Health

Pharmaceuticals and Vaccines

  • Public Health Threats and Pandemics
    What Is Avian Flu?
    A global surge in avian flu outbreaks in birds and some mammals is worrying poultry farmers, scientists, and health experts. The trend is provoking questions about the future of the disease and global public health.
    Backgrounder by Mariel Ferragamo May 7, 2024
  • Biotechnology
    Bernard L. Schwartz Annual Lecture on Economic Growth and Foreign Policy With Tony Coles
    Play
    Drawing from his distinguished career in the pharmaceutical industry, Cerevel Therapeutics Chairman and former CEO Tony Coles discusses developments in biotechnology, the implications of health policy on economic security, and leadership lessons learned throughout his career.  The Bernard L. Schwartz Annual Lecture on Economic Growth and Foreign Policy series focuses on two areas: the evolution of the relationship between business and government in the making of foreign policy, and ways for government to make better use of business in solving foreign policy problems.
    Virtual Event by Tony Coles and Michael Froman April 29, 2024
  • COVID-19
    When Will COVID-19 Become Endemic?
    Government leaders are optimistic that COVID-19 is becoming more predictable and manageable, but the pandemic isn’t over yet.
    In Brief by Claire Klobucista and Mariel Ferragamo May 24, 2023

Experts in this Topic

Luciana L. Borio
Luciana L. Borio

Senior Fellow for Global Health

  • Economics
    Cross-border Rx: Pharmaceutical Manufacturers and U.S. International Tax Policy
      I want to thank Chairman Wyden, Ranking Member Crapo, and the distinguished members of this committee for the opportunity to testify today. Tax avoidance by American pharmaceutical companies is a very real problem. It is also a very solvable problem. Straightforward changes to the U.S. tax code would encourage American and global pharmaceutical companies to produce more patent-protected pharmaceuticals in the United States, and to onshore rather than offshore their global profit. America’s pharmaceutical companies clearly have a critical role to play in creating a more resilient American and world economy. They have been at the forefront of many of the world’s most important medical innovations – helped, in many cases, by research funded by the National Institute of Health and other government agencies. To cite the most prominent recent example, mRNA vaccines helped dramatically limit the loss of life associated with the COVID-19 pandemic.   Unfortunately, most of America’s leading pharmaceutical companies currently have structured their businesses to shift the profit from their U.S. sales to their offshore subsidiaries. As a part of these tax strategies, American pharmaceutical companies also have shifted production and jobs to other jurisdictions.  My testimony will be divided into three parts. The first part will examine the incentives in the tax code that favor offshoring profits and production, to the detriment of the U.S. Treasury and the strength and resilience of the U.S. biopharmaceutical industrial base. The second will review the empirical evidence of profit shifting in the pharmaceutical sector, drawing on both the data disclosed by the large listed pharmaceutical companies in their own annual reports and on the trade data. The third will identify the reforms that I believe would substantially reduce the current incentive to offshore profits and jobs. 1. The U.S. tax code For many years, the U.S. tax code combined a relatively high (35 percent) corporate tax rate with the ability to indefinitely defer profits that were technically the payment of tax on income earned outside the United States. Technical tax rules evolved over time so that it became relatively easy for a U.S. firm to transfer its intellectual property rights to one of its offshore subsidiaries without incurring a U.S. tax penalty, and then to shuffle those rights among its offshore subsidiaries to gain additional tax advantages.  The results of the incentives created by this tax structure were quite apparent. Several prominent U.S. firms – particularly firms in the technology and pharmaceutical sectors – paid relatively low effective tax rates and accumulated large offshore profits.  Firms learned how to borrow onshore against their offshore profits to pay dividends and conduct buybacks onshore, but there was widespread agreement that the combination of global taxation and indefinite deferral generated perverse incentives that only advantaged offshore financial centers.  By the end of 2016, analysts calculated that the deferred profits of U.S. firms had reached close to $2 trillion. That included at least $150 billion in accumulated offshore profits by the 8 largest U.S. pharmaceutical firms.    The 2017 Tax Cuts and Jobs Act changed the structure of the U.S. tax code without, unfortunately, changing the underlying incentive to move profits and jobs offshore to obtain a lower tax rate. The Trump corporate tax cuts reduced the headline corporate tax rate from 35 percent to 21 percent. This new tax system was generally designed so that income earned in the United States would be taxed at the U.S. rate, and income earned abroad typically would not be subject to U.S. tax. In an inadequate attempt to put in place guardrails against abuse intrinsic to such an international tax system, the U.S. Congress created two special tax regimes – a 10.5 percent tax on some of the global profits of U.S. companies (the Global Intangible Low Tax Income or GILTI) and a special U.S. tax preference for export earnings above a 10 percent return on U.S. tangible assets. In technical terms, the result was a hybrid tax system – territorial in its concept, but with a low worldwide tax on foreign income that was taxed abroad at an exceptionally low rate.   By institutionalizing a large gap between the U.S. headline corporate tax rate and the low GILTI tax on U.S. firms’ global income, the new tax code generated strong incentives to continue to transfer profits and production abroad. The exemption of a deemed return on tangible assets located abroad from even the special 10.5 percent GILTI rate further encouraged firms to produce abroad, as increasing a firms’ foreign assets works to reduce its GILTI income and thus lower its global tax.  Tangible assets located in the United States received no such special treatment. Dr. Kimberly Clausing has rightly called this an “America last” tax policy, as the reform structurally favored foreign income over domestic income.  The last place an internationally mobile firm would want to book the global profit on its tangible assets is in the United States. Five years have now passed since these reforms were enacted and the results are clear. A minority of firms, primarily technology firms that generate most of their revenues from the sale of advertising, repatriated the global right to make use of their intellectual property and simplified their tax structure. But the bulk of U.S. multinational firms have opted to maintain global businesses models designed to shift mobile income out of the United States into low tax jurisdictions.    The U.S. balance of payments data provides clear evidence of the aggregate impact of these practices. U.S. multinational companies report earning $325 billion in seven low tax jurisdictions (Bermuda, the Caymans, Ireland, Luxembourg, the Netherlands, Singapore, and Switzerland) and only $50 billion in seven of the world’s largest economies (China, France, Germany, India, Italy, Japan, and Spain). The IRS data on firms’ country-by-country profits tells the same story – in 2019, the last available data point, American firms report earning far more profits in the Caymans than Canada and China combined.            2. The pharmaceutical sector in the tax and trade data After the enactment of the Trump corporate tax cuts, American pharmaceutical companies in particular have doubled down on business models based on offshore production to shift profits on drugs sold in the U.S. market to their offshore subsidiaries. There are two independent sources of data that illuminate the extent of profit shifting in the pharmaceutical sector: the data that publicly listed U.S. firms disclose to their own investors as part of their SEC reporting requirements and the U.S. trade data. SEC Disclosure America’s pharmaceutical companies are known the world over for their innovativeness, but they increasingly do not produce their most significant products in the United States. Rather, they produce many of their most lucrative patent protected drugs outside the United States in order to facilitate the transfer of the profits generated from U.S. sales outside of the United States and to avoid reporting a U.S. profit on their global sales. This is the clear pattern that emerges from a systemic examination of the 10-k annual financial reports of the main U.S. listed pharmaceutical companies. In these reports, companies generally detail the reasons why their actual tax rate differs from the 21 percent headline rate as well as disclose key risks, including risks to their current tax treatment.   Excluding Gilead, whose reported data is incomplete but suggests that it now books the bulk of its global income in the United States, and Eli Lilly, whose data is also incomplete but unfortunately suggests it engages in significant profit shifting, the major U.S. listed pharmaceutical companies reported earning around $10 billion in U.S. profits on $214 billion of U.S. revenue in 2022. These firms also reported earning over $90 billion abroad – a quite significant fraction of their almost $171 billion in reported foreign revenue. Actual tax paid follows the reported profits: these U.S. firms reporting paying a bit over $2 billion in U.S. tax and close to $11 billion in tax abroad.  2022 was a particularly profitable year for many pharmaceutical companies. But the pattern of small U.S. profits relative to U.S. revenues – and a small U.S. share of global profits – has been consistent over time.  