Academic Webinar: Equitable Vaccine Distribution and Pandemic Preparedness

Wednesday, March 24, 2021

Assistant Clinical Professor of Emergency Medicine, Icahn School of Medicine, Mount Sinai; Fellow, Center for Health Security, Johns Hopkins University


Vice President, National Program and Outreach, Council on Foreign Relations

Sonya Stokes, assistant clinical professor of emergency medicine at Mount Sinai’s Icahn School of Medicine and fellow at Johns Hopkins University’s Center for Health Security, leads a conversation on equitable vaccine distribution and pandemic preparedness.

FASKIANOS: Welcome to the CFR Winter/Spring 2021 Academic Webinar Series. I'm Irina Faskianos, vice president of the National Program and Outreach at CFR. Today's meeting is on the record, and the video and transcript will be available on our website, CFR.org/academic. As always, CFR takes no institutional positions on matters of policy. We're delighted to have Dr. Sonya Stokes with us to talk about equitable vaccine distribution and pandemic preparedness. Dr. Stokes is an assistant clinical professor of emergency medicine at Mount Sinai’s Icahn School of Medicine. She's also a fellow at Johns Hopkins University's Center for Health Security. She specializes in health systems strengthening in low- and middle-income countries, and her research focuses on increasing access to trauma and acute care in resource-limited settings. During the initial outbreak of COVID-19 in New York City, she was part of the frontline response treating patients in the emergency department. In addition to her clinical work, she served on the Mount Sinai Health System Best Practices Committee for evaluating and managing COVID-19 patients and contributed to the COVID-19 mass casualty triage protocol. She's a term member at the Council on Foreign Relations and she contributed to the CFR-sponsored Independent Task Force report that was released and titled Improving Pandemic Preparedness: Lessons From COVID-19. We released that last fall. So Dr. Stokes, thanks very much for being with us. It would be great if you could talk about pandemic preparedness, what we've learned, and what you're seeing in terms of the vaccine rollout and how we can make it more equitable.

STOKES: Thank you so much, Irina. And I also have to say thank you to the Council on Foreign Relations, to Tom Bollyky, and to all the members of the Independent Task Force on preparing for the next pandemic. It was a wonderful learning experience for me, and I hope that we can share some of those lessons today. But before we begin, I would like us to first define our terms. What do we mean by equity, especially when we're talking about equity with respect to vaccines? Do we mean equity for the purpose of averting excess mortality or excess death? If so, how are we measuring this? I want us to begin by looking at some of the different metrics for mortality because what seems like common sense can quickly become more complex. I'm going to be looking at information from Johns Hopkins’s mortality analyses. So in their tracker, they look at the twenty countries most affected by COVID-19. And they report on a specific metric called case fatality ratio. Interestingly, that's called CFR. I will try not to use that term specifically so we don't get confused today, but that is looking at which countries are having the highest number of deaths per hundred confirmed cases.

We go to the tracker. What are the top five countries there? So that looks like, as of the last twenty-four hours, Mexico, Bulgaria, Peru, Hungary, and Italy. Okay, is there another way of measuring this? Yes, we can look at the overall deaths per one hundred thousand of the population. According to Johns Hopkins, those top-five countries are actually some of the same, including Hungary, Bulgaria, Italy. The United States makes the top five there. But then what are we talking about again? Are we talking about averting excess deaths? Well, that does not necessarily immediately correlate with the places that have the highest number of deaths. We also have to look at other metrics, like the overall burden of disease, the number of cases, right? When we start looking at that, the number of countries that make the top five start to shift. But maybe we also shouldn't be looking at just the number of cases total, maybe we need to be looking at which countries have rising numbers of cases, right? And then that starts to change as well. In fact, actually, if you look at the daily number of new confirmed cases, which countries are having a doubling of cases? The actual top five there is very different. For example, you have Papua New Guinea that's making the list there. Somalia makes the list there.

So again, when we start talking about the terminology of equity of averting excess mortality, we need to make sure we're being very specific on how we're measuring it because the real-world implications of this when we start talking about vaccine equity have some consequences to that. This is something that was talked about very early on in the Independent Task Force on preparing for the next pandemic. In fact, it was anticipated in the report, and I highly recommend that you look at some of the recommendations that were made specifically in the report. But these were the concerns for the reason of the formulation of the coalition that's looking specifically at global vaccine equity, or COVAX, and that includes an alliance between the WHO, CEPI, Gavi, amongst others. These are the people that are trying to make sure that we are addressing all of these metrics and making sure we're getting vaccines to the places that need it the most. And then when we look at those numbers we can see because there are comparisons that we need to make absolutely direct factual statements about. So, as of now, we have almost 460 million doses of vaccine that have been administered; 76 percent of this has been in the high-income countries. And then, of course, if we're looking at COVAX, what have they been able to do? Thirty-two million vaccines to fifty-seven countries that they have been able to distribute or actually, I apologize, they've been able to cover the cost for in terms of the actual logistics of how that happens. That even gets more complex than that. And again, these are actual conversations that we need to have, because the real-world implications actually translate to this issue of increased mortality of excess deaths. That is the purpose of what we're trying to avoid here. And so from here is where I want to make sure that we're opening up the discussion leading from this position. It is a discussion, guys. This is not me lecturing at you. We call this a question and answer, but I actually want to make sure this is a conversation. There are aspects about equitable vaccine distribution administration that I might not have the answers for but you may. And so I want to make sure that we keep the conversation going in that respect. And from here, Irina, I want to start things off and see if there are any questions I can answer right off the bat.

