Corporate Program Young Professionals Briefing: Fact, Fear, and Falsehood: COVID-19 and the State of Global Vaccine Hesitancy

OLIVER: Thank you, and thank you all for joining today. Welcome to today's Council on Foreign Relations Young Professionals Briefing on vaccine hesitancy in the United States and also around the world. I'm Jove Oliver. I'm the founder and CEO of Oliver Global. And I am joined today by an outstanding panel of experts to help walk us through this vital question and also to take your questions at the end of the discussion period.

So, a quick round of introductions. We're joined by Alex Kendall, who's the vice president at Global Health Strategies. We also have Tara Kirk Sell, who's assistant professor in the department of environmental health and engineering at Johns Hopkins Bloomberg School of Public Health. She's also a senior scholar at the Johns Hopkins Center for Health Security. And Erin M. Sorrell, assistant professor in the department of microbiology and immunology at the Center for Global Health Science and Security at Georgetown University. Welcome, panelists, and thank you for joining us today.

We're going to take the conversation in three parts. The first, what's at stake with the vaccines? Second, diving into the problem of vaccine hesitancy, and concluding the discussion period with a look at some solutions to this really important problem. That'll take us about forty minutes, and at that point we'll open it up for twenty minutes of questions from all of you on the line. We have a great turnout today. I'm really thrilled that you could all join us. So please start jotting your questions down now. And we'll have time, again, the last twenty minutes we'll devote that. With that bit of housekeeping out of the way, turning to what's at stake here. I'd love to turn to you, Erin, and just get a quick history of vaccines. What are they? In thirty seconds, how do they work? A quick primer on the issue at stake here.

SORRELL: Right, thanks Jove and thanks to CFR for hosting this panel. So very quickly, if we think about vaccines, they look at mimicking our body's response to a natural infection. So if we are presented with a pathogen, we look at nonspecific and specific responses to that pathogen. Once we've recovered, we maintain a subset of what we call antibodies, so if we're re-infected by that pathogen or family of pathogens, we can fight off infection sooner, maybe become less ill, maybe have no clinical manifestations whatsoever. So vaccines skip that step by looking at eliciting antibodies to, develop antibodies based on presentation of either a killed pathogen or specific subunit, what we call an antigen, of that pathogen. And so the body develops antibodies, and then when we are presented through a natural course of infection, we fight it off quicker. So vaccines can take roughly two to three weeks to really develop what we consider immunity. Some vaccines require booster shots, so a second shot to elicit, maybe sometimes third shot, to elicit full protection or efficient protection. But then once we have that we're able to fight off infection productively.

OLIVER: Thank you. That's a great quick primer there. Alex, I want to turn to you. You work around the world with governments, UN agencies, NGOs. From your firsthand experience, how have vaccines really transformed things like global health, child survival, and other critical development priorities?

KENDALL: Yeah, and thanks, everyone, for having me and for joining today. I think the impact of vaccination on helping people around the world is hard to exaggerate. Vaccines are one of the greatest scientific innovations of all time. They are one of, if not the, health intervention that reaches the most people and often people's main source of contact with the healthcare system. Vaccination coverage rates are around 86 percent around the world. And in about the last thirty years, child deaths have decreased by over 50 percent in large part due to vaccines. Billions of people around the world are protected from a range of vaccine-preventable diseases from whooping cough to measles to coronavirus. And so they really are a core source of health around the world. And just a note, I think in the U.S. and in other high income countries, it can be hard to marvel at how amazing vaccines are because we really haven't witnessed the devastation of many of the diseases that vaccines help us prevent. So COVID I think has actually been a reminder to all of us of what is at stake and why vaccines are so important.

OLIVER: Absolutely. I want to kind of dig deeper there and turn to you, Tara. You work a lot of your day in global health security. I don't know how much our audience knows about global health security, but it's a really critical area of study. And I wanted to get your opinion on how vaccines contribute to our sort of collective global health security.

SELL: So thanks so much for having me here to speak. As you mentioned, my background here is in health security and pandemic preparedness and response. Obviously, when you're thinking about health security and pandemics, you have just a really limited solution set, right? You have non-pharmaceutical interventions, like keeping people at home, quarantines, those types of things, or you have everyone getting sick and hopefully having some sort of immunity and not having too many people get sick and die, or you have vaccines. And so really, if you have those three, you really prefer vaccines.

And the other thing is, in the last five or six years I've been working on risk communication. That's mostly because I came to the realization that you could have the best response plan, you can have the best vaccine and in fact, we have a bunch of really great vaccines. But if you can't get the public to go along with that, you are pretty much sunk. So, it's becoming more and more evident that if you want to communicate effectively with the public during a public health emergency, you're also gonna have to deal with mis- and disinformation. And just so that the audience is clear on that, misinformation is false information that results from mistakes or ignorance, and that's damaging but limited in scope. And then if you think of disinformation, that's a much more kind of insidious, false information that's created or purposefully spread, to deceive or achieve some sort of particular aim. Usually, that's political or social or financial. So dealing with these issues is a really important part of figuring out how to do a better job next time in a future pandemic.