Over the same time frame, many large U.S. pharmaceutical companies have consistently reported sizable foreign profits relative to their foreign revenues. Such a pattern is all the more striking because the United States is well known to have the highest pharmaceutical prices in the world.  The cost of pharmaceutical production does not vary significantly from jurisdiction to jurisdiction, so the profit margin on high priced U.S. sales would normally be expected to be much higher than the margin on foreign sales. It consequently is particularly noticeable that the bulk of the American pharmaceutical industry appears to barely make any money on their U.S. operations, while reporting large profits in countries that more intensively regulate pharmaceutical pricing. I want to highlight three companies in particular, based on their SEC disclosed tax structures over the last five years.    As Senator Wyden and his team have highlighted, AbbVie systematically transfers nearly all the profits on its patent protected medicines out of the United States. In fact, AbbVie reported a $4.6 billion loss in the United States in 2022 – and a near $20 billion offshore profit. The reported U.S. loss is not an aberration – AbbVie has reported a U.S. loss every year between 2013 and 2022. These domestic losses occur even though AbbVie reports that it generates 75 percent of its revenue in the United States, and its blockbuster drug Humira sells at a substantially higher price in the United States than in Europe.  Bristol Myers Squibb now displays the same pattern as AbbVie – it reported a U.S. loss of $0.14 billion while reporting nearly $8 billion in offshore earnings. It also reports that the United States generates nearly two-thirds of its revenues. Pfizer also historically reported losses on its U.S. operations and large profits abroad. That pattern was attenuated by the success of its Covid-19 vaccine, which Pfizer produced in the United States for the United States and many other global markets. Nonetheless, there are indications that Pfizer continues to be among the firms that aggressively shift profits out of the United States. In 2022, Pfizer reported that it only generated $5 billion of its $35 billion global profit in the United States. That is a change from its $2.9 billion loss on its U.S. operations in 2020, its $4 billion loss in 2018 and its $6.9 billion loss in 2017 – but it is still a remarkably small profit on $42 billion in U.S. sales in 2022.   Such profit shifting strategies explain why many major listed U.S. pharmaceutical companies report effective tax rates close to ten percent. Merck’s 2022 10-k notes that tax differentials tied to foreign earnings lowered its effective tax rate by about 10 percentage points. To quote its annual report: “the foreign earnings tax rate differentials in the tax rate reconciliation above primarily reflect the impacts of operations in jurisdictions with different tax rates than the U.S., particularly Ireland and Switzerland, as well as Singapore and Puerto Rico.”  Pfizer reports that lower taxation on its operations abroad lower its tax rate by about 5 percentage points; it observes “the reduction in our effective tax rate is a result of the jurisdictional location of earnings and is largely due to lower tax rates in certain jurisdictions, as well as manufacturing and other incentives for our subsidiaries in Singapore and, to a lesser extent, in Puerto Rico.”  Reporting from the Irish journalist Thomas Hubert indicates that Pfizer should also have highlighted its Irish operations; Hubert’s investigation concluded: “what will not appear in the group’s consolidated accounts is the central role Ireland plays in the development, manufacture and distribution of its ground-breaking medicines around the world – as well as its finances and tax affairs.”  U.S. Trade Data The story that emerges from a close reading of the SEC filings of American pharmaceutical companies is supported by the U.S. trade data.The United States now imports around $200 billion of pharmaceutical products (NAICS 3254) while exporting about $101 billion. If imports from Puerto Rico are included, imports would increase to over $230 billion (Puerto Rico, a U.S. territory, is inside the U.S. customs border but outside the United States for corporate income tax purposes).       U.S. biopharmaceutical exports increased during the pandemic as a result of U.S. production of the COVID-19 vaccines, which were produced in the United States for the global market and have raised U.S. exports of “biologics (NAICS 325414)”.  However, excluding the special case of vaccines, which were produced under U.S. government contracts that often required U.S. production, the U.S. trade deficit in pharmaceuticals has increased steadily after the passage of the Tax Cuts and Jobs Act. The United States now imports a bit over $150 billion of pharmaceutical products other than biologics, while exporting a bit under $60 billion – with imports almost doubling since the passage of the Trump corporate tax cuts. The trade deficit in pharmaceuticals is not primarily with low-wage and low-cost jurisdictions, as one might expect. Rather, the largest sources of imports are Ireland, Switzerland, and Singapore, with increasing imports from countries like Belgium – all of which offer special tax regimes for pharmaceutical companies.   The trade data maps to ongoing reports of U.S. firms increasing their offshore production. Merck has expanded its Irish production of Keytruda (Pembrolizumab), an important immunological treatment. Janssen Biotechnologies, a major subsidiary of Johnson & Johnson, is investing in Irish production capacity for Stelara (Ustekinumab), another blockbuster drug.  Eli Lilly has announced a $1 billion new investment in its Irish production facility, reportedly to produce a new Alzheimer’s drug, among others.  Pfizer has also reported a $1.3 billion investment in biologic production capacity in Ireland.    In my judgment, there is no plausible explanation for the current scale of U.S. imports of pharmaceuticals from Belgium, Ireland, Switzerland, and Singapore that isn’t tied to tax avoidance. The net result is a loss of tax revenue for the U.S. Treasury and a smaller biopharmaceutical industrial base. This clearly leads to a less resilient U.S. economy. The pandemic showed that a diverse advanced manufacturing base and a technically skilled workforce can be vital assets in rapidly scaling up production of innovative medicines in the face of an unexpected shock.  3. Necessary reforms Significant changes to the current U.S. tax code are needed to remove the current incentive for pharmaceutical firms, and other high margin manufacturing firms, to shift jobs and profits out of the United States. The starting point for any reform is straightforward: the U.S. Congress should increase the tax rate that U.S. firms now face on their global intangible income, and thus assure that firms that engage in tax games to shift profit outside the United States nonetheless pay a U.S. tax rate of at least 15 percent. In addition to raising the baseline GILTI rate to at least 15 percent, Congress should assess this tax on a country-by-country basis. Right now, firms that pay zero tax on their profits in say, Bermuda, or perhaps 5 percent in Ireland, can actually lower their overall tax rate by blending those profits with profits in high tax jurisdictions like Germany (a perverse outcome). Such changes on their own would clearly raise a meaningful amount of revenue, given the low effective tax rates that firms report in their SEC disclosures and the large reductions in tax that firms disclose as a result of “the jurisdictional mix earnings”. In addition, careful consideration should be given to deeming patent boxes to be in a separate foreign tax bracket for the purpose of calculating a firms GILTI income and tax liability. Such patent boxes currently create strong incentives to shift profits into what would otherwise be relatively high tax jurisdictions, such as Belgium. There is little downside to an increase in the U.S. global minimum tax. Thanks to the leadership of Secretary Yellen and others, America’s main trading partners have already committed to a 15 percent global minimum tax. Consequently, the United States should immediately enact the changes in U.S. tax law required to implement – or at least converge with – the second pillar of the OECD-G-20 Inclusive Framework. Without U.S. action, other countries will rightly be able to collect top-up taxes on under-taxed U.S. firms that operate in their jurisdictions and continue to systematically shift profits to low-tax jurisdictions. U.S. firms that have retained their intellectual property in the United States and pay U.S. tax on the associated royalty income by contrast will face much less of a risk of being subject to a top-up tax. Moreover, the United States should increase its tax collection from the pharmaceutical industry by enacting the first pillar of the OECD- G-20 Inclusive Framework. Pillar One shifts a portion of the tax a firm owes on its global income to the “market” jurisdiction – essentially the jurisdiction of sales. Foreign pharmaceutical firms that generate large profits on their U.S. sales would thus be required to make a payment to the U.S. Treasury. Pillar One would also raise U.S. tax revenues from U.S. pharmaceutical and medical technology firms that “inverted” and became Irish headquartered companies, even though the bulk of the firms’ operations and sales are in the United States. Even U.S. headquartered pharmaceutical firms could, absent changes in their tax structure, potentially be required to make additional payments to the United States, as many currently generate the majority of their sales inside the United States while booking the majority of their profits abroad. Aligning a portion of the taxing rights to these firms’ global income to the jurisdiction of sales thus would imply greater, not smaller, payments to the U.S. Treasury.   In addition to these reforms, most of which have been proposed by the U.S. Treasury, I would recommend a set of additional hard-hitting reforms to discourage firms from shifting profits earned in the United States outside of the United States. A higher minimum U.S. tax on the offshore income of U.S. firms reduces, but does not fully eliminate, the incentive to offshore future profits.  