FASKIANOS: Great, thank you. For all of you, you can raise your hand. Click on the “raise hand” to ask your question or else you can type your question in the Q&A box. If you choose to write out your question, please identify the school that you're with so that we can identify you properly. And let me see. We have a first question from Babak Salimitari.

Q: Hi, Dr. Stokes. My name is Babak. I am a second-year econ student at UCI. I have a question. What we know about COVAX, which is trying to get vaccines into countries that are more, I'd say, are less developed than us, but one thing that we've also seen is vaccine diplomacy. We've seen how countries like China are using their supply chain in order to get vaccines into countries that don't have the means of getting them. And they're giving away vaccines like Halloween candy. My point is we don't really know what's in those vaccines, those Chinese vaccines, because they've never had peer-reviewed lab studies or actual scientific data behind them. How do we know that those vaccines are safe and aren't going to jeopardize the lives of the people that they give them to?

STOKES: Thank you so much for the question, Babak. You actually highlight several different points. I want to see if we can unpack each one of those and then actually answer your question. So you do bring up a good point about COVAX, about areas where we're still going to have disparities even in the advent of COVAX. For example, COVAX only plans to vaccinate 20 percent of the global population, right? So we're still going to see shortfalls, and then even within that 20 percent, they have a funding gap. There's approximately a $27 billion funding gap right now that WHO's framework for COVAX is trying to make sure that they address. If anyone is interested please look up the ACT Accelerator through WHO and then you can see some of the ways in which, from an economic standpoint, people are trying to make sure they address those shortfalls.

But then with the question about vaccine diplomacy, the converse of that is vaccine nationalism, right? We're seeing that everywhere. Part of this is actually, I think, that we want to bring up how China has been aggressively pursuing vaccine diplomacy, but that doesn't happen in a vacuum, right? They're able to do so because we are not offering what Tom Bollyky calls a compelling alternative, right? We are not engaging. So to a certain extent to answer some of these questions, I mean, we really do need to come back home and address our lack of engagement. And again, that's partly due to just overall, I mean, every country is going to want to vaccinate their own populations, of course, but then this issue of vaccine nationalism that, again, we need to be sure that we're doing our part to remain engaged to offer those compelling alternatives so that when we do then go to these conversations of your question, how do we know that, for example, Sinovac and the different vaccines that they're offering from China, what do we know in terms of what is the components in them? Are there any safety issues? There are multiple governing bodies, for example, that are analogous to what we have here in the U.S., the Food and Drug Administration, FDA. They have their own in China and the independent way that we would look at this is through peer review. I agree, we still need to go do peer-review processes. I would say that part of making sure that we do not engage in the misinformation or vaccine nationalism that is actually hurting us overall is to allow us to have those channels of peer review so that we can have very clear, very direct discussions that are about safety. Your concerns are valid. Those are concerns that we should have for all drug formulations. And again, the answer to that is not necessarily making it more about politics but making it more about the science.

FASKIANOS: Great, thank you. I'm going to take the written question from Elizabeth Alfreno, who's a student at Ohio University, "Seeing as though it is difficult to make the vaccine mandatory for everyone or not everyone is able to take it, how are we able to move forward in this pandemic to help bring it to a close? If not everybody universally is able to have equal access to the vaccine, does that counteract the progress we're making towards overcoming the pandemic?"

STOKES: Thank you so much for the question. And vaccine mandates is something that I found interesting, because it's been happening even before we had vaccines available, right, this discussion on how we actually operationalize distribution and administration of the vaccines. The reason that I don't think that we're anywhere close to having this be a real-world discussion is because, again, exactly how you point out, this coming back to it has to be not just available, but accessible to the global population as a whole before we start talking about things like mandates or even vaccine passports or any of these discussions. It gets even more complex than simply making sure that we're distributing equal doses. I'm going to run through, for example, again, you're talking to somebody who's an ER doctor that looks at health systems strengthening, right, and specifically looking at areas that are low- and middle-income countries, areas of armed conflict.

I'm going to take one place that I worked in eastern Congo back in 2017-2018. So let's run through how we might actually go through from now that we have the vaccines where the technology is there, how do we actually get them to the people that, say, for example, in places where I've been working in North Kivu Province, right? Well, again, as pointed out by Tom Bollyky and the group at Think Global Health, there are some supply-side issues that are going to be massive problems that we need to address. So that is manufacturing issues and raw material issues that are just about the production of vaccines, okay? Let's assume that we actually fix that. That's a really big assumption. Now, we also have to deal with who is actually then going to be getting those to people, right? We do have several agencies that do this very well, UNICEF being one of them, Médecins Sans Frontieres being one of them. But let's say we actually employ those agencies to get those to people. There are issues about the accessibility in terms of the logistics, cold chain, where are you storing this? How are you protecting the supply? Who's actually going to be administering it? Then you come out against some of the other aspects of demand. So it's about awareness and acceptance within the communities. That's where misinformation has become such a big problem. So again, equity becomes these real-world bottlenecks all along the way that we have to address, both individually and then collectively. So vaccine mandates, I think, is not something—I know that we talk about it, but again, and it's not that we shouldn't talk about it, but in the real world of where things are going right now, until we address all of those other bottlenecks along the way, I don't think that this is something that is, again, a real-world discussion that has a lot of operational relevance. I don't know if that actually answered your question or just gave you more questions, but it just shows you just how complex this gets really quickly.

