supplies and then manufacturing nations where you may have the government actually seize those supplies. So, it is easy to envision a scenario in the circumstances if every other nation believes that other nations are going to behave like a nationalist, that they may behave like a nationalist, too. And as consequences both for health, economy, and geopolitical—so just very quickly from a health perspective—it'll extend the pandemic, which is in no one's interest. Because at the end of the day, a low-risk adolescent in the United States should not be receiving vaccines ahead of health workers in other places where the pandemic is raging. So, treating this virus, of course, knows no borders. Treating it like it does from an allocation perspective is a mistake, health-wise. Economically, if other economies are teetering on the brink of collapse, because they're confronting a pandemic, that's not in any country's interest, we're globally interconnected. Even countries that have done well, in this pandemic, are suffering economically because of what's happening globally. Geopolitically, there's going to be a legacy against countries that hoard early supplies. If we're not able to cooperate on a medical intervention that is in everyone's interest to share, what global problem are we going to cooperate on? How are we going to work together to prepare for future waves of this pandemic, the next pandemic, climate change, combating nuclear proliferation, any challenge where you need nations to work together. If we can't cooperate on this vaccine, what hope is there for other challenges?

KURTZ-PHELAN: Tom, in thirty seconds, you know, your piece sketches out a vision for an enforceable agreement to address these challenges. Give us a sense of how that will work.

BOLLYKY: Great. So, the environment we're in is effectively a prisoner's dilemma, where if every other nation believes other nations are going to act like a nationalist, they're going to act like a nationalist, too. So how do you shift a non-cooperative arrangement to a cooperative one? You do it through reciprocity. Fortunately, in this case, there's several sources of it. The first is ultimately, these export restrictions and seizures of local supplies. If other governments seize your supplies, if the government of India seizes what's being produced in India, you're not going to get it even if you've entered into an advanced purchase agreement—that creates a possibility. There's likely to be more than one vaccine. And as Mike suggested, the early ones are likely not to be that protective. So, what's happening with the pandemic may give you an incentive to get access to those later vaccines and inputs. So the way this arrangement is meant to work is to be supported by COVAX by creating some possibility of enforceability that governments would agree to forego export restrictions and expropriation against other participants in the agreement, which presides both an incentive to participate, as well as potential consequences for governments that decide to renege on the agreement. So, we think it's an important addition to have around COVAX, which while remarkable, currently doesn't have anything that addresses export restrictions, or the possibility of expropriations. That's not part of the arrangement.

KURTZ-PHELAN: Ngozi, given your long experience trying to facilitate this kind of cooperation, does that kind of approach seem correct to you, seem viable or is there anything that you would add to it to make it work?

OKONJO-IWEALA: You know, I welcome what Tom said, and I think we have to be creative and try all approaches. But if multilateralism were working very well—I mean, we do have multilateral institutions that have rules that underpin the way we do business. Under the WTO rules, underpinning the multilateral trade system does speak to the issue of export restrictions. And Tom is absolutely right, as at this moment, about ninety countries have export restrictions, or had. Twenty-eight I think have phased out, but that's still a large number, almost sixty countries. And no medical supplies and equipment and even food. But WTO rules speak to the fact that, okay, maybe in an emergency, security or public health, you can do that. But you have to notify, be transparent. It has to be, you know, temporary restrictions and proportionate, you know. So, if we're speaking to those rules, we should be able to activate them so that we don't get into this type of situation. But because multilateralism is not working as strongly as it should, we have, you know, these rules being ignored. And I think that's what we need to come back to. I think the WTO is a very important multilateral—and that, you know, we really need to strengthen that system and be able to invoke those rules.

Secondly, under the TRIPS Agreement, also of WTO, you have an article that under public health emergencies, you can invoke whilst protecting the intellectual property of those who have developed and manufactured, that countries can be given licenses, you know, to manufacture therapeutics. So, anything that comes up, any medical supplies, under this emergency clause, they can have a license to manufacture it themselves. They'll have another country manufacture it for them, provided they don't trade it. So, we have all sorts of things within the multilateral system already. That should be helping us, and we shouldn't need to be coming up with fresh rules. So, I would say two things: Yes, let's employ what we have already and make that work for the world. Second, if that is not sufficient, let's be open to creating new avenues that can bolster what is happening in COVAX. By the way, the biggest incentive, or one of the biggest joint COVAX, for countries that have the resources and are buying up, is that we have a portfolio of twelve vaccines. So, if you go and invest in one or two and they don't work, you're down on your money. If you join the facility, you have access to twelve, and out of the twelve, two or three—so you're mitigating your risk. And I think more and more countries, many of them who have bought supplies or, you know, gotten companies to pledge them supplies are realizing that if I go down that road of one vaccine or two, I might come up short. And I think they're thinking again, and many of them are joining the facility. That's why we have seventy-eight self-paying countries now, in addition to the ninety-two that we lower-income countries, under the advanced market commitment.