Specifically, the U.S. Congress should consider a set of reforms to reinvigorate subpart F of the corporate tax code. Subpart F dates back to the 1960s. It was originally introduced to the tax code to discourage U.S. firms from locating the passive profits and income from certain related party transactions, including sales and services income, abroad. Today many firms locate production as well as their intellectual property rights abroad, but the basic principle that firms should not gain a tax advantage by shifting profits outside of the United States remains important. Over time, though, subpart F has been effectively gutted, and it is relatively easy to find ways around its basic requirement that passive income and income from certain related party transactions be taxed in the United States at the headline U.S. corporate income tax. No doubt there are many specific changes that would strengthen subpart F. I will highlight three. One, foreign royalty income should be denied any exemption from subpart F, and thus taxed at the U.S. rate. To be concrete, this would raise the tax rate on the intellectual property that pharmaceutical firms, like AbbVie, have located in Bermuda and other no or low tax jurisdictions. Two, legacy “cost-shares” that allow firms to shift profits out of the United States by splitting the cost of research and development between the U.S. headquarters and a foreign subsidiary of the same firm located in a low-cost jurisdiction should lose their current special tax status. Three, transactions between foreign subsidiaries of the same firm that generate a substantial increase in the valuation of offshored intellectual property for the purpose of generating larger depreciation allowances in jurisdictions like Ireland could be subject to U.S. tax at the headline rate. To give a concrete example here, it has been widely reported that Apple’s subsidiary in the isle of Jersey was bought by Apple’s Irish subsidiary.  This transaction was designed to generate large depreciation allowances for Apple’s Irish subsidiary and thus to substantially lower Apple’s effective Irish tax rate without incurring any U.S. tax liability.  Under this proposal, the paper profits that Apple’s Jersey subsidiary earned from the sale of the global rights to Apple’s intellectual property to Apple Ireland would be taxed at the headline U.S. rate.     The intent of all these proposals is to discourage U.S. firms from transferring the right to profit from the intellectual property that they generate in the United States to low-tax jurisdictions, and thus to create strong incentives for U.S. firms to retain their intellectual property onshore. It would have the byproduct of substantially reducing tax incentives to offshore production and jobs, as the bulk of the profit on offshore production accrues to the intellectual property and the goal of many offshoring strategies used in the pharmaceutical sector appears to be to create the legal basis for moving the profit on U.S. sales out of the United States. As I noted earlier, in 2022, the large American pharmaceutical firms reported earning remarkably little – $10 billion – on their $200 billion in U.S. sales. Their reported earning on their foreign operations were equally remarkable: $90 billion on $170 billion in sales, an implied margin of over 50 percent.  These firms appear to have paid about $2 billion in tax to the U.S. Treasury on global earnings of over $100 billion, a remarkably small sum. Such reforms would both raise the overall amount paid to the U.S. Treasury and increase the effective tax rate paid by U.S. pharmaceuticals. Many foreign pharmaceutical firms already pay effective tax rates of around 20 percent, or close to the headline rate in their country of origin. Denmark’s Novo Nordisk is currently taxed at Denmark’s headline tax rate and pays the bulk of its income tax in Denmark.  France’s Sanofi also pays and effective rate of close to twenty percent.  Even the Swiss firm Novartis pays an effective tax of close to 15 percent.  These firms also tend to pay the bulk of their corporate income tax in their “home” country. The United States now stands out by allowing many of its major companies to achieve effective tax rates of 10 percent by moving both production and profits out of the United States – a giveaway to the shareholders of the pharmaceutical companies that comes at substantial cost to both the U.S. Treasury and the U.S. economy. In the context of a significant tightening of subpart F, I would also support reinstating full expensing for Research and Development expenditures, structured to be effective in the context of Pillar two of the OECD's global tax reform. Generous tax treatment for genuine innovation though should be combined with new rules that would claw back expensing for Research and Development if a firm moves its intellectual property to one of its foreign subsidiaries. Such a rule would be technically challenging, but I am confident that it is feasible.   Conclusion The United States generates the bulk of the revenue for American pharmaceutical companies, largely because Americans pay the world’s highest prices for essential medicines. Yet American companies typically report that they earn, at least for tax purposes, almost all of their profits abroad.    The information that American pharmaceutical companies report to their own investors provides strong evidence of systemic tax avoidance. In 2022, the United Stated accounted for 55 percent of the sales of a select group of large pharmaceutical companies, but only 10 percent of their profits. The most recent round of U.S. corporate investment in Irish pharmaceutical production highlights how the Tax Cut and Jobs Act only reinforced prior incentives to offshore both production and profits. I unfortunately do not think it is unfair to call the Tax Cuts and Jobs Act the Pharmaceutical Tax Cuts and Irish Jobs Act. There consequently is an urgent need to reform the U.S. corporate tax code to both to assure that some of America’s most profitable companies pay their fair share to the U.S. Treasury and to strengthen the U.S. biopharmaceutical industrial base. The incentives to offshore the production of some of the world’s most important medicines in the current U.S. tax code are in my view an issue of supply chain security and thus ultimately of national security. I applaud the Finance Committee for calling this hearing and encourage the Senate to move quickly to make necessary changes in the U.S. tax code.  
    Testimony by Brad W. Setser May 11, 2023 Greenberg Center for Geoeconomic Studies
  • Pharmaceuticals and Vaccines
    A Guide to Global COVID-19 Vaccine Efforts
    The swift development of effective vaccines against COVID-19 was an unprecedented scientific achievement. But production challenges, vaccine nationalism, and new variants have all presented hurdles.
    Backgrounder by Claire Klobucista December 5, 2022
  • Infectious Diseases
    Why Hasn’t the World Eradicated Polio?
    The world is inching closer to eradicating polio, but armed conflicts and opposition to vaccines stand in the way of finally eliminating the disease.
    Backgrounder by Claire Klobucista and Danielle Renwick August 22, 2022
  • Public Health Threats and Pandemics
    Major Epidemics of the Modern Era
    For more than a century, countries have wrestled with how to improve international cooperation in the face of major outbreaks of infectious diseases. The COVID-19 pandemic, which brought the world to a near halt in 2020 and has killed nearly seven million people, underscores the urgency.
    Timeline by Claire Klobucista July 25, 2022
  • World Trade Organization (WTO)
    The WTO Hangs On
    WTO members confounded expectations last week by concluding a deal on fisheries subsidies, the first major multilateral agreement in nearly a decade. But the trade body is not out of the woods yet.
    Article by Inu Manak June 22, 2022 Greenberg Center for Geoeconomic Studies
  • Health
    Renewing America Series: Public Health as a Public Good—What's at Stake?
    Play
    The COVID-19 pandemic amplified health disparities and renewed conversations about the limitations of current public health systems after decades of disinvestment. Panelists explore the idea of reframing public health as a public good to drive investment, modernization, and encourage better coordination across health systems. With its Renewing America initiative, CFR is evaluating nine critical domestic issues that shape the ability of the United States to navigate a demanding, competitive, and dangerous world.  
    Virtual Event by David Cutler, Linda P. Fried, Margaret (Peggy) Hamburg and Maria Freire February 14, 2022
  • Public Health Threats and Pandemics
    Data's Role in Preventing the Next Pandemic
    Play
    Over the past fifteen years, global health has been threatened by Ebola epidemics in West Africa, the emergence of Middle East Respiratory Syndrome (MERS), the spread of Zika through the Americas,and the 2009 influenza pandemic. The tolls of each event have been exacerbated by inadequate data systems. Ongoing struggles to track the global spread of COVID-19 demonstrate the need to fix problems in existing surveillance for infectious diseases.
    Virtual Event by Rick A. Bright and Jennifer Nuzzo February 14, 2022 Global Health Program
  • Public Health Threats and Pandemics
    Year Three: The Pandemic Continues
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    As we enter year three of the COVID-19 pandemic, three leading global health experts examine how the United States and the world have dealt with the evolving situation, the lessons learned, and the way forward.
    Virtual Event by Rebecca L. Katz, Michael T. Osterholm, Leana S. Wen and Michele Barry February 8, 2022
  • COVID-19
    The World Still Hasn’t Agreed on a Pandemic Playbook
    For two years, the world has been battling COVID-19 with masks, vaccines, and lockdowns. There have been impressive results and serious missteps, but countries have failed to channel their shared experiences into a blueprint for action.