OLIVER: Yeah, no, absolutely. And we could probably spend the entire hour just talking about the successes of vaccines over the decades and how much they've transformed the world. But I want to conclude this session with one final question to you, Erin. It used to take many, many years to develop a vaccine for something. I mean, a decade or longer when it first started. But now we've been hearing this sort of catchphrase mRNA floating around, and I think Pfizer and Moderna, I think there's a couple of vaccines that use the mRNA technology which is really exciting. Can you maybe spend a minute talking about that, but also how like these big killers we have infectiously around the world, malaria, tuberculosis, how can potentially mRNA change the game? Not just for COVID-19, but for other infectious diseases.

SORRELL: Sure, happy to. I think mRNA is an appealing technology and a technique. It's been around for a number of years, actually about twenty years, it just hasn't had success until SARS-CoV-2. And that's for a number of reasons. But the idea is that the mRNA vaccines actually work by providing what we consider a genetic code for ourselves to be able to produce those viral proteins and those viral antigens. And that's what our body then would respond to and develop an immune response. So the proteins themselves don't cause disease. And they could theoretically be produced by, mRNA vaccines could produce any type of protein. So it's a really attractive technology. Much simpler, as you mentioned, Jove, to manufacture than inactivated viruses or live attenuated viruses that can take months on a production line to create.

And it can be a really useful platform, not just for our traditional big killers like TB and malaria, but for novel and emerging diseases that we cannot anticipate. So it can become a plug-and-play technology for vaccine development. Once you have a genetic sequence, you're able to then create the mRNA, insert it into a template and then be able to create that vaccine. I think when we look at malaria and TB, again, major killers globally, TB accounts for the largest number of deaths worldwide. And we also have to consider antimicrobial resistance associated with TB, so a major public health issue, as well as malaria. It's targeting the right antigens in that mRNA technology to be able to create an effective vaccine. The current vaccine that's being trialed in a number of countries on the African continent for malaria was created in the late ’80s and has had some success. But I think mRNA could be a great platform to try for malaria as well as TB.

OLIVER: Awesome, awesome. So I mean, listening to all of this, I'm sitting here thinking this is kind of like a golden age of vaccines right now. We're sort of living in in the promised land and yet we also hear more vociferous, maybe perhaps well-organized opposition to vaccines as well. So switching to the issue, the problem of vaccine hesitancy.

Alex, I want to turn to you first. Can you walk us through the landscape? I mean, there's sort of anti-vax, there's vaccine hesitant, there's other kinds of legitimate questioning around vaccines. I just had a six month old. We were getting his first series of vaccines. We got a lot of questions for the doctor, but ultimately, we got the vaccines. And so can you break down the difference between these issues here in the United States, but as well around the world?

KENDALL: Yeah, it's a really good question. I think, the vaccine landscape is a lot more complicated as you know than people who are just for vaccines and against vaccines. I think a couple of foundational points that I feel are important to make before I dive into some of those differences are, one that the vast majority of people around the world believe that vaccines are safe and effective. One of the best resources that we have, which is now a couple years old, is a global study that was done by the Wellcome Trust on attitudes around health and science around the world. And globally, they found that 79 percent of people, respondents, said that they felt the vaccines were safe, while only 7 percent disagreed. Those rates differed by country and high-income countries showed the highest rates of skepticism again, potentially, because as I mentioned earlier, the diseases that are prevented by vaccines are less visible. In low-income countries, the rates were very high. 95 percent of people in South Asia and 92 percent of people in East Africa, for example, said that they felt that vaccines were safe and effective.

The second point that I think is important is that reluctance to get vaccinated is often not because of some form of mistrust, or fear, or lack of desire to get that vaccine. Often they're access issues, whether it's convenience, or logistics, or real or perceived affordability. So it's good to hold those two points in mind.

That said, vaccine hesitancy is certainly a growing source of concern, and very much in the context of COVID. The proportion of people who are truly anti-vaccine are relatively small. There's a much larger proportion of people who are skeptical or have questions, but are open to vaccines, and it's a very diverse group of people around the world. In different countries, the highest rates of people who express vaccine skepticism may be men, may be women, may be older people, may be younger people,e in the U.S. maybe evangelicals or people of color, so it's really all across the map. And sometimes vaccine hesitancy is around a single vaccine, sometimes it's around vaccines in general. So just a note that it's a very, very diverse group.

And often, I think contrary to some public opinion, people who have skepticism around vaccines are not irrational, they're not necessarily uneducated. There are a whole host of reasons why people may express some skepticism. So as you mentioned, Jove, it may be a parent who is worried about what they heard about side effects and are making a decision for the first time to get a newborn vaccinated. In countries that have complicated history with the West, polio campaigns, for example, are still really challenged by rumors around nefarious U.S. intent as part of the campaigns. In the U.S. in the context of COVID, where we see some skepticism among communities of color, and especially Black communities, there is often a history of structural racism in our healthcare system cited as a reason. So it's a whole host of reasons why people may have questions, but I think, important to note. And in my work in health communications, whereas folks who are truly anti-vaccine often have opinions that are not necessarily changeable, there is this large proportion of people who I think are open and who we can reach, even if they do have some questions.