FASKIANOS: To follow on that, a question from Wendy Hahn, who's a student at Georgia Tech. Just talking about the recent surge of anti-vaccine sentiments and paranoia, how do we deal with that and layer on to that the misinformation about which vaccine is safe, which one isn't? You know, there's been a lot of talk about the AstraZeneca data and how is all of that playing into this herd immunity that we hope to be building globally? It's not just enough to have it here in the U.S. We are interconnected, and we need the rest of the world to be vaccinated as well.

STOKES: I love this question. It's a question that I ask all the time. And actually, the interesting part about this is that it's not actually a new question. This has been an issue going on for a very long time, well over a decade. With the advent of social media, it's just become more apparent. And the speed with which misinformation is happening is definitely something I don't think we've actually seen before in terms of the healthcare setting. But in terms of how we address it, I would highlight, for example, in Think Global Health, they did publish one of my articles looking at this because I think we can learn more, not necessarily from what's going on with COVID-19, let's learn from past outbreaks, right? There is an article, and I will send all this information to you guys so that you will have actual access to it so you can look through the information that I'm seeing myself. But, I think, let's learn from the people who've been doing this for a really long time that actually have given us some actual ways in which we can get around this.

Vinh Nguyen, who is a physician who was working in some of the same areas I was working in eastern Congo with the tenth outbreak of Ebola in eastern Congo. So in 2019—this was published in the New England Journal of Medicine—he was working at an Ebola treatment center for MSF. There was an interesting discussion that actually came about while we were having a problem with people—they're not just reluctant to get a vaccine, they're not just resistant. We had over three hundred attacks on Ebola treatment centers. A lot of this came from misinformation, people getting into the community thinking that community health workers, people running these ETCs, these Ebola treatment centers, were doing so for the purpose of hurting the population, maybe even purposely infecting people with Ebola, which obviously not true, but again, once the misinformation gets out there, it is really hard to counter. Dr. Nguyen actually had a great solution to this. They were saying, “Well, of course, in a community where there's been problems with trust, with violence, it is really hard to come in as an outsider with potential new medications and vaccines to say, ‘Here, this is good for you. You should take this.’ Well, let's actually listen to what they're asking for what they need.”

Their solution at MSF and what Dr. Nguyen wrote about was let's give the people what they need, what they're asking for. Treatment for malaria, measles vaccination, right, measles, which has killed so many more people in central and eastern Africa than even COVID-19, right? Let's actually do that. And when we do that, we actually build trust with those communities over time. That trust is one of the best ways you can counter misinformation. The Center for Health Security at Johns Hopkins actually just recently published a great report about how we need a more coordinated effort on how we manage medical misinformation, at least from the national standpoint. But again, I think that while those points are absolutely wonderful—and I highly recommend that you read that report—I think there is some core issue we do need to address here and that is how do we actually just reestablish trust within our communities from us as clinicians and public health practitioners, listening to people, giving them what they're asking for what they need, right? I think that is actually one of the more powerful tools that we can use to combat misinformation.

FASKIANOS: Thank you, I'm going to go next to a raised hand, Mojubaolu Olufunke Okome.

Q: Thank you very much. I find your presentation excellent and really what we need. Well, what I just wonder is why there is so little learning from past experiences. Because a lot of the ways in which the pandemic, the current pandemic, has unfolded resembles the 1918 flu pandemic. A lot of the responses that people have in spite of the passage of time is very similar. So lot of harm has been done as a result of, you know, muscular nationalism. So how really quickly can a lot of the harm that's been done be undone to—because there's a deficit in trust as a result of people believing the anti-vaccination rhetoric. I mean, WhatsApp for the Nigerian community has become this director of passing on this bad information. I'm Nigerian. I teach at Brooklyn College in political science. And I’m Nigerian. I wonder what can really be done to knock out the bad information in a quick way that would enable people to embrace the vaccine. And it's not only there in Africa, there are people here in the U.S. also who are dead set against being vaccinated. So, that being the case, somebody else asked, how are we going to get to herd immunity? How are we going to build trust? And then in terms of equity, there are many of these vaccines that you need refrigeration at a level that is not available in many developing countries. So, how do these obstacles gets surmounted? Then patents, a lot of pharmaceutical companies are holding on to their patents tightly. You saw this also in the HIV-AIDS pandemic. So, what can be done to persuade the loosening up of patents so that affordable vaccines, generic, can be produced and then disseminated?