KURTZ-PHELAN: Mike, let me close with you before we go to questions. What are the two or three things that policymakers should be doing? I'm sure you have these conversations with them, and I hope they take your advice. But if you could share some light here, what should policymakers be doing now to ensure effective deployment and distribution when we do get there?

OSTERHOLM: Well, first of all, I think you've just heard a brilliant discussion of this international issue with Ngozi and Tom. I think they did a remarkable job of laying out the hype and the low points of where we're going. I think the one thing I want to keep coming back to is we're going to be in this pandemic situation for a long time. You know, I think some people think that there are going to be a fall vaccine arrival in the United States and the pandemic is over with. And I think if you've just heard both Ngozi and Tom very clearly [inaudible]. You know, even with all the vaccine capacity we have today, even with all the collaborative efforts that are going on, this virus will be able to continue to be transmitted in countries around the world for some time to come because vaccine won't be available for everyone. And so, as I think it's been said already, you know, a dangerous agent, infectious agent, somewhere in the world today can be everywhere in the world tomorrow. And I think that what we have to remember here is that we are in a global response, not just a national response. And so, I think that's a huge point of reference that we need to keep in mind. We're going to be doing this for a long time to come. It’s not going to be over with just an arrival of a vaccine in the United States.

KURTZ-PHELAN: Thank you. All right, Sam. Let's go to questions. Let me remind members and subscribers, that this meeting is on the record, and that includes your questions. The operator will remind you how to join the question queue. And please ask us a relatively crisp question and make it a question so we can get to as many as possible.

STAFF: Our first question will be from Katherine Hagen.

Q: Thank you so much. This has been a marvelous discussion amongst the three of you and well-moderated. I've been spending many years in Geneva, working on multi-stakeholder engagements, not only at the WHO, but also the WTO, and very much aware of the fact that these institutions have important roles to play but are in crisis mode at the time, particularly because of the friction between the United States and China, but also, certainly other reasons. I like that COVAX facility tremendously, I think that is a marvelous way to go. And I'm wondering whether the countries that are now looking to commit to it can be mobilized effectively to put their priorities on that. And Ngozi I would like some discussion about how that would happen. I know that Switzerland is one of the co-chairs of this initiative right now. And yet, the Swiss representative said, "First, we're going to do sixty percent allocation for ourselves, and then we'll get into the COVAX facility for the rest." And I think that is generally a phenomenon that is happening even in the European Union. So, the question there has to be, how do you get everyone to jump right into this idea that the COVAX facility is the better way? And then Tom, I think it would be useful to know what your suggestions are in terms of working with the G20 as an avenue for addressing these issues because certainly the weak institutions in Geneva make it difficult to mobilize through them. But there's been a lot of talk about making the G20 the avenue for this. And so, I would love to hear your views on that. And of course, Michael, if you can jump in on these it would be welcome, too.

KURTZ-PHELAN: Those are great questions. Ngozi, let's start with you.

