Symposium

Global Health Symposium: The Foreign Policy of Collective Action: Lessons for the Future of Global Health

Wednesday, April 12, 2023

This symposium will take stock of the lessons of COVID-19 for the foreign policy of collective action and explore how those lessons should be applied to future global health challenges.

Virtual Session: Global Health Symposium Session I: Lessons from the Collective Response to the COVID-19 Pandemic

BOLLYKY: Great. Good afternoon. So nice of all of you to join us on a beautiful day in Washington, D.C., where there’s so much going on. Topic of today’s symposium is “The Foreign Policy of Collective Action: Lessons for Global Health.”

The COVID-19 pandemic has been, of course, a global tragedy responsible for nearly 20 million in deaths globally as well as tens of trillions of dollars of economic losses. At the start of the crisis many predicted that this would be a watershed moment in world history, remembered in the same sentences with the days that started World War I, or years, rather, that started World War I or World War II or international financial crisis. This would be a watershed moment that would change how we thought about the international order and its role in spurring international cooperation.

But three years later you would be forgiven for concluding otherwise. When you look at the titles of the events around town this week very few of them are indicative of that change in world history. If you listen to the speeches of our leading foreign policymakers you see fewer and fewer references. If you read the writings of our international relations scholars many are starting to conclude that very little was changed as a result of the pandemic.

In short, the effects of COVID-19 on foreign policy and the broader dynamic around international cooperation is unclear and that is the topic of what we will talk about today. So in a week where the U.S. has quietly ended the national emergency on COVID-19 this provides a natural moment to take a step back and to consider how our experience in this pandemic has affected our ability to respond to other collective action challenges and what we must do to better prepare for whatever future COVID-19 has ushered in.

We have two great panels for you to have this conversation. The first will look at the COVID-19 itself, the legacy on the foreign policy of collective action and our responses to emerging and reemerging infectious diseases, and how that has been shifted by the lived experience of this pandemic.

It will consider questions like whether or not COVID has marked the start of an era where world politics is dominated by more nationalist-oriented governments unwilling or unable to cooperate with one another in a global crisis, or were the problems we experienced in COVID-19 specific to pandemic response and global health.

The second panel will discuss the legacy of COVID-19 and the foreign policy of collective action for other global health priorities. So it’s not just pandemics of emerging and reemerging infectious disease that require nations to cooperate with one another. It is climate and the health-related issues associated with climate: antimicrobial resistance, noncommunicable diseases, endemic—priority endemic infectious diseases like HIV, and the list goes on and on and that will be the topic of our second panel.

As a reminder, today’s event will be on the record so both the comments of the speakers and the questions both from those in person in the audience today and those participating—the hundred or more participating online.

My gratitude goes to the Bloomberg Philanthropies for their generous support of this event and I would also like to thank my colleagues Stacey LaFollette, Dan—Sam Dunderdale, Brianna Ryan, Isabella Turilli, and Cooper Wright for their excellent efforts in organizing this event.

And without further ado, I’d like to turn it over to Maria.

FREIRE: Thank you.

Good afternoon, everybody, and welcome to today’s Council on Foreign Relations meeting on the “Lessons From the Collective Response to the COVID-19 Pandemic.” This is the first session of this year’s Global Health Symposium on “The Foreign Policy of Collective Action: Lessons Learned for the Future of Global Health.”

I’m Maria Freire. I’m founder and principal of the Freire Group, and I will be presiding over today’s panel discussion.

This meeting is on the record. We will have forty-five minutes for the panel presentations and thirty minutes for members’ questions.

I would like to now introduce our panel. You have their bios in your packages.

But our first panel member is Tom Wright. He is senior director for strategic planning at the National Security Council. Dr. Wright is a co-author of Aftershocks: Pandemic Politics and the End of the Old International Order. Prior to joining the NSC, he served as director of the Brookings Institution Center on the United States and Europe. He joined Brookings in 2011 as a fellow in the Managing Global Order Project.

John Kirton, who will be our second presenter, is director of the G-7 Research Group, G-20 Research Group, and the global health diplomacy program at Trinity College at the University of Toronto. He has published widely on global governance, foreign policy, and climate change.

Wolfgang Philipp serves as acting director of HERA, the new DG Health Emergency Preparedness and Response Authority in the European Commission. HERA is the department responsible for implementing the European Union’s vaccine strategy to accelerate its development as well as manufacture and deploy COVID-19 vaccines. HERA also deals with planning and implementing actions under the European Biodefense Preparedness Plan, also known as the HERA Incubator.

And Loyce Pace is the assistant secretary for global affairs, reporting directly to the secretary of HHS. She is responsible for advancing the U.S. international health agenda through multilateral and bilateral forums and on setting priorities and policies that promote American public health agencies and interests worldwide. She was a member of the Biden-Harris administration’s transition COVID-19 advisory board.

So thank you, everybody, for being here today. We’re delighted to have you and we hope to have an interesting and robust discussion.

Tom, you were prescient in looking at the country’s response and different world responses to the COVID pandemic and you have been following their response longitudinally. In two or three minutes, which is not a fair time to give you, can you give us the lessons that you have learned and the insights that you have captured?

WRIGHT: Yeah. Thank you, and it’s a great pleasure to be here. I’m really looking forward to the conversation.

You know, I come at this not as a health expert but as someone who I think from a more of a geopolitical lens has been trying to learn from all of you and from others about health—global health challenges and the intersection of that with geopolitics and then in the NSC, I think—and I can talk more about this in a minute—in our strategy documents trying to find a way to appropriately sort of weave in shared challenges along with the other challenges we face.

So, you know, as I sort of looked at it, you know, there’s never a good time for a pandemic but COVID-19 hit at, like, the worst possible time, you know, geopolitically, and we had gone through, you know, periods since the financial crisis, the economic effects that that had.

We already had rising, you know, geopolitical competition with China. We had rising populism at home and abroad with more nationalistic governments. We had the Trump administration here, obviously, with quite a unilateral approach to foreign policy.

When COVID sort of hit at the end of, you know, 2019 it was in a context in a way in which all of those sort of supporting mechanisms that John and others have written, you know, extensively about on global governance had all sort of attrited, you know, away, and so there was very little sort of support there.

Elements that actually worked pretty well like the EU had a big blind spot, you know, on health governance. It basically wasn’t in their competency at all. So that tended back to a more nationalistic direction.

I think what we saw then throughout 2020 and to some extent beyond it was how sort of geopolitics and COVID-19 sort of had a negative, you know, synergy between the—geopolitics, I think, made the pandemic worse and the pandemic actually worsened, you know, geopolitical competition and this sort of negative, you know, spiral.

So we basically saw very little, you know, formal cooperation. When the G-7 was, for all intents and purposes, defunct, you know, during 2020 it could hardly, you know, meet. There was very little contact actually between several major world leaders including, you know, President Trump and President Xi Jinping.

Obviously, the China component to this, which we can talk about more, you know, was very problematic in terms of their cooperation with the international community and then even in Europe I think we sort of saw an everyone for themselves approach.

I think on the other side the genuine fear that people sort of faced, you know, led to, you know, people being rightfully, you know, distrusting of what they were hearing from other countries or having a more nationalistic approach to vaccine, you know, development and the like. And some of that improved, I think, as we had sort of changes in government to more learning, you know, over the course of the pandemic, but some of it sort of stayed in place as well with more unilateral approaches.

I think as we sort of look back in that and when we were crafting the National Security Strategy last year I think what we recognized was there’s no question that we’re in a period of intensified strategic competition, not just with China but, obviously, you know, with Russia as well, especially since the invasion of Ukraine.

But we also have these near existential, you know, challenges, whether it’s in, you know, pandemics or climate change in particular, you know, that can’t be ignored and actually affect people in a way much more directly and immediately than some of the strategic competition issues, and I think what we need to do is recognize that those two buckets of challenges should be pretty much if not coequal, certainly, very uppermost, you know, in our minds as we’re trying to, you know, craft our sort of national security and foreign policy strategy.

And we not—we need not just to deal with both. I think that’s pretty obvious. We do need to deal with both. We also need to understand sort of the relationship, you know, between each in that, like, as we look to try to strengthen our influence around the world and to build alliances and partnerships we have to be serious about tackling these transnational challenges on their own terms and helping other countries build capacity, you know, to do so and as we, you know, are trying to prepare for future pandemics we have to remember—or other shared challenges—that geopolitics will get in the way even if we want it to or not.

Even if we don’t want it to it still will be a factor. I mean, it’s very difficult to have, you know, real meaningful, deep cooperation with countries that we may be strategic competitors with. So we should reach out and in good faith and really try to build those connections and to try to cooperate with China and others on these shared challenges.

We also need to, you know, remember that when COVID hit all of the plans that have been cooked up and agreed upon before didn’t really matter very much, you know, in January of 2020. So we have to be sure that we’re building enough capacity, working with like-minded countries, and learning the right lessons, I think, to be prepared, you know, collectively for the next time.

But I’ll stop there and I look forward to—

FREIRE: It’s very interesting, I want to come back at some point in this discussion about this issue of the response of the world and the response of governments and how it compared, for example, to the response with the financial crisis of 2008, because I think that gives us a sense of perspective.

So, John, you’ve been in the middle of the G-7, G-8, G-20 for a long time. You’re very well known for knowing and being an expert on these issues. How did they do?

KIRTON: Well, let me start with what they did right and then follow Tom in what they did wrong. G-7 leaders met with unprecedented speed and frequency thirteen times already since COVID began in our part of the world at the start of 2020 and they started with warp speed summitry right here in Washington March 16, an emergency meeting, and followed up a month later with another one.

They made eleven COVID commitments at their first and, remarkably, the compliance of the members with those commitments was almost complete, 98 percent. Almost never do you see that. A year later over in Cornwall—the United Kingdom—they put COVID first by far. Eighty-eight commitments from the leaders themselves collectively on COVID. Three stand out.

They set a collective goal of ending the pandemic by 2022. They promised to vaccinate the world and they committed to, quote, “strengthening the WHO in its leading and coordinating role in the global health system.”

The G-20 leaders followed with two summits in 2020, three the next year, one dedicated to global health and the pandemic, and most recently at Bali last November they produced sixteen commitments on COVID despite their deep divisions and deadlocks over Russia’s invasion of Ukraine. So a G can transcend what would seem to be immovable geopolitical divisions.

