Academic Webinar: Global Health During COVID-19

Wednesday, September 23, 2020

Founding Director and Chair, Global Health Centre, Graduate Institute of International and Development Studies in Geneva


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

Ilona Kickbusch, founding director and chair of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, discusses global health during COVID-19.

FASKIANOS: Good afternoon and welcome to the CFR Fall 2020 Academic Webinar series. I'm Irina Faskianos, Vice President of the National Program and Outreach at CFR. Today's webinar 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 are excited to have Ilona Kickbusch with us today. She is founding director and chair of the Global Health Center at the Graduate Institute of International Development Studies in Geneva. Dr. Kickbusch is also a member of the global preparedness monitoring board established by the World Health Organization and World Bank. She serves as a council chair to the World Health Summit in Berlin. She has been involved in German G7 and G20 activities relating to global health, and chaired the international advisory board for the development of global health strategy. Previously, she was director of the global health program at Yale University, and was responsible for the first Fulbright program on global health. So Ilona, thank you very much for being with us today. Last week, the World Health Organization reported a one-day record for COVID-19 cases. Perhaps you can begin by providing an overview of global health priorities responding to the pandemic, how the World Health Organization is thinking about equitable access to therapeutics and vaccines, as well as reaction to President Trump withdrawing support from the WHO. So, over to you.

KICKBUSCH: Thank you very much, Irina, and thanks a lot for having me. And that was quite a barrage of opening questions already, that imply a lot of different dimensions and answers. I'd actually like to start with a theoretical concept, if I might, or, theoretical political concept. There is a German political sociologist, Ulrich Beck, who died recently, and Adam Tooze, actually also has been using his work. And he spoke about cosmopolitan moments. And he said these are moments of crises in international society, where we then have a political choice, either to act, or in a sense, to make the crises even worse. And, as you know, in the COVID-19 response, there has been this question of why are we constantly in this cycle of panic and neglect? So, first we have SARS, and then we have Ebola, and then we have COVID-19. And then we sort of say, oh, we must, we must, we must, and then we don't, both at the global and at the international level. So I think one of the questions is are we going to use that opportunity of learning that we're actually given in this sort of trick of history, if I can call it that, with COVID-19? And that leads to some of your other questions that I'd just like to unravel a little bit. First is the geopolitical situation. And you've alluded to the threat of the United States leaving the World Health Organization, something I don't think anybody who is either committed to multilateralism on the one hand, or anybody who's just a pragmatist in global health—we can only solve certain problems if we work together. So that, of course, is a threat, many people can't understand, but also a threat that has shown us that we need to work together differently politically in the global health arena. Of course, the United States has been an incredibly important partner. It's been an incredibly important funder, not only of the World Health Organization, but of course of global health in general. But that, of course, has also led to an imbalance, an imbalance of power and an imbalance of responsibility. Because in a sense, as long as the U.S. does this, why should we? And so what we're seeing now is something really, really interesting with this threat, this Damocles sword hanging up there. We see that other actors are, should I say, waking up. And what we have seen over the last six months is, for example, the European Union being a very, very proactive partner in global health, within the context of the World Health Organization, and in helping build some of these new institutions or processes that are starting to emerge, for vaccines, for therapeutics, for diagnostics, etc. And I'm sure we'll come back to them. So we're seeing power shifts happening. And it's not as you frequently describe it in a lot of your U.S. discussions. Oh, America moves, China moves in. It's actually a much more complex and interesting situation that's happening now. I think people who are involved in sort of political analyses would say the middle powers are trying to assert themselves. And they're doing that also in reflecting how should the World Health Organization be reformed? Because it must be, and how should the International Health Regulations be changed in order to really function. Because those are two problems we have encountered, WHO has been under pressure, WHO does not have enough money to act, and the International Health Regulations are a form of an international agreement, that isn't tough enough, if I can put it that way. It doesn't ask enough of the countries. And it doesn't bear any consequences if people don't live up to their responsibilities. So we're seeing a tremendous discussion. Also in the G7, also in the G20. Also at the U.N. Security Council, also at the U.N. General Assembly. So we're seeing that global health push through COVID-19 is—or you might call it global health security—is really at the forefront of everyone's agenda. And a big part of that agenda is what are we going to finance jointly? And that leads us to the vaccine discussion. Are we going to say, okay this vaccine, as many have said, is a common good, all countries need access to it. Nobody is safe, unless we are all safe. And so WHO together with other partners, and I might put that in brackets. Never has there been so much cooperation between the international health organizations in Geneva as right now, you will know that for money, for power, for everything, there has been competition between the Vaccine Alliance the Global Fund for AIDS, tuberculosis, and malaria, WHO, and everyone else that's there, suddenly, there is a joint purpose. The joint purpose has been formulated as the act accelerator, saying jointly, we have to ensure that therapeutics, medicines are available, that diagnostics testing is available, and that a vaccine is developed, produced, and is made available. And we have a new form of cooperation and within basically three months, we've created, or the colleagues in Geneva together with member states and others have created, a mechanism that at present has about 160 countries in it, saying we're going to work together to make a vaccine available. Quite extraordinary. Seth Berkley from GAVI has said, this is truly a historic moment. It has flaws, it has problems, we'll come to those I'm sure. But, we can see again, something new is happening, something is there in the bud that we need to look at. And maybe the last point as an introduction, is that we're seeing that the present financing models in global health don't work. First of all, you know, the financing of WHO doesn't work, WHO does not have enough money, and we can come back to the assessed contributions, the money by member states and other funding, but it's just not enough in terms of what we're asking of this organization. But if you look at the fact that for COVAX, we would now need $35 billion to be able to make it available to all countries and we can talk about the percentages that are being discussed, between 20 and 50 percent of the population. That means we're no longer talking millions. We're talking billions and actually, there's people who are talking trillions in global health. And that means our model of overseas development assistance to help countries move their health systems forward a little bit to finance vaccine programs, etc., is just not sufficient if we face a truly global problem. And we have to look at how are we going to do this? And this is why, maybe the last thing I'll say right now, is that it's been so important that in the context of the G20, it's no longer just the health ministers meeting. I mean, it was a revolution that there were health ministers meetings in the context of the G20. But now what the health ministers are doing, they're meeting with the finance ministers, they're meeting with the development banks, they're meeting with investors, and saying, we need a new financing model for this. And I think that's really a wakeup call. So we have a political opportunity, we need to look at financial opportunities, and we need to look at new solidarity opportunities that are out there in global health.

