Public Health Threats and Pandemics

Jennifer Nuzzo, senior fellow senior fellow for global health at CFR, discusses the spread of the avian influenza in poultry and dairy cows in the United States and risks that zoonotic diseases pose to human populations. Rick Bright, former chief executive officer of the Pandemic Prevention Institute at the Rockefeller Foundation, discusses measures being taken to mitigate the spread of avian influenza and U.S. preparedness for future pandemics. A question-and-answer session follow their opening remarks. TRANSCRIPT FASKIANOS: Thank you. Welcome to the Council on Foreign Relations State and Local Officials Webinar Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. CFR is an independent and nonpartisan membership organization, think tank, and publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy.  Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. We appreciate you taking the time to be with us for this on-the-record discussion. We’re delighted to have over 300 participants from forty-seven U.S. states and territories. I want to remind everyone that the webinar is on the record, video and transcript will be posted on our website after the fact at CFR.org, and we will circulate it as well.  We are pleased to have Dr. Jennifer Nuzzo and Dr. Rick Bright with us today to lead the discussion on “Avian Flu Outbreak and Preventing the Next Pandemic.” I will share a few highlights from their distinguished bios. Dr. Jennifer Nuzzo is a senior fellow for global health at the Council on Foreign Relations, where her work focuses on global health security, public health preparedness and response, and health systems resilience. She is a professor of epidemiology and the inaugural director of the Pandemic Center at Brown University’s School of Public Health. And she also directs the Outbreak Observatory, which conducts operational research to improve outbreak preparedness and response.  Dr. Rick Bright is the CEO and founder of Bright Global Health and works as a consultant for pandemic preparedness. He previously served as head of the Pandemic Prevention Institute at the Rockefeller Foundation. He was also the director of the Biomedical Advanced Research and Development Authority, known as BARDA, and the deputy assistant secretary for preparedness and response in the U.S. Department of Health and Human Services. And he was a member of the Biden-Harris Transition Advisory Board on COVID-19.  So thank you both for being with us today. I think we’ll begin with you, Dr. Nuzzo. If you can talk about the current status of the avian flu outbreak, the symptoms, risks it poses to animal and human populations, especially those working in food processing plants. NUZZO: Thank you so much, Irina. I really appreciate the introduction and the opportunity to participate in this session. I wish we didn’t have to talk about H5N1. H5N1 is an influenza A virus, we are—particularly called a highly pathogenic avian influenza A virus. It predominantly infects birds, but humans that have—humans have been infected, particularly those who have had contact with infected animals. And while we’re having this webinar now and we’re talking about this now, and it’s been in the news a lot now, I think it’s really important to understand that this is not a new virus. It’s actually one that we’ve been tracking for quite some time.  In fact, this virus was first recognized in the late ’90s, when it was detected in geese. Then in 1997, it caused a fairly large outbreak among humans. About eighteen cases were identified in Hong Kong, and of these six died. This was enough to prompt, you know, massive concern, you know, big chicken culling operations and attention on live markets, which thankfully sort of, you know, contained that human outbreak. But it didn’t eliminate the virus. In fact, the virus continued to circulate in birds, and ultimately spread to domesticated ducks. And this is thought to have then kind of contributed to the reemergence of the virus in humans in 2003, late 2003-early 2004, when we started to see outbreaks in a number of neighboring countries in Asia. About eight initially and then we saw the virus spread to a number of other countries as well.  Since this virus was first identified till now there have been about 900—just under 900 known human cases. But nearly half of these have died. And this statistic, while incredibly imprecise, is enough to be alarming, because typically when we, you know, find cases and we calculate the percentage of those who died, 50 percent is really—you know, really, really ranks up there in terms of severity. It certainly is on track to put, you know, H5N1 to be a much deadlier virus in terms of that percentage than, you know, the virus that caused the COVID-19 pandemic, certainly more so than seasonal influenza. So there’s a reason why we’ve been worrying about this virus for a number of decades.  As I said, the majority of these cases are known to have had exposures with sick animals. But there is some evidence that there may have been human—very limited human-to-human transmission. You know, people who have gotten it that didn’t quite know what they were exposed to. There was actually a study that looked back at that 1997 outbreak in Hong Kong and found evidence that healthcare workers who cared for some of those sick patients may have been infected, possibly without symptoms—which is concerning. But nonetheless, we haven’t seen any evidence of sustained transmission between humans.  And that’s fortunate because were we to see evidence of that, were we to see that, you know, multiple generations of people—meaning like, one person can give it to the next who could give it to the next—were we to see evidence of that, that would truly signify, I think, the beginning of a new pandemic, or perhaps the start of one, were we not able to contain it swiftly. Remember, this is—this is a new virus. You know, nearly—hardly anyone has actually gotten this virus. And so that that immune—that naive immune state, meaning we haven’t had, you know, background immunity to it, would make us likely all susceptible to this virus. So again, were are we to see evidence of sustained human-to-human transmission, that would very much signify the start of a pandemic.  Now, that hasn’t happened yet. And that is quite fortunate. But nonetheless, the worry about H5N1 persists. You know, I would say this virus has continued to circulate on the planet and hasn’t gone away, but I think some of the attention around the virus really, you know, began to wane a bit. In part because the majority of the human cases that we have seen to date really occurred between 2003 to 2015. And then there was a relative lull in the occurrence of human cases. And why that is isn’t quite clear. But that, combined with the occurrence of other health emergencies—including a pandemic caused by a completely different influenza virus, one that occurred in 2009—that was due to the H1N1 virus, not H5N1—you know, I think it really helped to, unfortunately, distract us from the threat that H5N1 poses. I would say that all kind of came to a screeching halt, that relative quiet and that relative distraction that people, you know, who kind of track these things were experiencing, really about a couple of years ago when we started to see much more viral activity from this virus. Started to see a massive kind of geographic expansion, the virus turning up in parts of the world that we typically hadn’t seen it, and also a massive species expansion. Meaning it was starting to not just affect chickens, and ducks, and other wild birds, but many other species—including mammals. And, you know, for me, that’s when I started getting worried because, you know, mammals are a lot more like humans than chickens are. And so that, you know, increases concerns that perhaps this virus is getting increasingly better at infecting things that are more like humans than chickens are.  That backdrop had been happening. And then really I think concern ratcheted up even higher when in March we heard about an outbreak on dairy farms—dairy cattle farms in Texas. That was surprising. One, because we hadn’t previously seen H5N1 in cows before. But also, influenza A infections have not regularly been reported in cows. And so that, you know, was just unexpected from a scientific perspective. But from a public health perspective it was concerning because, again, yet another mammal that this virus was capable of infecting. But in this case, it’s a mammal that humans have very close contact with. And so that raises concerns that humans would be, you know, exposed to—you know, humans would be exposed to this virus because they are exposed to these mammals quite closely.  Those concerns were realized when then we saw, you know, a case of H5N1 in a dairy worker. And then subsequently we have now found a second case in a dairy worker. This is quite concerning. Fortunately, these two infections were relatively mild. The dairy workers didn’t require hospitalization. They experienced eye inflammation, conjunctivitis. They didn’t have a positive respiratory specimen, which, you know, I think is an important finding. But it does raise the possibility that this virus is starting to do things that we don’t want it to do. There have also been just anecdotal reports from vets who are working on the farms that other workers may have experienced symptoms too. So I think reason to believe that these two cases may not represent the totality of dairy workers who have been infected, and certainly don’t necessarily mean they will be the only two dairy workers infected. Since then, of course, there have been more news developments. You know, finding of viral genetic material in pasteurized milk. Not entirely surprising that we would find it, but certainly concerning given the number of positive samples found, which suggests that this virus may be on more farms than our surveillance is telling us. Also recently, last week, there was a report that they found the virus in muscle tissue from a specimen taken at a slaughterhouse. So, again, concerning that this—concerning evidence that this virus may have a much larger geographic footprint than just the amount of testing that’s happening on farms would suggest.  And that’s really, I think, where I just want to maybe call our attention to. You know, the biggest worry that I have right now is really in protecting farmworkers. We have ample evidence right now to know that this virus, while it is not yet a pandemic threat—it may not cause a pandemic, we don’t know for sure, we have reasons to be worried, we don’t know for sure. But what we do know is that farmworkers who are exposed to this virus in the course of their occupation can get infected. And we know historically that this virus has not produced—you know, has not typically been a mild virus. And so that really, I think, creates an urgent public health situation where we should be acting to protect these farmworkers.  Unfortunately, the level of testing that we’re doing right now is really not sufficient to allow us to protect farmworkers. You know, the testing that USDA is requiring is quite limited. They recently put into place a new policy that people are calling sort of the test to move policy. If lactating dairy cows are going to be moved across state lines, it is required that cows from that herd be tested. But the farmers can basically pick the number of cows that get tested. There’s a maximum number that’s established. So, as you can imagine, that’s not quite comprehensive enough to find all of the infected—all of the cattle that may be infected. Other than that, testing is largely voluntary. It’s limited to cows with symptoms. It does not include beef cattle. And so you can imagine that there are lots of holes in our abilities to figure out which farms have the virus and which don’t. Which makes it hard to protect the workers on those farms. The testing that’s happening is not happening on the farms themselves. It has to be sent to a lab. So the test results aren’t timely enough to protect workers. So there’s just a lot of ways where exposures can happen that we wouldn’t know about, which, again, makes it hard to make sure that the workers can get, you know, access to antivirals that could protect them if they’re—you know, protect them from severe illness if they are infected. It also makes it hard to stay ahead of this virus and to understand what might be next for it.  So that’s the area that I think I’m most worried about right now, is, again, making sure these farmworkers have the protection they need. In my view, enhanced testing is really critical to that. I also think we need, you know, to make sure there’s greater use of protective equipment, particularly eye protection. I think we should also be talking about using vaccines and expanding access to therapeutics. But I know Rick will have a lot to say about that, so I will let him address that.  But I just want to sort of end with this overall notion that this virus has had a lot of ups and downs in the twenty-plus years that we have been tracking it. I will say I am much more worried now than I have been in those past twenty years. And I don’t think we should be waiting for it to be obvious that this represents a broader public health threat for us to act. We should be trying to get ahead of this virus so that it doesn’t become the catastrophe that we fear that it could be. We have tools, but we need to make much more proactive use of those tools. And I know Rick will have a lot to say about that. But I’m grateful he’s here to enlighten us on that front.  FASKIANOS: Wonderful. Thank you so much, Jennifer.  And, Rick, over to you. BRIGHT: Well, great. Thank you for hosting this, Irina. And actually, I could never do a better job than Jennifer laying out that background. You know, I started my post—my graduate student work in 1997 with the spillover of H5N1 in Hong Kong from those birds into humans. And so for twenty-seven years, I’ll age myself, twenty-seven years I’ve been like Detective Colombo with an open—file open case tracking this virus. And we’ve seen it come. We’ve seen it kind of abate. And we’ve seen it come. We’ve seen a kind of abate. And I think at some points we fool ourselves into thinking if it’s abated this many times over history, then maybe we shouldn’t worry so much about it.  And so I tell people that, you know, we are more prepared for an influenza pandemic than for any other pathogen pandemic, probably, that we know of. And that is why I’m concerned, is because of that preparedness. The twenty-something years of investment in understanding the virus, understanding the vaccines, and how they work, their challenges, and antiviral drugs and diagnostics—therein gives me the concern, knowing those vulnerabilities. And that some might be easily misled into thinking we’re ready, that we have this under control. You know, and so because of what we know about this virus, we know it is a shapeshifter. We know it can rapidly change. We know it can jump to different hosts and different species rapidly, and change, and evolve. Part of that is the nature of influenza viruses. They are these negative-stranded RNA viruses, so when they replicate themselves it’s kind of sloppy and they introduce these mutations. And those mutations can help it be more lethal, or adapt, or spread to humans and other hosts.  Sometimes because the genetic makeup of the virus is fragmented, there’s all these segments inside that virus, you can have two viruses infect a person, or an animal, or a seasonal virus and the H5N1 virus. And they’ll recombine and reassort. And you’ll have this virus that comes out with some of the best or worst of all worlds. And so we know the tricks of this virus. And because of that, we’ve been somewhat placated that we kind of think is manageable in the bird population. When we see a jump from the wild birds—ducks, geese—that’s sort of this reservoir. We’re never going to annihilate it from wild ducks. But when we see it jump to birds in the past, domestic poultry, we basically wipe out the flock and decontaminate the area. And that seems to abate it somewhat.  Never in history have we seen this virus spread in such a sustained way to so many different mammalian species. And that is a concern I want to echo that Jennifer’s put forth. Also want to say that this is such a rapidly evolving situation that anything we see today or know today can change tomorrow. It can change very, very quickly because of the nature of the virus. And also, I think, because of the complacency that we might also see now, because we think we have it ready. So some of the things we’ve invested in, we’ve invested probably $10 billion at the federal level. I was the head of the influenza division at BARDA before I became the director of BARDA. And through the many—or, ten years I was there, $10 billion in designing vaccines, changing vaccines, trying to transition from a 1940s technology of egg-based vaccines, to cell-based, to recombinant-based vaccines that could probably be designed and manufactured faster than egg-based vaccines. We’ve invested in antiviral drugs and we’ve invested in diagnostics.  So I’m going to tell you that that’s good news, because we have a lot of experience and a lot of expertise. The bad news is 90 percent of our global capacity of making influenza vaccines are still in 1940s technology of eggs. For the United States supply alone, it would take 900,000 eggs going into a facility every single day for six months without fail just to make a supply of H5N1 vaccine for the United States. In parallel, we would have to make a new—a chemical component of that vaccine called an adjuvant. And the adjuvant would have to be added to that vaccine. And we only have two manufacturers of that adjuvant for the world.  Globally, we only have about the capability, capacity to make four billion doses of egg-based pandemic flu vaccine in a year’s time. And Bill Gates and the Gates Foundation, about 2017 I think it was—2016-2017—did a model a transmission model showing that if we were to have a virus such as the H5N1 influenza virus that transmitted efficiently between people and cause a severe illness and death, in a six month period of time we could see ten million deaths in the United—around the world—around the world. And so that tells you that we have to move swiftly. That tells you 90 percent of our capacity is based on a 1940s technology.  We did invest in a cell-based vaccine approach. We have one manufacturer in the United States, Seqirus, that can make a limited supply of cell-based influenza vaccines. And we have three other manufacturers globally, so four total around the world that can make a cell-based vaccine. So that would come in handy, primarily, if an H5N1, which is a bird flu virus, were to infect the chicken flocks that are required to lay those eggs that are needed for that vaccine. Imagine how vulnerable that supply chain is. Those are fertilized eggs, by the way. So those are embryonated. Those aren’t just eggs we can go to the grocery store and buy. And they’re very select.  