OKONJO-IWEALA: Well, thank you so much, Katherine. And, yes, these two institutions have quite a bit to offer if multilateralism could be strengthened. And we should all be, you know, worrying about how to strengthen this. On the COVAX facility, you know, when you are a politician and you think about it, your population wants to know how you're going to take care of them. And, you know, they don't really want to hear or so many people think, you know, us first—all those other people in another country don't matter. And that's the knee-jerk—that's the kind of reaction you have, you know, when politicians start looking we need to take care of our population first. And that's, in some circumstances, that could work. The problem with this pandemic, as Michael said earlier, and we've all said, is that, you know, it is a pandemic. It's everywhere. So, the politicians have to give their populations reasons why they need to go beyond their nationalism and support others. And I think most people are smart. If you explained to them that being in your country and taking care of your needs, sixty percent-seventy percent, isn't really going to protect you. I mean, how many times can Switzerland shut off its border with France? How many times can the U.K. or, you know, any other country prevent people from Africa coming in. You can't do it forever. So, you've got to think logically and solidarity because it's in the interest of people even in the rich countries to make sure others—so that's the way I would approach the explanation for joining the COVAX facility, that this is no longer about just us, because if we do justice, we will not succeed. And we will have repeated waves of this pandemic, this COVID, and it will cost us more and more billions or trillions as we go down the line. So, the issue is that taking care of this pandemic now, may cost you billions. We're saying $37-40 billion will set us on the path. That's better than spending trillions. If I were a politician, I would put that arithmetic out for my population, as well as the health explanation I just gave. And lastly on the COVAX, the reason to jump in, and I think that's why many more countries, and regions, and the EU is also discussing with us is because it mitigates risk. You don't want to tell your population you invested in one or two vaccines. And then, you know, after third phase trials, you find that it's not really as effective, as Tom was alluding to earlier, or it doesn't work, or it's not as efficacious as you think. And then you're left. But if you join this facility—the COVAX—out of the twelve, which comes from a variety of countries and a variety of companies, you're bound to find four or five that will work ultimately, and then you'll be protected. So, there are very strong reasons, Katherine, that I would be telling countries, don't go it alone, come into this facility—it's better to approach it in a solidary way.

KURTZ-PHELAN: Tom, G20.

BOLLYKY: Great. So, I'll say a couple of things first. If all of you didn't know, Ngozi, of course, is a candidate for Director General for the World Trade Organization. An important dimension, because it's come up a number of times. She's an excellent one, and because this played nicely, her vision for the use of that institution. They need her because, unfortunately, the current rules at WTO are not sufficient to fix this problem. As she mentioned, particularly in an emergency, it's difficult to get restraints on export bans a way that you would like to see. And compulsory licensing is important, but of course, you need manufacturing capacity to make use of it and that is scarce in many countries. So, we need another vehicle that can mobilize support for COVAX—and the G20 might be it. They actually were discussing a trade and investment agreement already around COVID. This is possibility to leverage that ongoing initiative in this space. The fortunate thing is that dynamics with countries behaving otherwise being inclined to behave like nationalists, and reciprocal arrangements are what they're dealt with in trade all the time. This is a problem that we know how to solve. It's a matter of bringing the right tools together to be able to do so. So, I actually think there's some real possibility for the G20 on this particular problem. Particularly given that it could be limited for the time being for COVID. So, we're not changing larger dynamics and trade outside of this emergency and then maybe if it works, it can be expanded on in the future.

KURTZ-PHELAN: Mike anything you want to add on any of these dimensions?

OSTERHOLM: Yes, I'd like to build on what both have said and that is, don't forget, that as horrible as this pandemic has been for all the death and economic disruption we've experienced, if this were a 1918-like influenza pandemic, it would be much worse—in the sense of the number of deaths, the population impacted, particularly young, healthy adults. And so, what we're talking about here is not just setting up a system that works for now, which is critical, we're talking about a system that's got to be able to work for the next pandemic, which inevitably will happen. Influenza pandemics will continue to happen. They don't give way just because of coronavirus edged its way in this time. So, I think what both Tom and Ngozi have shared is really important to understand for now, but also how do we codify that going into the future? So next time, we don't have to have this discussion after the fact. We actually have had the discussion before the fact ever happened.

KURTZ-PHELAN: And let me again recommend the piece that Mike co-wrote with Mark Olshaker, "Chronicle of a Pandemic Foretold,” laying out just what we need to do and how much worse it could be.

Sam, let's go to the next question.

Q: Our next question is a written submission from Dale Mosier who says, "What effect will the Russian and Chinese vaccines have on global public good supply?"

KURTZ-PHELAN: That's a great question. Ngozi, do you want to start?