FASKIANOS: Fantastic, thank you so much Ilona that was terrific. Let's turn to all of you now for your questions. And hopefully, from lots of students. If you click on the participant icon at the bottom of your screen, you can raise your hand there. If you're on a tablet, you can click on the more button and raise your hand there. you can also put a question in the Q&A, and I'll read it out. So let's go now to all of you. We already have questions, hands raised. Noe Ramirez.  Please accept the unmute prompt and tell us what institution you are with, to give us context. And maybe for Ilona's sake, what state.

Q:  Thank you very much. I'm with the University of Texas Rio Grande Valley, that's in south Texas. My question is very simple. What's your opinion with respect to the polarization between science and politics? That is before us now the outcome of that polarization and so far as science, for example, gaining greater leverage, greater prestige, integrity, and so far as making the decision-making process more rational, if you will, worldwide, so that these matters having to do with the welfare of the world population are more recently addressed and intervened on? What's your opinion? I really appreciate your input.

KICKBUSCH: Thank you very much for that question. First of all, I think COVID-19 is an excellent example of, first of all, being confronted with a health condition, a virus, about whom we know very, very little. And that as the virus spreads, we start to learn about the virus and we start to learn different things. And one of the difficult things in the discussion around this virus has been if the knowledge has changed, just think of at what point were we sure that there was person to person transmission. At what point did we get more convinced that aerosols were really important. And so, what has been a major factor over the last six months is, first of all, how science communicates, how science learns that the kind of really critical debates you have within the science community are not necessarily the kind of debates you would have in a television talk show. And the way that science needs to interact with policy. And we have found that there's a very big difference in different countries. From what I gather, there has been more conflict between science and politics in the United States, than there, for example, has been in my country in Germany, where there has been a much more regular interface between the scientists. At first the virologist, then the epidemiologists, and now very much social scientists, because it's all about trust of people, behavioral issues. How can you discuss with people how important it is to wear a mask or not, a virologist can't answer that question. So what we're seeing is that in some countries, actually, a very good interface between science and politics has been established, in other countries, has actually been much more divisive. And I think that has really, really been a problem. In terms of the World Health Organization, of course, what has been a big issue is how quickly can we pull all that scientific knowledge from around the world, and how quickly can WHO as an international organization, then give the recommendation, this is where we stand, this is something that would apply to all countries. And some scientists have criticized the World Health Organization, think of the aerosol discussion, and have said, you're taking much too long. This is much more serious or partly, in the masks discussion. So one of the things that is also being discussed is that this science policy interface also has to be improved at the global level. It's worked very well in vaccines. We've never had that much scientific cooperation as we have had in vaccine development. It's absolutely extraordinary. It's absolutely historical. But we can see where a society is divided, where politics is tough and divided, then science is used and abused. And then, scientists find it very difficult to find a role for themselves.