So we have this candidate vaccine virus, that CDC mentions, the CVV, which is a starting material for an H5N1 that was made from a virus in 2020. And we could put that in our limited egg capacity. And what we learned from the 2009 H1N1 pandemic, that many of you were probably involved in, that we overestimated the productivity of that vaccine capacity. At the federal level, we were promising the country that we would have 120 million doses of vaccine six to nine months out, by October of 2009. And because the virus did not grow well, that candidate vaccine virus, CVV, didn’t grow well in eggs. At the end of October, we only had seventeen million doses for the United States, mostly for the world. And that came after two major waves of the virus in 2009. So it tells you we need a lot—to do a lot on the vaccine front.  On the antiviral front, we really have two classes of antiviral drugs. We had three in 2003 and 2004. The adamantane drugs, the M2 blockers, many of you might be familiar with. I actually published a paper in The Lancet showing that 100 percent of the viruses circulating, seasonal influenza, were resistant to that drug. We were using that drug for many years thinking it was working and saving our older population when it wasn’t, because no one did the testing. We weren’t doing the right surveillance and monitoring for drug resistance. So we’ve sort of learned our lesson. And we track the neuraminidase inhibitors—so Tamiflu, and Relenza, also Tamivir and Zanamivir.  And in 2008, we learned that every seasonal virus circulating was completely resistant to Tamiflu. We were lucky with the 2009 H1N1 pandemic strain, because it reintroduced a sensitive neuraminidase in that virus that circulated for the pandemic. Therefore, also Tamivir or Tamiflu was effective. But it was only three months into that pandemic we started seeing resistant viruses to also Tamivir or Tamiflu. So it shows you how vulnerable we are to that particular antiviral drug. So we invested in another one called Baloxavir or Zofluza. It works in a different mechanism and a different part of the influenza virus. In our stockpile, we have about 600,000 doses of that. And we have about 75 or 80 million doses of Tamiflu. But that Tamiflu drug was purchased in 2005, and 2006, and 2007, some of it. So it’s past its expiry date.  And I imagine that once we were in a full-blown response and we started shipping our limited supplies of Tamiflu from the stockpile to the states, we’ll see what we saw in 2022 in the influenza season, when we had spot shortages, and they started shipping out the oldest material from our stockpile. Many of the states didn’t accept it. It was hard to describe to people why they were getting a drug that said it expired in 2007 or in 2010. So we have a number of things to do in the antiviral drugs. In the testing space and diagnostics, we don’t have a test that will tell a clinician that a patient has H5N1. We have rapid antigen tests and some other lab tests that would tell you it’s influenza A or influenza B. But we don’t have one that says, this is H5N1. We need to have a test that we can really rapidly detect when a person is infected with this virus, because the antivirals that we have really only work if you use them in the first thirty-six to forty-eight hours of symptoms when you’re infected with this virus. And we also know from H5N1 viruses, traditionally it took about twelve to fifteen times the dose of Tamiflu to inhibit H5N1 viruses, compared to a seasonal H1N1 virus. So the limited supply we have would be cut by maybe fifteenfold.  So when you hear messages that we’re ready, we have this, I want you to really think about how ready are we. And therefore, it leads to the question, what can we be doing now to be better prepared? And that would be accelerated development of tests that can be in the hands of people and clinicians at point of care that could distinguish rapidly an H5 infection. It would be to accelerate the procurement of stockpiles at the federal level, and maybe the state level even. That’s a diversified stockpile that might be as part Tamiflu, might be part Zofluza, or Baloxavir. So we have at least options, if we saw resistance developing to the other. And, of course, we need to think about vaccination and how we can invest in technologies that would scale more rapidly so we can have more doses quickly that are independent of eggs. I talked about the recombinant-based vaccine that we built with protein sciences. That technology has been acquired by Sanofi Pasteur, and basically offshored and moved to—out of the U.S. So in the U.S. we don’t have that capability any longer.  We do have a stockpile, a surge capacity of eggs. We can surge to from 600,000 to 900,000 eggs a day pretty rapidly. But I’ve already described the vulnerabilities. So I think it goes back to, number one, what you’re thinking is, how do I tell people now—or, how do I reduce the chances of getting infected with this virus, while we figure out some of this other stuff that may not be directly in your hands? And, as Jennifer noted, I mean, the greatest risk are to those who are in close contact to the virus. That means those who are in close contact to infected animals. That might be an infected dairy cow. Might be infected cats, or birds, or raccoons, or skunks, or alpacas now. So if you see a sick animal, just stay away from it. Call animal control and let them handle the sick animal or dead animal. Avoiding contact with that is going to help reduce your risk.  Of course, we know that the milk coming from infected cows has very high titers of H5N1 virus in it, if it’s not pasteurized. So raw milk has super high virus titers, some of the highest titers of virus I’ve seen in any substrate. When we have this quantitative PCR analysis and you get a three, that means there’s a lot of virus in that milk. So discouraging raw milk consumption and raw meat, or undercooked meat, from potentially infected animals is primarily important. Keeping a distance from infected animals, staying off and the dairy farms, et cetera. If you have people in your states and areas that work on dairy farms, the CDC has put out some really important guidance on how to protect themselves working on those farms.  I know it looks uncomfortable. I can’t imagine working on a dairy farm and having to really gown up. The instructions that came out today look almost as if they’re protecting themselves from an Ebola outbreak, other than the hood. But they’re—the head-to-toe clothing and protection, head covers, the right type of respirators, eye covers, gloves—this is really important if they are working in environments that have infected animals, because you don’t want them to be the test cased that this virus infects and then have further opportunity for adaptation in the human population. But those are primarily simple things to do, sometimes complex to implement.  But right now, the general population, if they can stay away from infected animals and products, they’re pretty safe. But I do think it’s a ticking clock. I do think we’re about to hit midnight. I’ve never seen this virus take hold in mammals, so far—so broadly distributed in such a sustained way. And we are not doing the testing. We have not done serology studies. And maybe you can do that at the state level to start getting a baseline of human immunology, who is exposed, what level exposure there is among the general population, high risk individuals. Imagine if a lot of the infected dairy cows are going to slaughter, which they are, and if there is infected meat product going to your fast-food restaurants where a lot of this dairy cow meat goes. It goes into pink slime and it goes into fast food burgers, a lot of it.  And, of course, the FDA says if you cook that meat to 140 and 160 degrees it removes the virus. However, if you handle that meat in the process of it being cooked, you’re at high risk. So it’s really important to think about the entire chain of transmission, potential exposure, and protecting all people on the farm all the way through the market to the slaughterhouse and processing plants. So, I’ll stop there. Again, to remind you, this is an evolving situation. What we know today will change tomorrow. More crops—more animals are exposed. So pay attention. FASKIANOS: Thank you very much for that. And now we’re going to go to all of your questions and comments. Please use this forum to share best practices as well as what you’re doing in your own communities. (Gives queuing instructions.) And so with that, I’m going to go first to Renee Yarbough-Williams, who is the chief of staff and the office of Maryland Delaware (sic; Delegate) Cheryl Pasteur. Basically: Can the virus live in pasteurized milk? And how do—how will we know which farms are infected? Is there any tracking system that’s happening now? Or is it really as it gets reported out? BRIGHT: I think either of us can do that—Jen, do you want to do that first, and then I’ll take the next? Or either way? But, yes, why don’t we do that? NUZZO: So they have found genetic material of the virus in pasteurized milk. They have so far, from the tests done to see if you can grow the virus from milk, have not been able to. I’m reassured by that. I haven’t worried about drinking milk. My kids drink it a lot of times. I am not currently worried about that. I am worried for people who, as Rick said, are exposed to raw milk prior to pasteurization, because of the level of the exposure and because the process of pasteurization has not been able to render that virus incapable of infecting us. So that’s my concern. Regarding tracking, as I said, we’re not doing a lot of testing. So I wouldn’t assume that because you see it in some—know that it’s in some places, it doesn’t mean that it’s not in other places. BRIGHT: Yeah. And I’ll add to because—and this is where we can learn more from the states, and local levels, and others directly dealing with this. And I will agree that the limited experiments that have been done to show that heat can inactivate H5N1 in milk in a simulated pasteurization process does seem to be effective, if the amount of virus going into that process is low to moderate. And so my concern is the way we consolidate milk from various farms and take it to a pasteurization facility, it involves picking up milk—maybe one truck or a few trucks—picking up milk from various farms. If the ratio of milk from infected farms going into one tanker truck is low—so if you’re picking up milk from ten farms and two of those farms have infected cattle and eight are unaffected you’ve diluted that virus out quite a bit. And I think that pasteurization can handle it.  But as we continue to see this outbreak spread broaden and spread out across the country and farms, the ratio of infected milk will go up in that tanker, in that—in that batch going through pasteurization. So we don’t yet have data on the effectiveness of pasteurization as that viral titer gets higher going through that process. So that’s why it’s important to pay attention. And if there is anything noted that changes, and the pasteurization is not completely effective, that’s what we need to be completely aware of and be able to respond quickly. FASKIANOS: Thank you. I’m going to take the next question from Sean Murphy. Has a written question, but let me just see—oh, also a raised hand. If you can say who you are, that would be great. And unmute yourself, please.  Q: Hi, there. Can you hear me?  FASKIANOS: We can. Q: My name is Sean Murphy. I’m the mayor pro tem for a small town in Colorado.  My question is, what would you advocate on the local level for getting prepared for a pandemic like this? Thank you.  BRIGHT: I think that was— NUZZO: So—go ahead. BRIGHT: On the—on the basic level we know how this virus spreads. So I think it’s going to be—it sounds simple, but I know it’s going to be a very difficult conversation coming through COVID, what we know is hand hygiene can rid the virus—if you come in contact with it, you touch it, washing your hands actually can prevent you from getting infected and transferring that to your eyes, your nose, or your mouth. We also know that respirators—N95 respirators—are quite effective at managing the spread of influenza. So it could already be at the basic level in the community just awareness of hygiene, once again. No one needs to start wearing a mask right now, or being extra overly conscious for H5N1. But now’s a good time to reinforce just general hand hygiene and the concept that if this were to spread, we might have to wear respirators to protect ourselves again. NUZZO: And I would maybe just add, I think in the short term the thing that I’m most worried about is protecting these farmworkers. I’m quite concerned that there are a number of reasons why infections in this population may not be—might not be found as much as we would like to be able to find them. One, just to understand what’s going on with this virus but, two, really to protect these farmworkers. And so I think really outreach to providers who, particularly in farming communities, that these farmworkers may rely on, just what the symptoms are. You know, these—so far, the two known cases, publicly known cases, have had eye infections. And that might not be what clinicians think to try to test. It’s unfortunately a little cumbersome to test that right now, but nonetheless it would be important to think H5N1 if there were a farmworker with an eye infection.  So just in the short term, just doing outreach for the purposes of protecting farm workers. In the longer term, agree with the list that Rick gave. I will just also queue that this virus—we don’t yet know what a pandemic strain of H5N1 would look like, and if it will be the same as what we’ve seen so far. Again, the data that we have on H5N1 is quite limited. But the data that we have are enough to be concerning. We do typically know that influenza may be different than the SARS-CoV-2 virus that causes COVID-19. And one key difference could be that influenza viruses often are hard on kids. And there was a lot of debate about schools and whether kids should be in schools. I will tell you, I was on the side of keep the schools open.  It’s harder to argue in the context of a virus that is disproportionately affecting kids, a virus, influenza, we know is often seeded to the community from kids. And so that, I think, creates another scenario. So if I were a local leader, one of the things I would be doing is if there were a pandemic, what actions would we as a community be willing to take to stop the spread of this? What are the red lines for us as a community? What would make us shift our feelings on those red lines? Think about if we did need to start vaccinating again, how would we do it? Could we build on the infrastructure that we just used for COVID? Does that infrastructure still exist?  So I would be kind of going through those scenarios, again, hoping we never, ever need to act on them. But that if we did, that we would, you know, be able to hit the ground running, instead of trying to figure it out de novo. FASKIANOS: Thank you very much. The next question from Steven O’Connor, who’s an attorney: Is there an mRNA H5N1 vaccine in the pipeline? BRIGHT: That’s a great question. And a good answer is there are multiple H5N1 mRNA vaccine candidates in development. And Moderna has started a clinical trial. And also, BioNTech and Pfizer are also in clinical studies with H5N1 mRNA-based vaccines. Also, caveat to say that we’ve had—they’ve had many years of work in developing an mRNA-based vaccine for influenza. And there have been some technical challenges to address in that process. So we’re still learning. So even though they have a candidate in the clinic for H5N1, we still may need to optimize that in some ways. But the good news is that they are moving forward. They’re doing this at risk. And we should have some clinical data read out in a matter of months, I would say. FASKIANOS: Great. I’m going to go next, an oral question from Patrick Jordan, if you can accept the unmute prompt and tell us who you are. There we go. I see you’re unmuted. Nothing. OK, waiting. I’m going to go next to—there are a couple of questions in the chat about unpasteurized products. So one question about pasteurized eggs are not readily available. And then there’s another question from Deirdre Goins about, does this warrant a state pulling unpasteurized dairy products from shelves? Because this—you know, the outbreak. And how can states begin testing farms? What policies would you recommend, you know, putting into place at the subnational level? NUZZO: So in terms of unpasteurized products, first of all, there’s long been reasons to avoid unpasteurized products. Eggs, obviously, can be cooked. So that’s—you know, but eating raw eggs has long not been recommended. So I personally, you know, fall in the position that this has long been public health guidance and it should continue to be. I worry about the sort of rise in sort of, you know, fashion, I guess, of raw milk as a product that some people perceive to be beneficial. I quite worry about raw milk, not just the consumption but also, as Rick said, touching it and other exposure. So, yes, unpasteurized products represent a risk.  I will say, though, in terms of testing, I think one of the things—there is a notable difference in terms of our approach to handling H5N1 chicken farms versus cattle farms. Sorry, if you call them cattle farms. And the difference is that this virus has typically killed the chickens. And so the response to H5N1 in chicken farms has been much more aggressive, in part, because of the risk to the industry. So while I worry a lot that this virus is circulating on cattle farms and we are unaware because, you know, the cows are not being killed and because we know that asymptomatic cows can be infected. We don’t fully understand their abilities to transmit it, but we have to assume that that’s possible, in chicken farms it’s different.  Another key difference also is that there are financial incentives for identification and reporting of infections in poultry farms that don’t exist yet for cattle farms. And so I worry—my worry is focused right now on the cattle farms, because I think that the incentives are really, really important. We obviously have to balance multiple priorities here. The objective isn’t to put our farmers out of business. The objective is to be able to produce these products safely in a way that won’t harm the general public, but also won’t harm the workers who are involved in their production. And I think the incentives are key to that.  This is why I’m so interested in making sure we have available tools that can protect workers on these farms, such as personal protective equipment, but ultimately vaccines because it is—well, as Rick said, it’s hard to wear these personal protective equipment in the context of these farms. And, you know, we want to make sure if we have a tool that can protect humans, we should be using it on these high-risk individuals.  