    Article by Claire Klobucista February 4, 2022
  • COVID-19
    Reporting on the Omicron Variant and COVID-19 Testing
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    Jennifer Nuzzo, CFR senior fellow for global health, provides an overview on the COVID-19 omicron variant and information about testing. Shalina Chatlani, healthcare reporter for the Gulf States Newsroom, discusses framing stories on this topic for local communities. Carla Anne Robbins, adjunct senior fellow at CFR and former deputy editorial page editor at the New York Times, hosts the webinar.   FASKIANOS: Welcome to the Council on Foreign Relations Local Journalist Webinar Series. I’m Irina Faskianos, vice president for the National Program and Outreach at CFR. As you know, CFR is an independent, nonpartisan organization and think tank focusing on U.S. foreign policy. We take no institutional positions on matters of policy. This webinar is part of CFR’s Local Journalist Initiative, created to help you draw connections between the local issues you cover and national and international dynamics. And we put you in touch with CFR resources and expertise on international issues and provide a forum for sharing best practices. I want to remind everybody that the webinar is on the record, and the video and transcript will be posted on our website after the fact, at CFR.org/localjournalists. Today we will be discussing reporting on the Omicron variant and COVID-19 testing with our speakers, Jennifer Nuzzo and Shalina Chatlani, and host Carla Anne Robbins. I’m going to just give you a few highlights from their distinguished backgrounds. Jennifer Nuzzo is a senior fellow for global health at CFR. She works on global health security, with a focus on pandemic preparedness, outbreak detection and response. Dr. Nuzzo is a senior scholar at the Johns Hopkins Center for Health Security, and associate professor in the Department of Environmental Health and Engineering, and the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. And she’s also the lead epidemiologist for the Johns Hopkins COVID-19 Testing Insights Initiative within the Johns Hopkins COVID Resource Center. Shalina Chatlani is a health care reporter for the Gulf States Newsroom, a regional newsroom with coverage from public broadcasting stations in Alabama, Louisiana, and Mississippi as part of NPR’s collaborative journalism network. She covers health care access and inequity and has previously reported on racial disparities in the coronavirus vaccine rollout, and how the financial stress of the coronavirus pandemic is affecting communities of color in San Diego. And prior to that, she was a science reporter for KPBS in San Diego and the emerging voices fellow at WPLN in Nashville. And last but not least, Carla Anne Robbins is an adjunct fellow at CFR. She is faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. So thank you all for being with us. I’m going to turn it over to Carla to get the conversation started, and then we will open the floor to all of you for your questions. You can either raise your hand or write your question in the Q&A box. And we really want to hear from you as well. So get your questions ready to go, you’re reporters, we look forward to hearing from you as well. So, Carla, over to you. ROBBINS: Thank you, Irina, so much. And thank you, Shalina, if I may, and Jennifer, if I may. I’m going to call you guys by your first names, since we’re journalists and we’re incredibly informal. And thank you to everybody who’s here. Please, you guys—I’m sure you have a lot of questions. And so we’re just going to chat briefly up here and then throw it open to you. So, Dr. Nuzzo, Jennifer, if I may, I want to start with you. I’m puzzling through this statement, you know, from this top WHO official yesterday, Dr. Hans Kluge, I think is the way it’s pronounced, which had some news outlets predicting an end to the pandemic. You know, he said between vaccination and natural immunity through infection, quote, “Omicron offers plausible hope for stabilization and normalization.” What did he mean by that? And what does the new normal look like? NUZZO: Yeah. I mean, it’s a challenging thing to explain, in part because I think everybody has a different idea of what the end of the pandemic means. There’s no clear definition. (Laughs.) There’s no epidemiologic definition. Pandemic describes the whole spread. And I think it’s quite clear that this virus is not going to disappear from the planet. It’s going to continue to circulate. And, you know, we have seen evidence of mutation. We’ve seen evidence of reinfection. So with that, I think everyone has some reasonable belief that means that it’s going to find each one of us at some point in our lives, possibly multiple times. So but that doesn’t necessarily describe a pandemic, although it clearly describes global spread, which is usually how we define a pandemic. I think there’s another element to it, which is just how unusual or expected are what we’re seeing. And I think we don’t know for sure, but I think most people’s visions of when the pandemic is over is when our day-to-day efforts to try to stop the spread greatly change and manage it more like the way we manage other routine infections that we deal with. Doesn’t mean that we won’t have challenges from time to time. And I think probably the best recent example is influenza, where we had a pandemic in 2009 that probably a lot of people have forgotten about. But that same virus that caused that pandemic is with us every flu season. And some season we have a bad season. Not so much usually from that particular virus, but from other flu viruses that also circulate. And some seasons it’s not. We have tools that we use to try to mitigate the impacts, but we haven’t shut down societies typically for it. So in terms of what I think is one possible scenario, Omicron is leaving a tremendous amount of immunity in its wake. It’s my hope that everybody can protect themselves with a vaccine before they have first contact with the virus, but a lot of people are becoming infected, including people who have been previously vaccinated. And so when you add up all of the vaccines, plus the natural infections, it’s starting to feel like we’re building a base of immunity in the population, such that future occurrence of viruses are going to have a harder time causing big surges. That’s one possible scenario. But the asterisk here is whether a new variant will emerge that changes the game. Now many people think that we will—I mean, I think we should expect to see new variants. But whether we will see new variants that are more severe and as transmissible, I think there’s an open scientific question. And there’s some possible reason to believe that there are certain limitations on how severe a virus can be, and how immune it is, just given the amount of immunity that we’ve seen. We have different parts of our immune system that kick into place. And when people have had prior infection or if they’ve been vaccinated, they come to the fight against the virus with advantages that the totally unprotected population in 2020 didn’t have. So I think that’s what he was trying to describe. Was this thing is moving really fast. It’s moving around the planet. It’s really hard to dodge. And when it’s—you know, as it makes its way around, it’s building a base of immunity that will make it harder for other forms of the virus to cause huge disruptive surges in quite the same way, we hope. But, you know, never—(laughs)—get too cocky with this virus, because it seems to be hellbent on trying to prove us wrong. ROBBINS: Well, that was—that’s great. I mean, I read all the stories, didn’t understand it yesterday. And I think I understand—like, I think I understand it a bit better now. Although, I must say that, you know, I immediately looked up the Greek alphabet and looked at all the letters to come, and wondered to myself, you know, why couldn’t there be something even scarier? And you’re suggesting that there is some potential scientific limitation here, and that the—and that we are developing this response. Because I think all of us have seen all those really scary Stephen King things on television that would suggest that we shouldn’t get too cocky about it. But you seem a little bit more confident. NUZZO: Well, I don’t know if I want to say I’m confident. I just think that it’s—we can’t discount the tremendous amount of suffering that has led us to this point, unfortunately. And it is possible that we go into the future having protection, and absolutely possible that we can do more to improve our protection by increasing the amount of vaccination. I mean, one of the things is, if you want to take that scary, scientific sci-fi scenario off the table, the way that we do that is make sure that the globe has vaccines and that we reduce the circulation of this virus, and we reduce the likelihood that variants will emerge. That’s another thing that’s absolutely within our reach. It takes political will, but it’s absolutely within our reach. And, you know, that’s how—if you want to, like, write the ending to the story, that is how you do it. ROBBINS: All right. Thank you. So, Shalina, so I was just sort of thinking. I mean, I have the luxury right now of being more of a reader than a writer, at least on, you know, running stories. I get to pick and choose what I write about now. And I would think that the biggest, you know, challenge is covering a story that’s been going on for such a long time, even though it’s changing. And as we’ve heard from Jennifer, it’s really changing right now. So what do the readers you speak to ask you? What are they—what are they asking you that they want to know about this virus right now? CHATLANI: I definitely think it’s true that I, as a reporter, and many of my colleagues have a little bit of COVID fatigue—(laughs)—when it comes to covering this topic. But I think that, and this is true of public media especially, where, you know, when it comes to service journalism, media that is free and available to the public, the goal first and foremost is to inform people about what’s going on. And so I would imagine that my listeners, my readers want to, you know, have stories that tell them what is Omicron, what is this variant, how transmissible is it, how will it impact me if I’m vaccinated, if I have a booster, if I’m not vaccinated? You know, what does it mean if I’ve already been infected. Could I get infected again? And I think, you know, from science journalism there, you know, there needs to be an emphasis on the fact that science is really hard to understand. And this variant and COVID has been a difficult topic for a lot of people to wrap their heads around. And so I think whenever I approach stories around every new variant, the first thing that I want to do is just inform people about what’s going on and how it might impact them and their families. So that, I think, is the main thing that readers want to hear. And from there, you can kind of go out and expand on the reporting and getting a little bit more niche, and go to, you know, specific communities and see how they’re dealing with it, or look at specific topics like how is this impacting hospitalizations or, you know, certain supply chains? But