The biggest achievement in Bali was to authorize the launch of the new pandemic fund, more money of the sort badly needed now.

So what did they do wrong? March 16 they promised, with President Trump in the chair, to protect everyone in our countries, not the whole world. So vaccine nationalism was there at the very start and its legacy endures.

And after April they stopped meeting at all for nine months even as the deaths, the infections, proliferated in their own countries, throughout the whole world, and after the Great Leap Forward at Cornwall—the eighty-eight commitments—they then started to focus on other things—climate change and then the Russian invasion of Ukraine. So that final stage of the all too familiar cycle of panic, then neglect had started to set in.

Moreover, the focus also shifted from stopping the current COVID pandemic to starting to, well, let’s focus on preparing for the next one sure to come but we don’t know when, and looking ahead five weeks the next G-7 summit and health ministers meeting in Hiroshima and Nagasaki.

But you look at the list of Mr. Kishida’s priorities, six is a drop down. COVID health, it’s number six. End even there pandemics, yes, but it’s sharing the limelight with universal health coverage. Yes, they’re linked, but the clear and present danger is by far the first and, of course, they still haven’t ended COVID by now or by then.

G-7—they slipped back to only one meeting a year and they’ve only got one scheduled for this year in Delhi in September, and G-20 members have complied with their health commitments at a much lower rate than the G-7

ones. Only 72 percent in the G-20. So there’s still much for the G-7 and the G-20 leaders to do. And, boy, American leadership is needed yet again, now more than ever before.

FREIRE: So he’s looking at you, Loyce.

PACE: Yes. I can tell.

FREIRE: But I’m going to give the floor to Wolfgang here because the Europeans, as many of us, had issues related to how to tackle this pandemic but they came up with HERA, which was a very powerful and important instrument.

So tell us a little bit about it because I want to weave these conversations in together as to how was the government’s response to this issue and where do we need—Tom already mentioned that we need to look forward as to where we go. So let me hand the floor over to you.

PHILIPP: Thanks, Maria.

And if you don’t mind, I’ll spend thirty seconds just to react already on some points that are not—

FREIRE: I’ll forgive you. OK.

PHILIPP: Thank you very much. That’s great. Because, Tom, you mentioned the EU heads governance as a kind of a vehicle. I mean, that is a very complex construct and I’ll say we can come back to that later.

It might not be too interesting, but we are talking about twenty-seven member states, and we’re talking about European Commission on top, and the specific role here to coordinate response to cross-border health threats. It sounds like a complicated expression as well, but, I mean, it’s relatively simple.

The idea is you’re stronger if you’re united, if you react in the same way, and if you cover the response for the area you live in, and that is what we tried to do. So there was a lot of response activities going on across a large number of different policy fields.

So it’s not just public ads. It is also in research and development, the economic measures. On travel restrictions and border control there were measures. We had activities to fight disinformation. Then at the end of the day perhaps the most prominent was that the cooperation to ensure that not just the EU but also many other places in the world would have access to and quick access and equal access to vaccines once they’re there. So this is something we could dissect also a little bit later.

But another point I want—I would like to mention is that this time we reacted during the pandemic. So, you know, moving from panel to panel going through lessons learned and see what might fit here or there, at the end of the day, I think what is important is that we have something that comes with an implementation. So structural changes, political changes, policy changes that really have an effect, I think that’s the important thing. And that is the most prominent lesson learned, at least from my perspective.

So HERA, the Health Emergency Preparedness and Response Authority, is nothing else than a simple commission, directorate general, so entity inside the European Commission, and what we’re doing is we try to ensure that we have access to medical countermeasures in the future and that is done in a way, as we call it, end to end.

So we start with intelligence gathering to make sure we have the right information, the right decrypt, and fast detection of signals. We know what’s going—we know what’s going on and then we have a good assessment to decide if we need to move on in terms of availability or development of medical countermeasures. And once this question is answered, HERA would take care of producing, manufacturing, or bringing products also to a

stage of existence, and then also take care of the deployment of these medical countermeasures. Normally, that would be diagnostics at the beginning; vaccines, therapeutics, you name it—PPE as well and modern forms of that, for example, and other things.

So the idea is really to have an entity that takes care of detection down to deployment of medical countermeasures in case of needs, and perhaps you can then afterwards see if that is feasible or not.

FREIRE: I’m going to pick up on one of the points you made and, Loyce, this is your bailiwick, right. How do you get these to—in equitable fashion to people around the world. You’ve made a career out of that and it’s your passion. So help us understand the administration’s position how to move that forward.

PACE: Yeah. I’m happy to. I might weave in some reactions as well. But, you know, obviously, the biggest lesson that we learned during COVID, which we’re still experiencing, was around equity or the lack thereof, right, and so we absolutely need to focus on that and I think this administration has been focusing on that since we came in a couple of years ago.

Whether that was through not just G-7 or G-20 commitments but the COVID summits that we held and the ways that we tried to bring the world together or, frankly, the ways we came in and reengaged with the world in a way that we’d been missing because, to be clear, the world was still coming together. They were just meeting without us, right, and I think in particular, we have to give a nod to low and middle income countries who weren’t necessarily waiting on the G-7 or even G-20 to figure this out.

I think they were hopeful that those forums would come through. But, in reality, whether it was the global health security agenda or the Africa CDC emerging as a leader, let alone CARPHA and other parts or other initiatives around the world, people were taking action. They were just doing it in ways that we weren’t witnessing because we weren’t at the table. So I did want to make that clear and that’s important because those very forums have been informing how we show up, right.

Now, whether we listen to them is another thing entirely but we knew that the call to action not just among us but from them was that we needed to share innovations with the world and make it so that it wasn’t just a charity model but one that really focused on building this capacity from the ground up and ensuring that they had an opportunity to provide for themselves whether it was scaling and manufacturing these products or otherwise financing and investing in that work, let alone providing that technical exchange like we would from an HHS.

So those are some of the ways we tried to approach this question. Obviously, looking forward, we are very much engaged in efforts like negotiations towards a pandemic agreement or accord, which is, obviously, going to try and tackle this question.

We are very much spending nights and days on G-7 and G-20 discussions that also are looking to tackle this, whether from a financing or funding perspective or from a very tangible access perspective and kind of what mechanism we build to make this happen and make this work should the world face another pandemic.

And we know that that is on the horizon. That’s just our reality because we—you know, of course, COVID really taught us this lesson in a really tough way. But we had been seeing this film play out again and again and again, just at a more localized level.

And so I do think that we have been learning from those experiences, especially technical people on the front lines, and that’s why the system held the way that it did, even when the previous administration pulled out of the WHO or threatened to do so there were people still holding that line, right, and I just have to stop and thank them for making sure that I could come into this role and engage the way that I did because they kept those collaborations strong and they held to a great degree not just with WHO but with some of these other regional and national bodies with whom we have really strong partnerships and agreements that go back decades.

FREIRE: So, you know, going back to this global geopolitical balance and what you’re referring to is that there were groups and there was a spine there upon which to build.

But, Tom, you saw deterioration on the U.S.-China relationship very quickly and so how does that overlay into our response and has anything changed? I mean, Tom challenged us at the beginning. Have those things gone back to where they were?

WRIGHT: Well, look, I think there was a lot of, you know, learning throughout the pandemic, right. I mean, you mentioned the EU earlier. I think the EU did extraordinary things throughout 2020 in basically figuring out how to cooperate on something that wasn’t sort of a core competency of the union.

So the question is not really were countries and actors caught off balance, you know, at the beginning. I mean, I think everyone was caught off balance, you know, at the beginning and for the first period the question is how, you know, did they sort of react to that, you know, over time.

I think on the U.S.-China side I think, you know, it did play out in very geopolitical ways in 2020 and not just on the U.S.-China piece. You know, the China-Europe piece was also quite contentious, you know, and we might have expected to see cooperation between Europe and China but we didn’t really, you know, see that, you know, for all sorts of reasons, I think, mainly to do with, you know, China’s, you know, actions through the course of 2020.

I think our position, you know, to China I think the president is very clear on this. You know, he is going to—sees China as a competitor and it’s going to compete but it’s going to do so, you know, in a responsible way and will always be willing and wants to work on, you know, shared challenges including, you know, climate change and health.

Now, you know, to be honest that’s uneven, right? Sometimes that’s very difficult and last August, you know, China cut off the climate dialogue between the two countries after the Speaker’s visit to Taiwan. You know, we thought that was a mistake, that we should effectively compartmentalize, you know, cooperation in those shared challenges.

But I think for the most part we are seeing sort of reengagement on those issues and the two leaders and officials talk about those issues, you know, when they meet and I think there is an understanding that, you know, we have to be willing to work with all countries, including our strongest competitors, on interests that we have in common.

I think we also need to recognize that, you know, we need to build domestic capacity, you know, build capacity with allies and like-minded countries on these, too, because we can’t just put all our eggs in, you know, one basket at one institution or one mechanism, right. We need sort of redundancy, you know, within the system and I think we see that, you know, being prepared for and worked on as well.

FREIRE: So at the risk of pointing to the elephant in the room, I mean, this is all very—except, Loyce, for your comments this is all very much focused on, you know, large economies. What’s the impact on the middle and low income countries, right, in this whole construct?

I spent the pandemic and the first three months in Peru with a company that was—country that was completely shut down and very different reality on the ground from what we saw.

PACE: Right.

FREIRE: So what—how does that—Tom or John, how do you—how do you see that? How is the—

KIRTON: Well, I start with the G-20, of course, which is pretty equal between the Global North and what’s called the Global South. But of course, when we get down to the hemisphere, the Perus of this room, there’s many other summits that are active on global health.

One area I know best is the Caribbean. I’m a member of the technical advisory committee of CARPHA. And, of course, they include the biggest member, the poorest country in the world, Haiti, the tragedy of Haiti. But you do have a regional institution which acted quickly, acted smartly, and I think you should look at their number of infections, deaths, and the sequelae, long COVID. They have done remarkably well even though they have a tourist-dependent economy, right, and so close to the USA with U.S. Virgin Islands inside.

When you go out to Africa, of course, where the other poor countries are, then I think we really do need to build—one of the things that the Gs and others have promised, all right—domestic manufacturing capacity in Africa—the African CDC. And I come from a country that discovered, thanks to COVID—(laughs)—we needed domestic manufacturing capacity of our own. So we looked to one of our parent countries, France, to provide it for us.