FASKIANOS: Thank you. I'm going to take the next question from the chat from Chaney Howard, who is an international business major at Howard University. How is the 160 country mechanism established? How do they typically collaborate?

KICKBUSCH: Well, it's been established, basically, on the run. If you talk to people who established COVAX, they would say, we're flying a plane while we're constructing it. I think that's a very appropriate picture. What one wanted initially was a mechanism that every country will join and would agree that it was kind of an insurance policy, if I could say that, a pooling of risk that countries would join and say we joined this COVAX facility, and no matter what vaccines we have invested in, we would bring that to that facility, and then we would all benefit from the vaccines that are successful.  It turns out that it was more complicated than that, and that it was very important on the one hand, to be able to ensure that the poorer countries got access, that there was a mechanism that vaccines could be bought on their behalf. And on the other hand, that it was interesting enough for the rich countries, as we tend to say, to participate. And so now, a new kind of mechanism has been developed where countries on the one hand can join in order to access a certain amount of vaccines at a special price, others join so that they might have access to that pooling possibility, and others join in order to bring their investment into that COVAX facility. And that has made it so complicated because you need quite different legal agreements depending on which kind of membership of COVAX that you have. Initially, it was very much modeled on the Vaccine Alliance GAVI, which is also based on tiered pricing. But it became clear that you couldn't use that model one to one for COVAX. So actually, COVAX is being developed as we speak. And so of course, at first, when it was built more on the old ODA model of donors and recipients, initially it was more of the low and middle income countries that joined and the others were sort of holding back and saying what does this bring for us, and they were already making agreements individually with vaccine producers and the like, and no one has tried to bring that together. It's still a work in progress, if I can call it that, some countries, even though there was a deadline, some countries are still sorting out the legal dimensions of it. And some countries have more or less—well, one country has said we're definitely not joining, and that is the United States. Russia is not yet clear what it does, and China also hasn't yet said what it would do. Also, because these countries obviously use the vaccine, and all three have vaccine candidates, use that for geopolitical purposes. So we can already see that China is indicating with countries that it has close relationships with that they would have preferential access to the Chinese vaccine. We can see a similar thing probably happening in Russia. And of course, the United States has also said that it would make overseas development resources available for countries that it is in close cooperation with. So again, you see, there's the geopolitical development and tension that is also a part of the whole vaccine health diplomacy and the COVAX health diplomacy. But what we can see is, as I said earlier, is that the middle powers—so it's not just oh, it's the poor countries that want to be part of it, but that the middle powers want to be part of this game. So Germany is part of it, Japan is part of it, France is part of it, Australia has joined etc.

FASKIANOS: Great. Let's go to Maya Prakash.

Q:  Hi, I'm Maya from University of Southern California. So internationally, but especially in the U.S., COVID-19 has eclipsed other, maybe what we would have considered previously cured, epidemics like malaria, HIV, opioids, and other substance abuse disorders. Why haven't we, being countries domestically and international organizations globally, been prepared, at least, for countering those?