OKONJO-IWEALA: Yes, well, thank you. Well, let me just say this, that wherever the science and the development comes from throughout the world that can help us solve this problem—Russia, China, United States—we should support it. And just make sure that the vaccines that come out of this or the therapeutics are safe, and that the WHO has been able to certify, you know, either on an emergency basis or otherwise, the use of these. So, we should welcome all of that. The more of these we have, you know, the easier it will be to meet those billions of doses that we need all over the world. So, I welcome it. And it's interesting, I mean, in the portfolio of vaccines we're looking at, very early on there, China is represented, as I say, United States, France. You know, so many countries—Australia—are represented. I think Russia is coming in, has been in touch and talking with us in the facility, which is very good. So, the more we have this, the more the idea of a global public good, that can reach everyone, you know, and giving it to people free of charge, because that's what we need, the more possible it will be when we have many more countries. But that isn't to say that all of them, all the vaccines, should I think have WHO's stamp on them in order to mitigate, you know, this antivax strong movement. I don't know that it was Tom or Michael that referred to it in the beginning, so we need to assure the public that if we are going to go with a global public good, it's really a good and not a bad. So that would be the only caveat on that. But let's welcome all efforts to give us a science that works for all.

KURTZ-PHELAN: Mike, let me...

OSTERHOLM: Can I follow up on that, Dan? Because I think that just in support of that very statement, if you want to look at the price of diplomacy around the world, I can tell you that health diplomacy is the cheapest and one of the most effective forms of diplomacy we have. When countries reach out to help other countries and health crisis, there is nothing that is more well received, and in many cases, very cheap to do relative to all the other kinds of diplomacy we do. And so, I think what you're also hearing about here today, you know, the Chinese and the Russians understand that, and they are already making it clear that they plan to be part of a health diplomacy rollout with their vaccines. And I think we will miss an important opportunity, as the United States, if we aren't part of that. That we, too, have to understand health diplomacy is in our best interest long-term from a security standpoint and from an economic standpoint.

KURTZ-PHELAN: Mike or Tom, is the Russian acceleration of their process worry you at all from a scientific standpoint?

OSTERHOLM: Well, you know, I must say, honestly, I'm not sure what their process is right now. One day you're reading the news media that they have already been rolled out the vaccine and the next day you read that they are now in phase three. They've just published data in the last three days on their initial phase, phase two data, and so I'm not quite sure where they're at, but I think that as Ngozi said, it's absolutely imperative that all of these vaccines pass the overall test, you might say, of WHO, or some accepted international body to pass on this, the science, the safety, and the effectiveness data so that we know that. And I think that's a critical point for any vaccine from any country.

BOLLYKY: The one thing I would add to that, on that side, is I agree with all the points that both Ngozi and Mike had made. We need more than one vaccine to succeed here because, frankly, we need the supplies globally. That said, I do have some concerns about how the clinical development has occurred with some of the vaccines happening. The idea that soldiers are being enrolled, state-owned enterprise employees being enrolled, this is not following necessarily a normal clinical development. Mike is being diplomatic about the Russian process so far. I am hopeful that works itself out as we move forward, particularly with the Chinese who had actually up until enrolling those individuals, had been doing a very good job about being quite transparent about their process. But it is a concern. But the U.S. and other nations should recognize that for countries that are under a lot of pressure and do not have access to early doses, to other leading candidates, they may very well turn to candidates that perhaps can't get a stringent national regulatory authority to prove it, that can't get WHO pre-qualification. This could be a consequence of vaccine nationalism and is yet another reason to share.

KURTZ-PHELAN: Sam, let's go to another question.

STAFF: Thank you. Our next question will be from Joe Nye.

Q: I'd like to say that I agree a hundred percent with Ngozi. So, the question I'm going to ask is not because I disagree. In fact, I've written op-eds urging that Biden dedicate twenty percent of American vaccine to poor countries and first responders there. But I want to explore the dark side that Tom raised and ask a question to Dr. Osterholm. I read a University of Washington projection that there may be 400,000 deaths in the United States by December because of what happens when we go back indoors without having changed our behavior adequately. In those circumstances, are we going to see strong pressure inside the United States, including the potential division within the scientific community of whether to use certain vaccines prematurely? In other words, will you have pressure which is just beyond the election pressure to speed up the use of vaccines? And if so, how will the scientific unity come down on that?