FREIRE: Wolfgang, I know this is an issue that you think about a great deal. What’s your role in trying to get this at the global level?

PHILIPP: At a global level I think—I think there’s a couple of points—a couple of things that need to be fixed in a way that’s, at the end of the day, that we have a redundancy across the system. So that sounds a bit philosophical, but I mean, what it means is that we have manufacturing capacities, that we have knowledge, that we have financing, that we have solidarity, and a couple of other elements that need to be really developed—not just on paper that is being done now. I mean, in Geneva, for example, we talk about pandemic preparedness agreement or accord, whatever it’s called now. There are a couple of other rounds and fora that discuss these things. But it needs to be implemented, you know, and that requires—that requires funding, it requires political will and commitment—again, not just on paper or in the news, but in reality—and it requires a lot of complex and complicated discussions, perhaps also between countries or between economic areas that would not have this kind of discussions on the top of their—on the top of their lists. So that’s how I see it.

An element is, for example, strategic autonomy. That is what we are discussing in the EU. There is a good example why does this bill—why this remains still on the agenda that is simply the availability of vaccines that we had seen at the beginning. We were running short as compared to, for example, the U.S. or to U.K.—delivered earlier—a little bit earlier with higher quantities, and that created kind of a trauma, I must say, which we try to fix now through different policy instruments, you know, so that is for the European—that is at the level of the European Union. That does not mean it’s not going to be expanded. There’s a lot of activities and instruments that are being used to expand also capacities. For example, in Africa, President von der Leyen has been calling on strategic partnerships with South America, and now when these things are going on, also in the area of health security.

So what we need is good concepts, political will, but at the end of the day, implementation, and then real coordination so that things are, you know, translated into action, not activities. Otherwise we will be, I think—to be the devil’s advocate, I think, Loyce, I think you would agree to that, they will be in the same or even worse situation depending on what comes next.

FREIRE: So this issue of coordination—I think, Tom, you touched on that at the global level. One of the concerns that has been raised—and I think, John, you mentioned it earlier—is are all these initiatives now creating more fragility in the global health infrastructure rather than creating strength.

PACE: I mean, I can try to jump in here. Well, we have an opportunity to ensure that that is not the case—(laughs)—but certainly if one were to express concern about all the various initiatives, or forums and agendas popping up, that would be well-founded.

The good news is that people care, right, and people are taking action. Obviously, the danger is that they are sort of scattered in multiple directions, but I think it’s fair to say many of us are sitting around those tables. We need the same people who are sitting around those tables even if they are in different places around the world. So that, I think, presents the best opportunity to ensure this type of work is very much coordinated whether, you know, we’re talking about the ACT Accelerator and how that transitions which, by the way, they still will continue to meet on a regular basis while there is still in place a public health emergency of international concern. That has been confirmed, and that’s—they’re doing that at the advice of those of us who do sit around that table and know that there’s a gap left if ACT A completely sunsets because we’re not quite ready in G-20 or in the inner governmental—or international negotiating body to, you know, have a mechanism to help the world, if and when it needs it again. So that synergy is taking place at some level.

I do want to, though, pick up on this idea of it’s more than just proposals on paper or, you know, certainly it’s not just about kind of building facilities around the world and coming up with a bunch of products. We have to, first of all, you know, I think there are a few donors or other entities who have tried to really have a thorough landscape analysis, so kind of where these investments would be most valuable. It’s still unclear, though, who then takes that information and runs with it, right? You know, is that a WHO or some other global body? Are there regional bodies who are really—such as on the continent of Africa—really saying, OK, well, this is how we can coordinate these various hubs; this is what we need in terms of a regulatory body like the AMA and the page that it has to be on to support, you know, scaling some of these products.

It’s unclear, I think, to many of us how that is truly coming together in a way that it needs. I think we have good models in regions like Latin America, which has not gotten a lot of attention in this space, but frankly was already on this trajectory to try figure this out before COVID, and I think is even more motivated, let’s say, to land that because they were left behind largely in all of this.

And I think we saw and heard with Indonesia leading the G-20 and India now, you know, Asia really coming together and asking some of the same questions. But to me that, again, some of that coordination is happening without all of us—without those of us on the stage perhaps at the table, and so I have hope in the process in that regard. But I do know that I spend a lot of time on planes, right, and so—(laughs)—to the degree I can try and help connect dots or build bridges, then I feel like that is my job to do.

FREIRE: Thank you.

We have about one more minute left before we go into the Q&A session of the afternoon, so I want to go real quickly—things that have changed. Let’s start with you, yeah.

KIRTON: I started of course with SARS killing forty-four fellow Torontonians in 2002. The body count now from COVID is so much bigger that even if you don’t remember 1918, I think the memory will endure in the minds of our leaders, even if they are distracted by these other climate change and Russian things. So there is great hope and opportunity when they meet together that they can get things right if they keep meeting together again and again. And I guess after Hiroshima and Nagasaki, New York, the United Nations high-level meeting on pandemic preparedness where the leader of Peru and all of the 195 can attend. So if you want a global voice and global action on a few of the good things, another opportunity awaits.

FREIRE: Good.

PACE: I think—look, we saw, you know, in the wake of HIV and, say, PEPFAR, people really rallied around health diplomacy as a critical tool. I think now folks have really come to understand the importance of that, especially given COVID affected the entire world, and so, you know, so we’re not just talking about pockets, right, but I have staff in Brazil, and China, and India, and in these strategic posts we might say, who have never really been tapped the way that they were in the thick of it. And that was, I think, a revelation for people in those positions, but also for people here to understand really what it looks like to explore some of these partnerships and to really work with one another in spite of some of the other challenges we face. But I have a

lot of hope for that space and for the way we move forward in that regard, and frankly, it presents an opportunity for health and a potential crisis in health—let alone climate—to continue to unlock those doors in a way that will serve us more broadly.

FREIRE: Wolfgang?

PHILIPP: I want to be very brief. I would say both citizens as well as political decision makers understand what health security means and care about it. I think that has really changed.

FREIRE: Tom?

WRIGHT: Yeah, I think one thing we haven’t mentioned so far is just the role of technology—you know, particularly mRNA, you know, vaccines, but also the way in which, you know, technology just helped people, you know, work from home and mitigate sort of the economic, you know, effects of the pandemic. And I think in that sense—I know I said it in the beginning—there’s never a worse time for a pandemic, but I think the state of technology in 2020, I think, was a real—you know, a real help in mitigating its effects in multiple ways.

FREIRE: And it was a long-term investment, by the way. It didn’t come up, you know, immediately.

WRIGHT: Right, right.

FREIRE: This was long-term coming.

Well, so we now have time for some members’ Q&A, and so I just want to remind you that it is on the record. So yes, in the back.

Q: Hi. Chloe Demrovsky, president and CEO of Disaster Recovery Institute International. Thank you for this exciting discussion.

I think my question is primarily for Tom, but of course if anyone else has a keen and burning response, I’m all ears. Early in the days of the pandemic, but ever since as well, we’ve seen that one of the primary areas of fragility has been around supply chains, and health-care supply chains, the ability to provide personal protective equipment, inputs for vaccines, and so on and so forth into national security considerations all the way up into complex inputs like chips, for example.

So is that a way in which the status quo has perhaps changed? How do you see this area evolving? Thank you.

FREIRE: Well, I think all of us can probably address that question, but Tom, let’s start with you.

WRIGHT: Yeah, you know, my boss, Jake Sullivan, sometimes gets asked what surprised him most about the job, and I think one of his answers is he didn’t know he would be required to become such an expert in supply chains, you know, just writ large, right? I mean, we see that basically, you know, popping up everywhere, I think, over the last couple of years. It’s not just, you know, global health and COVID; it’s also on technology, you know, on the scarce supply of critical minerals, and in a variety of other areas. And I think ensuring we have, you know, secure, sort of entrusted supply chains is a key sort of aspect of our—it’s in our national security policy, it’s a key aspect of our, you know, foreign policy. That is not just, by the way, sort of a national, you know, goal. I mean, that requires, you know, international diplomacy and working with other, you know, countries, especially allies and partners—but to ensure that on—you know, in all of these areas, I think, but including on, you know, critical global health, you know, products, but also on foundational technologies and a number of other of areas, you know, I think it’s a key—it’s a key priority.

I think we have also, I would say, you know, have made some progress in terms of just the mindset on, you know, international, you know, economic policy. And it used to be the case, I think, that there was a relatively

narrow focus on, you know, within economic agreements, on FTAs and market access, and all of that, and I think that’s still, you know, important as to the focus, but there is a whole array of other issues on supply chains, on corporate tax, you know, on cyber and tech standards that I think, you know, need to be addressed, too. And we’ve tried to bring those into the mix as well.

FREIRE: And human resources.

WRIGHT: Yes.

FREIRE: It’s a huge issue. Anybody quickly on that? We have a couple of questions here and online.

PHILIPP: Yeah, let me—I would just like to add—I mean, and here supply chain intelligence is something which is part of the core activities, downstream activities because I think we all learned the hard way how important supply chains are, even for simple things that you need in the public as emergency or whatever kind of event—I mean, not expanding this now to other technology sectors.

So it’s a very critical—it’s a very critical part of cooperation—international cooperation, and I think we are all happy that we have, let’s say, a lot of innovative—innovation around in many of our partner countries and partner areas to work on—on, let’s say, secure and sustainable supply chain for critical elements that we need in public—at least for public health.

FREIRE: Before we go to our online questions, we had a question back there, and a few questions here. Yes?

Q: Thank you. My name is Komal Bajaj. I’m a physician and health-care quality leader with the New York City Health + Hospitals, which is the municipal health system for New York City. Thank you for your generosity of time today.

You know, as we are thinking about will and coordination, you know, I find myself spending a lot of time thinking about communication and trust, which clearly impacted how the pandemic rolled out. I’m curious, from your perspectives, what are some strategies or tips about sort of creating that understanding, whether it’s with policymakers or the public. Thank you.

FREIRE: Oh, dear. OK.

PACE: I’ll go first. (Laughter.) Don’t go last with this one.