OLIVER: Yeah, no, excellent point there. And I think, you know, it's not a brand new phenomenon, it's been going on for some years now, but the sort of celebritization of vaccine hesitancy. Rolling Stone actually had a list of seventeen celebrities who raised questions about vaccines, often alongside the very noted anti-vaccine campaigner Robert F. Kennedy Jr. Alex, how much do — or sorry, Erin? Sorry, got the questions wrong.

Before we go to celebrities I want to go back a little farther and go to you, Erin, because before the celebrities started getting involved, it was a little bit of an academic mistake, I'll say, that the Lancet made. It has since retracted the study by a guy named Andrew Wakefield, a prominent study in 1998, supposedly linking vaccines to autism. This was a really seminal event in catalyzing global doubts about vaccines. And so Erin, I wanted to turn to you and just have you talk a little bit about the Wakefield study, and maybe some other moments that have really served to generate and spin up a lot of questions about the efficacy of vaccines.

SORRELL: Great, thank you. And I think one of the benefits of being an academic is we can admit when we've made a mistake, and research is all about reproducibility, right? So particularly when you're looking at publications and being able to retract something, thank god this one was, although it did take a while, and it had a lot of damage in the meantime.

I actually wanted to bring up an example that had a global impact, and was only a few years following that paper. And it really began, Alex alluded to some issues with polio campaigns and vaccine campaigns in a number of countries based on political influence, mistrust of different international organizations or national entities that may have potentially influenced one way or another. In the late ’80s, WHO instituted a campaign to really look at taking polio out of Africa, out of the continent. And the final stage really took place in the late, in the early 2000s excuse me, and Nigeria was targeted in 2003 as kind of that final stage, particularly in West Africa, to eradicate polio. At that point, Nigeria accounted for roughly 40–45 percent of cases globally, but a majority of cases on the continent, about 80 percent, I would say. They are a very populated country, and that was a major target for WHO and for the regional office, WHO-AFRO.

There were religious leaders and political leaders in actually three of the northern states in Nigeria that publicly stated that this vaccine would create fertility issues in young girls, could lead to infection with HIV or include carcinogens, and was a risk for children. So even though the risk of infection from polio far outweighed the risk of having these major issues with your children if they were vaccinated, and communities complied. They believed their political leaders, they believed their religious leaders for a number of reasons, both in terms of mistrust of the central government, mistrust of Western nations and mistrust of international organizations that were really rolling out this campaign. The boycott, again, was only in three states in Nigeria, and it lasted about a year, about fifteen months. It led to over a thousand cases worldwide, because of travel in and out of Nigeria. And by 2008, Nigeria accounted for almost 85 percent of the global burden of polio.

So what would be considered kind of short-term boycotts led to major impacts globally in terms of eradication, as well as impacts in Nigeria. These rumors, of course, were fueled by local leaders and influential people, people that communities trusted. And it really took a collaboration between Muslim nations across the globe, local leaders, respected UN representatives from African countries, to come together to figure out how best to think about, as both Alex and Tara mentioned, risk communication, education, outreach about the safety and efficacy of the vaccine. And sadly, it really wasn't until last year in 2020, where the African content was able to be declared free of wild-type polio. So something that started in the late ’80s and really started to really move forward in the early 2000s took seventeen years potentially because of this fifteen month boycott. So there's just one example of how I think misinformation can really lead to major implications for vaccine preventable diseases and in this case for eradication on the continent.

OLIVER: Yeah, thanks Erin, and mentioning that critical role of community leaders, local leaders. Turning to Alex and Tara, I want to go back to my question that I was repeating with that sort of celebrity involvement, but also other spokespeople, other thought leaders and communities and how, the role that they can play in sort of either spreading misinformation or outright anti-vaccine conspiracy theories in some cases. Alex, you want to go first? And then Tara?

KENDALL: Sure. Yeah. I think there are a couple of different points that I feel are interesting to make here. One is that you mentioned celebrities, and of course, when anyone has a large platform on social media and they can reach many people, it's irresponsible and very problematic when they use that to push out mis- or disinformation. But I also think there's a differentiation between a celebrity who may retweet something, celebrities are actually not cited as a main source of health information for most people. And there's a good study from the Center for Public Interest Communications, that names the different sources that people have turned to.

But you named Robert F. Kennedy, and he is, I think, a part of a group of highly organized individuals and organizations who are part of this anti-vaccine apparatus that is really intentionally and consistently pushing out conspiracy theories and disinformation around vaccines. And so I think that is a very interesting thing to understand. In fact, there was a recent study from the Center for Countering Digital Hate that found that the majority of anti-vaccine content on Facebook originated from just twelve different anti-vaccine entities or activists, RFK being one of them. And I think Tara has done some work on this as well, if I'm not mistaken. So there's a really sort of intentional, professional propaganda apparatus that is at play here. And occasionally celebrities use their platforms to amplify some of that, but it often originates from this very small group of people and organizations.

SELL: Yeah, that's exactly right. I think that we have a small group here that's really expanding its reach. And they really worked to create a larger narrative that all these other sort of lies and misleading content really fit into, so that it all fits together, and it makes sense in people's minds. It pings on the values, and beliefs, and identities that they have. And so then it just works in sync, and so you have this whole set of things, and it's not just one fact that convinces someone that they have a problem with a vaccine. It's this swirling set of things that they're hearing from people they trust, or people they know, or being retweeted. And that can then be a real problem, because it's hard to peel those pieces away, because you have to peel every piece away.