STOKES: Thank you so much for this question. And actually, I would love to find a way to continue the discussion with you offline because I have a suspicion that you will probably have better answers than I have to give to you. But what I will say is this, we do have some amazing resources out there right now and people who are advocating for those. I would like to say that, specifically, there was a meeting that was just held recently. They call it the “Panel on Panels” that had the head of the WTO, Ngozi [Okonjo-Iweala], speaking with Tedros [Adhanom Ghebreyesus] and it was a wonderful thing what they were talking about. They were addressing some of these specific issues. They had a very clear plan. One is trying to connect vaccine manufacturers with other companies who have excess capacity to ramp up production. Two is a bilateral transfer of the technology between companies as well as production. So that we've actually already seen between AstraZeneca and places like in South Korea and in India. They also talked about a third point of coordinated technology transfer licensing. Again, what you're talking about in terms of both patents and issues related to the information that we have from the amazing innovation from the pharmaceutical companies who have come up with these vaccines. So I think, again, there are ways to do that. There are people who are advocating for it. I highly recommend that you go to the people who will be the greatest advocates for that. So you're going to see that from people who are supporting those proposals from the WTO, as well as the people who are supporting policies outlined in the Global Fragility Act. So that is one side.

Second, again, that's perspective, right? But how do we do this in the short term? Again, I'm your operations person so it's not just long-term thinking, pandemic preparedness. I'm thinking of right now. So not for the next pandemic, not necessarily even for the next wave. I'm thinking for next week, right? How do we do that? And so again, I'm going to circle back to that question I asked you from the very beginning. What do we mean by global vaccine equity? Is it for the purpose of averting excess death? How do we avert excess death, right? Well, again, some of these conversations are going to be better dealt by people who are from your background, the economics, or people who have the background in ethics. But if I look at the operations and then also the issue of misinformation, and I look at the guidance that was given by Dr. Nguyen from that amazing insight from just the Ebola response in DRC, why not actually—let's figure out some of the mechanisms that we can avert excess death right now to build trust in communities. So the World Food Program has actually highlighted a huge problem that's going on globally and that's food insecurity. And so why not address that issue that's going on? I have a suspicion that if we were to go out and say, “We're going to look at the funding shortfall that they have at the World Food Program,” which I believe right now is somewhere in the ballpark of $266 million because they're looking at three million refugees in eastern Africa that have this problem of food insecurity. Well, if we can address that, we improve their security and that actually, guess what, improves trust and will help. It's not a magic bullet for misinformation, but it certainly will help, right?

I think if we address some of those issues, again, give people what they need. Let's also, in the process as we're talking about global vaccine equity with respect to COVID-19, let's talk about global vaccine equity with the places where people in eastern Africa are dying from measles, right? The measles outbreaks that continues to hit DRC and places like Central African Republic, let's make sure we're not forgetting that part and give people what they need, what they've been asking us for. Let's actually listen to them and respond appropriately. That's pandemic preparedness as well, right? So, again, because we may not be able to meet some of the issues that are true supply-side shortfalls when it comes to COVID-19 vaccines, those discussions are happening with people that, again, will know this much better than any information I could give you. I do know about some of these other areas that we can address, and when we do that in concert, then again, that's how we build that trust. That's how we start battling misinformation when it comes to vaccines or medical misinformation in general.

FASKIANOS: Great, thank you. A lot of questions. Next question from Maggie Chambers, who's a senior international business major at Howard University, "Recently the Quad countries committed to giving one billion doses to people around the world. How do you see this changing the tide of the spread of the virus and the return to normalcy?"

STOKES: Thank you. And that is, again, when we talk about the distribution and the commitment of countries to make sure that we're doing allocation of vaccine doses, yes, absolutely, that solves one piece of that puzzle, that puzzle of supply side. But remember that sort of chain that I described for you. There are also of these other bottlenecks that we have to remember that we're not missing in the process of it. So how do we actually do the logistics of that? Who is going to be addressing cold chain storage, administration, and then, of course, all the other aspects of community engagement? So yes, absolutely as a solution to supply side, making sure that we're getting all the countries that have been able to have that amazing purchasing power of allocating vaccine doses to their own countries. I think that Kaiser Family Foundation has a wonderful article that sort of summarizes this where they say less than 20 percent of the global adult population is from the high-income countries, more than 50 percent of vaccine purchases have happened within these countries. If you include middle-income countries, that's more than 75 percent, right? So if we can address that sort of discrepancy by this, yes, that is a solution for the supply-side problems that we need to continuously engage with, especially in the United States. And for our other question that we had earlier in terms of vaccine diplomacy, that also addresses that issue.

I would alert you to one issue though—normalcy. Careful with that term, what gets us back to normal. I want to take a moment for everyone here on this call, by the way, to recognize all of you what you have gone through in this last year. And if it's hard to hear what I'm saying, because again, when you keep hearing statistics or people speaking at you, it can be a little hard to take in the information. Why is that? Because, well, what everybody has gone through has been—and I use this in a very deliberate term as someone who is an emergency physician—that's trauma, which we are engaging in continuously. It’s a trauma response. I don't call it post-traumatic stress syndrome, because we have to get to a post period, right? But it is very real. You have to make room for that. You have to allow yourself some time to also disengage, to have doubts about what people are telling you, when to disregard what we're saying. Leave yourself and your brain some room to be able to process, come back to it, continue the conversation. And then when you do, it's not that we're getting back to normalcy. Right now what I want us to get to is a place where we're okay and then eventually somewhere better. That's where I want to get us to. I don't want to go back to normal because you know what, in a lot of places where I used to work, that wasn't such a great place anyways. So let's figure out how we do this. I think one of the most amazing things that could potentially come from this, we're not there yet, but if we continue engaging in these conversations, we'll get to somewhere that, again, when we look back on this, it would have been worth it, right? For all the death and despair that we've gone through, let's make it worth it. And I do believe that we will do this if we continue these conversations.