This is—I mean, this has been a recurring theme since the pandemic started really, and for many of us on the front lines. And thank you for your service. I will just say it knowing how hard hit New York was in the early days. I just—I have a hard time still thinking about it. I’m sure it’s the same for you.

But this trust factor is so key, and yet I worry we still haven’t figured it out. Now look, I’m trying to give us plenty of credit for the ways we did reach people and the ways, frankly, people helped us reach people because we all know that’s the tried-and-true way of getting this right. But, you know, we wrestled with this on the COVID board, and we still talk about this today because now there has been this ripple effect, again, in the wake of COVID with how people receive public health information and sort of what we’re all fighting against in terms of all of the information coming in, folks.

I think there are a few things. One is just being honest with ourselves and with our audiences about how hard this really is, right, and, you know, I think many people have talked about how important it is for us to kind of come just meet people where they are, and be honest and vulnerable about what it is we don’t know, but what it is we’re trying to learn, and when we’re going to figure it out hopefully. So I think that’s one way.

And just the constant communication, the constant updates—I think what’s happened in the pandemic—and this is speaking from very personal experiences, you can just spend a lot time doing the work, right—whether you are a physician or provider, whether you are a policymaker, right, you’re just tackling what’s in front of you, and it’s hard to come up for air and check in with people, right, and make sure they understand what it is you are spending all your time doing. But it’s so important because otherwise they—you know, three, six, nine months go by before people, you know, really get it, and by the time you reach them, they’ve already decided something else is happening, right, other than reality.

So that’s—you know, it sounds quite obvious, but I think taking those positives and really, again, working with honesty, creating the space to even have these conversations, and then hopefully, frankly acknowledging when it’s working and how because, you know, I think we have a lot of conversations about where we’ve failed in our communications and trust building, but there are some bright spots there, too. And I, frankly, I think would appreciate hearing a lot more about that as well.

FREIRE: I’m going to take a call right now, yes.

OPERATOR: We’ll take our next question from Valentina Barbacci.

Q: Yes, hi. Good afternoon to you all. I’m in London, so it’s evening here. Thank you all for your time and thoughts.

To your, actually, recent point about trust and failed communications, it seems a lot of lessons learned have focused on the vaccines, and so I—and, you know, which were not what they were originally promised to be, and I’ll leave it at that without going into details too much. But it sort of helped—or didn’t help, rather, to build that trust level with the authorities that we were, you know, very much led to believe in and trust initially in the pandemic.

So I’d like your thoughts on alternative remedies that should have been, could have been focused on more, and we were actually led astray from in the beginning, that had proven to be actually quite effective in other countries where the vaccines didn’t reach as quickly as they did in other developed countries.

And then secondly, I would be grateful for your thoughts on sort of reporting mechanisms and the failures thereof because it seems where we are here in London—where I am rather—in London we have the Yellow Card system; in U.S. there’s the VAERS system, and many other countries have their own, you know, vaccine authority of adverse effect reporting mechanisms. And they seem to not have served us well—let’s put it that way. They seem to have failed us to put it bluntly in that they are not flagging the issues that we should have been seeing early on, quite frankly, and that many reputable and very distinguished doctors were trying to flag issues about early on, but we were so focused on stamping out misinformation that we actually stomped out good information as well from these doctors. So I would be grateful—

FREIRE: Thank you, Valentina.

Q: —for your thoughts on those. Thank you.

FREIRE: Yeah, appreciate it. Can you give me just one example on where other technologies or techniques work better than vaccine?

(Pause.)

Q: I’m sorry, is that for me?

FREIRE: Yes.

Q: Oh, sorry. I was muted so I didn’t think it was directed at me.

I was thinking of existing remedies such as Ivermectin, for example, that was dubbed as a horse pill in the U.S., and therefore quickly disreputed in the U.S., but it actually has proven to be very effective in other countries. And that’s just one example. There are others where studies have now come out to prove that effectiveness.

FREIRE: OK, thank you very much. Last I read in the literature there have been plenty of studies—at least one that I know of—Ivermectin was one of the medicines that was tried in Peru, and it didn’t work. And I know that we now have clinical trials to prove that it is not efficacious.

But I appreciate your general question, and the question again goes back to trust, and trust in technology.

Wolfgang, do you want to touch on that issue?

PHILIPP: On communication trust—

FREIRE: Yeah.

PHILIPP: Yes. I think you mentioned it; it’s an active process. We live in—I mean, technology has developed. We don’t get our information from printed newspapers anymore, so it’s a matter of who is there first, and who is there with the right information at the right level of trust. But that’s quite difficult.

I would say what we have seen, also because of so much misinformation that was sent out there, and which is still sent out, and still communicated at all levels, including in parliaments—I’ve seen that. The point is simply we need—we need really specialists and professionals dealing with that, you know, so creating trust is a matter of having, let’s say, a baseline of good, reliable, correct, and precise information that people understand. I think that is the point.

I see here in the room a former health minister of Germany. You gave me once an advice on communication. I will not repeat this now, but I think it was very good. The point is we need to have somebody who has—who has the competence and who has the knowledge to communicate on something, and not having a huge crowd of—huge crowd of people becoming specialists throughout a pandemic. It’s difficult, but it requires active fighting of disinformation, and that requires specialists and professionals doing that throughout these situations.

FREIRE: It is fair to say, however—and I think Valentina has a point—that we did not know a lot about COVID, and at the very beginning, we were giving as much information as we knew, which wasn’t very much. And that I don’t think created a great sense of comfort.

We now can look back, and there’s a lot more information, a lot more data. But at the beginning, we didn’t even know how it was being transmitted. So it’s something that we need to acknowledge—that it was very hard for us to do.

PACE: And I think we tried to make some of those adjustments over time, right, and really say, OK, this is what these vaccines are doing based on the data, and this is what we understand in terms of severe illness. These are the ways that you can still protect yourself if you are not yet vaccinated, such as through masking, through distancing—and so helping people understand the spectrum of options to them, let alone, you know, the importance of testing and treatment, where available, was I think critical for us to realize over time. But that’s the point of it being active and being iterative. Coms is not a standalone, stationary thing. It’s something that needs to evolve over time based on data and evidence—to be quite clear—but something that we need to be brave enough to revisit if and when needed.

FREIRE: I’m going to take a question right there.

Q: Sonia Stokes. I’m an emergency physician and term member at the Council. Thank you to the panel for this discussion.

My question is about violence targeting health-care workers. Multiple regions are experiencing rising anti-science sentiment, not just in the U.S., but globally, and this is often translating to increasing threats of violence against scientists, public health practitioners, and even clinicians. This is not just happening online; this is happening to those of us in real life working on the front lines. What are some practical, actual steps that can be taken, if any, to stop this alarming trend on threats of violence against health-care workers? Thank you.

FREIRE: Oh, dear. OK. (Laughter.)

PACE: I have some things to say, but I’ve spoken too much.

FREIRE: I’m going to—I’m going to give that to Thomas—

PACE: Yeah.

FREIRE: —in national security.

WRIGHT: I’m not sure I—I’m not sure I’m—I mean, I’m very sorry to hear that, but I’m not sure I’m qualified—

FREIRE: Well, let’s consider it a national security question—

WRIGHT: —to give an answer to that.

FREIRE: —because it really is, but going to—I’m taking you off the hook here.

PACE: (Laughs.) Well, we—I know the White House does have an online task force, and I’m not getting the name right right now, but really looking at this issue across the board. I think there’s interesting ways that that could be fused with ways our department is thinking about supporting health workers worldwide, you know, around this—I mean, frankly, I see it as a—lending itself to them as a health crisis also facing health workers in our countries worldwide.

You know, in terms of practical steps, it’s I think making people aware of how at risk many of us are is really important. One thing you didn’t mention, but I was hearing in your comment was also the fact that many health workers are women, right—the majority in fact. And so it’s all too easy, as we know from trends in gender-based violence, to target women and health workers who are largely women as a result. You know, that said, it’s not enough just to raise awareness. I think we have to ensure that there are protections in place for health workers, and frankly, penalties and punitive measures in place for people who do target health workers—again, as you said, either remotely or in person.

And I have experienced this myself, and so it’s something that I feel passionate about. And I know that my experience is not nearly sort of commensurate with what others have faced. But it really is a crisis because it not only is putting an important workforce at risk, but it’s preventing people from wanting to join the profession, it’s making people leave the profession, and at a time when health crises are so ubiquitous. We need all the people that we can get. And I worry a lot about our capacity to address the range of issues we have worldwide if we don’t keep people safe.

Q: Thank you.

PACE: I’m sorry you’ve experienced this (that we have here ?).

WRIGHT: I would add one thing actually to that, you know, because we focus mainly, I guess on the international aspects, but I think one part that I think gets to what you said that I think is particularly, you know, concerning, is how in the course of COVID-19, the pandemic and the response to it became sort of deeply politicized and divisive. And I think there are many, you know, reasons for that, but I think unless, you know, we manage to address that I do worry that that will compromise, you know, our ability to deal with future pandemics if it’s because healthcare workers are being targeted, or people don’t trust, you know, information, or because there is a period of denial the next time. You know, the next pandemic could be more lethal, or more contagious even than COVID-19.

So I think that, coming out of it—not just here in the United States, but I think in many, you know, places around the world, I mean, this lasted for a long time, and it was deeply, you know, traumatic for a lot of people. I think, you know, lots of things happened in terms of distorting, you know, information as well. I think that is something—you know, I don’t know when the right moment, you know, is for that to be properly addressed. If we don’t get that right, I think, you know, before the next pandemic, I do worry about our sort of collective, you know, response the next time around.

FREIRE: Absolutely. Yes, back there.

Q: Thank you. I’m Julio Frenk, president of the University of Miami.

I have a specific question, which is what is the likelihood you all see of actually coming up with an instrument—a treaty or accord—of some nature that would actually provide the instruments that are required to fill the gaps in the global governance for health, particularly the—first of all, the lack of incentives for epidemiological transparency. There is a huge penalty when a country actually reports an outbreak the way things are right now. And secondly, the existence of sanctions when a country doesn’t follow the regulations, and then puts everybody else at risk.