FASKIANOS: Rick? BRIGHT: No, I mean, that’s exactly right. I mean, and the does bring up a question, maybe some things to think about at state-level policies. There could be discussions and considerations to making the vaccines that we have in the stockpile available to vaccinate high-risk individuals, those working on farms—dairy farms, or in the slaughterhouses, or milk processing. And so even though the vaccines that we have in the stockpile may not be exact match of what could circulate if this were to become an efficient human-to-human transmitting virus, we’ve done a number of clinical trials through the years with our stockpile and what we call prime-boost studies or mix and match studies. And there’s a number of published data that show if we were to give the first dose of vaccine now, with what we have in the stockpile, it would prime the immunity of those of the highest risk.  And we know that takes two doses of an H5N1 vaccine to make a sufficient level of immunity in a person, because this is a virus we’ve never seen before in people. But the data show that we published in our prime-boost studies, that if we do the first dose with what we have now on the stockpile when that virus takes off, and we have the match to vaccine, we can give that second dose and it will actually make that immune response really robust to match what was circulating even before that virus took off, and then the circulating strain that became a pandemic. So there’s a lot of data to support discussions and considerations for perhaps immunizing at least a first priming dose in individuals at a high risk. FASKIANOS: Great. And just to say that that question from Deirdre Goins, works in the office of Representative Andrew Gray in Alaska.  So Patrick Jordan, who was unable to unmute or we were having technical difficulties, wrote something I want to just read out loud: Getting back to the mayor pro tem from Colorado, here in Ionia County in Michigan, we’re at ground zero for avian flu. Our health department is working closely with the state. We’ve tested twelve to fifteen dairy farm workers with zero positive. But the critical thing here, with the migrant farmworkers, is building relationships with the organizations that serve migrant families, that migrant families trust and are used to working with. So I just wanted to read that because I think that is a good contribution to the discussion. BRIGHT: Irina, can I say— FASKIANOS: Yeah, please go ahead. BRIGHT: I’d say that we should make a poster with that statement on it, because that is crucial. I mean, and we’re learning that much of the workforce across the U.S. at highest risk are likely to be migrant workers. And there are so many issues with getting health care and tracking or monitoring for infection or sickness, or treatment and recovery in this population. And the relationships that are built now around trust and trying to help and make things available are critically important, because in the context of an outbreak and something really devastating it’s that much harder to build trust and work on those communication lines. NUZZO: And just to add that that’s likely to be a durable benefit. Meaning that it’s not just an avian flu benefit to doing that. I mean, this was critical for the H1N1 pandemic in 2009, which didn’t involve avian—an avian influenza virus, but nonetheless this was a vulnerable group. And there was some stigma because the virus was thought to, you know, have started in Mexico. So there was—there was really to do that. There was a mumps outbreak on mushroom farms. So, anyway, this is something that I think public health would benefit from, just regardless, because I think the overarching lesson from all of these events is that, you know, outbreaks, epidemics, pandemics, they expose our vulnerabilities. And that remains a highly vulnerable population and worthy of having strong relationships and, as Rick said, a high degree of trust. BRIGHT: And, Irina, as you get the next question, I’m going to add one more, because that was such a good comment. It was loaded. I loved it. You should have the next panel—he can be on the next panel. But he also mentioned the fact that they’re testing some exposed individuals, monitoring. One of the biggest gaps that we have right now in this outbreak, in the animals as it adapts to humans potentially, we don’t have access to those data. So we have no data in serology, or the virus, and the things that are happening in people or the animals. And we understand that there are jurisdictional challenges. There are database challenges. So many issues, even in the United States, between the federal level and the state level, the state and local, local and the farm, and et cetera.  And it’s so important at the non-federal level—wherever you fall in the local, state, wherever it might be—sharing data in real-time, as real-time as possible, is the only way we’re going to understand what’s happening and be able to sharpen our tools that we have and be able to get in front of this virus. If the data aren’t shared for whatever reason, made publicly available for whatever reason, then we will be caught flatfooted. We won’t know that this is taking off and spreading and killing a lot of people until so many people are infected and dying that we can’t stop it any longer. The key is held right now in the sampling that Patrick just described. FASKIANOS: Thank you. Next question from Jonathan Olvera in Lacy Lakeview, Texas: What season do you believe will be the highest risk for transmission? Or what season should we be aiming for our preparation? NUZZO: I don’t know that we know this answer. I mean, there’s a couple of ways of looking at it. Typically, respiratory flu viruses, we see a higher activity in the months that we go inside where there’s not a lot of humidity. So that’s the kind of late fall, early winter, early spring. Why we’re seeing these infections now, don’t know. Maybe tied to bird migration. But we’re still learning about this virus. And I would say that’s one of the concerns that I have—and I’m just going to—I’ve been looking at the questions in the box and there’s a lot of questions about where. And I would say we can’t answer where because the type of testing that we’re doing is—we’re only finding cases where we are shining a light. And we are not shining a light in enough places to know for sure.  We should be shining a light so we can answer these questions. So we don’t fully know why it is now. I worry, though, that we are looking at the numbers and looking at where the cases are and drawing the conclusions on not only incredibly limited data, but possibly highly biased data. So one of the concerns I have is if you look at the USDA map of which farms—which states have infected farms, that map has remained unchanged for weeks, despite the fact that they keep finding more and more farms in the states that have already identified outbreaks. So this virus is moving around. We’re finding it in wastewater. It may be from wild birds. We don’t know. But the number of states reporting outbreaks hasn’t changed.  So that that makes me highly suspicious that what we’re seeing is an artifact of our surveillance and not an indication of the viral activity. So I worry that some people think that this is on the nadir because we just haven’t found more and more states, and that this is just on the way out. I would love that to be true. But I cannot tell you that, based on the data that I’m seeing. So that’s my overarching, like, take home for everyone today, is don’t assume evidence of absence is evidence—you know, that the absence of evidence is evidence of absence. We really don’t know where this is. We need to be much more proactive in our testing to get ahead of it.  One way—you know, people have asked me, well, if we’ve only had two human cases in dairy workers, and those cases have been mild, does that mean this virus may be much more mild than we think? If we did serology studies that told us that, like, 90 percent of the population had already had this virus, that would change my opinion about it. But we haven’t done that and we don’t know. I would like to see us do much more testing to better answer these questions. I think the fact that in the 1997 outbreak when they tested healthcare workers, they did serologic studies, they looked for evidence of prior infection, they found that these workers likely were infected and that many of them didn’t have symptoms. That was that virus, not this one. But that’s interesting and important to know. But we haven’t done the kinds of studies that would allow us to better answer some of these questions. And that’s to our peril. BRIGHT: Yeah. I’ll just add too H1N1 started in April, went through May, June, the summer is when we had the waves. 1918 H1N1 pandemic also burned through the summers. So it started in the spring and burned through the summer. So it’s unusual that we don’t see—when we see these pandemic flu virus outbreaks really take off in the spring and go through the summer. This is unusual, non-seasonal influenza virus. I worry that we might—if it abates in this summer, that we might think it’s under control or under management. And it will cloak itself within the seasonal winter respiratory viruses because we don’t have test monitoring for H5. We’ll just think is influenza A and we’ll miss it. And it will adapt during that time, and then when the spring hits next year, it’s really six weeks—six months after that when we could see this resurgence. So we could be blessed with a window of time to prepare, but I would not relax if I did see—if I saw the reporting drop in cases lower or the next month. I would intensify preparation for the spring. FASKIANOS: So there’s a question from Mayor James Fahey of Corrales Village in New Mexico: Do you know if anything is being done on swine surveillance, as it is my understanding that they both have the Alpha 26 23 receptors? BRIGHT: There is some surveillance in swine. I mean, again, when we think about the ratio of testing for human influenza viruses versus swine surveillance or, you know, cattle surveillance, or other animals, it’s very limited. But, I mean, the infections that we see in pigs historically aren’t that harmful to the pig. So the pigs can be coinfected with a seasonal influenza virus, human strain, and a H5N1 avian strain. It really is in the combination of those two viruses in that mixing vessel that we see things that can emerge. And we see actually an unusual triple reassort, we call it, strain that emerges most years lately around the state fair time. And so we constantly see this unusual reassort – (inaudible) – come out of pigs around state fairs. And it’s affected several states for many years.  And so I would say, because of that we have some decent surveillance in the swine population. It could be bolstered, probably should be, in context of what we’re seeing now. The thing we don’t have a lot of is reporting and sharing of those data. So even if farmers, and veterinarians, and others are testing in swine, there is not a lot of information about viruses that have been found in swine. They’re not sharing the sequences, necessarily, or posting them in the database, like, GISAID database where most influenza sequences are collected and analyzed. And so if there is additional testing being done in various animal populations, I can’t emphasize enough the importance of submitting and sharing that data into a database that will allow us to monitor for mutations, evolution, or recombination events in any of those animal populations to be better prepared for a human outbreak. FASKIANOS: Wonderful. And there was a question asked about is the stream readily detectable by wastewater surveillance. Jennifer just answered it in the answer thing. I’m just going to read it for the— NUZZO: I’m trying to get to these questions. I see a lot, so I’m just typing them if I can. FASKIANOS: Yeah, no, that’s great. CDC is doing a wastewater testing for influenza A. H5N1 is not—is one, but not the only. And it will soon do testing for H5 specifically. And she put in the chat the link to the CDC.gov. So you should take a look there.  We don’t have much time left. We’ve got, like, three minutes. So I wanted to just ask—this is probably a good question—how would an H5N1 outbreak compare to COVID-19, given low uptake of the most recent COVID-19 vaccine? What can be done about vaccine hesitancy in the public? And that comes from Steven O’Connor, who asked a question earlier. So if you could answer that and leave us with any final thoughts, that would be great. And I’m sorry we couldn’t get to all the questions here. NUZZO: So one key way is that, you know, I would say a blessing of COVID-19 is that it largely spared kids. It didn’t fully spare kids, but compared to influenza viruses it did. We don’t know what an H5N1 pandemic will look like. But the fact that young children, as well as older adults, could be affected—possibly young, healthy adults. You know, we just—there’s a larger age range, I think, to worry about. So that is—that is one key way. I am worried about our willingness to do what it takes to respond to a flu pandemic now, following a COVID-19 pandemic, given sort of where we are politically and where we are just from a pandemic fatigue standpoint.  I will say that it is important to note that we do regularly use influenza vaccines. But a pandemic H5N1 vaccine would not be like a regular seasonal flu vaccine, likely because, as Rick mentioned, it would use an adjuvant, which is an additive that’s meant to provoke a higher immune response. That’s not something we use that frequently in our vaccines. And I think it’s something that warrants specific conversations with the public about what adjuvants are and why we would use them and what it would mean that they might have more of a reaction than they would otherwise get, and why that potentially is beneficial. So I think there’s a lot of work that we have to do on the front end to talk to people about these vaccines, to hear their concerns about it. Anyway, I’m just—I’ll stop there so Rick can say—get some words. BRIGHT: Well, I think that’s important. I think the conversation should start now. And they just start in the high-risk communities. I think they should start—the lessons for from COVID-19 vaccination is there’s a lot of distrust. There was a lack of information and details from the federal level to the state and to the locals. And we should now use the time we have to have those conversations, build those trusted messengers and relationships—on the farms, in the communities, in the barbershops. I mean, I’ve worked with a lot of groups that taught us a lot of lessons. Now’s the time to have those conversations. And you can have them with seasonal influenza. And you can talk about the differences in how bad different influenza viruses can be and the importance of vaccination.  Jennifer has mentioned something that’s really critical in avian influenza viruses or pandemic influenza. It hits the very young and the very old hardest sometimes, and sometimes they’ll hit those with the most robust immune response. Sometimes your body’s immune response does more harm to you than the virus itself. So it’s really important to think about educating everyone for vaccination to make sure that they are protected when that time comes. And I’ll leave you the thought of we are better prepared for influenza than any other pathogen, and therein lies the rub. We can’t be complacent. We can’t think this is going to pass. We must do everything now in this window of opportunity to educate, communicate, and prepare. FASKIANOS: Wonderful. That was a great note to end on. So thank you both, Dr. Jennifer Nuzzo and Dr. Rick Bright for sharing your expertise with us today. And thanks to all of you for joining us for your questions and comments. We will send a link to the webinar recording and a transcript. Until then you can follow Jennifer Nuzzo on X at @JenniferNuzzo, and Rick Bright at @RickABright. And, as always, we encourage you to go to ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on international trends and how they’re affecting the United States—and, of course, CFR.org. And please do send us your suggestions for future webinars by emailing [email protected]. So thank you all again for being with us. And thank you to you, Jennifer and Rick, for your time. We really appreciate your expertise. BRIGHT: Thank you. Been a pleasure. (END)  

Yanzhong Huang, senior fellow for global health at CFR, and Rebecca Katz, professor and director of the Center for Global Health Science and Security at Georgetown University, lead the conversation on global health security and diplomacy. FASKIANOS: Welcome to the final session of the Winter/Spring 2024 CFR Academic Series. I am Irina Faskianos, vice president of the National Program and Outreach here at CFR. Thank you for being with us. Today’s discussion is on the record, and the video and transcript will be available on our website, CFR.org/Academic, if you would like to share these materials with your colleagues or classmates. As always, CFR takes no institutional positions on matters of policy. We are delighted to have Yanzhong Huang and Rebecca Katz with us to discuss global health security and diplomacy. We circulated their bios in advance, but I will give you some highlights now. Yanzhong Huang is a senior fellow for global health at CFR. He is also a professor and director of global health studies at Seton Hall University’s School of Diplomacy and International Relationships—sorry, Relations. Dr. Huang has written extensively on China and global health, and is the founding editor of Global Health Governance: The Scholarly Journal for the New Health Security Paradigm. And he is author of—his most recent book is Toxic Politics: China’s Environmental Health Crisis and Its Challenge to the Chinese State (2020). Rebecca Katz is a professor and director of the Center for Global Health Science and Security at Georgetown University. She previously served as faculty in the Milken Institute School of Public Health at the George Washington University. Dr. Katz’s work primarily focuses on the domestic and global implementation of the International Health Regulations, as well as global governance of public health emergencies. And her seventh book is coming out next week, I believe on Monday, and it is entitled Outbreak Atlas (2024). So you should all look for that. Dr. Huang and Dr. Katz coauthored a Council Special Report entitled Negotiating Global Health Security: Priorities for U.S. and Global Governance of Disease, so we did circulate that in advance. And I think we will begin with Dr. Katz to talk a little bit about global health security and diplomacy, and some of the findings from your report. So over to you. KATZ: Thank you so much, and really appreciate the opportunity to speak with everybody today about global health security and diplomacy. I could note—a quick disclaimer that like many people in Washington I wear multiple hats, including one that works for the United States government, but I am speaking today only in my academic capacity and not representing anybody else. So we are—we’re living in interesting times in the global health security and diplomacy space, and just the work of global governance of disease. As we speak, negotiators are working through what is hopefully a final agreement on amendments to the International Health Regulations. And in about a week, yet another version of possible text of a proposed pandemic agreement will be circulated to member