But the thing that's really critical here, and Alex mentioned this, Erin mentioned this a little bit, that we need to have people who communities trust. That these celebrities, they can say what they want, but if your local pastor, someone in your community, a community leader, even someone like a local weatherman who you see on the news every day and you trust, these things, these groups of people who are part of the community, who are in the trenches, who can tell people this trusted information that is really critical. And at the stage we're at right now with the COVID-19 vaccine in the U.S., they're probably the most important set of communicators we have. Because people who have not gotten their vaccine yet are not the people who are listening to Dr. Fauci and they're not going to be convinced by anything he has to say. So we need these on the ground communication efforts from community members and people who are trusted, and that's really the next step.

OLIVER: Yeah, I know, I saw a lot of polling that people's local doctors and focus groups, like people they know that have gotten it and it's super, super effective. Thanks, Tara.

I want to, so this is sort of admittedly unscientific, but I went through and just guessed in advance of this, guessed at some possible drivers of vaccine hesitancy. We've touched on a few of them now. I'm just going to rattle off a few of these and then kick it to each person on the panel to sort of go through quickly and see if I hit on stuff that made sense or not.

It feels like social media and the speed and scale at which these conspiracies or questions or whatever it is, can travel is just growing by the day and is unprecedented and that seemed to be a major driver. I mentioned that I recently had a baby and we were, my wife was doing lots of research and she came across this horrible rumor that could the COVID vaccine cause infertility and I was just like that's, absolutely no science behind that. But these sort of memes that play at your psychological weaknesses or things you're concerned about seem really, those sort of false narratives seem really problematic.

But then, we have very, valid things of like J&J and AstraZeneca briefly suspending use of their vaccine around a blood clotting issue that turned out to affect a very small number of people. And they did the right thing by stopping, making double sure, and then reintroducing. But also, I wonder how that lands in the public psyche of raising questions.

And then I think, I've seen some places you have complacency. I was reading an article about Australia, where they have relatively low rates, leading to some complacency in getting the vaccine. What do you all think? Maybe we stay with Tara for a moment, and then Alex and Erin. What are the drivers of vaccine hesitancy in your opinion?

SELL: Well, I mean, I think that you've named a lot of them, that we have a combination here of social media, we have political and social drivers that are pushing people in certain directions, and financial issues happening. We have unforced errors by especially AstraZeneca. And just a number of issues and communication problems that we've sort of put on ourselves, only trying to communicate with people who are inclined to listen to us anyways.

But I actually, I love your list for another reason, because I think it tells us where some solutions could be. And I know we're going to talk about solutions in a little bit. But it's also telling me that we have problems in a lot of different areas. And so, social media is one problem we need to have people fix. We need social media to fix their algorithms. But, that's not the only, that's not going to give us the solution, right? We need that. And we need to deal with these false narratives. We need to manage the politics, we need to do a better job communicating all these things. I think the problems you pointed out also point us towards a solution, which is probably a difficult and big solution, but it's a solution.

OLIVER: Yeah. Erin, Alex, anything to add to that?

SORRELL: Alex, please go ahead.

KENDALL: Yeah, I mean, I think your list is a good one, as Tara said. I think vaccine hesitancy is often fundamentally an issue of trust, whether that is trust in governments, trust in the pharmaceutical industry, trust in science more broadly. And when there is lacking trust in the system, for whatever reason, it's much easier to sow doubt among people. And social media allows people to either broadly push out conspiracy theories or disinformation, or really amplify specific occurrences or events that happen, say with J&J, and run with that. So it is kind of a perfect storm of different psychologies and lessening trust in certain institutions, with the platform then to really push out those theories widely.

OLIVER: Yeah. And maybe, Erin, I'll turn to you first on this last question in the second section, and everyone can weigh in as well. But what does all this mean, globally for the fight against a COVID-19? Dr. Fauci and others have said we're probably not gonna reach herd immunity here in the U.S. We might have to live with SARS-CoV-2 at a lower rate, something like flu previously. Erin and then others, what is it, all these drivers, all this misinformation, what does it mean, ultimately, for this sort of golden age that we started talking about when the conversation commenced?

SORRELL: I'll say, as a retired virologist, because I haven't picked up a pipette in a number of years, I think what's interesting and challenging, right, is that, and I'll sound like a broken record, when you think about diseases it's not a national issue. It's a global issue. So vaccinating the U.S. is not going to protect us from coronavirus variants that continue to circulate in other parts of the globe because vaccines are not equitable or accessible. So we have to think of this as a global issue. And Dr. Fauci has mentioned that, a number of public health experts have mentioned that, as well as diplomats and world leaders. This is a global challenge. We're seeing variants coming out. There was just an article this morning about highly transmissible variant popping out in in the UK that was circulating in India and looks to be something that could be at risk for the U.S. So until we look at how to contain the virus and how we provide it an opportunity not to infect anyone, right so through vaccines, that's the best that's our best response.