absolutely, the first thing is explaining the science and what this thing even is. ROBBINS: So this is, you know, fundamental news you can use. Which people love news you can use. That said, it’s also science. And people tend to get scared by science quite often. So when you go out and you—and we were talking before we started and I asked you whether you actually left the house to report. And you actually do leave the house to report, which is a wondrous thing. So you have the great joy of talking to real people in person. And you’re in the South. So do people, A, welcome you to talk about Omicron, or more generally about COVID? And do they ask you questions, I mean, about it? You know, we tend to—particularly those of us in the elite northeast—tend to sort of think that everybody’s in utter denial in the South about this. You know, what’s the interaction like, and how do you do your job explaining and, you know, what feedback and questions are you getting from them. CHATLANI: The South is a little bit of an interesting region, for sure. And I think I can say that because I grew up here. (Laughs.) So there’s a lot of different communities here that, I’ve discovered, have varied opinions about what coronavirus is, what the vaccines are, whether they’re effective. And I think the first thing I do whenever I’m talking to anyone is to just come at them with a sense of compassion and, you know, like we talked about. Science is hard. And it’s really difficult to engage with science journalism if you’re not really used to listening to the news that often or reading the news that often. And so whenever I’m asking people about whether they want to get the vaccine, or whether they believe in coronavirus, or how it’s impacted them, I try to just talk to them like they’re normal people and like I’m a friend or, you know, someone who is just wanting to have a simple conversation with them. It’s not a sort of, like, coming at you, give me information, I want you to be, like, this character in my story. It’s more of a tell me what’s been going on. Coronavirus has been with us for a long time. Has it been difficult for your family? Has it been difficult for you to stick with your job? What types of challenges have you faced? And then we can get into those questions of, so, how do you feel about the vaccine? And once you kind of bridge that human divide there, you know, and talk to people, like they, you know, do know something about what’s going on, I think it yields better responses from people. And that’s especially true in the South, where there is a history of skepticism, as we have seen coming out, and resulting in the hesitancy around the vaccine. There is a little bit of, you know, lack of trust in government and media institutions. And so I don’t want to come in like the person who’s trying to make a characterization out of anyone, because that’s absolutely not the goal and should never be the goal. It’s more about just approaching people as who they are and asking them where they are in their lives when it comes to the pandemic and the possibility of getting vaccination. ROBBINS: So I have some reporting advice questions to ask Jennifer, but I did want to ask you one very quick question. Do you wear a mask when you interview people? CHATLANI: I do. Yes. ROBBINS: Are they wearing masks? CHATLANI: Sometimes no. Obviously, that creates—has created some safety challenges and some concerns. But I was very quick to get my vaccine. And as I got my vaccines, I did feel more safe going out to some rural communities in the South that do have low vaccination rates. But I think that it is something that a lot of health care journalists have been thinking about, especially the ones that do go out and do reporting about what type of, you know, situations that they’re putting themselves in. And you just always have to make sure you take safety precautions. I double mask whenever I go into under-vaccinated communities, or if I’m going into a hospital setting. I make sure I have hand sanitizer, or that, you know, I have whatever precautions I need to stay safe. ROBBINS: And people talk to you, even though you’re masked? They don’t find—they don’t just—I find that, you know, wearing masks in certain circumstances, I feel like people are looking at me askance. Even when I just go in and I’m not even interviewing them. CHATLANI: In the South it’s—you know, some—I might walk up to someone and be wearing a mask and they might think that I’m silly, but there is an emphasis on individual freedom. And I come at people with, you know, my—you know, I’m wearing a mask because that’s what I want to do. I see you’re not wearing a mask. Interesting, tell me about that. It’s not, like, supposed to be accusatory. And so it builds a little bit more of a relationship with the other person that you’re talking to. ROBBINS: So, Jennifer, I sometimes—a question that plays off of this: In past pandemics, is this level of politicization on just basic sort of health hygiene, you know, mask wearing, getting shots—is this sort of a normal thing? And how much of this is an artifact of our current political situation? And how much of this do we just blame on the previous administration and people who want to be, you know, Trump mini-mes? NUZZO: Yeah. So I’m not a historian. I have sights on past epidemics, but real—and pandemics—but really other than the—you know, we’ve been fortunate that the ones in the—to the most part—that have been in recent history have been much more mild than what we’re currently dealing with. And flu was a different virus. You know, I think we can’t forget the fact that this for many people was a virus that they’d never really heard of. Even if you’d kind of heard of SARS in 2003, that was something for most people that happened over there. And so that element actually plays a lot into the reaction to it. When it’s a known virus that you’ve heard of before, that you’re used to people getting, plus, you know, all the experts know a lot about it, that’s just completely different. So I think one element is this was a new virus for many people. It was more severe. But in terms of the political response, I mean, there was just so much about how this played out that for me was absolutely predictable. Just give—I mean, we’ve done—I’ve done tons of, like, tabletop exercises with leaders. There are just some habits that you have to anticipate. Like, as soon as something happens, a political leader—particularly one who’s inexperienced—is going to try to shut down the border. And that will be the totality of the response. It almost never works to stop the virus from coming. And then suddenly they realize that. And then they’re scrambling. Like, there are just some things that you can absolutely predict. I think it is not uncommon for political leaders to try to make a political situation out of a crisis, particularly when they’re in charge and it’s not going well, or if they’re not in charge and they’re trying to make it look more to their advantage. I think we absolutely have to expect that that could happen. I really hope that as a society, as a democracy in particular, that we will elect leaders who just draw the line somewhere. You know, at some level of human suffering where it’s not worth their political careers. I really think that we have to, as a society, have a reckoning about that. But I will tell you, one thing that, to me, feels incredibly different this time around than I have seen in any past event is the degree to which disinformation is dominating our conversation. And it’s clearly some are willingly misusing the information for political gain. But there are just reasonable people who are trying to do their own research and just cannot find facts, based on the fact that our information environment favors the spread of lies. You know, the search algorithms and the social media platforms make it impossible sometimes to see the truth, and much, much easier to see the lies. And so I have seen—you know, I mean, I have talked to all sorts of people from top leaders to QAnon believers. And let me tell you, there’s some similarities in what people believe. And some of it is because it’s coming from the same sources that are being propelled forward by social media and the search engines. And so I had a very senior person in a D.C. circle ask me as question that, you know, a reasonable, like, minute of research would have debunked. But this person either didn’t know to do that, which I find hard to believe, or tried to do it and was unable to turn up the correct information. So when I see people who, frankly, have the resources and sort of should know better not know better, that just makes me think that it’s really impossible for people to navigate the information environment. And that is basically like gasoline to these political infernos that people are setting. ROBBINS: So, you know, we reporters obviously are trained to get information, to get information fast. But not everybody who covers this is a trained science reporter. You know, not every newsroom has the resources to have specified science reporters. There’s a lot of general assignment reporters that have to cover these things. So if you have something like yesterday, and you have the WHO making a statement like that—which drew a lot of attention, because there was this sort of light at the end of the tunnel reaction—so, Jennifer, where would you recommend people go to find the best interpretation of, you know, statements like that? There’s also just an enormous amount of, you know, because our knowledge of these things changes all the time, and, you know, the CDC says this about masks, and then they say this about whether kids should stay home or not stay home, there’s constant, you know, issues that are changing all the time, which feeds into a lot of political anxiety as well as personal anxiety. What do you think are the—you know, the five best places to go to get information if you’re on a deadline? NUZZO: Yeah. So, first of all, I mean, it seems abundantly clear to me that social media is driving news making, both in terms of discovering things that are potentially newsworthy—I think there’s probably no avoiding that. But it also seems to be driving who is commenting on the news. And that’s not necessarily bad. I think it’s a way to identify a diversity of voices and to kind of get more of a collective impression. But proceed with caution, because there are people out there that are just using that to gain fame, frankly. Or, you know, sometimes the loudest voices are the ones, frankly, with the least to say. And the other thing that I deeply lament is that there are some incredibly experienced people who have been through many events—many, many events, who just aren’t active on social media. Sometimes they’re older and it’s just, like, that’s not their thing. Or they just are busy. And I have noticed that they’re often not quoted in papers. And I—you know, and news articles. And it’s possible that they’re not making themselves available, but I think more likely they’re just not being discovered by people who don’t know the beat. So, you know, I think one of the things is to evaluate not just, like, what is this person’s degree in, but do they have actual experience? Like, what is their experience