I am one of those who thought this was a watershed moment, that the magnitude of losses, as Tom said at the beginning, was so extreme—not just the human lives but to the economy—that this was the moment we had been waiting for some really radical measures to fix some of these missing pieces in global governance for health. And the time is ticking away, and there’s a lot of meetings, and a lot of very compelling reports, but, you know, I do have that feeling that there’s a window that’s closing. And I wanted to ask you what’s your perception about the likelihood that something real, with actual instruments to both protect those who follow the rules and sanction those who do not for the common good of protecting everyone, how likely is such an instrument to become reality in the next few months?

FREIRE: Spoken as a true minister of health, Julio. Thank you very much. John, do you want to take that one on?

KIRTON: Yeah. Not being inside the chain or on the frontlines, I think it’s going to be a long and difficult haul. The first thing we have to do, and this goes back to the integration and fragmentation question, is how would the new pandemic accord relate to, supersede, integrate with the international health regulation reform process, which is going on? And they have, of course, a much greater path dependency and a constituency, and legal forces already. Then you’ve got the internal questions of where does the ultimate authority for implementing an accord rise? And the WHO is—I think should be the obvious choice, but you’d have to build the capacity there to do it. And we’re still waiting to see how much and how fast the members will comply with their commitment at the World Health Assembly to move up to 50 percent in the core budget contributions within too many years.

And then finally, the ultimate question, which some of America’s best friends ask all the time, for it to really work do you need the advice and consent of the U.S. Congress? And what chance is there at getting that in Washington these days, and as we move into the elections soon to come?

FREIRE: I’m going to look at the European perspective on this, Wolfgang.

PHILIPP: I think you—(laughs)—what John said is something I could subscribe to. The point is simply—I think one word you mentioned is fragmentation. I think that’s the real risk now. I’m pretty sure—I mean, you’re following these negotiations on a daily basis, so I will be very short to give you—to leave you time. So I’m pretty sure that there will be—that there will be accord, that there will be an agreement on many aspects which are not yet covered under the IHR that reinforce certain parts of the International Health Regulations. So this, from a formulistic point of view.

But at the end of the day, what is important is really that in parallel that we don’t wait for that, but that we continue to overcome the fragmentation in terms of health security architecture at a global level. You see a lot of players—new players coming into the field, a lot of old players reinforcing their activities. (Inaudible)—and there’s many other entities coming into the game. But at the end of the day, I think the important thing is how to find the ultimate authority that is really able to consolidate these efforts, which would be, when it comes to health security, WHO, no? But that requires a certain step up of capacities, of structures, and so on and so forth. So I’m very optimistic that we will see something better in the near future than we have today.

FREIRE: The issue is timing, right? Because I think Julio is right, that window appears to be closing.

PHILIPP: Yeah, and funding.

FREIRE: And that’s very dangerous. I’m going to take another call from our folks online.

OPERATOR: We’ll take our next question from Yanzhong Huang.

Q: Hi. This is Yanzhong Huang, senior fellow for Global Health at the Council on Foreign Relations.

This question’s mainly directed towards Loyce and Tom. And we know that China played a critical role in global health security, right? COVID shows that. SARS shows that. And just yesterday, China recorded the world’s first human death from H3N9—H3N8. And Tom also, you know, just said that we want to work with China, you know, on shared challenges, which certain include global health, right? But for more than three years, there has been no serious discussion between U.S. and China on public health. And I’m curious, why is that? And who is responsible for that lack of progress in speaking with China on global health security? And does the Biden administration have any immediate plan to talk with China?

FREIRE: Tom.

WRIGHT: Yeah, no, look, it’s a great question. I think agreed here that we want to work on these shared challenges. I think the two presidents had a constructive summit at Bali, you know, in the fall. I think obviously the—you know, we’ve seen challenges over the last couple of months, I think. But I hope we can—you know, we can work with China on this issue and on other shared challenges.

I would say that I think, you know, part of the—part of the challenge has been—I mean, really, it’s a question about how each country conceives of international cooperation in a time of competition, right? one way to look at it is to say: We have these challenges in common. These should be ring-fenced off from security competition and regardless of what happens we should continue to work on those because we have a shared interest in getting toward that goal. That’s sort of essentially our view, right? The other way looking at it is we can only really work on those issues if the other issues in the relationship and the other points of contention are resolved, creating a context in which there can be cooperation on that. And that has been more sort of the view coming from Beijing on occasion.

I think we have to find a way to be able to cooperate with these things, because the stakes, you know, are too high. And we know from COVID and from other challenges, you know, we are interconnected. And what happens in one part of the world, you know, affects the other. What happens in China affects here, and vice-versa. And in many other places as well. And so I think it would be a shame if we ended up with two different

sort of block approaches, you know, to—you know, to health cooperation or cooperation on other challenges. That is not absolutely what we want. So I think we will find a way, but I think it is—you know, we’re at a—you know, it’s a generally sort of challenging, you know, period.

And I think we’re at an early-ish stage in more competitive relations internationally. And it’s incumbent on all of us to sort of find a way in which we can cooperate in a context that will be different probably than cooperating in a period—and you mentioned 2008 earlier. It’s probably going to be different than that. It’s going to be more difficult. And in some respects, health is, like, particularly difficult, because I think it can, in certain cases, get to direct issues of sovereignty and things that are happening directly inside a country. I mean, the economy is to extent that too, but I think we did see in COVID, you know, how deeply it touched on issues of sovereignty in different countries. But that is, I think, all the more reason, you know, to really engage in all of these diplomatic efforts that are underway to try to strengthen, you know, international architecture so we’re better prepared next time.

FREIRE: And it also tested the—these are bilateral discussions you’re talking about. But it also tested the role of the U.N., and the WHO, et cetera. Very briefly.

PACE: Yes, I’ll keep it as brief as possible.

FREIRE: Because we have time for one more question, and I don’t want to cheat the audience.

PACE: Yes. I just don’t want anyone to think that we’re not working with China. (Laughter.) So there have been conversations at the leadership level that we could probably do a better job communicating to folks. Our health minister has met with theirs. We have a health attaché on the ground in Beijing, in addition to FDA and CDC officers. Our CDC director has an ongoing communication with their leadership. And so that’s happening, in addition to our work at WHO. I mean, I sit next to their representative on the executive board. So I appreciate the question, and certainly want to convey that we are taking that seriously in every opportunity we can to engage.

WRIGHT: I agree with that too, I just meant more on the—sort of the summit level, yeah.

PACE: No, you’re fine.

FREIRE: Well, at the risk of being shot by the organizers, I want to take one more question. Because that clock is fast, and that clock gives me one more minute. (Laughter.) OK, over here.

Q: Hi. I’m the press fellow at CFR this year.

Quick question. I’ll just direct it to Loyce Pace. So if the U.S. is, you know, committed to better access next time, and things like that, I was just wondering, so there’s his new sort of—it’s called, I think, Biden’s new—it’s like Operation Warp Speed take two, the next generation vaccine initiative. Which is great. I think it’s $5 billion. Is there anything that’s being worked out, like, in those contracts or agreements that will kind of move towards not repeating what happened last time, where there wasn’t enough manufacturing?

PACE: Oh, Amy. It’s always the last question, isn’t it? (Laughter.) Well, we’re really excited about that announcement. And more to come, certainly. I can say briefly and generally that, you know, we’re obviously going to tie all these things together, right? So we’re sitting in these negotiations around the pandemic accord actually trying to tackle it in a way that will keep us preventing the same—or—prevent us from making the same mistakes, excuse me. So whether we’re talking about procurement, or liability, or, you know, other important components that you know we’ve been out and proud about, that, I think, is going to inform the way that we go about sort of advancing these innovations through Project Next Gen.

The great news, I think, for USG is we’re seeing how much our domestic and international initiatives really play with one another and need to feed off of one another in constructive and productive ways. And so that’s my hope moving forward, is that you’ll see more of that from us in the next couple years.

FREIRE: Well, thank you all very much. I really appreciate all the contributions of the panel. And I appreciate the time of all of you today. I will have to end this panel, although we have, I think, more questions than answers raised. But please note that the video and transcripts will be available and posted on the CFR website.

Our next session is entitled “Collective Responses to Other Global Health Threats.” It will start in fifteen minutes, at 5:00 p.m. So this concludes our first session. Thank you all very much. (Applause.)

(END)

Virtual Session: Collective Responses to Other Global Health Threats

KICKBUSCH: Well, good afternoon and welcome again to this Council on Foreign Relations meeting on Collective Response to—well, you know. (Laughter.) I got muddled up. “Collective Responses to Other Global Health Threats,” that we are going to look at now. So this is the second session, the final session, of this year’s Global Health Symposium.

I am Ilona Kickbusch. I am the founder and chair of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, and I’m the co-chair of the World Health Summit Council. And I’ve been asked to preside over today’s meeting. So I’m delighted all of you are.

And I’d like to underline, again, that we have probably over a hundred online participants. Some of you might have looked at the names of those participants. Quite extraordinary people who are out there listening to our discussions. So we have a fantastic panel here, with the three of the panelists here in person and one panelist online. Very big welcome. And we’ve agreed that we’re not going to read out bios. That you can all check on these wonderful people. You know some of them, of course, quite distinguished speakers.

We have Alice Hill, who’s the David M. Rubenstein senior fellow for energy and the environment at the Council on Foreign Relations. We have online Ramanan Laxminarayan, who is the founder and director of the One Health Trust, and he’s also a Council on Foreign Relations member. We have John Nkengasong, who is the U.S. global AIDS coordinator and special representative for health diplomacy, U.S. Department of State. And I must say that in October he was awarded—he was the first awardee of the new distinguished Virchow Prize on Global and Public Health, which he received in Berlin. And last, but not least, we have Juan Pablo Uribe with us. He is, of course, the global director for health, nutrition, and population at the World Bank, director also of Global Health Financing Facility for Women, Children and Adolescents. And a special thanks for him to be with us here because, of course, we have the World Bank and IMF spring meetings going on. So I guess every staff from there is running around like crazy in I don’t know how many parallel meetings.

So we’ve been asked—while each of us could talk a lot about the specific areas and technicalities of the issues that we deal with—to look at the foreign policy dimension of collective action. And in the previous panel, we really heard a lot about how geopolitics is now starting to influence global health. And we want to hear in the other areas that are partly represented here, is this also the case? Are people feeling this—what one of the previous panelists called—this negative synergy that is going on? And we’d like to touch on some of the other issues also that were mentioned earlier, but the earlier panel was totally focused on health. Here we have finance represented, we have—and we also have the environment. And we have a new coming together, like in the whole one health discussion, which again makes things even more complicated. And, of course, we have one person who actually has a foreign minister or a secretary of state as his boss. So we can hear more about how that interface works.