states in advance of the resumed—the INB, Intergovernmental Negotiating Body, negotiations that are now scheduled, I believe, starting the 29th of April, where they may possibly finalize substantive negotiations in advance of the World Health Assembly. It is not a surprise, though, that the negotiations themselves have stalled, and they’ve stalled primarily over issues around access and benefit sharing, and the relationship between developed and less-developed countries. There are significant remaining redlines, including related to the way that pathogens are shared or the information around pathogens is shared. It’s related to the production of medical countermeasures, access to medical countermeasures. There continues to be an evolving power dynamic at this time of call it strained geopolitical tensions. And there are some real questions about the future of multilateralism and just the global governance of the disease space in general. So while this is all sorting out, the world is also working on questions like how do we fund pandemic preparedness and response. So there are questions around the World Bank’s Pandemic Fund, and the breadth and scope. There’s the role of what is the evolving role of the more horizontal entities like the Global Fund. There is limited response funding in general and overall kinds of shrinking budgets. In the academic space, there is a really interesting space set evolving looking at predictive analysis, and some of the technologies and scholarship that’s coming out to think about how do we predict and adapt, both from surveillance and thinking about the evolution of outbreaks. There is the rise of wastewater surveillance. And as the disease threats continue to evolve, we’re also looking at these threats as part of the climate crisis, and a community that’s very keen in looking at the role of artificial intelligence and changing biothreat landscapes. So there is—there’s a lot of movement. There’s a lot of things that are going on. But at the same time, there is diminished interest of governments as competing priorities reenter the fray, and increasing challenges thinking about response capacity in an age of mis- and disinformation and eroding trust in science. So, all this is to say that the space is challenging. It’s dynamic. There is a tremendous amount of work still to be done. Which is one of the reasons that we need to be thinking about how do we use all the roles and approaches that are available to us, including enhanced efforts to focus on the role of diplomacy. I am delighted to see the launch of a Foreign Ministry Channel for Health last month, and we’re now seeing ministries of foreign affairs around the world organize—better organize to address these health challenges. So not all the challenges are easily solvable, but heartened to see this coordinated effort. We’re trying to more fully realize diplomacy for health. There are—there is a lot—there’s a lot of swirl, but why don’t I stop there and turn to my colleague Yanzhong. HUANG: Thank you, Rebecca. Thank you, Irina, and for the Council for invite me to speak at this important event. Thank you for participating. And Rebecca just talked about this progress for the ongoing negotiation over the Pandemic Accord; the need to better organize to address the challenges we are facing. When we’re speaking of the challenges, you know, we—you might have—if you read just the CFR Negotiating Global Health Security—I’m seeking to advertise that one more time—(laughs)—you know, we basically talk about all those different global health security challenges, which are real. We already in the United States experienced a major global health crisis, that officially is not over yet, but—(inaudible). All of the important threat—serious threat we are facing, you know—mind you that COVID caused more than 7 million deaths, right, more than 700 million infections. That 700 million is a clear underestimate, right, because to my knowledge, right, in China alone they have more than 1 billion people infected, right? And now WHO is talking about Disease X, you know, the name given by WHO scientists to an unknown pathogen which they believe could emerge in future, maybe. So it could be, you know, anything, right, with pandemic potential. Like, it could be Zika. It could be Nipah. You know, or it could be another coronavirus, you know, that could cause a serious international epidemic or pandemic. You know, and unfortunately, Rebecca just mentioned climate change is the major contributor to this increasing risk, right? Warmer temperatures can affect the transmission dynamics of pathogens. But the climate change alone could also cause direct loss of life and morbidity, right? The projection is that by the end of this century the millions of heat-related death could be comparable in scope to the total burden of all the infectious diseases. And we also face the threat of antimicrobial resistance, or AMR, which is one of the top global public health threats. The estimate is that bacterial AMR is directly responsible for 1.27 million global deaths and contributes to 4.95 million deaths in 2019. So you combine those two and it’s, like, pretty much close to the COVID death in three years, right? And then there’s the problem of food insecurity. You know, we are facing a global food crisis. This is the largest one in modern history. We talk about nearly 350 million people around the world experiencing, you know, the most extreme form of hunger right now, right? And then—and finally, last but not least, the threats of violence and revolution, you know, that presents new risks to global health security. You know, last time the Council had an event, you know, we saw the former national security advisors participating, speaking, and weighing the—they were asked: Is there an issue that’s on your mind that’s not in the news all the time? I remember former Secretary Condoleezza Rice, you know, said that I worry that we are not paying attention to things like synthetic biology, which could have a huge impact on things like pandemics. So, all the threats call for good health governance, right, global/national level, you know, giving it, right, this—the implication. But I want to emphasize that geopolitics actually are complicating, not undermining, this prospect, right? When you talk about, certainly, right, the armed conflicts, right, worldwide, you know, they can lead to widespread displacement of populations, wide destruction of health-care infrastructure, disruption of supply chains of essential meds and medical equipment, and also increase the risk of the infectious disease outbreaks, right? And certainly, civilian population will bear the brunt of all—most of those impacts, right, that we saw, right, in Ukraine, Syria, now in the Gaza Strip. Sometimes this—that is of particular importance to global health security, the issue of lab safety, right? You know, laboratories taken over by warring parties or in areas under direct attack risk releasing the dangerous pathogens that could start an epidemic, not a pandemic, right? We all—you might recall in April last year, the WHO said, there was a high risk of biological hazard in Sudan’s capital, Khartoum after one of the warring parties seized a lab, holding measles and cholera pathogens and other hazardous materials. Rebecca talked about misinformation and disinformation. You know, the—in a way, the wars and conflicts also encourage, right, disinformation/misinformation, right? For example, the wars in Ukraine, right, they essentially reduced Russia’s incentives to participate constructively in global health governance, right? Russia, in order to justify its invasion, launched a disinformation campaign claiming the United States was secretly aiding Ukraine developing biological weapons. You know, that conspiracy theory sort of echoed, you know, by the U.S. Five Eyes and in China, right? The wars, of course, also exacerbate the other global health issues like food security, right? We know the war in Ukraine, combined with the COVID pandemic actually disrupted the supply chain, fueled inflation, and aggravated the food insecurity problem. But, I think it’s equally important when we look at the issue of how geopolitics or geopolitical tensions actually curbs the prospect of international cooperation addressing all the threats we just talked about, right? Because geopolitical tension, rivalries between nations, can hinder international cooperation and funding for global health initiatives like disease surveillance, sample sharing, vaccination campaigns, research and development of new treatments and preventive measures. Just to use my familiar area—(laughs)—the U.S.-China geopolitical competition, as an example, most certainly U.S.-China geopolitical competition is not new, right? But it is only recently that China became so-called America’s most consequential geopolitical challenge, right? You know, that sort of leads to zero-sum thinking even by the international cooperation over issues like the probe of the COVID-19 pandemic’s origins, sample sharing, supply-chain resilience. And in fact, during the beginning stage of the pandemic we saw China basically threaten to use this leading—the status of being a leader in pharmaceutical—active pharmaceutical ingredients manufacturing to sort of—like as a weapon, right? When the Xinhua News Agency said that—because the U.S. instituted travel bans on China, basically, China at that time was unhappy and said, you know, here we decided to ban our export of APIs to the U.S., so we are going to be plunged in the what they call the sea of COVID, right? So this is an example of how even the medicine could be weaponized during—as a result of geopolitical tensions. And then if you also look at how this U.S.-China geopolitical rivalry could be combined with the lack of personnel—personal exchange, right, sort of deepened by these mutual misunderstandings and misperception, you know. So, you know, now we’re seeing that even after almost the end of the pandemic, right, that the two nations still have no serious discussions over public health issues, even though we think, like, China is actually one of the biggest risk factors. But there is just not much enthusiasm in supporting, like, a serious dialogue with China on cooperating on disease surveillance, sample sharing—not to mention, like, co-development of vaccines or therapeutics. And finally, I want to add that these geopolitical factors could influence the availability and affordability of health-care services and medical supplies, particularly in developing countries or regions affected by conflict or economic sanction. That sort of leads to disparities between North and South in access to essential health care and drugs. Again, the U.S.-China geopolitical competition during the COVID, when China launched this—the so-called vaccine diplomacy or mask diplomacy, the U.S., you know, sort of viewed that as a threat; they—it launched its own mask—vaccine diplomacy. You know, this competition sort of mitigated this so-called vaccine apartheid between the developed world and developing countries; but it also meant that, you know, the vaccine diplomacy would prioritize those countries that’s viewed as strategically important, right? That, in turn, exacerbated the global disparities in access to the vaccines—(all the ?) COVID vaccines—(inaudible). So, to address these challenges, I think we need to have a global health détente with geopolitical rivals. We need to embed the health diplomacy in a multilateral instead of a bilateral framework, right, and support WHO Global Health and Peace Initiative—the GHPI—to better address the underlying diverse critical health needs in fragile, conflict-ridden settings. So, with that, I can stop there. (Laughs.) Thank you. FASKIANOS: Thank you both. Appreciate it. Let’s go to all of you for your questions and comments. (Gives queuing instructions.) OK, so with that, let’s go to the first question. I’m going to go to Mojúbàolú Olufúnké Okome to ask her question. Q: Thank you very much. I’m Mojúbàolú Olufúnké Okome. And I teach political science at Brooklyn College. I’m also Nigerian. And the pandemic showed a lot of the fault lines in terms of the global governance arrangements for health issues, because there were—I mean, the vaccine—the disparity in access was profound for Africans. And, you know, the lucky thing is that not as many people as could have died, died. But I’m just wondering, because we’ve had the HIV/AIDS epidemic, we had Ebola, what is the learning from that? And how come we had all these challenges with the pandemic that we went through, the COVID-19? The other thing about it—that I want to talk about is food. And then there is—I don’t think the problem is insufficiency of food in this world, but distribution equitably. So, what would it take? I mean, and there are all these really heartbreaking photos and, you know, documentaries and reports. What is it going to take to solve this problem and make things equitable so that lives are not being lost unnecessarily, and then health challenges that come from malnutrition are not generationally affecting human populations? Thank you. FASKIANOS: Who wants to go first? KATZ: I will, very briefly and inadequately, try to address the question around vaccine equity. And then—and then I will—I will punt on food security. Since that’s more of Yanzhong’s expertise. I think the point you bring up is critical. And the issues of vaccine nationalism, of vaccine inequity are what is driving current discussion, debate, the feelings around global governance of disease and the effectiveness of it at all? It is—it is the issue that prompted the beginning of a negotiation for a new—(inaudible). And it is—but the solutions are why nations are actually stalled right now. I think your question around what have we learned, well, I think what we have learned is that there’s—whenever anybody talks about future of global governance of disease, you could probably count the number of times somebody says the word “equity.” Yet, operationalizing that is extraordinarily complicated. And unfortunately, we haven’t seen it yet. And I think that you can see that with, you know, the mpox outbreaks and the number of cases that were—you said, you’re from Nigeria—the number of cases that were in Nigeria, the number of cases that have been in the DRC. And the, I think it’s fair to say, insufficient amount of medical countermeasures that have reached populations in sub-Saharan Africa, just for mpox. So, I think there is—there is certainly widespread understanding, realization that we need to fix this—we need to fix this. Because we can’t—we can’t actually talk about we’re all in this together, disease spreads, knows no borders, we all need to work together, and then have situations like you did during COVID where populations just didn’t get access to lifesaving vaccine. So but now getting to the point of trying to figure out how we solve that is exactly what is—what is causing the discord in Geneva right now. And I’m not sure there’s an easy answer for you on how it’s going to be solved. HUANG: Well, I have—(laughs)—well, I really agree with Rebecca, right? There’s no easy answer, right, to all these questions that the professor just raised, you know, that—like the vaccine aspect, right? We know many of the low-income countries, right, that the vaccine—the vaccination rate was even low—very low even by the end of the COVID pandemic. But you know, there’s, like, multiple factors that contributed to that. Certainly, vaccine nationalism is one reason. But you know, even weighing we have all these vaccines available, right, they—the COVAX did a very good job of trying to reach this segment of the population, but then there’s the other issues, right? The shipment, right? How do we make sure they ship and distribute these vaccines in a timely manner? That’s become another issue. And so, I think, well, at this moment the solution that—for the—I think the transport technology for the vaccine technology, that is important. Now, I believe that the Pandemic Accord will talk about—is talking about that in the negotiation. But in the meantime, I think we should also invest to make sure those countries, especially with the manufacturing capacity, will repeatedly sort of have that—some investing there, like their capacity to manufacture the vaccine, right, to sort of—to scale the access. You know, that could be one of the solutions. Then, speaking of the lessons we learned from the pandemic, certainly what we have, right, the—(laughs)—I think it’s fair to say we know the problems, right? The experts—the global health experts, public health experts—they know where the problems are. It’s just that, you know, many of the issues—(inaudible)—only, you know, that it can easily slow them down. For example, we know that the WHO—(inaudible)—by strengthening its capability, enforced by the International Health Regulations. But in the—(laughs)—international system, where anarchy is the rule of the game, you know, that, yeah, I think much of this improvement will be still, you know, state-centric, that—and driven by national interest, just like we saw during the pandemic. Essentially, the IHR was talking about avoiding the disruptions in trade, disruptions to people’s movement, essentially tend to be ignored, right, by the nations there. But there’s another issue, is the lack of coordination. When states tried to use to institute all the travel, you know, the trade barriers, you know, they—there was no, like, coordination, no cooperation. You know, that sort of created this little tragedy of common situation, that then everybody actually was hurt. Finally, the issue of the food insecurity. Well, this is, again, not something new, but that clearly the pandemic, right, exacerbated the problem, in part because of the—this disruption of the supply chain. But in the meantime, there’s some other issues that, you know, could exacerbate that problem. Yeah, like in particular countries like North Korea, for example, we know that in this country—what is arguably the world’s most isolated state, right—they say—the people say—suggested a situation where it’s the worst, right, it has been since the 1990s, you know. But you know, people—the North Korean government certainly could blame the international sanctions. But in the meantime, the government mismanagement, right, is also to blame. In actually still—better still in the pandemic 2020 that cut off, right, the virus supplies, and that is also to blame. You could also talk about the—(inaudible)—killed more by starvation. Is this part of the humanitarian warfare, and especially, you know, in the war setting, where the humanitarian aid is twisted into the conflict by the—(inaudible)—and warlords that seeks to control the food supply as a means of increasing their military and political power, right? So, you know, that—the deliberate use of starvation, this the term we use, kind of war by starvation, right, that’s also was exacerbating in those that conflict zones. FASKIANOS: Thank you. I’m going to go next to the Fordham IPED. Q: Hello. I’m Genevieve Connell with Fordham Program for International Political Economy and Development. Thank you for being with us today. And my question