The next is looking at non-pharmaceutical interventions, as Tara mentioned, right, thinking about social distancing, facemask wearing. If the virus has nowhere to go, it goes away. If there is not a human host that is susceptible, we no longer have an issue. If the virus is able to create a variant that escapes immunity, we have an issue. So the more opportunities we give this virus to create variants and to circulate and transmit, we're opening up the door for this to be a long-lasting issue both in the U.S. and globally.

OLIVER: Yeah, no, absolutely. Tara, Alex, anything to add on the problem section before we turn hopefully with some more optimism to solutions to the issue?

SELL: Let's get to the solutions.

OLIVER: (Laughs.). Move to the solutions it is. So maybe we'll start with you, Tara, because you began to give us the sort of distinction between misinformation and disinformation. I've been seeing in my Instagram feed just tons of warnings, and even when I'm seeing people post that they just got their vaccine shot with a big smiley face, there at the bottom it's like this is, could be misinformation. I forget what it says exactly, but I'm seeing the warning pop up on all vaccine content. Can you talk a little bit, Tara, we started talking about social media from the problem standpoint, you alluded there, maybe some solutions there, maybe expand on that a bit?

SELL: Well, I think the solution set is bigger than just social media. But like I mentioned, social media is a huge stakeholder, right? But I think what we really need in the U.S., and globally this is going to be harder to do, in the U.S. still hard but not as impossible, is that I think we need a national strategy to manage health-related misinformation and disinformation. And so this needs to be something that brings in all the stakeholders, that includes social media, that includes public health, that includes the national security apparatus, news media, scientists, bioethicists, bringing these people together to help develop a solution, perhaps including a commission to help develop the guiderails for how we sort of define and manage mis- and disinformation.

But that strategy is going to need to think about how to control the sources of misinformation, control both the spread and the sources of misinformation and disinformation, to increase the voice of and the circulation of good information. Because a lot of these health departments, they've got one person doing all their communication, and that's just too much, we need to change that change that variable. We also need to make it so that the public is more resilient to misinformation. So we know we'll never be able to get rid of it, right? But if it can hit people, and they know it for the falsehood or misleading content that it is, then it's not as impactful, right? So we need to give them the tools and the digital literacy to figure that out. And then finally, like I was mentioning before, we’ve got to bring all those stakeholders together. Get the agencies, this is a multi-agency effort, we can't have it be one agency at a time, one stakeholder group or industry at a time, it needs to be collective action. Otherwise, we're just going to be playing whack-a-mole.

OLIVER: Yeah, no, absolutely. And, Alex, I want to turn to you next. You work a lot in public health communications. And we've talked a little bit about that. I'm always fascinated by the comms people. I was googling around before this and Frank Luntz, who's a Republican pollster, had a bunch of Republicans, we mentioned how politics can be a driver or pull people and tribalism can pull people. We were mentioning it's those sort of local connections, people's own doctors and families, that are some of the best messengers for changing people's minds if sort of anti-vaccine or have questions. So Alex, from a sort of public health communicator standpoint, what are the solutions here? What are the solution sets? And how does that maybe differ a little bit for more advanced economies to working in some of the lower income, developing countries that you work in?

KENDALL: Yeah, I think there is no single intervention that is going to convince people to get vaccinated or change people's minds. But I do think there are some really important points that are clear and that we're continuing to learn. One, going back to what I was saying before about the diversity of people who are vaccine hesitant. People want to be listened to, and I think it's really important that as communicators, we lead with empathy and understanding and that we treat questions that people have with respect. I think it is far too common that people who encounter someone who is vaccine hesitant dismisses those concerns as ignorant. But we really do need to engage in some form of conversation and have listening, social listening on social media to see what concerns people are expressing and where that is coming from. And then, conversations that are really based in an active listening about vaccines.

The second point that we've each talked about is that the messenger really matters. People trust messengers who they know, where they trust their motivations. People trust people within their networks that align with their identities, their morals, their worldviews. And so thinking about who those people are around the world in different communities, whether it's religious leaders, or moms, or teachers, or your own personal doctor. I think the FDA, Fauci, the World Health Organization, these are not always going to be the sources that people turn to. So really localizing who is getting those messages out and having them do so in their own voices within their own context is really important.

And then the one other thing I want to note is the importance of personal and emotional storytelling. The public health universe is, our communications historically had been very fact based, very evidence based, and the small but organized anti-vaccine community has been much better at telling really emotionally resonant personal stories. And in some ways, all the anti-vaccine community needs to do is plant a seed of doubt, so that people don't take an action. A community trying to encourage vaccination has to convince someone to actually take an action, proactively. And that's a harder job. But people listen less to facts being thrown at them than they do to really personal storytelling. And so as a community, I think we need to get a lot better at how to tell the stories of what's at stake and why vaccines matter.

OLIVER: Excellent. We're going to turn to questions in a minute, so please get your pens out and write your question down and think about getting in the queue. But before we do that, I want to turn back to Erin and Tara. We talked about a few things beyond COVID-19. But this is not just a COVID-19 problem, as you all know. Can you talk a little bit about health-related misinformation, disinformation, around future health threats? Whether that's infectious diseases that are operating just in one region that can grow and become worse, I'm thinking Ebola, or drug-resistant tuberculosis, or other future health threats that we haven't even heard of yet. Maybe we'll start with Erin and then Tara.