I’d like to ask you to start, Alice. We’ve—in global health, we’re in a situation where there is presently a negotiation going on for a treaty. You might have heard towards the end of our discussions before coffee, there was a question, you know, will we get such a treaty? Will it be serious? Will it have incentives and sanctions and things? But I was wondering, if you look from the eyes of environmental climate issues, you look at the treaties that exist there, and if you could share with us how important has it been in the—in the environmental arena to have treaties? And how—what role did geopolitics play in these treaties? Would you have gotten the Paris agreement today?

HILL: That’s a great question. Would we get the Paris agreement today? I don’t think so, at this moment. Certainly, we’ve seen greater divides across countries. I think that for climate, we can’t call the treaty system a success. If you look at where there world is at this moment, carbon accumulation in our atmosphere is at its highest level ever. Methane, which is a greenhouse gas emission that is particularly damaging in terms of heat, it has rapidly grown in the last few decades. The molecule of methane up in the atmosphere doesn’t last as long,

it only lasts maybe twenty years, but it causes eighty times more heating. So very serious that we have more methane.

Our treaties have not stopped us from heating up. And when we look at health, unfortunately, our work on trying to get the treaties has kept us from really focusing, in my opinion, adequately on what—the impacts that we already have occurring in the world now. That would be flooding, wildfires, drought, extreme heat. And all of those impacts have serious consequences for human security and particularly health, human health and the health of pretty much everything that lives on the planet. So your question is well taken. So far the global system of governance has not succeeded in keeping the planet in a condition safe for humans and other living beings.

KICKBUSCH: Thank you for that really optimistic start to our discussion.

HILL: Hey, I’m not going to dress it up, yes.

KICKBUSCH: And of course, the director-general of WHO has said that climate is actually the largest health threat that we face right now. And that, of course, again, if you look at collective action and if we look at the organizations we have now, shows us their restriction. I mean, there’s a lot of discussion about the definition of health of the World Health Organization, but if you go to the constitution, you know, the threat through environment, climate, and everything we’re discussing is not really reflected there.

So I’d like to go to you, Ramanan. You know, you focus on one health. And we don’t have a one health treaty. We have, you know, some good agreements between key organizations to actually work together. Could you give us your assessment of how, within that multilateral U.N. system, these organizations are working? Does it work? Is it just a showcasing? We’ve had a tripartite and then a quadripartite. What are we to expect from this move to one health? Is it more than a word?

LAXMINARAYAN: Thanks, Ilona. And I’m sorry to not be there in person with these amazing panelists. I would have loved to have that conversation in person.

Now, speaking specifically first of AMR, because AMR constitutes—or, antimicrobial resistance—is an important piece of one health. It exemplifies a lot of the ideas around one health, the idea that human, animal, and environmental health are intricately linked and we need to engage in all of these spheres in order to make a difference. We did have not a treaty but a high-level meeting at the U.N. General Assembly back in 2016, which resulted in a fairly progressive statement which was a consensus statement by all countries at the U.N. General Assembly, agreeing to, you know, treat this as a priority and work together.

Now, since 2016 and coming up to 2024, where a similar meeting will be held in New York on the side—you know, as a high-level meeting at the U.N. General Assembly, I would say that progress has been made in some countries, particularly high-income countries which now recognize that anti-microbial resistance is a clear and present danger to current health, but also in a pandemic sense. So, for instance, about ten days ago the U.S. Presidential Advisory Council on Combatting Antimicrobial Resistance, PACCAB, we put out a report on preparing for the next pandemic in an era where the antibiotics will likely work a lot less well than has happened in previous pandemics.

We already saw that during COVID, where there was a massive use of antibiotics, a lot of it unnecessary—in fact, most of it unnecessary. And resistance went up across the world, in the U.S., in India. Wherever it was measured, drug resistance went up. So, you know, it’s sort of a glass half full/half empty story. Yes, we’ve made progress in specific countries. Just to give you an example, the U.S. used to spend probably $5 million a year on antimicrobial resistance across the federal government in 2013-2014. Today it spends well over a billion dollars. And I’m not just saying the money is the only thing, but there’s certainly—different parts of the government are very seized with the problem.

Unfortunately, that prioritization is not consistent across countries. And there are many countries where antimicrobial resistance—which, you know, kills about 1.4 million people every year, more than—you know, almost as much as HIV and malaria put together—just does not get enough attention. So and then, just going back for a second to the broader one health lens, I think we live in an era which is of significant increase in production of animal protein. If people look back at the twentieth and twenty-first centuries, and say, well, what happened here? You know, certainly greater longevity, you know, computers. But the significant part is also that human diets changed tremendously. And that increase in animal protein consumption comes with a significant amount of risk, both in terms of disease risk but also with respect to antibiotic resistance.

So I don’t think, you know, it’s too early for us to be taking that very seriously because this way of raising animal protein is likely to pose the biggest risk for us in terms of the next pandemic, whether it’s avian influenza or certainly with antimicrobial resistance. And last thing to mention is that I know in pandemic preparedness we’re very focused on viral pathogens, but we have to remember that historically it’s bacterial pathogens—whether, you know, plague or cholera—that were responsible for most of the world’s pandemics. And one of the reasons why we don’t see as many bacterial pandemics is because the antibiotics, you know, work. And if the antibiotics stop working, as they have in many parts of the world, we are at risk for a bacterial pandemic as well, or a viral pandemic with secondary bacterial infections which could be equally bad if not worse.

So I guess that’s a summary of where things stand today. Thank you.

KICKBUSCH: Thank you. So I heard you say that, yes, through collective action, through the discussion, actually the focus on antimicrobial resistance and some of the one health issues has increased. But at the same time, not sufficiently enough. And of course, with the COVID-19 pandemic coming along, the AMR that was just gaining attention actually moved to the back again. And we had a focus on COVID-19 rather than this invisible and silent pandemic, as a number of people call it.

Juan, if I can move onto the other issue around where collective action is needed. There is, you know, the continuous call, of course, for financing. And that countries should show collective action through collective financing, for example, through joint funds, et cetera. And there was an incredible hope that because, you know, the G-7s and the G-20s actually helped us resolve the financial crises, they would understand the financial impact of this pandemic, and help take it forward. Now, after a lot of discussion, we won’t go into details, there is a Pandemic Fund. But it seems that the will for collective financing is not quite where it should be. I think you’ve raised a little bit more than about 10 percent of what’s needed. So could you share with us what’s actually standing in the way? I mean, they lost trillions because of this pandemic. And now they don’t come up with $10 billion a year. Why is that?

URIBE: So we’re continuing on this positive note, no? (Laughter.) It is a good question, Ilona. I’m very happy to be here. And thanks so much to the Council for opening this space.

Look, let me try to be a little bit optimistic, but of course the conclusion is we need to do much more and much more will need to be done in order to confront the multiple crises and the future risks. But I do believe that having been able to create a Pandemic Fund in the way in which it was created at the end was an expression of multilateralism, of many, many different countries and constituencies coming together, regardless of many possible disagreements that could be, and building a governance structure that brings civil society, that brings all the countries. And being able to quickly identify some core priorities, Ilona, which are extremely important and could be extremely effective in improving the preparedness of the low- and middle-income countries. And making that money concessional not only for the low-income countries, the IDA countries, but also for the IBRD countries. I think all of those are positive developments.

Of course, we’re very much, as has been said, below the expected, let’s say, levels and scale of financing that is needed to improve the pandemic preparedness and prevention in our countries. But it’s a very good start. As

you know, the Pandemic Fund did a call for expressions and got an incredible demand, Ilona, that you know, that adds up to roughly $7 billion, with a call for proposals that will give out $300 million. So the for sure conclusion is that there’s going to be a very important, unmet demand. Good project—by the way, Ramanan, good projects on one health, good regional projects bringing together countries, which is much needed in pandemics, that will probably not be able to be funded in this first call for proposals.

What I hope is that it’s going to have a demonstration effect that there’s good proposals, good country leadership. It’s extremely important, country owned leadership behind those projects. And a need for more financing for the Pandemic Fund. At the same time, to be very fair here, the Pandemic Fund has to prove its value proposition as well, in order to have a stronger case for additional financing that is needed. And a great element behind that value proposition is the catalytical capacity it has to mobilize additional resources, including domestic resources and resources from other sectors, for example, including the private sector.

So I want to stop, again, with not such a pessimistic note. Of course, much more is needed, but here is a start. Here is something that has been—that we didn’t have one year ago. Now we have it. It’s our collective creation. It has a lot of positive elements already brought into its structure and governance. There’s a high demand for it. And if we’re able to show that it has value added and it can really transform that reality in our countries and in our regions, I think it will be able to leverage more resources. I want to be a little bit optimistic.

KICKBUSCH: OK. We’ll move back and forth between this continuously, I think. You know, is the glass half-full or is it half-empty? And I’m sure some of your questions will also be taking this up.

John, you’re the one that has an absolutely unique position, I think, globally in terms of the responsibilities you have within the foreign policy of your country as a coordinator of a specific disease on the one hand, of, you know, the—but having health diplomacy in a broad way in your title. If you could explain to us the logic that was behind this position. Why is it that your country, the United States, actually moved in that direction? Was it just, you know, to attract you to leave CDC Africa, and say we’re going to give you something really great if you come? Or what is it—what will make the difference that the AIDS coordinator now is where he is? And I say “he” because, obviously, you’re a he. So would you share that with us, John? And what are some first experiences you have now, you know, working in a foreign policy context?

NKENGASONG: So, absolutely. Very tough framing. (Laughter.) I think, let me lead with my reflection, which—I promise that I’ll ramble a lot, because I remember the answer to—the specific short answer to that. So when the panel discussion focuses on global health threats and collective action, I think it appeals so much to me because I’m partial to collectivity, the whole philosophy of collectivity, whether collective security—(inaudible)—or if I use the word global health security, collective security, health security. And collective action ties to that.