KICKBUSCH: Well, what has happened is that internationally, also, what you described for the U.S. has happened internationally as well, that many of the disease based programs as we say, ranging from malaria, tuberculosis, to polio, to programs for maternal and child health, etc., have seen first of all, reduced political attention, it's very difficult to do any fundraising, advocacy, etc., for those issues right now. But also, of course, have seen money pulled away to be invested in COVAX and in other COVID-19 initiatives, which is why initially also, when the COVAX initiative was created, it was explicitly said at the fundraising events, that one would not accept normal ODA money because there was an awareness, we can't be robbing Peter to pay Paul. But it's a stark reality right now. And we also see that because the funding of so many health programs is so volatile anyhow, I mean, even the strong organizations like GAVI and the Global Fund, have every three years to go around with a hat and do fundraising initiatives to do their replenishment. So there is no real stable funding in global health, even for the World Health Organization, there is no real stable funding. And then much of that funding, and that's a major criticism. And to some extent, I think it might apply also domestically to the United States. Funding is very focused on diseases or vaccination, we will vaccinate so and so many children, we will reduce tuberculosis by so and so much, we will bring HIV/AIDS medicines to so and so many people. It's very pushed by measurable outcomes and by saving lives, which is incredibly important, but it definitely neglects building any kind of primary healthcare infrastructure, of building a reliable and sustainable health system. And so if in countries, people are dependent on totally separate, fragmented programs for whatever disease they might have, then of course, the fragility of that system comes to bear, the minute there's a big crisis. We saw that with Ebola in West Africa. We see it everywhere now, everywhere, with COVID-19. And, of course, at the same time, and I think that's something I must add, people are losing their jobs, their livelihoods, they're falling into poverty. And we have an immense increase in poverty now throughout the world. They have less income, and many people have to pay for their health care out of pocket, they can't afford it anymore. And so this is a sort of—you have several waves, in a way, that come on top of each other. And as with all health crises, it's the poorest and the disadvantaged, and then all the special problems you have faced in your country with structural racism, etc., that then bear the brunt of such a pandemic.

FASKIANOS: Thank you. I'm going to go to Zero Lin now, he's a senior international relations major at Maxwell School at Syracuse University in New York. Here's my question: As the COVID-19 outbreak exasperates, the Trump administration filed a departure from the WHO and criticized it for being virtually controlled by China. So how would you comment on the U.S. departure? I think we did touch upon that a little bit at the outset. But how would you predict the global health governance of the WHO in the future? Do you think China would become a new leader and the biggest contributor in WHO?

KICKBUSCH: Well, I think one has to look at that in its complexity that first of all, if I start with the latest question about the financial contribution, there is in WHO what we call the assessed contributions, that's the contributions countries must pay to be a member. And that is calculated according to U.N. rules, size of population, size of domestic product, etc. And it is the case that I think it was about five years ago, those assessed contributions were recalculated, because countries have been developing. And so I think as far as assessed contributions go, China actually now is the second or third contributor in terms of assessed contributions. So if the United States were to leave—I guess that depends on the outcomes of your elections— then for the assessed contributions, China would be the largest contributor. But that's the smallest part of the WHO budget, because the assessed contributions are only 20 percent of WHO's budget, and then the contribution by China in assessed contributions would be about 16 percent of that. So with that 16 percent of 20 percent, with that, you don't dominate an organization. China has not been like—contrary to the United States, which gives or has given an extraordinary amount of what WHO calls voluntary contributions to the organization for special programs, polio, tuberculosis, etc. China has not done that. Actually, we see that many of the European member states and the European Union itself are those that give significant amounts of voluntary contributions. Actually, of those 80 percent that are not assessed contributions, 80 percent are contributions by member states and the European Union. And so, within those again, you see countries giving a different amount and then of the remaining 20 percent, I think around—I forget now—between 11 and 15 percent, are, for example, from the Bill and Melinda Gates Foundation, the majority of which goes to the polio program. So it's not U.S. moves out, China moves in. Actually China is, right now, expressing solidarity It's said vaccines are a global public good. It's very supportive verbally of multilateralism, etc. But quite honestly, we don't yet know how that will play out, which is why another group of countries has been incredibly active, particularly a coalition between the African Union and the European Union. And they have, in a sense, politically, taken on the shaping of the World Health Organization agenda, they have put forward reform proposals, and they are working on the revision of the International Health Regulations. So it's quite a different ballgame than is sometimes seen in the United States, where much of that WHO conflict is interpreted as a U.S.–China conflict, as which your president has defined it. But on the ground in Geneva, in the regional offices of WHO all around the world, that's not what's happening.