FASKIANOS: Thank you. I'm going to take the next question from a raised hand. Tanisha Fazal.

Q: Hi, thanks so much for taking the time today. I'm a political science professor at the University of Minnesota. You've been talking a lot about misinformation. I wanted to ask you about lack of information or data issues, especially when it comes to sub-Saharan Africa because of your background working there. One of the things that I've been trying to figure out, when you look at Our World In Data or other data sources, for example, is how much of what we're seeing in terms of the numbers is due to—particularly, again, in sub-Saharan Africa—is due to a lack of testing versus some of the predictions that you were hearing, maybe last summer that because of skewing younger, the COVID-19 pandemic wouldn't be as bad in Africa. So I was wondering if you could just speak a little bit to what your sense is of how severe the pandemic is in sub-Saharan Africa. Also because you were talking about other diseases and maybe they have just always overshadowed an illness like COVID. Thank you.

STOKES: Tanisha, thank you so much for that question. I'm going to reference two people in particular who have been just phenomenal resources for getting information like this. One is in your actual neighborhood—Michael Osterholm, your team at CIDRAP. I follow that team relentlessly. I think they've been some of the most amazing public health practitioners in the public spaces, particularly in communicating information in a way that actually gives us the best immediate guidance for what's going to happen in the next few weeks. And by the way, if you did not listen to the live stream that happened from Michael Osterholm in CIDRAP yesterday, please do it. You can even disconnect from this if you don't have time. I would say go listen to that. If you listen to that, learn from it. It can save your life. Okay, one. The second person I follow when it comes to specifically epidemiologic methods in complex emergencies is Dr. Les Roberts over at Columbia University. It's actually his surveillance system in DRC that I was helping with back a few years ago.

Now, how do we get the information if—you are absolutely correct, there is underreporting happening in central Africa and eastern Africa. There is underreporting that's happening, by the way, six blocks from where I am right now here in New York City. We have underestimated COVID-19 at every turn, and we are absolutely globally everywhere behind with testing. So that's everywhere. And, yes, of course, just like we have global vaccine inequities, we have global testing inequities when it comes to COVID-19. So if we know that there's a problem with testing because we just can't get tests there, we don't know how we can get that operationalized. What are some of the other ways we can do it? So Les Roberts describes this as a method called triangulation. If I cannot directly measure by a test, what is another way of looking at it, okay? Because when it comes to, for example, mass casualty incidents, mass death, over a period of time that can be pretty hard to hide, right? You can, and I have seen mass graves in eastern Congo, but again, in the places that we're looking at, right, it would be something that would be hard for us to ignore, especially over this period of time. So I do think that there is a component of this that is underreporting, but when we triangulate the information, we actually do see, well, again, still not seeing the high rate of death that, as we were saying, just as I was mentioning, those countries that were making those initial lists from the mortality analyses from Johns Hopkins, right? And that, I think, is again the multifactorial issues of younger populations, populations that have higher rates of exposure to different types of infectious diseases. There are other issues that are possible factors. I don't think it's appropriate to discuss this in a public setting, because I never want to participate inadvertently to misinformation by something being extrapolated. So I’m happy to talk more offline about these. But again, Jennifer Nuzzo and the team at Outbreak Observatory is pushing for, again, as people are pushing for global vaccine equity, they're pushing for global testing equity. I think both things should be pursued to be able to protect us overall. Again, though, we still do need to be aware of the numbers.

Last thing I will actually say, by the way, speaking of Michael Osterholm and the team at CIDRAP, they did highlight something yesterday. They were they were talking about numbers because up until recently, we haven't seen the level of mortality, right, for the number of the reasons we just discussed in central and eastern Africa. But he did highlight some issues that potentially are going on in Tanzania potentially with variants and the dynamics of what populations are being affected, what ages and what people are being affected. That might change, right? We might actually see younger populations more affected. We need to be aware of that. And so just because what has happened in the past might not necessarily be what's true in the future for COVID-19, again, all the more reasons to have the discussions on vaccine equity.

FASKIANOS: Thank you. So in the chat somebody wanted you to repeat the names. It’s Mike Osterholm and Les Roberts, those were the two. Jennifer Nuzzo is also, in addition to her post at Johns Hopkins, a fellow at CFR, which we're happy to have her part of the team. And so building on that, Kevin Lockett, who's a student at Ohio University, referenced Osterholm and [Mark] Olshaker talking about developing a universal coronavirus vaccine that would target the pieces of virus particle that all variants share, saying we require an effort on the level of the Manhattan Project. So his question is,
“Given that this is a global issue and it's spread outside of national boundaries, how can legal mechanisms be used to incentivize countries together their respective resources to work collectively together toward producing a universal coronavirus vaccine?”