So when we have a common threat, such as other threats, I think, Ramanan and others have touched on, the AMR. Before the Ebola outbreak in West Africa, the leading fear we had was AMR. Then Ebola came, pushed it back, and then COVID came, pushed that back again. I just want to appeal to that as well. The other threats include human security, which is different from global health security, the noncommunicable diseases that are rising and the debts from noncommunicable hypertension, cardiovascular, cancers, and some of the infectious disease as a human security threat. And of course, I would be remiss not to mention HIV/AIDS, which is still a serious threat out there, which is a disease that I’m paid to work in.

So there are two things when you—in my years of reflecting over disease threats, what is it that drives foreign policy and diplomacy? I think it’s two things. It’s either you are sympathetic to the cost or you are concerned with the cost, as a country. HIV/AIDS, again, leading with positive examples, HIV/AIDS offers to us one of the best examples where in 2002 or 2001, Kofi Annan, the U.N. secretary-general, and others worked with other leaders, mobilized the world, and said: Here we have a serious problem going on in the world, and especially in Africa. Let’s take collective actions. The Global Fund was established. Juan Pablo, with that same spirit of

collectivity, has brought back to this that you create a global Pandemic Fund, and raise many more millions. So that is a good example of collectivity in action, where it’s appealing from a humanitarian perspective, but it morphs into a foreign policy very quickly, or diplomacy very quickly.

PEPFAR. When a group of Congressional Black Caucus leaders in the Hill write a letter to President Bush and said: President, we have a whole continent that may be wiped away by HIV/AIDS. Take action. And the president looks at that and takes bold action. He was doing that from a place of humanitarian, from a place of sympathy, but suddenly, of course, it morphed into a foreign policy platform, what I call soft power. Becomes a soft power for the United States. And it has proven extremely impactful in the world. So concerns for a common threat, sympathy for a common threat are the two things that govern or drive diplomacy and foreign policy when we look at that.

Now, diplomacy and foreign policy in the context of disease threats can actually also be confusing and misconstrued. When we were all faced with the COVID vaccine situation, a word emerged that I was truly not comfortable with it, in my previous job. It was vaccine diplomacy. And when you look at what diplomacy and foreign policy, it speaks to friendship. It speaks to friendship. So in other words, I’m giving you ten thousand doses of vaccines not necessarily because I’m meeting your need, but because I want to maintain our friendship. So it doesn’t necessarily meet my aspiration and goal, but it makes me, the donor’s, goal of maintaining our friendship.

I think that doesn’t—it doesn’t become helpful in that space, because of that skewed interest, what I call utilitarian diplomacy. Meaning that you use the other person’s and play with the other person’s sympathy, which we should all recognize and acknowledge that it was so deeply rooted in the way we responded to COVID-19. So the lessons I’ll leave there is that collective actions can only be effective if there’s effective cooperation, if there’s effective collaboration. Otherwise, the concept of—or, the philosophy of collectivity doesn’t hold, and foreign policy suffers, if you have that shortage of cooperation. That’s why some foreign ministries—or in countries you have not ministries of foreign affairs but ministries of international cooperation. Because of the word “cooperation” on the mind underlines and defines foreign policy. And that is true for disease threats as well.

KICKBUSCH: How well you avoided answering my question. (Laughter.)

URIBE: You said it at the beginning. (Laughter.)

KICKBUSCH: We’ll try another way afterwards. So, Alice, can I come back to you? After you’ve heard some of these responses, again, half-full or half-empty, talking to the colleagues at WHO, they’re incredibly proud that for the first time at the upcoming COP-28 there is going to be a full health day. What will that mean? What would you recommend to the health colleagues that they use that health day for? How can that health day help drive the environmental and the climate agenda?

HILL: Well, it is a wonderful opportunity. I’m not sure how many of you have had a chance to attend a Conference of the Parties. We’ll be on our twenty-eighth this next year in Dubai. I would liken it to a trade show. You have lots of booths with lots of people trying to convince each other of the wisdom of their products or policies or what have you. But it is a tremendous opportunity to bring attention particularly to this issue of health, which is just underappreciated what climate change—1.5 degrees Celsius doesn’t sound like a lot. But I can tell you, we probably are going to exceed 1.5 degrees Celsius at all likelihood. And even at 1.5, huge impacts to human health.

You can look at Mozambique. They just had the—probably the longest-lasting cyclone. Now they’re facing a spread of cholera, and then also a spread of mosquito-borne diseases, malaria, because of the standing water. You can look at Pakistan, India, extreme heat, heat at a level in India that threatened to—not sure if you heard of the wet bulb temperature, but the human body can’t survive because we can’t perspire enough to keep

ourselves cool if we have high humidity and high heat. And a country’s moving into a zone where it’s going to have much more frequent days, and it doesn’t have widespread air conditioning. And that would assume that the power works, so you get the benefit of the air conditioning.

And then you can look at droughts. Just look at our western United States, valley fever, that conditions are dry, you have the spores kicked up, and more people suffering from that disease. Pretty much any impact, wildfire, people inhaling smoke and then the burning of environmental hazards and what the soil has left and the water. So this day, in my opinion, is a huge opportunity to bring attention to an underappreciated threat. And this is how underappreciated it is, to me. There’s been a lot of work to try to make sure that medical schools, public health schools, nursing schools teach the soon-to-be practitioners about climate change and the health threats that they will see in their clinical practice, that they need to do research on, and that they need to understand to be successful going forward.

The current estimate, and it’s hard to get full understanding because most medical schools aren’t revealing their curricula, is that only 15 percent of schools have a curricula on climate change. Now, the schools will say, well, we already have to teach so much, we can’t fit it in. But the students will say, and most of the students are onto this, we need this education. We’re going to have patients presenting with tick-borne diseases. We are going to have patients with greater asthma. And I don’t know if any of you are suffering from the pollen right now, and we’re, all of us, are going to have greater allergies—not all of us, but some of us who suffer already—from climate change.

So it’s been very slow. And part of that is that the faculties in the schools don’t understand climate change. They were educated at a time when climate change wasn’t an issue. And that is true for most of our leaders. So this moment is an important one in getting out the message. It’s also an important—hugely important—that we have great success there for all of us, to get better global commitments to reduce the harmful greenhouse gas emissions. But the health message could, I think, contribute to certainly driving greater action.

KICKBUSCH: So that actually indicates that, you know, various organizations, groups, et cetera, that tend to look at their threats separately. You know, this is our threat and I want to get the money. You shouldn’t, I should, because my threat is more important. That here is an opportunity to actually come together. But you also said something else in relation to the underappreciated threats that I want to ask Juan about, because on the one hand we’ve said, OK, because of this threat we now have the Pandemic Fund. Let’s be optimistic. The countries are going to show they really use those 300 million (dollars) well, and then everyone will come and say, yes, we’re going to pay for the remaining billions that we’re missing.

But you were on a panel this morning. And this morning you said, where we really need to invest in is in health system strengthening. And that says, you know, there’s a whole load of threats out there but, actually, might we not be needing to do something else than investing in each of these threats and the response to them individually? And so can you say a bit more about that? And what competition is there? I’m thinking, you know, at the U.N., day one, pandemic summit. Day two, UHC high-level meeting. Day three, tuberculosis. What progress are we making? Are we competing with each other?

URIBE: Ilona, I won’t sound optimistic this time. (Laughter.) I will go back to my normal pessimistic role. No, I think we all need to be very critical. You’re making one of the most important questions, I would say, to the global health recognition and to the way in which global public health is being conducted today, and as we all need to think about it. This morning, by the way, there was a minister of health from a low-income country in Africa, Yan Baroside (ph). And she started by saying, I’m sorry about all these things, and then explained all these things. They really take shape in the community, in the village with the community health workforce, with our primary health care network. That’s where it takes place, and that’s where we should start.

I think she’s completely right. We’re talking about the human development phase of climate change, that we need Alice to strengthen. We need to put it in the center of climate change, that human development, that

human phase. Where if you’re talking about pandemics, and AMR, Ramanan, or it’s there. And she ended up saying, by the way, her conclusion in the panel was: If you bring top-down approaches—and these are my words narrowed—that are being dropped in the country on the side of the health system, that will not help us either. And I think she’s absolutely right. I can see this. There’s no shortcut that I know about when we’re talking about these threats and challenges ahead that affect health.

We need to do the long-term health system strengthening ever, Ilona. It has to have strong public health functions and strong primary health care. It has to be able to build on collaboration and solidarity, and trust. It has to advance towards universal health coverage, understood like the financial protection for household and individuals whenever they really need care. Those are the elements, by the way, that we’re seeing in resilient health systems, Ilona. We’ve gone across all the agents and all the countries in the world trying to see what made the difference in the response to COVID in many of those cases, where the resilience can come from. And it came from those things.

And, by the way, not all those things can be bought with money. You cannot through financing, exclusively, build those elements. You need additional non-financing elements. In particular, you need to construct institutional capacity—(inaudible)—and that requires consistency and political stability. You need leadership, leadership, and leadership. And you need—and you need a lot of community engagement. So I want, again, to highlight that. I think those are core elements that explain why we need to come together and stop fragmenting the public health arena. And understand that when a minister tell us in Sierra Leone, Juan, if I get the antiretrovirals but I don’t get the needed nutrition, I will have the same sick boy in front of me. And he’s absolutely right.

So let me stop there. I’m not so optimistic on this. I think this is our challenge, by the way. And I think everybody recognizes it. What we need is to be able to act on it, not fragmenting this more, and hopefully converging a lot of these efforts, which are completely intertwined. Just to conclude, I see, for example, the three biggest global public goods that we’re discussing in the evolution road map at the Bank right now, so intertwined: climate change, pandemics, and migration and fragility. I’ve seen them coming all together, by the way. You’ve seen them coming all together in many regions of the world and many of our countries. So they need a collective response.

KICKBUSCH: Thank you. So, John, can I come to you then? If we look back twenty years, we created all these AIDS organizations. I mean, that was really the start of that enormous multitude of global health organizations that we have now. And which, you know, sometimes helps, sometimes does not. If you look back twenty years and I say, OK, now we have, you know, this tremendous investment over twenty years in AIDS, would you say we’re moving into something similar now in relation to the pandemic? You know, we created five, six, seven, eight organizations. Now we’re starting to create, at least it’s suggested, a whole number of pandemic associations. Would you say yes, go ahead, because it attracts money? Would you say, be careful, this was our AIDS experience, if I could go back twenty years? Maybe take a slightly different tack? What’s the experience that AIDS gives us, last not least, in terms of universal health coverage and what we did not do?