FASKIANOS: That's very helpful. I'm going to now call upon Lusia Sari, who had put a couple of questions in the Q&A, and also raised her hand. So Lusia, I'm going to let you answer it, or ask it. And please accept the unmute prompt.

Q: Hi, Ilona and Irina, thank you for the nice presentation. So my question is, first, if the fiscal capacity—sorry, I'm Lusia, from NYU, graduate student of master in global affairs, my question is, if fiscal capacity is the single most important factor to determine, on how developing countries handling the pandemic situation, what are another influential factor that should come to mind in such a situation? Sure, people living in poor countries rely to foreign debt or ODA, and who is the greatest lender in power. Is it the U.S., China, or who else? And my second question is, do you think intellectual property rights regime will prevent vaccines from becoming global public goods? Thank you.

KICKBUSCH: Thank you, Lusia, and hello to whoever is there with you, so next generation in global health. So you've touched on a number of very, very big issues for which we would need a lot of time. I think the intellectual property issue is an important one. And in general, intellectual property has not been that much of a key issue in relation to vaccines, because vaccines up to now, have not been such a profitable part of global health. And that's why also a number of innovations that I mentioned with tiered pricing and the Vaccine Alliance, etc. were possible. There was only, there's very few pharmaceutical companies up to now that continue to produce vaccines, because other parts of pharmaceutical products were or are much more profitable, we might see that change with COVID-19. And suddenly everyone wants vaccines. And that is something that also the COVAX facility is trying to address. But it leads me to one point that's absolutely critical: we're all staring at the WHO right now, I think we should be looking very carefully at the elections happening at the World Trade Organization. Because a lot of the issues around intellectual property are resolved there, the Doha Agreements, on access to medicines and for public health needs, etc. And so, I think the whole issue of pricing and IP is one that is really going to be at the forefront also of negotiations at the World Trade Organization. So, one has to look at that triangle WHO, World Trade Organization, and World Intellectual Property Organization, and one has to have a great interest as to who would become the next the director general of the World Trade Organization, because that person will be taking forward a very, very important IP discussion, which also relates to vaccines. I urge you to look at the candidates, and actually one of the candidates is the president of the board of the Vaccine Alliance. And she has stated very clearly, she would want to take up the issue of vaccines as a global public good within the World Trade Organization. So I think a big agenda that is really also breaking open, in a new way, a lot of the intellectual property and access to medicines discussions, and transparency issues, the push to say that pharmaceutical industry should show exactly where they stand with vaccine development, they open trial protocols, and things like that, an issue that was critical at the World Health Assembly a year ago, about transparency and transparency of pricing. So I think we're going to see a big, big discussion there in the NGO civil society is critical medicine [inaudible] is pushing for this access agenda at the Global Health Center, the new co-directors of the center have made that one of their priorities. So I think that's very, very important. Fiscal space is critical for building universal health coverage, we have just seen just before COVID hit, WHO did a number of very, very in depth economic studies of how financing for universal health coverage is improving. And one actually saw an increase of public investment in universal health coverage in a whole range of low and middle income countries. That of course, at this stage has come to a halt. And that again means less people will have access out of pocket payments will probably increase again. What we can't resolve that with is small sums of ODA, and we can't resolve with through a whole bunch of fragmented disease-based programs. You know, perhaps, that last year at the UN General Assembly, there was a number of declarations around universal health coverage. I'm the co-chair of UHC 2030, which is an advocacy platform for UHC. And we said very, very clearly that international funders, development banks, the World Bank, etc., need to invest much more in health systems and not just in health programs. And this is the really worrisome thing that we don't see this investment right now. And we don't know how it will play out. And that's the third dimension of your question, in terms of geopolitics. I mentioned that China is indicating it's going to give its vaccine to certain countries. We will see if we get into a real geopolitical standoff, whether the same thing that we had in the cold war is going to happen, that meaning you will only get our health support, if you also support our ideological position. And that is the issue that's worrying people most in political global health right now, that we get into a health cold war that we have not had over the last thirty years.

FASKIANOS: Thank you. I'm going to go to Catherine Zeman.

Q:  I have a question here from one of our students, Nadir, would you like to read your question?