STOKES: Thank you for the question. And I will once again highlight my biases and limitations—emergency physician. Yes, I do know health systems strengthening, but when we're talking about more specifically about not necessarily vaccine distribution administration, but development, innovation, right, when we talk about things like that, I defer to the experts on that. I will highlight a couple other people—Angela Rasmussen and Luciana Borio. In addition to the team at CIDRAP, these are the people that I look to. Also I will say Florian Krammer, who's here at Mount Sinai’s Icahn School of Medicine. These are the people that I look to when I need guidance, specifically there because, again, we need to know what our biases and limitations are. Now, if we try to translate and say, again, we resolve these issues of innovations, we do get something on the level of a global coronavirus vaccine. Again, a big assumption there, right? And how do we leverage in terms for addressing some of those issues from not just manufacturing but a legal standpoint? Again, please, I would highly encourage you to look at the WTO, who has portrayed some of the issues that have been voiced there in terms of how to address these issues. I will say this, even in the advent of the legal framework, let's say, for example, we do address issues that are arising, let's say about patents regarding the innovations, right? Please don't ever forget, again, operations. Remember, where is this excess manufacturing capacity that we're going to find? We need to make sure that we're highlighting those places. It's not just the ability for people to do it, they need to have the quality control to do it. A good example of what's happened with this is Merck, a fantastic pharmaceutical company that has stepped up when their own development they decided, “Look, our vaccine, does not seem to be meeting the efficacy numbers we want.” And so they're supporting other pharmaceutical companies to do production. That's a perfect example right there. So trying to take Merck, which continues to be this leading company in terms of not just innovation, but just ethics. Following that model, seeing how we can extrapolate from there, I think that is a good guidance for us.

FASKIANOS: Fantastic. I'm going next to a written question from Kelsey Thompson, who's a student at Fletcher School at Tufts, “What have you seen being done regarding vaccination of displaced populations, refugees, and those in armed conflict zones? I've seen recent articles about state responsibility for vaccinating displaced populations within their borders but wasn't sure if there were greater international efforts supporting their vaccine and overall COVID-19 health care that you might be able to talk about.”

STOKES: The most unfortunate aspect of this is I can answer this quite simply. It's not happening. I would rather us just be straightforward and honest about this. There's a lot of talk about it. There are a lot of papers that are going to be published; I'll have to read a lot of them. The operational relevance of this and the real world lives saved, again, there's a reason I brought up that. It was more than just a thought experiment. It's real problems that me and my colleagues actually have to talk about, among them Les Roberts and Craig Spencer. How do we actually get vaccines into arms of those people that are at risk? There are other conversations that then come up again. We want to make sure as we're having those conversations about COVID-19 vaccine equity that we're not in the process displacing some of those other really crucial interventions that would actually save immediate lives there. So notice in the entire time here, I haven't really talked about suppression of variance, right, as a primary reason for global vaccine equity. I focus on reducing excess deaths because, again, I think when we talk about suppressing variance, the irony in the conversation of equity is that sometimes it actually displaces issues of equity with respect to averting excess death, right? We're talking about suppression of variance because COVID-19 remains the number two cause of death now for high-income countries. But again, if we're having that conversation and not addressing the actual causes of mortality in the places that are low- and middle-income countries, specifically in places of humanitarian help or refugee and IDP populations, again, you have to do both, right? Both is necessary and definitely not one without the other, not one that actually is going to in the process take away from the things that they actually need right now to save their lives. And again, I will say it until I turn blue in the face, which might be a sign of COVID-19, no, please, please, please, look at the people who are doing those real-world interventions that will help right now—World Food Program. Looking at supporting initiatives from the WTO. These are things that are actually going to translate to those specific issues of mortality in the places where mortality is hitting the hardest, and not because of COVID-19, because that's just how it's been for a very long time. Again, we talk about a better future, right? What do we want to look like at the end of this? I would love it if at the end of everything we've been through with this pandemic that we actually come up with solutions. We commit ourselves to those things that we've been talking about for decades, if not for centuries, and actually find a way to actually have some real-world solutions.

FASKIANOS: Thank you. Next question comes from Michael Raisinghani, who is from TWU, "Since we do not have longitudinal data on any of the COVID-19 vaccines, how do we know about the side effects? Is it realistic that we could win the battle against COVID-19 by 2025? And how do we proactively minimize the threat of the next superbug?” Well, you just said that you're not looking at the variants and the next one, specifically, but—

STOKES: I mean, this is a great question, Irina. They're all interconnected. It's not that I'm trying to sort of disregard some of these discussions. They're all valid, right? But again, my focus is a reflection of my bias and limitations. I will say this. I get this question a lot when it comes to looking at the safety of vaccines. And I don't just mean from my patients or even from my fellow providers—my family and friends. You are in very good company with people that I hold dear to myself that have these questions all the time. And by the way, even after we have the conversation, we usually have to have it again next week and then the week after that. Do not be surprised. It's an iterative process, right? It's a process that requires, again, I call these conversations because truly we need to have them again and again to remind ourselves. So let's talk about vaccine safety, okay? Within the U.S. the three vaccines that are currently available to us are made by Pfizer, Moderna, and Johnson & Johnson, right? Well, how do we get to that point in the United States, in particular, of not just a distribution but administration of a vaccine? Again, I referenced the FDA. There's another body, the ACIP, that looks specifically at vaccine safety. The rigors of going through that are profound. To get a vaccine administered in the U.S., a COVID-19 vaccine, it's an enormous feat. It's what's one of the miracles truly of the amount of investment that's come from the pharmaceutical companies, from funders, from governments to get this going, right? I should also tell you, guess what, we could have probably done this with a lot of other diseases. But again, we just have not had that level of collaboration, right? But again, it happens absolutely with this very intense review process of safety.