is: During the COVID-19 pandemic we saw dissent where many people blamed China for the pandemic, which has catalyzed racial violence against people of Chinese or Asian descent in many cases. What implications do such social upheavals and demonization of a specific group have on global diplomacy and our ability to collaborate in future health response efforts? HUANG: Well, I’ll try to be—(laughs)—to be the first, whether Rebecca could weigh in. Well, this is, again, not something new, right? During the SARS epidemic, you know, that you also saw that the Chinese were sort of, like, blamed, you know, for sort of causing epidemic. You always, you know, target the certain group of people to blame. You know, you could—(inaudible)—like, historical, that could be traced—there’s a pattern there, right, that during the Bubonic Plague, for example, European Jews were blamed, right, the—for causing the pandemic, you know, that sort of to enforce to them to migrate towards Eastern Europe. You know, that certainly sort of the—poisons the atmosphere for tackling the crises, especially, like, when there’s intertwining geopolitical tensions between China and the United States. You know, that—remember that—and also, you have internal politics by the way, the Trump administration trying to find a scapegoat, right, for its mismanagement of the crisis, you know, that China become an easy one. So he sort of, like, started to talk about, you know, this is sort of a China virus, or kung flu, right, the thing that only—that sort of intoxicated the atmosphere of cooperation with China, making it even less willing to cooperate with the United States, especially on issues like the origin probe. So now, you know, we’ve seen how that—we were probably—given this sort of lack of cooperation, China, you know, really probably we are never going to find where that virus actually come from. But in the meantime, you know, also this created—sort of contributed to, like, a more divisive society in countries like the U.S. given this anti-Asian sentiment. Rebecca? KATZ: You know, I don’t have too much more to add, except that I just—it’s an interesting question. And I actually would put it back to you a bit too. That I think it’s important to separate out the challenge—I bucket the challenges slightly differently. So the challenges of the types of stigma and bias that might arise for subpopulations within our own country. And we’ve, as Yanzhong just mentioned, we’ve seen that over and over and over again. And so you think about the types of ways that that can be addressed, and people can be protected, and how we can think about, you know, it’s not really a vulnerable population, but populations at risk of inappropriate stigma. So I think there’s that question. And then there’s—I bucket into a separate issue of how the government response and dealing with other countries, and the geopolitical tensions that might arise, and how that affects the response into a different category. And that’s—and Yanzhong already kind of addressed some of those—some of those challenges along the way. But none of it—none of it is easy. And it’s often not done sufficiently. FASKIANOS: Thank you. I’m going to take the next question from a written question from José David Valbuena. He’s an undergraduate student at Buffalo State University. And the question is, what are the potential risks and limitations of implementing economic structuralism to improve global health security? HUANG: Define economic structuralism. KATZ: Yeah, I was going to say, I’m not sure how to answer that because I’m not sure what your—what you want us to get at? FASKIANOS: All right. So, José, I think if you’re in a place where you can—you can join in live, or unmute yourself, why don’t you do that? And if not, then we’ll move to the next question. KATZ: Here he comes. HUANG: To use that—something like the Marxism sort of argument, the economy, right, just determines the—(laughs)—almost the upper infrastructure, or whatever. If that if that is the case, right, there, you know, they—I think, you know, a single focus on economic development certainly does not help, right, in improving public health, even though a well-developed economy, you could find the policy high correlation, right, between the, like, high level of economic development improved, right, the health-care standards and, like, the average life expectancy increased. But in the meantime, the single focus on economic development could hurt the public health and global health, you know? One of the examples is urbanization, the industrialization, like, the—could, right, the—sort of make us more likely to be exposed to those dangerous pathogens that increase the likelihood of a dangerous pathogen of jumping species to human beings, you know, then start a—potentially, right, that if it obtained that capacity for efficient human-to-human transmission, right, the potential for a pandemic. KATZ: I think I just saw a note that he’s going to reframe the question, but maybe talk about economics, just one point I would love to be able to add to maybe help frame some of the—some of that discussion with a little bit of data. When we talk about what do we need for health security—and we can talk about the threats, and Yanzhong was talking about, you know, the challenges of urbanization and globalization—(inaudible)—land, and the competing challenges of looking at economic development and—but I do want to note—so one of the things that our research team has been doing for about a decade is trying to figure out what it costs each country to be able to develop their capacity to be able to prevent, detect, and respond effectively to public health emergencies, based off of their international legal obligations and then also looking at each region in context. And it—just so everybody has a number in the back of their head, the number that we currently have is approximately $300 billion that would cost at the global scale for every nation to be able to build sufficient—and sustain—sufficient capacity for health security. That’s in addition to approximately $60 to $80 billion that’s required at a global scale for things like research and development, and supply chain, and manufacturing. So just to note, we have approximately $380 billion problem. And we are definitely not spending that right now. And if we think about it as a problem, the pandemic itself cost—well, we’re not exactly sure what it cost—but somewhere around $15 trillion dollars. So $300 billion dollars sounds like a lot, but it’s actually very little if you’re looking at your return on investment for being able to address a future pandemic. But it’s a lot in the world of public health, where there’s very little money, and there’s shrinking budgets, and there’s shrinking opportunity for nations to be able to actually invest themselves, as well as international financing. So I’m using—I’m using the question as an opportunity to just throw that out there, so folks understand. HUANG: Yeah. I forgot to throw out, again, with the pandemic example, right, that the countries that are most developed, doesn’t necessarily mean that is the most—or, the best prepared for a pandemic, right? Before the pandemic, there was Global Health Security Index, that showed the U.S. was one of the best prepared. But as it turn out, it was the worst—one of the worst hit by the pandemic. FASKIANOS: Thank you. I’m going to take the next question, raised hand from Braeden Lowe, who also wrote his question. But why don’t you ask it? And if you could identify yourself, that would be great. Q: Yes. Can you hear me? FASKIANOS: Yes. Q: Perfect. My name is Braeden Lowe. I’m a graduate student at Middlebury Institute of International Studies at Monterey, studying international trade. My question is, how effective have multilateral development banks been in the development of health infrastructure in countries that need them? And could there be a greater role for them in the future, such as maybe development banks that are focused primarily on the development of medical infrastructure, and facilities, and the development of medical technologies? Thank you. HUANG: Rebecca. KATZ: Yeah. I mean, Braeden, it’s an excellent question. And I think that the history of the development banks has been mixed over—pre-pandemic and in the current situation. Let me start with—well, so, yes. The banks have been involved in developing health security capacity and including medical countermeasures—less on the medical countermeasures, more on mostly national capacity and regional capacity. And some have been more involved than others. The Asian Development Bank was really engaged for a long time. ASEAN was really the driving factor for coordination in that region. The Inter-American Development Bank has been engaged. IMF had programs. So there have been programs. And prior to the pandemic, the World Bank had something called the PEFF, the Pandemic Emergency Financing Facility, that they stood up both for preparedness as well as a response window. That came under a decent amount of criticism because the triggers for using that mechanism were so stringent that it basically became not helpful. And while the Bank and IMF and the regional development banks did assist throughout the pandemic, you could have a pretty lively debate on how effective they were, how fast they got into the game, where they could have done more. I think the general lesson is everybody could have done more. But where we are right now is that the G20 High-Level Independent Panel—well, the G20 appointed a high-level independent panel that was—that came up with some proposals for how to better position the world for being able to support national-level development of pandemic preparedness and response. And the recommendation was to use the World Bank as the mechanism for that. So about a year and a half ago, the World Bank—the World Bank board approved the creation of the Pandemic Fund. As I mentioned before, we have about a $300 billion problem. The first round of funds that was given out over the summer was for $337 million dollars. So we got a—$337 million dollars went out on a $300 billion problem. And there were—and that went to thirty-seven different countries where there were proposals, however, from—there were 600 proposals that were submitted. And these thirty-seven went out. So the next round is out right now. And the plan is for the Pandemic Fund to provide approximately $500 million dollars in this round. But, again, so it kind of—it depends on if you’re a glass half empty, glass half full kind of person, and whether you think that the banks are super engaged in doing all that they can, or if they’re really—if there’s a lot more that they could do. And that’s not even getting into all the other mechanisms that that they have contemplated and thought about in terms of being able to use to help countries, particularly being able to mobilize resources quickly. FASKIANOS: Great. Thank you. I’m going to take two—combine two written questions. The first is from Nicole Rudolph, who is an assistant professor at Adelphi University. Who is leading initiatives to integrate health security with climate resilience efforts? And then there’s a question from Izabella Smith. I don’t know her affiliation. How do you deal with the mass politicization of health safety, specifically before and after COVID-19? KATZ: Easy ones, right? (Laughs.) FASKIANOS: Yeah, very easy. (Laughs.) KATZ: Well, Yanzhong, why don’t I—why don’t I do a really quick answer, and then and then turn to you, particularly on the health and climate space. Except for, Nicole, I would say that I’m glad you’re working on this. We’ve always considered one health and climate as first principles of health security and health security threats. So they are, in our head, completely intertwined, and really need to be addressed that way. I think to Izabella’s, man, how you deal with the politics? It’s—we are in a really, really complicated environment right now. I’m a public health professional. Before the pandemic, most people did not know we existed. (Laughs.) And maybe that was OK. It was difficult because there was no money, but we were kind of quietly left to do our job. And we were most successful when people didn’t know we existed. What happened during the pandemic, particularly in the United States but also around the world, we saw the—a lot of these issues have always been political. They had never been partisan before. They became very partisan. And there was a tremendous amount of backlash against public health officials. There are—there are academic efforts underway to help and capture the—just the type of backlash that existed. The fact that there are academics who are measuring—there is categories for how many public health officials were threatened with gun violence and didn’t get support from their local law enforcement. And the fact that that number is so large, that there is a category for counting it, gives you a sense of the type of backlash that’s been experienced. I think what we’re seeing right now—I can talk to the United States—but a massive movement to roll back public health authority legislation and regulations. There are state legislatures across the country that are stripping their governors of emergency powers and putting that authority into the state legislative branches, which is basically going to make it almost impossible to take rapid action in the—in the next event. And, you know, there will be a next event. So it is—it is really difficult. We are seeing the—based on the vaccine—the increase in vaccine hesitancy, and in part due to the rise in mis- and disinformation. And now we’re seeing measles outbreaks across the country. And, you know, situations where the current public health officials are not taking scientifically based action to stop those outbreaks. So we’re—it’s rough out there. Let me just put it that way. As well—at the same time that people are quitting in droves because people did not sign up for this. So just that. HUANG: Yeah— FASKIANOS: So before—Yanzhong, before you—before you weigh in, and I’ll give you an opportunity. Rebecca, this is a group of professors and students. And so what would you advise—what’s the call to action for this group to—you know, to help, you know, push back on or help sort of make—to ensure that guardrails remain? KATZ: I don’t have any—I don’t have a great one-liner on that, right? Except there is, how do we—how do we rebuild trust in science, in public officials, in governance? There is a need to raise public literacy. And so I start there. There are a lot of folks who are working on how do we counter mis- and disinformation. I think those are two very different things. There is—you know, there’s a need to—you know, it’s everything from being able to do the policy surveillance of what’s happening in the world, to being able to—all the way towards advocacy and trying to help, you know, get programs and policies sufficiently implemented. But I think also just having kind of a strong evidence-informed voice. I wish I had a great, better answer that said, if you just pushed this button or did this thing, it would all be better. But I don’t. And I think—I think this is why a lot of people in the community are really struggling with how do we—how did we get here, and how do we fix it? FASKIANOS: Great. Yanzhong. HUANG: Well, I—just follow what Rebecca said, I think trust is, like, the key, right? You know, our colleague Tom Bollyky, his research has just already, like, demonstrated how important trust is in fighting the—dealing with a public health crisis, like COVID-19. You know, and to the question, actually, the challenge is how to build the trust, right? You can talk about maybe better transparency, better accountability. But you know, I think in a country like the U.S. which is so divided now, I think in order to rebuild that trust it’s very important for the—these different groups, like even—like, I’m talking about, you know, the two groups, they need to be able to have a dialogue, basically, need to speak with each other. There needs to be able to build consensus. But maybe I’m asking for the impossible. But the—so when we talk about politicization, I want to also add that it’s not just happened at the national level; it certainly has been—this past pandemic has shown that this also occurs at the international level. In fact, you know, I think, you know, we never have, you know, a public health event that has been so politicized as the COVID-19. You know, just to give you an example, the SARS, right, when we talk about the origins of SARS, you know, people never thought of, like, politicizing the origin probe. But it’s become a big issue during the COVID pandemic, in part because this is, like, the first time we’re seeing, like, ideology being encouraged by the pandemic response. This entire response to the pandemic is sort of framed as a competition between authoritarianism and liberal democracy, right. And also, geopolitics, like, again, right, the tensions between U.S.