FASKIANOS: And Catherine, can you tell us where you are?

Q:  This is Catherine Zeman, from the University of Northern Iowa, and Nadir Khan from the University of Northern Iowa has a question. Hello, thank you so much for this discussion. So I'm Nadir Kahn from University of Northern Iowa. My question is that how the country or the people behavior is changing, or will change, as a result of this current pandemic with the respect of environmental and its effect of COVID. How do those two things are making a change in people's behavior or country's behavior.

KICKBUSCH: Well, thank you for that again, it's a big issue. First of all, we're seeing very, very different responses in different countries. And we're seeing right now, for example, in your country that, it seems to be a very divisive issue, which is actually even linked to politics. You know, if you belong to one party, you wear a mask, if you don't, you don't wear one. So it's very different in different parts of the world in terms of behavior. Also, we see changes in behavior at different stages of the pandemic. If I take our European example that I'm most familiar with, that there was a very, very big wave of solidarity in the first phase of the pandemic linked, not only to extreme lockdowns, but also to, more just restrictions in movement, etc, and new neighborhood initiatives were created, and everyone went on their balcony and sort of clapped for the health professionals, etc. So that was a feeling oh, our society's coming together. But then, in the next situation, particularly when summer came, there was this push, oh, gosh, you know, we've had enough of that we want to move forward, we want to live and particularly young people, fully understandable, wanted to live a life again. And so there's been a lot of discussion, how can there be good information from the side of the authorities, from the side of politics? How can there be consistent information? It's a big question of political trust. And in societies where in general, there is no trust in the political system, there will be no trust in the messages that come, in terms of behavior in relation to the pandemic. What one is trying to do as a message is to say, you're actually doing two things if you behave responsibly in terms of COVID. And, countries have tried to make sort of simple rules, like Japan has three C's, and Germany has something it's called AHA, which is about wearing masks and washing your hands and keeping the distance. So things people will remember that easy to think about and relatively easy to do. But we have found that in many cases, there does need to be rule setting. To give you an example, in Switzerland, where I live, there was a question about masks, and the survey said 80 percent of the people thought, one should wear masks in public transport, for one's own safety and for the safety of the others. Actually was only about ten people who wore masks in public transport no matter what they thought. And then it needed a rule to say it's mandatory to wear masks in public transport. And then, I'd say roughly 95 percent of all Swiss wear masks in public transport. So it's—that's why we say we need to involve more social scientists, psychologists, behavioral economists, etc., in the COVID response, because getting a change of a whole society is an enormous challenge. And we can't just say, we are all going to go back to normal. We have to learn to live with COVID-19, at least another two years. And that means there needs to be a systemic approach to behavior change to responsibility for one another. Not just I keep myself safe, but through the actions that I do, we keep each other safe. And the messages are moving in that direction. But it's very difficult. And it's very dependent also on the messages of political decision makers.

FASKIANOS: I can take Morton Holbrook's question next. And he is talking about the U.S. election, Joe Biden has expressed taking a stronger stance on COVID. Can we expect, if he won, that the United States will rejoin the WHO and what effect that would have. And obviously, you see here in the United States, President Trump saying masks aren't necessary and Joe Biden saying we should wear them. So what is your response to that?

KICKBUSCH: Well, I think that's an illustration of what I just said, I mean, a public health measure for the whole community should be built. And, now we're going back to a whole lot of the other questions that were raised, should be built on the best knowledge that we have. And on the best way we want to organize our society. And we have learned, for example, in COVID-19, that we don't need to make a tradeoff between the economy and between our health, because we've seen, you know, where there has been a consistent public health approach, the fallout of the economy has not been as large, and the bounce back has been quicker than in other places. So I think making public health, or global health for that matter, a divisive issue and ideological issue is the worst thing that can happen to a health issue. And that's exactly where we are right now in some countries. And that is very, very worrisome.

FASKIANOS: Yes well, health does not know ideology, doesn't choose one or the other.