Now, so I can tell you right now that in terms of when we talk about long term, right, I have people that are asking me, “Well, how do we not know five, ten, twenty years from now we're not going to see some side effect?” Again, I’m always going to be straight. Anyone who tells me they can know what's going to happen in five, ten, twenty years clearly hasn't learned anything over the last year, which is, we need to be dynamic, and that we learn new things all the time. I will tell you this, in addition to the very rigorous safety review that the FDA does, we have now had hundreds of thousands of people that have been in the original vaccine trials for almost a year. Remember I talked about that process of triangulation, right? Well, I can't get a time machine and go twenty years from now to see what the vaccines are doing. Then what do I do? I triangulate that information. We have not seen anything other than we have had some severe allergic reactions, meaning anaphylaxis. Like all medications and drugs—and even by the way, sometimes foods do to us—it’s not exceptional to the vaccine at all. Nothing, no reports whatsoever. That's phenomenal, right? And so when I'm looking at how to triangulate information I have right now to be able to tell me what's going to happen later, that's a huge indicator. One. And two, we have, in addition to COVID-19 vaccines, a century of information on vaccine development in general that just shows just how safe they are, right? Truly it is one of the safest things we do in medicine. As an emergency physician, you should take that to heart because I can see all of the different ways in which some of the things we do in medicine that are very high risk. This is one of them that isn't, and it's one of the things that are actually going to save people's lives. I don't like using the term getting us to normal. It will get us to something better, though. So please, please, please, please, when you hear me, it’s absolutely safe and most likely long-term safe. It will save lives right now.

FASKIANOS: Sonya, you obviously are on the frontlines of this. Thank you for all that you're doing. I'm in awe of doctors and nurses who have been just on the frontlines in the ER and intensive care units taking care of people. There's been a lot of talk about how people have postponed regular visits, children aren’t being vaccinated for other diseases because of the pandemic. Can you talk about what you're seeing in the ER and your concerns just on sort of what we thought were the normal things or that we knew about in everyday life and your concerns there?

STOKES: Any emergency physician who would hear that question would be so thankful for it. Anyone on the front lines, because, yes, this was an issue. It remains an issue of people avoiding regular care for underlying medical illnesses that, by the way, put you at risk for COVID-19. For example, people not following up with their regular physicians for care for their hypertension, for their diabetes—this is a big problem. In the early days of the outbreak, the first wave in New York City, and I can have a very vivid memory of this exact day last year of what it was like in the emergency departments in New York City, it's something I will think about every day for the rest of my life. I could understand at that time people's apprehension of coming to the ER, especially in a pandemic, especially if you watch a movie like Outbreak back in the day. That was, I'm dating myself here, because that was a movie that came out when I was younger. That's again, these are things that people are looking around, again, they're looking for information so that they can know am I putting myself at greater risk by seeking care. And again, this is coming from a perspective that knows, that recognizes in the early days and was something I was concerned about even. The health-care systems have made enormous changes to address these issues, and it's something that I've been highly encouraging of my patients and the people I care most about in this world. Please do not forego care for these issues because in the end we might see, again, when we're looking at mortality and how we measure it, we might actually find, and the CDC has been tracking data on this, that we're going to hurt ourselves in the long term by doing that, that it will actually increase our mortality by doing that. For all of these issues, please make sure if you have access to a primary care physician or a specialist that you're supposed to see regularly, always stay in touch with that physician or that provider and also be highly cognizant of the fact that in the United States that is a privilege, having access to a health-care provider. So what we can also do to help support that is please let’s support initiatives in the United States that supports primary care, because I am very well aware that it is very difficult, even here in New York City, to talk about accessing any health-care provider outside of the emergency department. It's just not something that people have either because of a lack of health insurance or inadequate health insurance. These are things we really do need to address. Speaking of equity, we need to do that at home. We need to do a better job with it.

FASKIANOS: Great. I’m going to take a written question from Joanne Michelle, who is a PhD student at the Mailman School of Public Health at Columbia University, “If you could talk about the role of the medical and public health colonial legacies in this discussion and address the myths or misinformation in many humanitarian settings. How do you manage that as you're on the frontlines to deal with those uncomfortable histories to getting people to take the vaccine?”

STOKES: Again, I hope that we had some of these answers or at least more questions from this question earlier on, seeing the models of the people who are doing this best, okay, I mean, we should just be very open about some of our failures here. I'm very well aware, by the way, of having the ER doctor in New York City talking about global vaccine equity when I myself had access to a vaccine  and we have health-care providers in South Africa, right now, colleagues of mine on some of the WhatsApp groups that I run, who, again, have not had any access to any vaccine at all. These are health-care providers, right? So the best way I know how to do this is by making sure that we are first learning from the people who, quite frankly, are doing this a lot better than us. I think the best way to address any issues of historical or colonial issues is by recognizing our failures. I don't mean our failures abroad, I mean our failures at home and then taking a step back and asking the people who do this better globally, “How did you do that?” and having them front and center. Let's talk about how we would do that even within the U.S. By the way, if we look at the top-five states that are administering vaccines here in the U.S., New York City is not even making the top thirty, by the way, or New York State. It's Wisconsin. It's Nevada. It's New Mexico. I want to hear from those people. How did you do that? You need to tell us. So I want to actually take a step back, let's accept some of the ways in which we failed, and then let's learn from the people who seem to be getting it right. That's actually how we do it in a real way, in a real-world way that actually, as I said, averts excess deaths and saves lives, which more than anything is number one in the middle of a pandemic.