SORRELL: Thanks. So yeah, I think this is a really important topic and will keep my comments brief, because I'm sure Tara has a lot to say on this as well. I think it's important, I think as both Alex and Tara have alluded, that how we correct misinformation or disinformation that's coming out, particularly about novel or emerging diseases that may seem scarier because they're new to us and they elicit an emotion of something that we don't know how to control or we don't know how to understand, includes not just local respected leaders, but thinking about the fact that scientists are allowed to make mistakes, and that we're learning and we are doing conducting research in the midst of an outbreak.

And so if we think about effectively communicating and having experts, both basic scientists, public health experts, local leaders, religious leaders, even our I think, as Tara mentioned, our local weathermen and women, be able to tell that story and say, here's what we know right now. It could change, please continue to listen to us, please continue to trust us, we're doing our best with the information we have at hand. Particularly for those scary emerging or novel diseases that we don't know the risk for global spread, or we don't know the risk to our neighbors or to our loved ones, or to a country that we have friends and family in that could be a risk to us at home.

It's thinking about how as diseases emerge, research emerges, data and information will emerge. And trusting the public health experts and those basic scientists that are doing the research to develop either the countermeasures or the vaccines, to sometimes get it wrong, but to ultimately get it right. And I think that's what we saw with SARS-CoV-2 the challenge is making sure that as you're communicating your information, you say, again here's what we know. It's going to potentially change, or we may have guessed right, and I think that's really critical in moving forward and thinking about the diseases that have yet to really hit us in terms of a public health or global health perspective.

OLIVER: Right. I want to give Tara the last word. But first, Alexis, do you want to give people the instructions on how they can queue up and then they can start to queue up with their questions while we get the last word from Tara on the discussion section.

STAFF: [Gives queuing instructions.]

OLIVER: Great, while they're queuing up, Tara, do you want to give some final thoughts on that and wrap it up for us a bit?

SELL: Sure. I can't emphasize enough what Erin just said. That scientists need to do a better job communicating. If there's a future threat, we need to understand that probably what we know is going to change. And it would be great if the public had that sort of scientific literacy to say, oh yeah, well our understanding of, we're going to collect more data and it's going to change and that would be great. But let's be honest, we could probably just sort of start to head that off as we grow scientific literacy, and say okay, here's what I think now.

And I certainly wish that I could have gone back and taken back a few comments that I made about masks early on, and said, well, here's what we think right now based on what we've what we know about masking in the past. But if I could change, I wish that I had done that. And certainly that's a good lesson for all of us going into the future. Being able to say I don't know.

Now, Jove, you brought up the Frank Luntz polling, and one thing he said was that, oh well, people don't really want to hear about uncertainty. But I feel like I've got to tell you when I'm uncertain because otherwise, the next time I say something you might really have a problem with me if I was wrong. So I'm going to keep telling people when I don't know what I'm talking about because I think that that's really important. That's critical. The other thing, that I, oh I've just completely lost my thought. Going back to the question that you asked. So anyways, we could go on, and I'll jump in if I can, if I get —

OLIVER: — Yeah just around the misinformation and disinformation in the future of public health…

SELL: Oh! That reminds me.

OLIVER: Did that jog your memory?

SELL: Yeah I got it! Yeah. So my team actually did an analysis of tweets about Ebola that came out in 2014. And while the misinformation and disinformation that we saw was not at the volume that we see now, many of those stories you could just cut and paste and replace the name in there. So I think that we have the tools and the lessons, and it won't be exactly the same. But we certainly know what kind of narratives we're going to have to deal with, if we have to deal with a future pandemic.

There may be new ones, there may be surprises, but based on the fact that some of these narratives have been used since smallpox, that we should be able to sort of think ahead and develop some communication strategies that manage them, because we know what we're going to hear.

OLIVER: Yeah, no, absolutely. As a reminder, the raise hand icon, we're still waiting for our first question. So don't be shy. We've got great experts here to talk about that. I have a bunch of other questions. I'm just going to keep going until we get that one from the audience queued up there.

There's been a lot of discussion about vaccine passports, right? And I feel like, I want to go to some tropical island for vacation, because I have not been on a plane a long time. And I'm like, do I need a vaccine passport for that? And so I was just reading about this issue before the panel. And, there's a lot of employers who are now thinking about workers coming back to the office, are they gonna, all of us here are probably gonna have to grapple with, are we going to conferences, or are we doing, in-person stuff? And if so, do we need a passport? Do we need, are there going to be mandates for mask wearing or vaccines? And who should be giving those mandates? Is it going to be state, national employers?

Employers in a recent survey said they would much rather than government deal with this question than them. Can y'all comment on that? And maybe we'll start Alex, with you. And then anyone else who has thoughts on this, talk about the tension on that policy standpoint between sort of state, national government and employers who are trying to grapple with some of these questions and they're not health experts, and they don't have a CDC they can call.

KENDALL: I actually wonder if Erin wants to jump in here. I don't feel like I'm an expert on this at all.

OLIVER: Yeah. Erin, do you want to take a shot at that?