KICKBUSCH: Well we have got to be very careful, health is always political. And we see that certain approaches to health are more linked to one political ideology than the other. Wanting a national health service is more linked to, as we in our part of the world would say, a leftist, social democratic agenda, than having, another type of health system that is more linked, to the private markets, etc. So those things, go on all the time. But that is different, particularly within a democratic society. That's the kind of debate we need to have, and people can go to elections. But if there's a virus out there, that's killing people, that virus isn't left or right or anything. That virus is just killing people. But what the virus does do, it in particular, kills people who are disadvantaged, who don't have access to health services, and who are not protected. And so that is why in our report from the global preparedness monitoring board, we have said, there can be no health security without social security. And that seems to us to be an absolutely critical message.

FASKIANOS: Perfect. Let's go to Jonathan Azuri next. And go ahead, we see you're unmuted.

KICKBUSCH: Jonathan?

FASKIANOS: Okay, we're having technological issues. We're not—his sound is not coming through. So I'm going to move on, I will try to come back. So I'm going to go now to the chat function. Malik Majeed, who is—Oh, are you there?

Q: Yes, I am.

FASKIANOS: Okay, go ahead. Go ahead, Jonathan. Then I'll continue.

Q: Thank you. Thanks. So I'm Jonathan. I'm an MBA student at the University of Southern California. So I'm wondering, as we're going through this pandemic, I wanted to better understand if it was really unprecedented. And as I was reading, through the 1918 pandemic, and how that kind of evolved, it wasn't really unprecedented, right? I mean, not in our lifetime, it didn't happen. But it did happen before. And I was able to draw a lot of correlations between the way in which humanity dealt with the pandemic a hundred years ago, and the way that we're dealing with it now. And, the virus was different, technology was different, medicine was different. But I'm wondering, if we ought to leave a better world for our children and grandchildren, and we had a lamp similar to the one that Aladdin had with the genie, and we had three wishes that we could ask for, what would we do differently? What would we ask for to be better prepared for the next pandemic?

KICKBUSCH: Well, thank you for that, Jonathan. And you know, you're very, very right. And actually people are digging out suddenly, all kinds of information and stories and analyses of the so called Spanish Flu from a hundred years ago. And that was an event that most of us even in public health had forgotten, it just wasn't there. And I'm sure I'm much older than you, and even going back, asking my parents at the time about the Spanish flu when I was studying public health, it wasn't so part of their mindset. And we're seeing now, as you rightly say, that a lot of the things one has to do are actually not that different from then, despite this enormous technological advance. So we don't learn from history, that's point one. And so, maybe that would be one wish, that in some areas, particularly in public health, we do learn from history, because so much analysis is done. We did so much analyses following SARS, we did so much analyses following Ebola. And the political decisions that were necessary, were not taken. So in that sense, that might be my second wish to Aladdin, to say that we have, at least for a certain period of time, a bunch of really globally minded, politically responsible decision takers, that would put in place, the kind of infrastructure and the kind of communication mechanisms, we need to be better prepared. And, the list is this long. But if I take my own country, Germany, finally it's woken up, that we need to invest more in public health. And as a start, you know, 4 billion euros have been made available to strengthen the German CDC, to strengthen local public health systems, etc. And that would be a third component to strengthen the institutional infrastructure and the legal infrastructure, both at the national and at the international level, that makes us work together that allows us to work together, and that allows us to take responsibility for each other. So I think those are three things, we know what to do, but it needs to be done. And therefore, that would be my wish to Aladdin, get people in charge who will do it, and let's build the institutions that can help with that preparedness. There will be more pandemics. There is no question about that. And unless we're prepared, we're going to continue to spend trillions on the negative effects rather than having invested, as I said earlier, the billions that can actually help us be prepared. So I hope there's an Aladdin somewhere that will help us. Well, no worries.  Sorry about my phone here.

FASKIANOS: That's okay. So I am going to group three questions, since we're running out of time and we have a slew of questions. So from Mark Storella, Boston University, can you talk about what COVID-19 pandemic has taught us about the weakness of the International Health Regulations in terms of the obligation of member states to share information? How do we reform the IHR or is a new structure needed? And then there are two questions that are on vaccines. From Heather Carleton, who's in the doctoral program at the University of Mississippi, how great are variances in requirements on vaccines throughout the world and how will this affect access to vaccinations and their effectiveness? And the follow on to that is from Malik Majeed and Tsinghua University. While mechanisms like COVAX may be successful in developing procuring vaccines, they do not solve the delivery challenge. How should the global community mobilize to solve the delivery challenge, especially in developing countries where public health systems are weak. So hopefully you can thread all that together.