-China sort of also was driving, right, the global pandemic response. So I think, you know, in order to sort of—we need to start to depoliticize—(laughs)—this process of depoliticization. We need to reduce the geopolitical tensions. But in the meantime, we need to start the—sort of have—investing in those trust—or, confidence-building measures like having, like, a track-1.5 dialogue between the two countries. FASKIANOS: Thank you. I’m going to go next to JY Zhou, please. Q: Hello. FASKIANOS: Yes. Thank you. Q: Hi. Awesome. Well, my name is Chris Nomes. I’m an intelligence analysis student at James Madison University. And my question is about threats to global health. Specifically, do we—do we face any risks, like, from our adversaries or from lone groups that want to purposely tear down global health? Are there any risks? And how do we counter those risks, if they exist? HUANG: That is Rebecca’s expertise. (Laughs.) KATZ: I got it. Maybe I got it. I mean, I think—listen, you know, when you start the question you asked about threats to global health. And immediately I start making lists of, like, oh my gosh, right, how are we going to talk about the signal—the, what, 90,000 signals that WHO received this month and the, you know, 300 that they’re investigating, and then the thirty, like, field investigations are happening in a given month, and all the—all the emerging infectious disease challenges, including, you know, H5N1 in cows in the U.S., to mpox, to, you know, again the long list of infectious disease challenges that nature throws at us every day. But your question then pivoted to talk more about the threats of deliberate biological events. And that is definitely a thing. I mean, so let’s just say that. That is a thing. That is an area of work. I will say that for about fifteen years I supported the U.S. delegation for the Biological Weapons Convention. So there are—there are people who get together often and work through trying to assess what that threat is and how it’s best addressed. There are—there are mechanisms for trying to investigate allegations of deliberate biological weapons use, and the use of the UN Secretary-General’s Mechanism. And there are now a lot of folks who are deeply concerned about how AI is changing the threat space. And so, you know, in this forum, I think the answer we can give you is, yes. It is a threat. It is a thing. And there is a world of people who work on this, including within the intelligence communities around the world, to better address that threat and then feed that into response and planning efforts. I will say, though, that in the—in the event—the challenge is if there is an actual event, the response may not be very different from a naturally occurring event, at least not initially. And putting attribution assessments aside, and any kind of political response you might have. But that that’s the other thing that is trying to be sorted out, is that, you know, if you are in the midst of a response to what looks like a naturally occurring event and suddenly there is information there or an entity claims responsibility for having released an agent, how does that change? What stakeholders now need to be involved? And also, who—how is that managed at the national, regional, and international system? So, basically, you opened a can of—a huge can of worms for me. But I think the answer is, yes, it is a—it is a thing. And it is a thing that there are—there is a community of people who think very deeply about it. HUANG: Yeah. I’ll just—you know, I think what the problem we’re dealing with, like, deliberate-caused outbreaks, right, the challenge here is that this is not like a war against, you know, terror, because we are facing—we don’t know, actually, even who actually started the attack, right, whether it’s from individuals or states, because in part of this—(inaudible)—of the biological weapons or the use of, you know, the dangerous pathogens, you’re not going to find out whether, like, something unusual is happening. And here, right, a large number of people flooded the ER rooms complaining about the same kind of acute symptoms. So the logic of, like—of deterring such an attack would be different from logic of deterring, like, a nuclear attack, right? Because we have to rely on the building of the health infrastructure, greater trained health professionals, you know, the so-called deterrence by denial, in order to sort of decentivize the potential perpetrators from giving up such an attack. FASKIANOS: (Off mic.) HUANG: Irina, you are on mute. FASKIANOS: I am muted. And how long have I been doing this? (Laughs.) We’ve had a lot of questions and written and raised hands that we could not get to. So I apologize to all of you. Rebecca, I want to give you thirty seconds to talk about your book, Outbreak Atlas. KATZ: Oh, yay! (Laughs.) Sure! I was telling folks before we started the webinar, in academia we write a lot of words, and often we write words and they’re, you know, meant for four people in the world to read. But we put a book together that is designed for hopefully addressing some of the public literacy issues that we brought up earlier. For years we had been supporting public health emergency operation centers around the world in helping provide information about kind of all the activities that happen in an outbreak response. And what we’ve done is we’ve taken that and we’ve written it for a public audience. So, it is illustrated. It has 120 different case studies. Anything you ever wanted to know about what happens in an outbreak, or every epidemiologic term that you heard your grandmother talk about that you’re, like, wait a second, is that right? So we’ve written it all out. If anybody’s interested, Outbreak Atlas. And it comes out on Monday on Amazon, and all those other places. So I’m really excited. FASKIANOS: Great. Fantastic. And, Yanzhong, is there anything you want to highlight that we’re doing at CFR in the global health space? HUANG: Well, thank you, Irina. Thank you for your patience of staying through that one-hour conversation. So, yeah, we are facing a lot of threats. We are—you know, we are aware of many of these challenges we are facing. We know the loopholes in the global health governance areas. It’s just that, I think the—(laughs)—the challenge is how to fix them; you know, don’t expect those negotiations in Geneva can you solve all the problems. The problems are going to rise up all the time in many decades to come. But if you want to learn more about this area, in addition to reading Rebecca’s Outbreak Atlas, read our—this is more CFR’s Negotiating Global Health Security. Thank you. FASKIANOS: Thank you. Thank you both. So you can also follow them on X, formerly known as Twitter, at @YanzhongHuang and at @RebeccaKatz5. This is the last webinar for this semester. Good luck with your finals, and everything that comes with this lovely month of April and May. And for some of you who are graduating, you can learn about CFR paid internships for students and fellowship for professors at CFR.org/careers. We’re open right now. We’re accepting applications for summer internships. And they can be virtual. So that’s always a plus. And they are paid. Please follow us at @CFR_Academic, visit CFR.org, ForeignAffairs.com—and I’m going to really highlight; I do it every call—but our ThinkGlobalHealth.org site, which provides a forum to examine why global health matters and to engage in efforts to improve health worldwide. So, if you’re interested in these issues, you can—you should go there. We hope to be a resource for you all. Again, good luck with your finals. Enjoy the summer. And we look forward to reconvening in fall 2024. So thank you, again, to Dr. Katz and Dr. Huang. (END)

In January, the U.S. Supreme Court debated whether to overturn Chevron v. Natural Resources Defense Council—one of the most cited U.S. cases of all time, which established the principle that the courts should defer to federal agencies when they interpret the law in the course of carrying out their duties. During the COVID-19 pandemic, the deference owed to federal agencies’ exercise of public health authorities was already heavily litigated. How much overruling Chevron would alter U.S. health policymaking is a matter of debate, with some claiming the change would be modest while others argue that FDA decision-making and Medicare administration would be rendered unworkable. Mr. Nicholas Bagley, the Thomas G. Long Professor of Law at Michigan Law and an expert on administrative law and health law, and Thomas J. Bollyky discuss what replacing the Chevron doctrine might mean for U.S. health.

FRIEDEN: Today we have Dr. Atul Gawande for a roundtable discussion. And Dr. Gawande is currently the Assistant Administrator for Global Health at the US Agency for International Development. He is legendary in the health field, not just a renowned surgeon, but a wonderful writer who has written a series of important and best-selling books on health and health care–one of them, famously, “The Checklist Manifesto”, which really is quite relevant for our conversation today about primary health care and how to make it work for people–as well as a regular writer in the New Yorker magazine. And if I completed at least a partial introduction, it would take up way too much of our time. So just to say that, Atul, really delighted to have you with us today, and looking–really looking forward to the conversation.  We're going to start with your comments on the issue of primary health care. Just to be clear, for almost fifty years, the world has had a commitment to primary health care, and yet, still, outside of Latin America, Thailand, Sri Lanka, very few low and middle-income countries have strong primary health care systems. In fact, the U.S. doesn't have a strong primary health care system. So how are we going to go from the lofty rhetoric that we've had for half a century to people actually having a provider they trust and can access without financial hardship? GAWANDE: Tom, it's great to see you. And thanks for posing the central question right off the bat. I want to frame it by describing what I see as the challenge and the opportunity of global health. We've had a century of discovery that has doubled our lifespan. Essentially, if you're in the top one percent of income, where life expectancy in the United States was mid-forties in 1900, it is now eighty-seven years if you're in the top one percent of United States because you have been able to be the beneficiary of the last century of discoveries that have enabled capabilities in medicine and public health, that if you have access to them, has that enormous effect. Now the challenge is, we have identified seventy thousand different ways the human body can fail, seventy thousand different diagnoses and conditions. We've approved, in the FDA, nineteen thousand drugs, we have four thousand medical and surgical procedures, and north, I count, of a thousand public health interventions that have significant value. And our job has become to deploy these capabilities to the right people in the right way to everybody alive town by town. I've argued this is the most ambitious thing human beings have ever attempted. We are still learning: How do you make it possible to get all of that capability and the most important components of it in the right way in the right time and not bankrupt society, make it and–and reach everybody? And I see primary health care is the center of answering that question.  I can't have this discussion without also saying a little bit about my role at USAID. I have the best–I have the best medical job that most people in health care have never heard of, which is leading global health at USAID. I have twenty-five hundred people in sixty-three offices around the world touching over a hundred countries. We deploy ten billion dollars in aid for advancing our–advancing equity and survival, and also addressing ways to prevent health threats from abroad, threatening global security and national security.  And so, you know, my natural goals coming in, I've been in this job for two years, were focused on, you know, first addressing COVID. Number two, dealing with and preventing pandemic threats. And the third I made advancing primary health care. And why? First was the fact that we've endured the first global reduction in life expectancy during the pandemic since World War II. It has set back core areas of basic public health work. We've seen declines in vaccination of children, sixty-seven million children who've missed vaccinations, declines in basic access to sickness care, rise of infectious diseases, setbacks in our efforts to eradicate polio, and turn TB, malaria and HIV into manageable endemic respiratory illnesses. We've seen declines in health services for maternal and child-health survival. And these are in the low-income countries of the world. But we've seen setbacks and health services in every country in the world.  We have the indirect effects of COVID, of the diversion of resources away from health, economic damage resulting in health budgets slashed, disrupted supply chains for health. And so we've seen development happen in reverse. And we have set a target at–in our program, that with the countries we work with, that we want to see that we're getting to better than pre-pandemic levels of mortality by 2025, just want to see us catch back up to what to the ground we've lost. And so we're tracking the percentage of deaths occurring to people under fifty, as a marker of whether we're getting to the place we want to be. So how do we do that? It's not going to be by going disease by disease and category by category. It's going to be because we recognize that there is a basic scaffolding at the community level, which is primary health care that delivers the vast majority of interventions that most advance our lifespan.  All–virtually all of our work flows through primary health care. Whether it's being, as you've called it, Tom, having an epidemic-ready health system, you know, it's going to be frontline primary health-care workers who are going to recognize when someone has an unusual fever or unusual cause of death, and recognize that the alarm bells have to go up and this needs investigation for a possible pandemic outbreak. But it's also the same people who are doing the vaccinations and doing the child prenatal care and the TB detections and so on.  There is robust evidence that investments that raise coverage levels for the essential services end up decreasing mortality, and that primary health care is in the center of it. I can–we can walk through some of the evidence around it. There's been randomized trials of putting, for example, neighborhood health posts into place in a place like Ghana, where people were trained to a nurse level, not even at the physician level, with outreach workers, community health workers attached to the clinic, who were in sufficient numbers to touch every home at least once every three months in order to do preventive education, assess needs and make sure people are connected into the system, “Oh my gosh, you're pregnant, you need to get into prenatal care”, and be integrated into the next level of primary health care. And the result was within three years, a fifty percent decrease in child mortality, a seventy percent decrease in seven years, a decrease–an increase in the contraceptive use rate enough that the fertility rate dropped by one birth per family. And that impact then was replicated at scale. And this is where it gets super interesting to me.  What we see across countries is the richer you are, the higher your lifespan, and it's like one to one. It's a very tight relationship. But there are a few countries that are positive outliers. And, and you named some of them. Thailand is one where we supported Thailand to build its–build up its health system, meet public health goals. And they did it by building on a primary health-care scaffolding, like the one that's in Ghana, and you know, it got them through addressing malnutrition, and that community support could recognize malnutrition, water and sewage issues, and connect services, but then maternal and child-health survival, and then non communicable diseases. So that today that Thailand with three hundred dollars per person per year for health care achieves the seventy-nine-year life expectancy, which is actually now higher than the United States where we spend thirteen thousand dollars per person per year. You have Portugal, Chile, Costa Rica, Ecuador, Panama, four countries in Latin America that exceed US life expectancy. Chile and Costa Rica have the highest life expectancy in North and South America, tied with Canada. And all with a scaffolding, where there is not just a clinic in a box where a primary-health clinician can be there to provide services, but have this other component of a community health worker, which we will need to talk about, doing outreach to make sure that–in every society there are people who are disconnected from the system–and they are connecting households and families into the system to make sure they have the critical needs met, wherever they are in the life course. I'll note that when we needed to get COVID vaccinations to ninety-five percent or more of the elderly, people over sixty-five, even though we have universal health coverage and insurance, we could not get over three quarters of them covered without hiring what ended up being more than a hundred thousand community health workers who are from communities going in their community, door to door, and offering vaccination, making sure that people were pulled in the system who weren't. And we got to ninety-five percent of people over sixty-five, Republican and Democrat, this was not, this is not partisan in any way.  So how to pivot, how to how to drive to action in PHC. USAID is oriented like many public health programs and the NIH, largely in in terms of these, what we call vertical silos of TB, malaria, maternal and childbirth related care, vaccinations and so on. And that means that you can make enormous advances and not necessarily have built up the strong horizontal health system, a platform that you build on, that scaffolding that I talked about. And so, what we set out to do was learn from what has made those programs successful, establish clear targets for the strengthening of primary health care, focus on a workforce that is enabled at a community level, and collaborate with others: the governments, private sectors in these countries, the civil society, and with other aid sources to make progress.  We launched what we call Primary Impact last fall. In seven countries we made–we chose seven countries that were doing what the WHO’s Director General Tedros had called for which is making a radical reorientation of their health systems towards primary care. And that meant that they were putting a larger percent of their health budgets into primary care. And we were looking for places that had demonstrated that they were making those investments to have more of that community health capacity. Often it was signified by World Bank support, World Bank, you know, seeking loans and development assistance from the World Bank, which is one of the largest–probably the largest source of funding for system-based interventions. They were seeking World Bank funds that were primarily focused on their primary health care system. Often the World Bank is where people turn to for the financing for hospitals, and secondary care, but not enough on the primary health care and these seven countries were. There were five in Africa, so Cote d'Ivoire, Ghana, Malawi, Nigeria, and Kenya, as well as in Asia, in Indonesia and Philippines. And with that, what we aim to do is ensure that where we're supporting HIV programs to get to critical HIV targets, or TB, to get to the targets for elimination of TB, etc., that we were doing it in ways that we're connecting to help build the country primary health system, according to country led plans.  So, for example, in Indonesia, they had started with less than twenty percent of their budget going for health care, going for primary health. They have sought–they have gotten 3.8 billion dollars in loans from the World Bank over the next five years focused on investments in their health system, and they put the primary focus of that on the primary health system. So the result is, already today, they're at thirty-four percent of their budget going to primary care, it’s going to go to fifty percent of their budget going to primary health care. I’ll note we have less than eight percent in the United States going to health care.  And the focus of our support is in five areas. We’re enabling integration of service delivery, so we don't just have a malaria worker or a TB worker but integrated so that they're able to see a variety of conditions and capabilities and increasingly work across the lifespan and not just on children and pregnant women, which is often where we're concentrated, to a broader base of services. Strengthening governments at the subnational level, most primary health care is managed at a local or state level, where there isn't as much expertise in quality improvement, or monitoring the system. Third, around having enterprise digital health systems that enable those workers to be part of the larger digital health system. And then having support for the government in developing their universal health coverage financing systems, their domestic financing approaches, in ways that capture and support their primary health care system, improve the benefit package for primary and preventive care as critical components of that work.  