FASKIANOS: Great. I'm going to take the next written question from Beatrice Guenther, who's an associate professor of French and international studies at Ohio State. No, not Ohio State, excuse me, Bowling Green State University in Ohio. Okay. And she wants to know, “What would be your top-three recommendations that you propose for pandemic preparedness?” Or maybe we could state it as what are the top-three recommendations that the task force, the Council on Foreign Relations task force, proposed for pandemic preparedness? Not that we want to think about the next one but—

STOKES: I would say that there is a list of the recommendations from the report that are given equal weight. I wouldn't want to say what the top three—to speak on behalf of the membership, I think we all contributed our different perspectives. I will give my own perspective from the report that is in there. I highly encourage you to read it. Again, thank you to all the members of the report. So number one is actually creating dialogue. How do we do that nationally and globally, because that's actually how we do leadership, right? What is it that we're going to do in terms of addressing some of the issues where we have time and again seem to have failed in terms of just the communication? So when we have breakdowns in our chain of command and our lines of communication in public health, what are some of the ways that we can get around that? And then, again, please refer to some of the work from Tom Bollyky and looking at this from the Council on Foreign Relations on some of the different ways in which we can address this.

Number two—investment in public health. I'm going to say also primary care, which I think is public health. We really do need to actually address how we invest, what are the means for that, and making that actually operationally relevant. Someone very recently told me that the difference between pandemic preparedness and response is about having responsive responders. We need to actually make sure the responders have a way in which the recommendations, the investment that we do in public health and primary care actually translates to those responders being able to use that—contact tracing, testing, making sure we have adequate surveillance. So that's number two.

Number three is I would argue something that is actually a little excerpt that I gave at the end, which is I think we actually need to look at surveillance another way. I think that some of the different ways in the report that's trying to address that we want to with respect to the sovereignty of nations, we want to make sure that we are addressing sort of those shortfalls in public health. But I want to prepare for failure. That's what I want. As an emergency physician, it's great if we can restock the National Stockpile, have innovations in vaccine and treatment development, testing, contact tracing. I want all of it. I’m an ER doc. We know a good thing when we see it, and we never turn down a good thing. But what happens if we have those same limitations and parameters all over again, right, what do we do? I want to prepare for that. I would highly recommend and, again, my bias and limitations are pretty apparent here, but I would say we need to invest in how we do pandemic surveillance and response. I would integrate that into our hospital systems, specifically in emergency medicine. This is what we do all day long. I would invest in that globally. I would network us and make sure that your ER doctors, your responders are talking with each other. Because guess what, guys, how did we do this in the beginning? What were we hearing from about this pandemic? We were networking with each other pretty much as soon as the first wave hit here in New York City. And that's actually how we came about saving our patients’ lives and each other. Let's figure out how to actually make that systematic and scale that up is what I would recommend, because we have to prepare for failure again. I don't want to prepare for a future that may never come, all right. I want us to get to somewhere better, but also be prepared in case, in case we don't get there, in case this happens again. And then we will truly be able to get through this together as a community to something that is worthwhile.

FASKIANOS: There's been a lot written about how we here at home have not been resourcing or providing adequate funds to the health-care industry. And so, as you know, as we have gone through this pandemic, we're now over the year mark. Do you feel as a health-care professional that there is the determination to start funding and better fund our health-care system?

STOKES: I don't know this word determination. I know that there is a demand from us who are health-care practitioners. I know that there's this disparity with the amount of funding that seems to go into the health-care system in the United States, but doesn't seem to translate to actual equity, that our vulnerable patient populations remain even more vulnerable now. It's disturbing to me, in the middle of a pandemic, we're cutting resources to emergency departments. I don't know if there's determination because I don't know this word. I do know it's necessary. It's about our survival. I really hope this translates to something that we can work on together, not just in some distant future. Right now it would be great.

FASKIANOS: In the present. On that we will end. Dr. Stokes, thank you very much for being with us today, and for all that you have done and are doing. We really appreciate your service. It is so critical to saving so many lives. So thank you very much. I encourage you all to follow Dr. Stokes at @sonyastoked. You can follow her on Twitter. We will send out additional resources to the groups, things that were referenced. Dr. Stokes does have a reading list, too, so you can get more. I hope you will do that. Again, on our website CFR.org, Think Global Health, which is a global health initiative being run by Tom Bollyky, who is a fellow at CFR, and, of course, ForeignAffairs.com, you can find additional resources. We encourage you to go there not only for this issue, but for many other issues in international relations and foreign affairs. So thank you, Sonya.

Our last academic webinar of the semester will be Wednesday, April 7, at 1:00 p.m. Eastern Time with Susan Thornton, senior fellow at Yale University's Paul Tsai China Center. She will talk about the U.S. response to China's Belt and Road Initiative, which is the topic of another CFR-sponsored Independent Task Force report that we just released on Tuesday, yesterday. So, we will send out the link to that so you can read that in advance. So thank you all for being with us. Please do follow us @CFR_Academic on Twitter, and I mentioned the other Council resources. So thank you.


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