OSTERHOLM: Well, thank you, Joe. That is a very critical question. Let me just say, first of all, and I just want to remind all the listeners here, all models are wrong. Occasionally some give you useful information. So, if you look at the track record of this particular model, they've been off a lot in terms of their estimates, and then finally what happens. So, I don't know what's going to happen in the fall. But as I laid out at the beginning of my comments, I think we're going to see a continued increase in the number of cases. I think that the mortality rates will continue to be moderated relative to what we saw in the early days, even in the highest risk groups for severe disease. Not that they're not going to occur, they're going to, but I think that we've learned a lot about how to provide better care. So that's why I think today you're seeing not just lower rates because more young adults are impacted relative to the number of cases, but also better care. But I think the point you raised is absolutely a critical one, and I understand exactly where you're at on that. And as things do become, I think, increasingly more challenging through the fall, there is going to be that call for that kind of vaccine to come forward. Again, I come back to the fact that this is about the integrity of the processing. You say, well, that doesn't make any difference to me if people are dying. But in the sense, I think there is going to be a balance between saying, you know, if we give throughout the system for safety and effectiveness evaluation, what do we have left going forward for vaccines? I'd never trust another vaccine again, because they've now become a political measurement, not a scientific measurement. So, I think you're going to see the public health committee doing everything to move these vaccines as quickly as possible, but at the same time holding tight on the critical nature of approving them based on safety and effectiveness. And it's going to be a challenge. I think you've said it very well. And, but at the same time, this is not just about now, this is about the integrity of our entire vaccine portfolio for now and forever.

BOLLYKY: Mind if I just quickly add something, Dan, on that side. The only thing I would say to add to this process is make another plea for not cutting the clinical development process too short. Ultimately, nobody is expecting the United States or any other nation to give up all of their supplies of vaccine doses. The question is, are we going to vaccinate everyone? And if we do not have good research on what the allocation of these vaccines should be—to meet public health priorities—the argument will be that we need to vaccinate everyone. If we don't pursue the rest of the clinical development process along its ordinary course, we're not going to generate that kind of research. So, it's really important because nobody expects us to forego vaccinating healthcare workers or other most vulnerable populations. But are we going to have the information to allow us to identify what our priorities should be?

KURTZ-PHELAN: Sam, let's do one more very quick question.

Q: Our last question is from Kilaparti Ramakrishna who says, "Ngozi mentioned that the United States, as a member of the international community, is not part of vaccine development and distribution, although companies in the U.S. are. Things may change after the November elections, but can you comment on whether the world can develop effective international cooperation and governance systems without the United States?"

KURTZ-PHELAN: Ngozi, I'll give you the final word here.

OKONJO-IWEALA: Well, I said that they'll have, not as an official, you know, officially the U.S. as a country has not joined the COVAX facility. But certainly, there's tremendous cooperation from U.S. companies and scientists and others. So that's very comforting. And I think that what has happened with the ACT Accelerator and the COVAX facility demonstrates that where there's a coalition of the willing, you can have effective international cooperation. Is it complete? The answer is no. Would it be wonderful if every country came on board? It's not only the U.S. that is not on board. I think we are talking, as I said, China, we have some vaccines from China and China is looking at the facility. Russia has also been in touch. So, if we could have them, all the players and international community coming together, that would be wonderful. But I think we should take what we have. I'm saying that we have seventy-eight countries that have come into the self-paying part of the facility—that's an awful lot of countries. So, I think we can build around that solidarity and move forward. And we should leave the door open for any country that has not joined, to join at any time. But I don't think we should wait until everything is perfect. So, I do believe that we can build solidarity as we move along. We should build it, because we don't have an option with this pandemic. And I want to say one more thing. We are so focused on this pandemic, but you know, I want to just quickly say, that we shouldn't forget the other illnesses that also need to be taken care of. You know, a good example is in DRC—Democratic Republic of Congo—when we're focusing on Ebola, and then two and a half times more people died of measles. So, once we are fighting COVID, everybody keeps talking about the flu season. Let's also remember all the other things that we need to be conscious of, less we lose more people from that.

KURTZ-PHELAN: That is a great note to end on. Let me thank all three of you again for joining us. And you have extremely busy schedules. And thank all of you for all you're doing to make this effort better. And, we're all extremely grateful. And again, thanks for joining us today. And thanks to everyone on the line for taking the time this morning after the holiday weekend to join us. Everyone take care, and we will hope to have all of you back in the pages of Foreign Affairs soon.

OKONJO-IWEALA: Thank you.

BOLLYKY: Thank you.