in handling these issues? You know, and I have to say, as an outsider—and, you know, this will sound like a criticism of the industry—but I do really think that there is something lost when there are not subject matter reporters. And I know there may have been a trend earlier to kind of, you know, spin off science sections or reduce science sections. But, like, the biggest challenges society is going to face in the next century are going to be incredibly scientific and technical. And I think it’s really shortsighted, from a business perspective, to not have the right journalists on staff who can interpret that thoughtfully, and then, you know, answer the question better of who really should be a source on this topic. ROBBINS: I don’t think there’s anyone on this call who would disagree with you. But I think there are, you know, probably a few people on this call who, you know, have to pray every morning that their news organizations are going to still be there by the evening, given the— NUZZO: Well, let the rest of us be an advocate. You know, I mean, honestly. It’s—society will be better served with more of you all doing your jobs. ROBBINS: So we have a question from June Leffler. Ms. Leffler, do you want to ask your question, and can you identify yourself for everyone? Q: Hello. My name is June Leffler. I’m the health reporter at West Virginia Public Broadcasting. And I’ll just read what I wrote: So how should we go about reporting on crisis levels at hospitals? So this is a—“crisis level” is a term that I hear from our state health officer and, you know, our West Virginia Hospital Association. But I don’t know really—you know, just talking to those people, I still don’t have a deep sense of how I can illustrate what exactly that means for our listeners. And that’s definitely in part because, you know, I haven’t been in these hospitals before. And so I’m wondering, you know, how can we go about, you know, reporting on hospitals and what they’re facing during this pandemic? And which questions should we be asking them? What data should we be asking them for, knowing that these are private institutions, in my state. And, you know, they want to keep up the veil that they’re doing the absolute best they can. NUZZO: I can weigh in on that. I don’t know who it was directed towards. Yeah, this is a really important area of inquiry, and one, I think, that’s hard to do. I have a few suggestions of storylines that I would like to see explored. One is that it’s—I do not doubt that hospitals are absolutely stressed and operating at the max. It’s really interesting when you look at the hospitalization data over the course of the pandemic how flat the totals have been, but the categories shift. Which really speaks to there’s this upper, fixed capacity that has existed for the past two years, and in some cases has actually ratcheted down because they have lost staff. And when we’re talking about hospital capacity, what we’re really talking about is are there enough staff to take care of patients. And so they’ve lost staff. And that’s been discussed widely. But what are they doing to fix it? Like, what are we as a country doing to, like, raise the line? We talk about flattening the curve because we’re trying to—we’re trying to flatten the curve below the upper—the line, which is the upper limit of the health care system. But, you know, this, like, lean, just-in-time staffing approach to health care is clearly not working in this situation, and frankly doesn’t work in many situations. I mean, we talk about past pandemics, but the 2017 flu season was a killer. I mean, hospitals, if you spoke to them, if somebody actually showed up and talked to them in 2017, they would have found that they were really at the brink, from not a pandemic just a really bad flu season. So I think there’s a storyline which is just, you know, what are the drivers of this? I think some of it are about the business models of these places. I think some of it are about staffing limitations. Some of it may be in terms of limitations of what—who we can bring in to help work in these settings. That’s one area where I’d like to see. The other thing is talking to patients and finding out what they’ve not been able to get done because of the crunches. So, you know, the people who have not been able to get—to see a specialist because they’re putting certain procedures on hold. You know, hearing from people who are not necessarily needing to access the health system for COVID, but for other—just the other stuff that’s not getting done because we’ve had to kind of pivot the whole system. I think hearing about what is not happening from the perspective of patients is really key, because I think there it’s really more revealing when you hear about it. I had a friend whose family member was in the hospital and really needed to be transferred to somewhere that could give adequate care, but there were just no transfers happening. Not for COVID, but there was just capacity issues. So how has the provision of regular care degraded because of the crisis situation we’re in? To me, that’s more revealing than what the numbers say, because the numbers to some extent are—there’s some artificial constraints on them. But how we fix them and how—and what is the consequence of those numbers I think are the stories that are quite important. ROBBINS: Shalina, you’ve done quite a lot of reporting on this I know, about nursing shortages and all of that. So what stories have you been reporting? And have you been able to pry, you know, certainly what Jennifer was saying is absolutely essential. But I suspect, you know, we love numbers. We love data as well. CHATLANI: Yeah, I do have a few suggestions for June. I think that the first thing I would do, when I’m thinking about whether hospitals are going through a crisis, is to figure out what the state defines as crisis standards of care. So that’s a term that gets thrown out a lot when health departments are talking about hospitals being overcapacity. So what does that actually mean, from the state’s definition? So does that mean that there are more patients than there are beds? Does that mean there are not enough staff for every bed? Does that mean that they have to ask, you know, emergency management agencies to ask for certain types of help? Do they have to seek help from the federal government for something? And then I would go to the state hospital association and ask them if they have heard any reports of any particular hospitals that have faced these particular, you know, crisis standards of care. And then I would go to that hospital that they identify and ask them what’s going on. So, you know, in addition to that, some things that I do to figure out what the state of care is in a state is to go to the CDC. Because the CDC actually releases data every day on what percentage of hospitals don’t have enough staff to meet care. They also have numbers on transmission levels. It’s really, really, really detailed. And it gives you a really good picture of what level of hospitalizations are at in the state, whether there’s enough staff. And then, again, I would take that data and go to the hospital association and say: This is what the CDC says. Is this what’s actually happening? To an extent, I agree that, you know, private hospitals might be wanting to save face and say, you know, everything is fine. But on the other hand, I’ve noticed that hospitals, they’re also trying to be really transparent, right, because they can’t do the best job that they could possibly do caring for patients that are there if they’re overcapacity. They’ll have to care for patients in hallways. You know, I’ve heard of that happening in a lot of rural hospitals that are overcapacity. They will have people waiting in emergency rooms that they can’t see. They absolutely don’t want this to be happening because it is—it just puts unnecessary pressure on the staff and the hospital, right? So I think that there’s definitely a healthy level of skepticism. But for a lot of hospitals that are operating at really low, you know, budgets that are dealing with this crisis, they’re just trying to get by. So I would go and check out those data sources. Look at definitions. Go to the health department. Go to the hospital association and ask them: Where is this crisis standard of care erupting in the state? And go there and go to those communities. Go to the hospital. Talk to the leaders. Go, you know, talk to people in that community and ask them, like, have you had a situation where you need to go to the hospital? Have you been able to go? Did you have to wait? I think there’s definitely a way to approach that. And that is definitely, to your question, Carla, what I’ve been trying to do with the nursing—the staffing crisis stories, is—basically, those were all the steps I took. I looked at the CDC data, figured out what the situation was. I went to the hospital association. I’ve asked, you know, are there any hospitals that are on the edge right now, that are closing beds, you know, because they don’t have staff. And that’s how I’ve been able to find hospitals. And a lot of them have been very honest about the situation because they don’t want it to be the situation. They have lots of patients that they need to see. And a lot of people in health care are burnt out and sad that they can’t, you know, treat some patients as well as they would like to, because they are so overburdened. And I think you should play into that fact. You know, creating a villain, I think, out of some staff is just not going to get you what you want. And approaching them from a standpoint of, like, hey, I know this is a crazy situation. Tell me about—a story where you had to make a snap decision because there’s a patient that is on a ventilator and, you know, could die. Do you care for them, or do you care for the person who just came into the emergency room? Like, asking them about those situations can really yield a lot of results. ROBBINS: So we also had Alexandra, is it Pare or Pere, from Tucson Local Media had her hand up. Alexandra, can you share your question? Q: Hey, can you guys hear me? ROBBINS: Absolutely. Q: Hi. My name is Alexandra Pere from Tucson Local Media here in Tucson, Arizona. I just wanted to know, you know, I’m really interested in how to properly communicate and explain how vaccines help to stop mutations of the virus? I haven’t really gotten a good explanation on that, and I would just love to hear your perspectives on how to explain that to the community. NUZZO: So, you know, I think it’s really more of a simple math, which is every time the virus replicates there’s the opportunity that it’s going to copy itself incorrectly. And because of that, that’s one reason why mutations tend to occur in people who—not exclusively, by any means—but people who are immunocompromised, because they often have the virus in them for longer, so there’s just more copies being made over a longer period of time. But the way you see that at the population level is the fewer people who have the virus, the fewer viruses that are copying themselves, and the fewer opportunities for mutations to occur. Also, when mutations occur, they may not have any functional ability on their own, but over time they may gain them. And