KICKBUSCH: Well, first of all, going to the IHR. I mentioned before that so many suggestions have been made, particularly after Ebola, how to revise the IHR. Definitely there's a strong feeling that the requirements and the pressure on countries to report needs to be strengthened. That there need to be, there are discussions of incentives, there are discussions of sanctions. There are questions, how can WHO gain more authority and independence to actually go into a country and check what's really happening. There's a whole range of things, but most of them are related to what countries would define as sovereignty. And what they were not willing to concede when the International Health Regulations were negotiated, I was in the room when they were negotiated. And countries were very keen not to give any kind of additional power to the World Health Organization. So unless countries are willing to concede some of that sovereignty for the common good, we are not going to get it anywhere. That's why I said, I hope we have a—everyone is so frightened right now that we have a cosmopolitan moment where they might be willing to do something. WHO has called the IHR revision committee, they are working on all the proposals. There's a good document by the CSIS in the United States on the various components that where the IHR would be changed, strengthened, revised, maybe you want to look at that. And I find that is very helpful, but it's about independence, it's about reporting, and it's about authority of the World Health Organization very, very clearly. And then, a whole lot of subcategories that are not strong enough, scientific cooperation, supply chains, and one area is very weak, because it's outdated. And that is the whole area of trade and travel, because this was written at a time where we didn't tap you know, the amount of tourist movement that we have now, etc. So, a very critical area that needs to be looked at. And you will remember there was all this question, which borders can and should be closed and all of that very, very political. Vaccines, I think, the delivery is really the key issue. WHO has started to try and work on ethical guidelines. But I said Berkley has said recently, in this case, there's one thing you can do to sort of try with you know, the various mechanisms COVID is trying to—COVAX is trying to put into place to get that to countries, but how it is going to be distributed in countries, meaning, first of all, who gets it, has to be an issue also of the countries. You would define that very differently in Japan with a very aged population compared to Nigeria, with a very, very young population. You would do it differently in countries that have a high percentage of health workers, than those that have hardly any. And you've indicated already a key problem, how can you do that in countries that don't have reliable health systems? Then you have to rely, for example, on the mechanisms and structures that have been put in place by polio program, for example. A key issue is we don't know yet what kind of vaccine or vaccines because actually, increasingly, we're talking of several types of vaccines, because the vaccine might not work in the same way for all people, for people with preconditions, for children, for younger people, for older people. The key issue is, do I have a vaccine that needs to be stored at minus 70 degrees, then it can only be given to people mainly in the urban areas, because nowhere else do you have a cold chain like that. So the problems are enormous. So we remain in that situation of building the plane, as we're flying it. So, as you rightly say, once we have the vaccine or we have a group of vaccines, we will have to see what's the best vaccine, first of all for what kind of population, and then we have to see how we get it to that population. And that will be such an enormous effort, which is why you know, we're talking $35 billion right now.

FASKIANOS: Well, we are at the end of our hour. Ilona, thank you very much for taking the time to be with us, this was terrific. And to all of you for your questions. I'm sorry, we could not get to you all. There are a number of still raised hands, but we do try to end on time. So I encourage you to follow Ilona on Twitter @IlonaKickbusch. And again, thank you very much for being with us. Next week in between the first and second presidential debates, we are hosting a virtual election 2020 U.S. foreign policy forum on Thursday, October 1, from 3:00 to 4:30 p.m. Eastern Time. This discussion will address the foreign policy challenges awaiting the winner of the 2020 election and critical issues for Americans to consider as we all cast our vote this November. So I hope you will join us for that discussion and share the invitation widely with your friends and your colleagues. And our next Academic Webinar will take place on Wednesday, October 7, at 1:00 p.m. Eastern Time with Matthias Matthijs, senior fellow for Europe at CFR and associate professor of international political economy at Johns Hopkins University on European integration and Brexit. So thank you all. Please follow us CFR Academic on Twitter @CFR_Academic and go to CFR.org for more resources and I hope you're all staying safe and well and school is going well for you all. So, take care and we look forward to your continued participation.


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