SORRELL: I will admit, as Tara said, we should always say when we're not completely sure. So I'm going to say this is my opinion. But I think what's challenging is when employers look at encouraging or requiring vaccinations, right? Then the onus is on them to make sure that their employees are getting access to the vaccines, maybe they're helping them cover it with insurance. They're making sure they're complying with, depending on the vaccine that they get, a potential booster.

And if employers differ, there's going to be challenges with maybe individuals who don't want to wear a mask when they're not vaccinated will choose one company over another in terms of maybe a grocery store or a home goods store or, pick and choose. Target has a different policy than Walmart that has a different policy than Giant. And that might influence where you do your shopping. So that can be tricky I think, from an employer standpoint.

In terms of more of our employers that aren't providing services, if we think about how to encourage and make sure that employees feel safe in that environment, that working environment, I think it's really tricky if there isn't a set policy nationwide. And so for the U.S. where we have both a federal and a state-level public health system, public health is owned by the states in the U.S., but we do have federal entities that should oversee things like pandemics, because it's not a state-level issue. I think there's a balance there.

From other nation's perspectives, again, depending on how their government is structured it can, it can vary on how that requirement would get allocated out. But I do think from at least my personal opinion, if I can throw in a little professional personal opinion, I think it's important that health offices or health agencies at the national level support vaccines and encourage citizens to get vaccinated and provide opportunities for equitable access. And mechanisms to get that right, even in the U.S. thinking about social determinants of health and how certain populations in the U.S., if they didn't have a mode of transportation could not get vaccinated even if they wanted to. And so thinking about providing platforms where individuals can get access to the vaccine, I think is critical. So I dodged your question a little bit there, but.

OLIVER: No that's great. We have our first question from the audience. So I'll kick it over to Alex, Alexis, excuse me, to get that question going.

STAFF: Sure, we will take our first question as a written question from Mary Ioannidis, who asks, how can platforms like Facebook and Google do more to address vaccine hesitancy?

OLIVER: Tara, I feel like this one was tailor-made for you.

SELL: Well, I do think that Facebook and Instagram and well, I guess they're owned by the same company, and Twitter, they have recently done a lot to try to tone down the lies and the misleading content that they have on their platforms. We were in the middle of an analysis, and we actually had a bunch of tweets that we had noted, and then we went back to take a second look at and they had been taken off. And so this is an active issue that's happening. I do think though that more needs to be done, we need to be active about, having the algorithms take down or downgrade the more misleading content and push up the public health content, because that's pretty difficult. Right now, public health departments don't have the best following and they just don't get up there.

But my caution here, is that I don't really want Facebook to be determining what's true and what's false. That kind of weirds me out. And that's maybe because my personal feelings about what businesses should be telling me is true or not. But I think that, we should be careful about that, just like we should be careful about government censorship and these types of things. And so that's why I think that it needs to be kind of a larger stakeholder effort, where we bring in public health, news media, all these groups. And also that we figure out a way to allow people to have dissent, because in some areas, scientific understanding changes, our understanding of the topic changes, and we can't be sort of so focused on one thing that we can't allow for dissent. It just is a trickier issue, because this dissent can sort of trigger this vaccine hesitancy, plays into a narrative and that can be really problematic. So I think it's a sticky issue and not one that I'm going to be able to find a solution to. We're going to need a lot of people, not just me or us on this call.

KENDALL: I guess a couple other quick things to add to that, which is that when you look at the kind of timeline of missing disinformation, from creation, to posting, to going viral, to trying to myth bust, a lot of interventions that happen now among, on both platforms and among public health agencies, is towards the end of that timeline, fact checking or myth busting, correcting. And, it may be somewhat helpful, there is some evidence that it is somewhat helpful, but it is often after misinformed posts have been really widely seen.

And sometimes when a video say that has been viewed millions of times has been taken down that actually kind of fuels the fire in terms of speech being censored, or, it gives it kind of a second lease on life. So I think Tara made a really interesting point earlier on about how we think about interventions, sort of towards the front end about equipping people with more digital literacy and more information to sort of make sense of what you're seeing on your own as well.

OLIVER: Yeah, excellent. We have a couple more questions. Alexis, do you want to go to the next one?

STAFF: We will take our next question as a written question from Kelsey Ritchie, who asks, how does vaccine hesitancy differ among different demographic groups? For example, are we seeing certain narratives gain traction within a certain community or demographic?

OLIVER: Yeah, I don't know, Erin, or who wants to take that one?

SORRELL: I'm happy to answer that. But I don't know if Tara, based on her research, has it. I defer —

SELL: I'll let you go, Erin. I mean, I don't know a particular rumor for a particular demographic. I'm not sure about that.

SORRELL: Yeah, I mean, I think this is a great question. And this is an important thing to consider with risk communication with public health outreach to different communities, to different demographics, to different age groups. Everyone's going to have different priorities based on their health outcomes, what they think their risk factors are. And so I think that they're, I don't know specifics, but I would say that I would guess there's definitely differences in how messages were received, or how vaccine hesitancy has been received and complied or practiced, let's say, across different groups. I think that's when conducting that research and doing that analysis, collecting that data, will help us then really be able to tailor additional communication out to those target audiences in the platform that they are most receptive to. So I think that's an important thing to consider.