so that the more you pass that virus onto others, the more opportunities for it to, you know, try to perfect—(laughs)—the mutation. So generally speaking, the fewer copies of the virus there are on the planet, the less—the lower the likelihood that mutations will occur. ROBBINS: So that actually raises this question—I’m sorry, Alexandra, did that answer your question or do you have a follow on? Q: No, I think that did answer. I think I just hear a lot of pushback from people who are like, oh, why don’t I just, you know, end up getting Omicron, and then I’ll have natural immunity, as opposed to getting the vaccine. And so I just wanted to clear away to kind of explain how the vaccine halt the mutations. NUZZO: Can I just chime in on that, because I think those are two separate issues. Because really I think we have to think about the vaccines, above all, as protecting you against severe illness. We certainly do see fewer cases reported among people who have been vaccinated, but clearly people who are vaccinated get this virus, including—you know, and we are seeing people who are multiply infected with the virus naturally, including people who have been vaccinated. So my answer to that is less about the variants, and more about, listen, Omicron has some features that may make it less likely to make you severely ill, but part of why we’re seeing less of an impact in terms of severe illness is because we have prior immunity in the population both from natural infection and from vaccination. So people are going into that first contact with Omicron with armor—(laughs)—you know? Their immune systems are ready to fight. And we have certainly seen people who have not had previous immunity through vaccination or prior infection, who have gotten Omicron and died. So the answer to why you want to get vaccinated is because you want—you don’t know where you’re going to be on that curve of people. Sure, most people who get infected don’t die, but you don’t know on an individual where you’re—if you’re going to be the rare case or if you’re going to be the average case. So the vaccines are the insurance that really buy down your risk in terms of having severe illness. ROBBINS: Can we talk about—I’m sorry. Yes, Shalina? CHATLANI: Well, just to add to that, Alexandra, I think as a reporter one thing to really equip yourself with is a set of really simple metaphors. Like, if you were to write down a twenty-second explainer for why the vaccines are important, and just keep that with you, because you’re going to be engaging with people that don’t think about, don’t read about, don’t know about science. And the vaccines are unlike other ones. I mean, the technology has existed for a really long time, but most of the time when people think about vaccines, right, they think, oh, you’re getting a little bit of the virus so then your body learns how to fight it off, and so you build up this immunity. These vaccines are different from that, the first ones that came out. So it’s really difficult to explain it to people. And then once they get another variant, they wonder what happened. You told me this was going to give me protection. So, you know, maybe, Jennifer, you have an idea for what those metaphors could be, but I think really sitting down for a second and thinking: What is the simplest way I could possibly explain this to someone, can be really useful to you. And I guess one way that I think about it is the vaccine is like a code in your body that tells you to fight off the virus when it—when it gets to you. Like, there’s a code there. And sometimes that code has to be tweaked, and you get a booster shot. So, I don’t know, that’s one way I think about it. What do you think, Jennifer? NUZZO: Yeah. I mean, you know, I try to stress to people that they’re not bug zappers. (Laughs.) Like, the vaccine doesn’t repel the virus from your body. (Laughter.) It is a set of instructions for how to defeat the enemy. And your—it trains your immune system for the fight. And I say that because some people are, like, but I eat a plant-based diet. I’m healthy. And you’re like, that is great. I’m glad you’re doing that. But that’s necessary, but not sufficient, because, you know, you could be a generally healthy, fit person. But if you showed up to run an ultramarathon never having trained for the race, you’re probably not going to do very well. So vaccines really train your body specifically for the fight, and so that you have a better chance of defeating the virus when you meet it for the first time. And you’re right, it’s not the same as natural infection, which has strengths and weaknesses, truthfully. And part of the reason that it’s not the same is that your body never sees the virus until you get infected. It just sees a piece of it. And it’s the piece that the virus uses to hook onto your cells and to enter into your cells. So, you know, there is now some evidence that people who had prior vaccination who then got reinfected probably together have better immunity than each of those separately. ROBBINS: Do we have another raised hand? Liz from New Jersey Advanced Media. Liz, is it, Llorente? Q: Yes. Yes, Llorente. Can you hear me? ROBBINS: Perfecto, si. Q: Oh, muy bien, muy bien. OK. (Laughs.) Thank you, Carla, for knowing how to pronounce my last name. (Laughter.) OK, Jennifer, question: Just, you know, I’ve been writing about—like we all have, I guess—about the pandemic. And of course, you know, one of the issues that I find is that, especially in New York and New Jersey, we have a lot of restaurants, a lot of businesses saying, you know, get a vaccine for yourself and for—and to protect others. But does my getting a vaccine protect other people? I mean? NUZZO: Yes, it does. I think not as much as we had hoped. (Laughs.) And when—I think when we were probably in the blissful period of sort of the end of June/July, I think we had a belief that breakthrough infections—which I actually hate that term, because I think it was setting the vaccine up for an impossible standard that vaccines can’t possibly meet. But I think we thought that if you were vaccinated the likelihood that you would experience symptomatic illness after becoming infected was much lower than it has turned out to be. But it is clearly lower. And one way that it does help is that if you do become infected—and some portion of people are going to become infected and literally never know it—that the time period in which you can transmit is actually probably shorter. So if you’re walking around and you don’t know it, the period of time in which you’re exposing people potentially in a dangerous way is shorter if you’re infected. And if you think—like, if we all did that, that would add up to a much higher level of protection in the community than we would have if people weren’t doing that. But I really think—I mean, I continue to stress for people that, yes, do it for others. And, you know, there’s some evidence that maybe it helps a little bit in your household. But really, do it for yourself. I mean, it is, again, arming yourself against the worst possible outcomes. It’s the free insurance against the worst possible outcomes from this virus. ROBBINS: So thank you for that. John Allison, who’s the director of content for the Tribune-Review, has a comment in the Q&A, and who notes that we may not have subject-matter experts in our newsrooms but we do have many in our communities, such as the Johns Hopkins Center for Health Security Fellow Dr. Amesh, is it, Adalja? NUZZO: Amesh. Amesh Adalja. Yeah, he’s a colleague of mine, yeah. ROBBINS: OK. Great. And we routinely ask him five questions and present as text and video. And he’s got a link. This is a really interesting feature that you guys have set up. John, do you want to talk about it? Is John still with us? Maybe not. Q: I’m unmuted. ROBBINS: Oh, perfect. You want to talk about how you guys set up that feature? That sounds like a great idea. Q: Yes. He is—Amesh is very media friendly. And he’s—I’m in Pittsburgh. He lives in Pittsburgh, and he’s associated with the Baltimore Institution. NUZZO: Yeah. We work together. (Laughs.) Q: Yeah, exactly. NUZZO: And we’re friends, yeah. Q: Yes. Yes. And that’s good. I didn’t want to step into some rivalry, so I’m glad you’re friends. NUZZO: No, not at all. No. (Laughter.) I ask him questions all the time, yeah. Q: Great. For us, this has been a perfect way to present it succinctly. Five questions is a nice round figure. We do it a lot. We’ve established him as an expert. And we’ve followed others, we have a couple of big health care centers in the Pittsburgh area. And we pull them in. We are not going to be able to hire a medical doctor on our staff. I’ve worked at other newspapers that have. So, Carla, thank you for—you know, but we are stable financially, but just by being the size that we are we couldn’t maintain that. So thank you to Amesh. Thank you to you, Dr. Nuzzo, for speaking clearly. Your work on Twitter is very important. It leads us to experts who can speak and thank you. NUZZO: Thank you. Yeah, Amesh is wonderful. He is a rare person because he has expertise in multiple medical fields—critical care, infectious diseases, and emergency medicine, which is basically a unicorn. So you’re lucky to get him. But he just loves—he’s an educator, and loves sharing what he knows. So if we could clone him, it would be good for the country. ROBBINS: Shalina, do you have any unicorns of your own you want to share with us? CHATLANI: In terms of sources? Well, there’s a lot of sources that I go to in the South when it comes to specifically equity issues in science. There’s Dr. Thomas LaVeist at Tulane University, who works in public health policy but also has a background in understanding health in diverse communities. And so he’s a source I go to pretty often because you can’t really talk about health equity in the South without talking about socioeconomic and racial divides. And so I try to incorporate that into a lot of my reporting, and find subject-matter experts like him that sort of, like, know about health but also know about community issues. ROBBINS: So that’s another unicorn. That’s great. Love unicorns. Catherine Marfin—Catherine, do you want to ask your question and tell us with whom you work? I’m sorry, I don’t have the list right in front of me. Q: Hi. Can you all hear me? ROBBINS: Yep. Q: OK. Sorry. I’m in Starbucks. It might be a little loud. My name’s Catherine Marfin. I’m with the Dallas Morning News in Texas. I was just wondering, Jennifer, if you could elaborate a little bit on why you take issue with—or, I guess, kind of have a problem with the term “breakthrough infections.” And I guess is that possible—is that, like, are “breakthrough,” quote/unquote, infections possible with other vaccines? NUZZO: Yeah. So, again, you know, if you think about how—what vaccines do, they train your immune system to recognize the virus and then to react quickly, hopefully before you have any symptomatic disease but certainly before, you know, too many of your cells become infected from—by the virus. But again, they’re not forcefields. Like, they don’t repel the virus from your body. And so how does your body know that the—that the virus is there? Usually, it’s when the virus invades your cells, which