And so our next efforts are in expanding our focus countries in this coming year to a larger group, building out expertise with our health directors in those sixty-three countries–sixty-three country offices. We have joined it with the World Bank in aligning what we're doing especially around something called the Global Finance Facility that brings multilateral donor money into primary health care but has been underfunded. And then also working with other donors. At a country level, we launched something called the Community Health Delivery Partnership, as an effort to move in more lockstep with many countries around the world.  Finally, I'll end by saying there's a kind of reverse opportunity that has been created out of this. There's been, for several years, dashboards around that begin to track how primary health care investments are going. For example, looking at the percentage of health budgets–percentage of budgets going to health and the percentage of health budgets going to primary care. Massachusetts became the first state this year that has put out a state dashboard on the condition of primary health care and they were the ones who demonstrated that less than eight percent of health spending goes to primary health care. Milbank then created the first US dashboard on primary health care this past spring, and HHS is taking the signal from that and going to be coming out with a primary health-care dashboard and strategy. But already just a couple of weeks ago, maybe it's been a month now, CMS, the Medicare-Medicaid program, established billing codes and capacity for community health workers to be paid by Medicare and Medicaid. And those are the things that become dramatic game changers everywhere. So, Tom, back to you on this. Hopefully that got us started. FRIEDEN: Great, really exciting and interesting and wonderful. Let's start with the issue of the balance within the health-care system: to put it bluntly hospitals versus primary health care. There's an over reliance on hospitals that, as I travel around the world, I see it country after country, it's certainly the case in the U.S., and there are multiple reasons for that. Many of the hospitalizations are necessary medically, but unnecessary if there had been good primary health care. But there isn't really a financial incentive to prevent the preventable hospitalizations. And there've been discussions of using total cost of care models or capitation.  What we see though, is this kind of gravitational pull to the hospital and escaping that is going to require more than exhortation. It's going to require, I think, changing the financial incentives within the system. How do you see that happening? We're not opposed to hospitals, hospitals are really important. And there are very many important things for them to do. But we don't want them either gobbling up all of the costs, all the budget of the health-care system so we can't do primary care, or spending so much of their time caring for people who really should or could have been cared for in the primary health-care system. How do we rebalance the hospital situation? GAWANDE: So I promised I would try to give you MSNBC answers and not stories, but of course, a story comes to mind. So Jim Kim, primary physician, became the head of the World Bank–this is now more than a decade ago–comes in and discovers the World Bank is one of the biggest financiers in the world of hospital building. And he's in Hungary, and they tell him, “Our beds are full, we need more–we need more hospitals”. And he's, you know, been asked to approve a country plan that's requested, you know, bigger loans. And he happens to be there on a visit, so he goes into the wards, and he sees that it's full of people. In the ICUs, with people in diabetic crisis, who are being diagnosed for the first time with diabetes, sent out, you know, after days of requiring intensive care to have survived it, given insulin, and told, “This is what you're supposed to do, manage your diabetes”. And there's no primary care to take care of them, and so they bounced back three months later, and then they need to build more hospitals. They had more hospitals in Hungary–already threefold as many hospitals in Hungary as Denmark did. So, you know, with a similar population. And so he was like, “What the hell? How do we ask for requests for primary health care?” And the governments weren't asking for them. And they're, you know, they're guided by what you're asking for.  So there were two things that were critical. Number one was the state and condition and the spending on primary health care was not visible. World Bank started to come up with metrics that say, “Hey, how much of your health budgets are going to health care?” Really important. But then “How much of that budget is going to primary care?” And, you know, the levels–there is no kind of stock level of what it can be, we haven't arrived at a norm. But it's very clear, it's like baking a cake. Survival isn't going to work if you don't have enough of one ingredient versus the other, you just get, you know, something that doesn't–if you're making bread, it's not going to taste like bread. And so, when you're making health, you don't get health, if it's all in the hospital and secondary structure. And investing, you know, in middle and low-income countries, in that primary health base requires going north of thirty percent of budgets, and getting to that place. And when they do, you see these sustained efforts, leading to, you know, these life expectancies that way outshine their income level.  The second thing was they created the Global Finance Facility for women, children, and adolescents. And that was a reward system that said, “If you choose to invest your loan in primary health care, with a focus on starting with elevating your child's survival, and your survival of women and adolescents, there will be an add-on to your loan”, so that you will get essentially, for every dollar–every seven dollars that people get in World Bank loans, now if it's in primary care, you get another dollar that gets added on. And it draws then more interest and has drawn more interest in investment from thirty-six countries now since it was launched in 2015, low-income countries that have directed their loans towards primary health care.  The third is really recognizing that we, as sources of aid for global health, have not sought out the country plan on primary health care and investing in it as part of what we're doing. We focus on whether we're getting the outcomes we're looking for, you know, reduction of HIV rates, or reduction of TB rates, and so on. And often, it is recognized that your best results are if you build that primary care system, but where there are weak primary care systems, we're often building around it with private partners, implementing partners coming in and enabling services because the country systems aren't providing them. And that's not building the long term system. And so that's also something that we track increasingly: how much of our development is going into country-led plans, and that's a critical part of what we have to be doing. FRIEDEN: I would love to ask follow-up questions about that, but moving along. We've talked about community health workers, and they clearly play an essential role. And yet, how do we make sure that a health-care system is supportive of all levels so that the community health worker is supplied, supported, supervised, can connect with higher levels of curative care when needed? Community health workers are a really big part of the solution, but they're not the solution. GAWANDE: That's right. So what is a community health worker? I think of it as two different kinds of people who are providing care at a community level. One is often someone at a nurse level, sometimes below a nurse level, who can be the first point of contact for the care itself and can be trained at levels that provide a wide swath of essential care, before having to leave your community to go to the, you know, emergency room or the hospital level or the secondary care level. But then the second component is the community health promoter. They're often volunteer, but are really vital because they do the home assessments, and provide preventive education, often do vaccinations, provide recognition of stunting and lack of nutrition, etc.  And, you know, Africa has twenty-five percent of the world's global burden of disease, but only four percent of the health workers. Those workers, eighty-five percent of them are unpaid community health volunteers who are, you know, not drawn into the system. So in Africa, we have a severe health worker shortage, and we're not seeing them become paid. Africa CDC has set a goal that there will be two million paid community health workers–health workers in the workforce, and you see–and have rallied heads of state behind those goals. Because this ultimately is a domestic commitment. No amount of foreign aid in the world can enable that to come forward.  So, we are seeing now that's happening. President Ruto in Kenya has committed to paying their 108,000 community health workers. Now they will be salaried, and in fact, are salaried now. In Nigeria, the new president has come in and Muhammad Pate, who used to be at the World Bank working on exactly this project, has committed that their 120,000 community health promoters will now become paid, and they've identified the financing pathway to be able to do that. And then organizations like ours can come in and say, “Well, we'll be happy to support training. We'll be happy to support getting them onto electronic systems. We'll be happy to support ensuring the local governments are better trained to support those workers and those systems that make them successful.” And so you are off and running. And those numbers of, you know, that's part of why we formed the Community Health Delivery Partnership is virtually all countries have had these plans, but have not had support, technical assistance, and visibility, that these are, you know, essential, essentially: the investments that we can come in behind and support even as we can't finance all of it. FRIEDEN: Let's talk about digital health for a minute. My perspective, having traveled to dozens of countries is that largely, digital health interventions have failed. They are often designed in a capital city somewhere they look great on paper. If you look at the U.S., we spent more than ten or thirty billion dollars digitizing healthcare and most doctors hate their electronic health records. In our own work at Resolve to Save Lives, we have shown some success with a deeply user-centric information system that understands the ground realities of connectivity and hardware and other things. But we see a lot of, kind of, false promise and false hopes for what digital systems will do. What's your perspective on how digital systems could strengthen primary health care? GAWANDE: There's lots of complex reasons why doctors hate their computers–or nurses [do] or other folks. They're built for many purposes other than making the care itself easier for a patient and a clinician to navigate. The reality, however, is that as you get electronic systems in, even in a reasonably basic way, they enable transfer of information: a record of a patient that allows you to begin to follow whether it's what vaccines they had, their medical history, their medications, and enabling safer, better outcomes of care. There are a few components that, you know, there's been twenty years of apps being built for here, apps being built for there, and no enterprise system that is actually effective. And what you end up having to build is the digital scaffolding to support the primary health scaffolding in the first place. That digital scaffolding has a few basic components. And what countries have to do is have a digital plan and then a lead who implements that plan.  The plan has to allow for four things to happen. You need an identifier for a patient–for people–that can follow them, that is their identifier, you know, wherever they go in the system. You need to be able to connect different sources of information that that identifier carries with it. You might have gotten immunizations here, a hospital visit there, and end up going for a child delivery in a birth center. And you need the information to be able to be connected to your identifier from those different sources without, you know, being controlled or owned by the government. So it has to have a private connection. The third is a clinician has to be able to receive that information and have access to that system. And they themselves need a smartphone, a tablet or a computer to make that happen.  Once you have that–India is now, in several states, having built systems that enable that kind of function, and you get the ability to layer on top of that, applications that actually work and matter and are updated over time for clinicians to use and have an ecosystem where people are building around this core platform. We don't have that core platform in the United States: a common identifier, a way your information can be connected between spots and a common language and agreement to do that. But you will see now more and more countries that are building on that kind of system. Kenya has established its national digital plan. Indonesia has now done it, India has done it. But you know, we're almost having to go back to basics at this point of making these pieces come together. And then you get to: Here's the intuitive way to track people's blood pressures or the immunization records so that clinicians can enter the system. But it requires that initial scaffolding. FRIEDEN: I want to open it up for the group. But I'll ask you one last question. There's been a long-standing discussion, debate, disagreement between what’s sometimes called selective PHC and comprehensive PHC. With the understanding that we'd really like to provide comprehensive PHC, but since, in many countries, we're not even providing selective PHC, we probably have to start somewhere. Where do you stand on this? And how do you think checklists are relevant for strengthening PHC? And then we'll open it up for questions. So think of your questions, because we'll turn to the group next. GAWANDE: You know, I'm coming in from the outside. I'm a surgeon, so what do I know about primary health care? What I see from visiting all the places that you've been to many more times than I have–even as much as I've gotten to see things–you always start with something that's selective PHC. There's nowhere to start except selectively. You know, in Costa Rica, they started with providing malaria services, nutrition assessment, and some basic vaccinations. And then on top of that, as those workers became more skilled and malaria got almost eliminated, they then expanded to being maternal and child health services and about childhood illnesses. And they were working with a checklist, you know, it's often an integrated management set of algorithms around how you manage the child with a fever, how you manage the prenatal visit, the postnatal visit, and so on, and the services widen. But now, over time, those clinics, each of them have, in Costa Rica, you know, by the year 2000, they had grown to match US life expectancy. And by the mid-2000s, they'd exceeded life expectancy in the United States, which meant that you had to be able to see people who were coming in, who had everything from depression, to diabetes, and hypertension, to geriatric needs. And the capacities were, you know, now they’re physician led with a primary physician–a family physician–have nurses on the team, a pharmacist, and community health promoters who go door to door: they're called EBAIS workers. And they're able to track and assess a very broad range of people's illnesses. It's much more comprehensive. It's never fully comprehensive, and you have things you have to refer up the chain, but they know their communities, they know their needs.  And they in a way we don't–in many countries they set public health goals that, you know, in our community, our biggest killers are, it might be hypertension, it might be cervical cancer and wanting to get HPV vaccination, it might be COVID and they want to get the COVID vaccinations out. But in any given year, they have their goals for the top five killers across the life course. And they're making sure that on those they're getting the ninety plus percent performance, reaching people, not letting anybody fall through the cracks. And that's simply an approach we don't take. FRIEDEN: Thank you. So we'll open it up for questions now. If you have a question, raise your hand or you can, I believe, put it into the chat. If people don't ask questions, I'll keep asking. And you can see the instructions there, you hit the raise hand icon on your Zoom window. While people are asking questions, let me ask you a political question, if I may. The Congress has been willing to fund programs like malaria, TB, HIV. The appetite for funding, primary health care is not very strong. Is that something that you're going to be able to address, especially in this fiscal climate? GAWANDE: So this is so crucial. And it goes back to, you know, we've had fifty years since it was declared that we ought to all be focusing on primary care, but we're not doing it. I totally understand the feeling that if I'm a taxpayer or a congressperson working for the taxpayer, feeling like primary health care is where I pour money into a bucket, and it just comes out the bottom and I don't know what happened here. It should, you know, the critical measure that we're tracking are our essential health service indicators. You know, we should see as a consequence of this work that we're more likely to meet the HIV goals of ninety-five percent of HIV patients getting diagnosed with HIV, ninety-five percent of those folks getting on treatment, and ninety-five percent becoming free of viral load. And it should show that we're meeting the TB markers and meeting the–increasingly closing the contraceptive unmet need. Those indicators that our Congress measures us by should be the ones that we track, and that we're delivering on.  