KENDALL: Yeah, just to echo that, I do think that there are different forms of disinformation, rumors, theories that take hold in different ways in different communities and different demographics. This is true all around the world. Often misinformation is very contextualized. And so to just echo Erin's point, their response also needs to be highly contextualized and localized. And that's why both the messenger and the messages that are being used can't be cookie cutter, and are so important to think about in the context of what different groups are responding to and feeling.

OLIVER: Yeah, thanks, Alex. Can we take our next question, Alexis?

STAFF: We will take our next written question. What advice do you have for people who are now interested in working in public health following their own experiences with the pandemic?

OLIVER: I bet all three of you have excellent advice on that. So maybe we'll start with Tara and then Erin and Alex.

SELL: Sure, so there are a lot of really burnt out folks in public health right now and we would love to have some new fresh blood, some excitement, and some people who are passionate about this. So I think that that's great to hear. I think that we, coming to think about joining public health departments, going if you don't have an MPH, a master's in public health that can help.

But I would also say, if you're interested in being employed in, or to have public health to be more of a priority, we need to lobby our policymakers that this is important that we need to fund this more and public health at a federal level, preparedness for these types of pandemics. This funding has gone down and down and down and down. And when there's federal funding that goes to the states, and then the states sometimes take away what they're contributing to. So, we need to have across the board funding of public health as if it is a priority because it is. We have learned that and I don't want it to be a cycle of panic and neglect. So welcome and also, we need to make sure that we have the political support to funding better public health force.

OLIVER: Erin, your advice?

SORRELL: Yes. Come. Welcome. Join us. Echoing Tara 100 percent. I think one of the things that, particularly this group of professionals, young professionals coming into the career, whether it's through graduate program, through continued education, or on the job training, we saw in this pandemic and I think public health professionals knew this and now the world knows, it's multidisciplinary, right? You can approach public health from an economist’s perspective, from a policy perspective, from a security perspective, as well as a myriad of science and technology perspectives. So you can get into the public health field really studying anything and applying it and educating that cohort from that perspective.

And as Tara mentioned, funding is key. If we do our job well, there's nothing to report. And so it's really hard to get funding because no one knows you save the world. It's only when disaster happens that the funding really comes in. And so it's really hard to show that return on investment. So my challenge to everyone interested in coming into this field is how do we get people interested in funding so that we can prevent and we can detect versus having to respond and recover? I think that's going to be a big challenge for everyone joining us in the future.

OLIVER: Alex, any other advice from you?

KENDALL: Yeah, I love this question. And as Erin said, if you're interested in foreign relations, if you're interested in economics, if you're interested in gender equality, you can make a long, long list, health is really at the foundation of a lot of those things. I think something that the pandemic has made incredibly clear to everyone, that a lot of people in the public health space have known for a long time, but now we all know every day, is that global health is local health and local health is global health. Until this pandemic is over everywhere, it is not going to be over anywhere. And so I think for those of us thinking about health at a global scale, also really looking at our own backyards around how issues of inequality, access, coverage are unfolding is an incredibly useful place to begin to study and understand some of the dynamics that are relevant to the world over. So an open invitation to join the global health space and to reflect on that both in the world and at home.

OLIVER: And I'm just gonna, we have two last questions and we only have one more minute, so we're gonna do a quick fire drill where I'm going to really quickly mention both and then just like thirty seconds from each person as a closing thought. Someone asks about lessons learned coming out of this both for public and private sector, what lessons should we really keep top of mind and then any anything on incentives in addressing vaccine hesitancy? So really quick, last final thoughts, either addressing that question or closing out with your own. And maybe we start with Erin, and then Tara and Alex finally.

SORRELL: Sure. Thank you. Great question. So I would say, and I've heard a number of people say this as well so I can't take credit for it, we say lessons learned, we write after action reports. I think a lot of them are lessons observed and not learned. And so how do we change that? How do we change it from observed and documented to actually learned? I think this pandemic has showed us that everybody needs a pandemic preparedness plan, not just the public health sector. And so that's my final thought. And thanks, everyone for their time and attention. And thanks so much to CFR.

OLIVER: Thank you, Erin. Final thought, Tara.

SELL: Yeah, I just think that this has shown us that, preparedness for these types of things, trying to think through how we can make sure that these systems start rolling the minute that we have a pandemic recognized, or at least we know we have something going on. So that we don't have to wait for someone to trigger all the different preparedness efforts and actually capabilities that we do have. That those actually start rolling as soon as we can. I think that's really an important lesson from this pandemic.

OLIVER: Right and a closing thought, Alex, please.

KENDALL: A pandemic can be a forcing mechanism to look at a lot of the gaps and inequities in health systems. But these are issues that we should be looking at every day, around people's health and well-being around the world. So when we talk about vaccine hesitancy in the context of COVID, there are also issues that are meaningful for routine immunization, for children's ability to live healthy lives. So I hope that when we put a recovery plan into place and countries around the world that it is not just about this pandemic, but it is really about supporting healthy populations in the long term.

OLIVER: Thank you for that. Thank you to all three panelists for an excellent stimulating discussion. Thank you all for joining today. Reminder the remarks today were on the record so feel free to use them. A recording of this will be on the CFR site soon. Have a wonderful day and thanks to everyone.

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