is the technical definition of infection. Now, it may be possible if we had a different kind of vaccine for this virus, maybe, like, an internasal vaccine, that there would be more immunity at the site. But it’s still even unclear—I think we’re sort of rethinking, like, what vaccines actually do, and whether this idea of preventing infection is even that feasible. Part of what we’re seeing too is that we are aided by a level of diagnosis and testing that we don’t see for other diseases. And if we had—you know, often hold up the measles vaccine as, like, the standard of the best vaccine. But if we had a lot of measles circulating, and if we did a lot of testing, would we see a lot more breakthrough infections that we just don’t notice because the symptoms are so mild? So that’s why I just don’t like that term, because it implies that the vaccine filed, when in fact maybe it—I’m not sure failure is actually right. I think the vaccines are doing what we need them to do. I think people would love to feel less lousy when they get infected, but I view any infection that doesn’t send somebody to the hospital as success, because if this virus could never put people in the hospital or kill them, most people would have never heard of it. And I think losing sight of that is, one, fueling a level of anxiety that I think is just unhelpful, but also underselling the vaccines and how incredibly powerful they are in gaining freedoms for us, and removing worries, at cetera. Obviously, there are people who still we worry about, for sure. And I don’t want to downplay the risks that they experience. But they’re not risks that we don’t see for other viruses as well. And so that’s where we need other tools to try to protect people. ROBBINS: Jennifer has a Ted Talk, and we’ll share the link with that, which I recommend. I do do my homework for these things. But there’s a very interesting question here. We have unreasonable expectations, I think, of people who are in the world of medicine. You know, you go to a lawyer and ask her a question and she says: Come back in a week and I’ll give you the answer. And no one says: Oh my God, you’re not prepared for this! You go to someone in the medical world, you expect them to give you a definitive answer, and the answer to stay, right? And so the fact that this has been a moving target, and that we’re getting different answers over time has not only created anxiety among people, it’s reinforced the skepticism that Shalina was talking about. And it’s certainly played into the more general anti-government feeling that exists out there. And, you know, this raises a really interesting question about looking forward about communications strategy. You know, we, as recipients of communications strategies, as reporters, I think also have the responsibility. And we’ve been dealing with questions of the big lie, you know, have truth sandwiches, and all these other things. How do we do this? What sort of caveating do we need to do when we’re told something that sounds definitive—like, masks, you know, do this, or vaccines do that, and knowing how many times it’s turned out, you know, as great as Fauci may be, he may have to change his mind or change the message three months down the road. Should we, as reporters, be presenting things that sound definitive with more caveats, but without, at the same time, running the risk of undermining the important message? That’s for Jennifer, but I’m sure Shalina’s thought about it too. NUZZO: Yeah. I mean, it’s tough because you’re either faced with not answering because you just don’t know definitively, or answering and saying, listen, this is my best guess based on—this is why I think this. I tend to fall in that camp, because particularly—I mean, the most frequent questions I get asked from people that I encounter are just, like, how to live life, right? And so people need to have an answer to that question, because they can’t not live life for the next six months while we gather data. So I fall on the camp of saying, listen, this is why I think this. This is possibly what would make me change my mind. So in the future I’m going to be looking at this. And if this changes, then I’m going to do this. Like, I try to describe the scenarios. But I think where officials have erred has been on not setting up—not describing the process that they have come to that conclusion, and then describing what is currently not known that could lead them to change their minds. And that when they do change their minds, describing very clearly what evidence was used to make that change. Because sometimes I think we are just getting these very clipped, summarized statements that are doing a disservice because they are not being accompanied by the supporting material. And I think that sometimes that’s done for the purposes of message clarity, but I’m not sure that’s what it’s achieving. ROBBINS: Shalina, how do you think about this? I mean, you must have covered many things that sounded definitive and then you had to change them, without writing a correction, three months down the road. CHATLANI: Yeah, it was definitely—in terms of what to trust when it comes to the science, that was definitely hard when I was a hard science reporter in San Diego at KPBS, because this was something that we had never dealt with. And, you know, talking to different scientists and getting news alerts, getting press releases, it was really hard to wade through what is news? What do I report on? What do I tell people is something new? One example I think about, as I was covering, you know, the search for the vaccine, because San Diego has a lot of research institutions. So I would be getting a lot of press releases about it. You know, every other day I’d hear about an institution that found an antibody. And they were, you know, an antibody, which is something that the body produces to fight off the virus, right. So they could isolate an antibody and use that to create a vaccine, or think of a different therapy. And everyone was looking for antibodies. So it’s, like, do you—do you report that a research institution just found another one? Or do you just go to—you know, or do you just let it go, because then you’re giving people false hope? So it was really hard. And the way I kind of dealt with that is I had some key scientists that were kind of straight shooters, that, like, would tell it to me straight. And I would go to them. And I would say, hey, this person just told me that this thing happened. What’s your opinion? And a lot of times the scientists that I had developed this relationship with—that I honestly think had no skin in the game when it came to whether their vaccine was the one that was going to be—you know, the one that got picked, or anything like that—would say, eh, that’s just another antibody. We don’t have a vaccine yet, you know? And that would help me. So I had, like, a lot of trusted people that I would go to. When it comes to things like masking, whether the vaccines are safe, I think pretty generally we know at this point that masking helps give you protection. Like, that’s the—that’s the (net grab ?) on masking. Vaccines help build your immunity. And those are really the only two facts I think you need to know when it comes to reporting on those two issues at this point. And those are the only things that are really going to be in people’s brains when it comes to how it impacts their day-to-day lives. And I think the reporting has to shift to real-world impacts for masking and vaccination. For example, here in New Orleans, we have carnival season coming up. There’s Marti Gras. Marti Gras last year wasn’t that great, because a lot of people, you know, were scared to go out and, you know, get infected. Of course, that did happen. And we had a huge surge in cases. But I think a lot of people at this point just want their kids to be back in school. They want to be able to go to their jobs. They want to be able to have Thanksgiving and Christmas with their families. And the messaging should be masking helps protect you so that you can do these things that you want to do. Vaccines help protect you so that you can do these things that you want to do and you can get back to your normal day-to-day lives. So I think now it’s this. ROBBINS: So, just to follow on this—and we only have two minutes left—Vicky Diaz-Camacho from Kansas City PBS, can you ask the question in a minute, so we can give Jennifer one minute to respond? It follows on exactly what Shalina was saying. I think— Q: Yes, it does, actually. So I lead the Journalism Engagement Initiative at Kansas City PBS. And so I get a lot of public questions about vaccine efficacy and all of that stuff. And I think that I’m sensing a lot of fatigue from the message “vaccines are safe.” So I see that there are less people going out to get their boosters. And so I’m hoping you can explain, how do you get the clear message across about societal responsibility and the need to still get boosted? NUZZO: Yeah. I’m not sure that that’s the best message for everybody, I’ll just say honestly. I mean, I think people when they’re making a medical decision are largely making it for themselves and their loved ones. I think there are some people that that broader, like, protect a grandma that you don’t know, like, resonates with them. But I would tell you, by and large, like, when I talk to parents who are wondering about getting their kids vaccinated, I talk about how it’s going to take some worries off their plate. You know, so I’m not sure the message is do it for somebody you’ve never met. It’s, listen, we’re all going to come in contact with this virus. And if you have the third dose, you’re less likely to—you know, you may be sick for four days instead of two weeks. I mean, I just—I think that message is more compelling for a lot of people. ROBBINS: Well, I just want to thank Shalina for sharing all your—including your sources, which is—which is—(laughs)—usually we don’t do that. And Jennifer, for extraordinary insights. And we will, you know, push some information out to you guys, including the link to Jennifer’s Ted Talk, and links to some stories that Shalina has written. And I turn it back to Irina. And this has been a great conversation and great questions from you all. FASKIANOS: It has. Just to echo what Carla said, thank you all. And we will be sending out a follow-up email with a link to this webinar so you can listen to it and share it with your colleagues who could not join us today. And I just want to point out, you can follow Jennifer Nuzzo on Twitter at @jennifernuzzo. Some of you already are, but if you aren’t, follow her there. Shalina at @chatlanis, and Carla at @robbinscarla. So go to Twitter to follow their sources. And please visit CFR.org, ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on coronavirus and international trends, and how they are affecting the United States. And as always, we look to you to share suggestions for—suggestions on topics, speakers that you would like in future webinars. So please send an email to [email protected]. So thank you all and stay safe.
    Virtual Event by Shalina Chatlani, Jennifer Nuzzo and Irina A. Faskianos January 25, 2022 Local Journalists Webinars
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