I've added two measures, you've heard me refer to them. One is what are called the UHC Service Indicators. It’s a bundle of fourteen indicators that we should see improving. Those include prenatal measures, immunization measures, TB, HIV, malaria, and health worker density. And we should see that the percentage of deaths that occur in people under fifty go down. And the hypothesis is that when Congress and taxpayers see that for a given set of dollars you're putting into the space, you're getting these outputs then–that will be supported and justified. I see it as not an either-or HIV and primary health care, TB and primary health care, but that we are never going to reach the unmet need and close our goals in these spaces without the scaffolding and it will increase the success of our reach. FRIEDEN: Great. Well, we have a bunch of questions. Let me start with Farzad Mostashari. Farzad? You have to unmute yourself. Q: Hi, good morning. Hi. GAWANDE: Farzad! Q: Hello, hello. This is Farzad Mostashari, currently with Aledade, formerly responsible for doctors hating their EHRs and information not moving where it needs to go as National Coordinator for Health IT. The question I had is actually not about the technology, it's about the financial incentives. You give the example in Hungary where it just makes sense, right? If you're thinking long term, and if you're paying for care directly, for government to be able to do long term planning and say, “We're going to invest more in primary care now and it's going to reduce our acute care costs down the line.” In the U.S., we don't have the central division of care and the government has created a way for private actors to–if they improve primary care–to capture some of the value created in reduced hospitalization and acute care spending. And that's what I'm engaged with currently.  Do you see–on those two sides of the coin, do you see globally, on the government sponsored health care side, what's the barrier to government's thinking long term like that? Is it that they don't really believe that more primary care is going to reduce total cost over the long run? Or is it having a short investment horizon, and then what could be done on that? And then on–where healthcare is privately mostly provided, do you see any other examples of countries that have followed the kind of risk-sharing model that the U.S. has done. GAWANDE: It is true that everywhere, it is hard to convince people to invest in what's going to save lives, you know, ten years, twenty-five years, fifty years, in the long run. There's a study I read about, I think, more than a decade ago, but I was enthralled with, which looked at bridges, and that you could keep bridges alive for a hundred years or more, if you provided maintenance services on those bridges. And every state has its maintenance fund, and every governor raids the maintenance fund in order to build a new bridge, right? So, we are chronically, you know, it shouldn't be that the majority of your spend is in the maintenance fund and the minority is in the building-new-stuff side. And you–there's an optimal level, but you know, on the political horizon, you don't get credit for the bridge that doesn't fall down, you get credit for the bridge that you built, right? And so, everybody's maintenance funds are too low. The way we use–our percentage of spending on maintenance is always lower than we want.  All of that said, what I've seen in the countries that establish this work is that the value–Costa Rica is a nice example because I dug into it, but it's similar in Chile, Thailand and other places, but I know the politics of it better in Costa Rica. When they didn't exist, it was seen as a huge expense. And then they built having a community health-care capability that had a clinician and a visit to your home at least once every three months to assess your needs. And then it got its own momentum that once those places had those services, other places wanted those services. It's like, you know, we don't always invest in schools, but it ultimately pays off to have a school, and communities that have those capabilities want them.  It is also the case that I have seen that those public health–those public platforms with a primary-health structure have been virtually always built on a public government basis, whether it's local, state, or national government building, that core scaffolding. And on top of it, there's always a private sector that people can choose to go to, instead of that system, but that that system was always making sure that people were not falling through the cracks, that there was some outreach. And the public system is rewarded for prevention, is sustained on the basis of what its outputs are for actually making health achieved. Whereas the private sector is almost always rewarded for acute needs and it's very difficult that people don't pay for and tend not to buy expensive insurance for what they do on the preventive side. It's not that it's hopeless.  So, where there are the capitated models, as you talked about, a panel fee or a subscription that you pay, and the Medicare approach with Medicare Advantage, in theory, enables those services to happen. But no one screams about whether, you know, “No one came to me to offer me my COVID vaccine!” They scream about what happens if your acute care didn't follow through, and they sue, and they do all of those kinds of other things. So the, you know, we are always swimming uphill–it's public health–in seeking resources and enabling what pays off in the long run, you know. We don't miss smallpox. We didn't reward any politicians for getting rid of smallpox in the world, but it was a huge payoff. And it's still–I see it as a fundamentally public function with the private sector needing to come in and as far as we can, enabling on the private sector side, support that can, you know, reward and recognize the value that gets paid off.  The fact that in Medicare people can hold on to–tend to hold on to people's households for–or at least families for years of time, does provide some incentive for making sure those private primary needs are met and pay off in the long run. But you know, you're in the middle of that grand experiment and seeing whether it actually ends up translating into more of that prevention. FRIEDEN: We have a bunch of questions. So let's try for crisp questions and crisp answers. Charles Holmes– GAWANDE: The answers have been crisp so far–questions have been crisp so far. I'll work on the answer being crisper. FRIEDEN: Charles?  Q: Thanks so much, Tom. And thanks, Atul. This has been amazing. And thanks for all you're doing too, with Primary Impact and also really trying to leverage the multilateral funding into primary care. Two really click questions. One is, you know, primary care is almost more than anything else entirely–almost entirely workforce dependent. We see so many challenges with government management of their health-care workforces, they tend to have a lot of trouble with performance management, a lot of trouble with the administration and expansion of those groups. As we move towards more of a paid workforce, how can we make sure that we're investing in those performance management systems that have really bedeviled so many of the countries that I interact with? As we try and, you know, expand the roles that the primary health-care workforce can–that management–is really invested in?  Secondly, how can primary health care in this sort of post–so much to COVID vaccination, yet, we're left with so much sort of vaccine hesitancy. We're moving towards more adult and adolescent vaccines like TB vaccines, for instance, in the next few years. How can we–how can primary health care help rebuild that trust to ensure that we do even better next time? Thanks. GAWANDE: I'll try to do this as tightly as I can. So, on performance management in primary care. I mean, we have across the board, it's not exclusive to primary care, secondary care, hospital care, delivering health care is very complex. It involves huge–the amount of coordination and system building that's required is massive. And we're still learning: How do you manage that quality and performance? But we've made huge strides. You know, the more we learn how to measure, how to set targets, goals, that are–that we all aspire to as teams, and the more we function as teams rather than individual actors, the better and better the results we're getting. And, you know, it's the slow, as I said, it's a generational problem. It's not a one-time fix, it is mastering that art.  What I will say, however, is for all of the difficulties, you know, Chile has people in the streets just a few months ago, complaining about the quality of their primary health care and wanting to see, you know, better–significant improvements. And they–with a fraction of our income, less than less than a quarter of our income per capita–are achieving an eighty-two-year life expectancy. And so, you know, it's not that we have to get it perfect, it is within reach to make sure that these essential services are there. And the critical component is being able to say that we actually have goals for our primary-health clinics that they should be achieving: getting to ninety percent of the high blood pressure recognized and delivered on cardiovascular disease, the biggest killer that we, you know, as one example, that Tom works very, very hard on. And in the United States, you know, we're barely past fifty percent of us–we don't set a goal. There is no goal that we, you know, we have a cure for Hepatitis B and C, and we have not figured out how to set a goal that we're going to make sure every one of our communities or clinics are oriented towards making sure that that is addressed or that the blood pressure is measured and managed. So that ability to have goal setting, to track it at the primary-health level and marry it to public-health goals, is what many places are doing and what we need more places to be able to do. FRIEDEN: Thank you– GAWANDE: Oh, and then, there was, on the vaccine hesitancy. I'll just say, you know, the more we move past the politicized moment, the better–the better off we'll be. You know, early on, HPV vaccination was really–there was a significant political divide about each vaccination against cervical cancer. And then, you know, the heat was turned down, it was pulled out of the headlines. People, you know, moved on to the next social cultural war. And we've quietly gotten past eighty percent of our adolescent girls vaccinated and dramatic drops in cervical cancer.  You know, Australia, which is–which has similar rates, slightly higher, is starting to see that they can set a goal of eliminating cervical cancer, of the types covered by the vaccine. So there, vaccine hesitancy, I think happens, is addressed at the community level with community health systems, primary health systems, that approach people, talk to them about the facts of what's on offer to save their life. And we see again and again in those settings, if we can make sure that that system is what people have access to, they deliver real results. FRIEDEN: Great. Next question is from Kyla Laserson. Q: Hi, thanks. This is Kayla Laserson from CDC– GAWANDE: Hi, Kayla! Q: Hi. Thanks so much for this, this is great. Just a question about what your thinking is on–especially globally–diagnostics at the primary health-care level, especially for acute febrile illness and partnership with the private sector for that? GAWANDE: Well, so this is where I get to plug one of the things I've been very excited about. I mean, first of all, we're moving diagnostic capabilities like molecular diagnostics to diagnose TB and other conditions, increasingly becoming something that can be done at the primary health-care level. You know, it used to be these genetic–diagnostics can only be done in national labs. Now it can be, you know, we have increasingly portable handheld less than ten dollars a test capacity and that price is dropping.  But what's exciting to me is we're seeing other tools also land. I'm rolling out in seven countries, in our TB program, AI based chest X ray detection systems where you have, on a laptop, a AI based program that will read digital, portable chest X rays that can be done with a–with a system no larger than a backpack, that are deployed at primary health-care levels in Nigeria, in Vietnam, in a variety of other settings. In Nigeria, the combination of a chest X ray, you can do at the primary health care level to screen people or look into whether a pneumonia is present with a molecular diagnostic has contributed to a forty percent jump in the number of TB diagnoses made in the last year. So, I think we have an increasing variety of tools–we're going to be testing out AI based ultrasound for pregnancy as well–that move capabilities that formerly required really high-level radiologists and technologists to have those tools be more and more available at the bedside level. FRIEDEN: Great, thank you. Next, Tom Bollyky. Q: Hi. Thanks so much to Tom and to Atul for this great conversation. I'm Tom Bollyky, I direct the global health program here at the Council on Foreign Relations. Atul, a question I had is obviously we're coming out of the pandemic, many countries are struggling with debt. On one hand, this would seem like a particularly inopportune moment to try to advance this agenda. But there is another way of looking at it. And I wonder how much the conversation around primary health is being seen as part of the discussion of how to have that fiscal restructuring in countries, how to have policies that are more sustainable and more conducive to their debt levels, and to the degree to which you are working with our multilateral bank partners or treasury on those issues? GAWANDE: Yeah, so you know, they have been, I would say they're only loosely connected. The connection that I see–so as you're pointing out, debt levels after the pandemic have risen enormously. A lot of that debt is held by China and by European bond markets. And for health systems in low-income countries, that means you don't have cash to buy pharmaceuticals, to buy vaccines, to buy fuel for getting health workers out. And so, it's devastating for health systems.  And the biggest challenges around trying to get China and public markets to recognize that that needs to be restructured. You need to, you know, expect now that the countries are simply not in ability–don't have an ability to pay, to pay it off and retire some of that debt. But we're not getting there yet. When you're having to do with less fiscal space, because you see countries like Kenya, for example where the budgets, the amount of budget, the majority of the federal budget now is going for debt payment. In a tighter fiscal space, there's a strong case to be made that your top priority has to be primary health care. And coming out of the pandemic, the disruptions in the primary health-care delivery, you know, simply not being able to provide pregnancy services and other things like that are making it critical to have choices that address these primary health needs.  So, it's an indirect effect, it is hard, you know, when you're, as Tom said, when you're facing off budgets for hospitals with urban environments that have more political clout often, and the more dispersed community health needs of a primary health sector. However, a dollar goes so far in this setting, that being able to get a hundred-thousand workers paid in Kenya at relatively low costs, because they're your lowest cost health worker cadre was politically salient, very powerful and important in Kenya, given that they wanted a win in a tightened fiscal environment. As a way to address the debt crisis, it doesn't help provide a pathway out from a situation where the costs of debt are outpacing your growth in your economy and your tax receipts. FRIEDEN: Paying the health workers is one thing. Supplying them may be something else. Jordan Kassalow. Q: Yes, thank you, Tom. As the mortality and morbidity burden moves from infectious disease more to the non-communicable diseases, like hypertension, cardiovascular disease, diabetes, one of the challenges that we see is that many of these top killers are asymptomatic, whereas from my experience working in particularly under resourced places, what drives people into the health system are things that are visceral. And the most common visceral problems to the human being tends to be oral health issues, ocular health and or vision issues, auditory issues. And the problem is those areas have not gotten any, any leverage, any– FRIEDEN: I’m just going to interrupt because we're just about at time. So we have time for a quick question and quick response. Q: The question becomes, how can we leverage these visceral issues that are so common, to both solve those problems themselves, but also to help drive people into the primary health-care system and get them the things that they need for the killers? GAWANDE: Okay, well, two quick things. Number one is the majority of deaths in Africa are still in many of the common public health areas of focus, HIV, TB, maternal child health, malaria. And so–but we've got now a large space that has come for cardiovascular disease and coming when you had the chest pain is way too late. So completely agree. There is–if we go to Asia or Latin America, where we have advanced to the point where those systems are now treating people across the life course, where the infectious disease burden has become quite low. That is, in fact, what they're adapting to do. The needs that they're being called upon to address may be oral, they might maybe eyes, they may be geriatric needs. You know, and they've built out and trained more geriatricians per capita in Costa Rica than the United States has, as a result at that primary health level. So, you do become demand driven. You get people in the door for what they–for the ways in which they feel badly. And then you attach to that your preventive needs to make sure that their care gets to doing–gets to the goals we have for the longer run. Tom, this has been really great as a discussion. I appreciate you inviting me. FRIEDEN: Thank you so much. I’m sorry that we didn’t get through all of the questions, but thank you so much, Atul and thanks for the great questions. It's a great discussion, it's a crucially important topic, and I'm just hoping the coming months and years see lots of progress in lots of countries so thank you so much.

The Global Health Security and Diplomacy in the Twenty-First Century symposium is cohosted by the Council on Foreign Relations and the recently launched Bureau of Global Health Security and Diplomacy at the U.S. Department of State.  This event convenes a globally representative set of influential policymakers, practitioners, and thought leaders to discuss the global need for better cooperation, coordination, and communication in tackling health security threats, which also threaten national security. Speakers include U.S. Global AIDS Coordinator and Senior Bureau Official for Global Health Security and Diplomacy John Nkengasong, former Chief Medical Advisor to the President Anthony Fauci, Director of U.S. Centers for Disease Control and Prevention Mandy K. Cohen, and UNAIDS Executive Director Winnie Byanyima. Speakers making welcoming remarks include U.S. Secretary of State Antony Blinken (pre-recorded video message to participants), U.S. Ambassador to the United Nations Linda Thomas-Greenfield, and Director-General of the World Health Organization Tedros Adhanom Ghebreyesus.   This event is part of Thomas J. Bollyky's Global Health, Economics, and Development Roundtable Series. Please click here to view the full symposium agenda.

Panelists discuss the future of U.S. foreign policy on global health and ways to address future pandemics, climate change, health-related development goals, and other challenges in a divided country and geopolitical world. This meeting is made possible by the generous support of the Bill & Melinda Gates Foundation.