NKENGASONG: I think HIV/AIDS, and the creation of platforms like PEPFAR and Global Fund, offered us a unique opportunity to understand how in trying to solve one problem you can solve many problems. The platforms that HIV/AIDS—for PEPFAR, for example—have created begin in workforce development. PEPFAR has supported the training of over 340,000 health care workers, many in sub-Saharan Africa, strengthened over, 3,000 laboratories, strengthened over 70,000 health care facilities. And those platforms, we’ve seen them being used during this pandemic—the COVID-19 pandemic. Global Fund has done similarly.

So when I think of preparing for pandemics, I’m always conflicted in my mind as to what is the best approach to do this, when faced with scarcity of resources or scarcity of attention? I think something tells me that the best way to prepare for the unknowns is to adequately invest in the knowns. The knowns are those threats that we’re dealing with every day—the TB, the malaria, the HIV, and antimicrobial resistance. If we have those platforms,

(and at times ?), and most of them is the same concepts or health system elements that Juan mentioned that will enable us to fight for the unknown disease, is workforce development, transport systems—(inaudible)—or supply chain issues. It’s laboratory systems, et cetera. (The same thing ?) is elements that we’ve used effectively over the last twenty years to fight HIV/AIDS.

And to the extent that we are hoping that in the next seven years we might—we might bring HIV/AIDS to an end as the public health threat, even though you still have millions of people living with HIV/AIDS who receive their treatment every day, but it would not have that public threat again. So it’s a big lesson there to be learned that we should really think hard as to is our investment for the unknowns adequate for the preparedness component or for the response component? I would argue that the response component needs a lot of attention. And what is the response component? Make sure that we democratize manufacturing of diagnostics, vaccines, therapeutics as much as possible, and personal protective equipment, because that is the response element.

And people always say, well, what is the difference between that? I say, well, you may have little boats standing by around and prepare for the day the flood arrive. And when the flood arrives, you don’t have people to go take it around and then evacuate people, then you don’t have the response. So in my view, this is a complementary area that I hope that the fund can, should, focus on. That way, the investments that we are putting into the vertical programs complement those response elements, which the vertical programs are not currently doing.

KICKBUSCH: Thank you, John. And I’ll go to Ramanan. You noticed you made his list—you know, was list of diseases plus AMR. So you made it there.

LAXMINARAYAN: Twice, twice. (Laughter.)

KICKBUSCH: And so tell me then, listening to this, you know, investment in universal health coverage, investment in workforce, specific areas, what will make the difference to not every time a new thing comes along to push AMR in the background? What will keep AMR in the foreground, do you think, in terms of collective action, attention of countries and other actors to the issue?

LAXMINARAYAN: So, you know, first of all, I agree with everything that has been said by Alice, John, and Juan. And, you know, particularly picking up on the piece that John made, that collective action is really critical. That you can have AMR arise in any country. I think people are aware of the fact that there’s now a multidrug resistant strain of Klebsiella which came into the U.S. from manufacturing, potentially in India, from, you know, artificial tears. So you have this very rapid movement of multidrug resistance around the world, you know, just by something like that. And so it’s clear that we can’t just, you know, ringfence every single country.

And, you know, I fear that one of the—you know, what used to be said very often in Washington, you know, a crisis is a terrible thing to waste. And I feel like we have wasted COVID. We have not take advantage of COVID. We’ve forgotten this thing about, you know, everybody safe—we’re safe only when everyone is safe. We’re completely not saying that anymore, which used to be on every panel that I was on two years ago. You don’t hear that anymore. And that applies very much to climate change as well.

So I feel like there are a couple of things here. One is that we do live in a world where there’s limited attention, particularly from ministers, on the sets of things that they can do. But as people working in this space, we cannot be limited by just what the mental bandwidth of ministers is. They have a job to do, which is of today. But it’s our job to be able to imagine what will happen with threats like climate. And, frankly, we will fail because of our failure of imagination of what climate change will actually bring.

When I think back at reports that we did twenty years ago on climate change and disease, it was remarkably sort of simplistic. We were talking about expansions of malaria territory, things of that nature. We just didn’t even think about things like, you know, fungal pathogens being far more common, or, you know, valley fever, for 

instance, or, you know, expansion of territory of things that were not threats at that time. Candida auris was not a thing till 2004. And these represent our biggest threats.

The one health lens is not just a luxury that, OK, we have one more lens to put on it. It’s simply because our connectiveness to what’s happening in the environment has drawn a lot because of climate. And we continue to grow. And I think the operative word in climate change is really not just the climate, it’s also the change component. I think that one of the things we fail to appreciate is that the pace at which these things will move over the next thirty years will be a lot faster than what has happened over the last thirty years, simply because the climate is changing a lot faster over the next thirty years.

So, you know, whether it be the Arctic permafrost, which actually, you know, potentially is maybe less worrying—you know, the Siberian permafrost and new bugs coming out from there—or of drug resistant pathogens, which seriously undermine our ability to threat bacterial infections and fungal pathogens. I don’t think people realize that for fungal infections we rely primarily on one category of drugs, a category of drugs that we also happen to use extensively in the environment as fungicide, you know, for plant funguses.

And we’re sort of standing on a very narrow wedge in some of these places. And I think that the conversations should be around, one, what are we failing to imagine will be the next threat. And the second is, when that threat inevitably arises, and it’s just a matter of time, how well-prepared are we to leverage that crisis for doing the things that we need to do, you know, going forward? Because this is not—this is going to be a conveyor belt that we’re on right now.

And I do hear your point about the—you know, preparing for the system versus individual diseases. And I think both are very important. You know, you’re going to have to do some amount of specific conversations on AMR or TB, just because there’s a lot of detail that’s specific to that. But I certainly agree that, you know, these broad, cross-cutting threats, like climate, do deserve a lot more attention. And the work—the onus is really on us to be able to be imaginative in what could happen and be creative in communicating this.

And the last point I’ll make is I think the point was made about workforce. This particular report that we came out with for U.S. pandemic preparedness in the face of antimicrobial resistance, the first point is not any technical point. It’s really about trust. And the reason trust was important was in the series of sort of, you know, panels that we had and public meetings that we had, you know, with various experts and lay folks, it was felt that one of the places where COVID really—you know, we really fell short on COVID, particularly in the U.S., was on dealing with marginalized communities, you know, diversity. We didn’t do very well there. And we just did a really poor job on trust.

And trust is not something you can build when you have a crisis. Trust is something we’ve got to build well in advance of the crisis. And we’ve got to demonstrate that, you know, there’s a rational and a scientific process to why we’re calling out these threats. And that doesn’t have to wait till the next pandemic. That can happen right now. So, you know, certainly workforce is very important. So I don’t mean to underappreciate the workforce. The workforce is number two, by the way, followed by things like infection control, and stewardship, and, you know, new drugs, and diagnostics, and surveillance, and all of that stuff. But again, as I think as was mentioned by both Juan and John, these are issues that have to be done anyway for all the diseases that we have already. And doing that much better will leave us a in better position for the next pandemic.

KICKBUSCH: Thank you very much. We’ll now move to you. And I’d like to invite the members and guests to join the conversation, either with questions, with comments, show your imagination, as we were challenged. I have to remind you that this meeting is on the record. And who has the first question or statement? So, we have Michele over there that raised her hand first.

Q: Thank you, Ilona. I’m Michele Barry, dean of global health from Stanford.

And this is a question to Alice Hill. By the way, students are by far the driving force for climate into our curriculum.

KICKBUSCH: A bit closer? We can’t hear you well, Michele. Would you put the mic a bit closer to you?

Q: OK, can you hear me now?

KICKBUSCH: Yeah, much better. OK.

Q: OK. Can you hear who I was? (Laughs.) I’m from Stanford. I’m the dean from Stanford. And I was making the comment that what you said is completely right, that students are the driving force for putting that curriculum—climate into our curriculum. But we have a lot of pushback. But my question to you, you’ve written very eloquently about resiliency. And so I’d like you to comment on the particular vulnerabilities that women have to climate impact on health, and also, similarly, comment about the lack of leadership at COP-27 and at the COP meetings by women.

KICKBUSCH: Thank you. Alice.

HILL: Well, I’ll just share—obviously, I’m a woman. And I’ve thought about women and our role in society really since I was a kid. But when I was writing my last book, which is entitled The Fight for Climate After COVID-19, I began to really look at the gender issue. And I just remember sitting at my desk and finally realizing how fundamentally awful climate change is for women and girls. That includes in developed nations. So where that will be is—could be for health care outcomes, just because a lot of the, you know, research is on men, other things.

But for climate change, think disasters. And you’ve got a lot of people displaced all of a sudden. And you might have a single mom with a few children. She can’t—doesn’t have transportation. Or you might have a young girl who’s separated from her family. I used to be a prosecutor. I used to be a judge. Human trafficking is a big risk for women and girls in these events where there’s little security presence. That’s here in the United States and that’s globally.

And then you move globally—and there are other issues for women here—but you move globally—including their poverty and the fact that they earn 70 cents on the dollar compared to men. So just don’t have the means. They may not have the ability to evacuate. They may not have as much access to credit, other things here in the developed world. But you get to poorer economies, and you start thinking about the way women dress. So think about having a lot of long clothing, and you’re trying to evacuate in a flood or some other event. Very difficult. The girls often aren’t taught to swim.

So you’ll see, it was—I’ve forgotten the name of the typhoon that struck, but a typhoon in Asia. And about—a huge percentage of the women were killed. Many more men survived. It’s fourteen times more likely that a woman will die in a disaster than a man. So we’re looking—and that’s because of physical strength. Just think, trying to hold onto something. It’s just harder for women. We don’t have the kind of same strength as men will. And then you think about as drought occurs, women have to—girls and women—walk further and further. They’re the ones that collect the water. And they’re further away. And not only is that physically demanding, when there’s food shortages and other things, but they’re also at much greater risk of sexual assault, or any other kind of assault.

And so it was when I was writing that book that I realized as much as our U.N. and our other global conferences call out gender, honestly, if you look around, it’s mostly men who are running the show. And gender gets cited, but we haven’t made nearly the progress we need to make, in my opinion, to protect the young girls and women that are facing these situations already. We are failing them. They are dying, because of their sex. And that was a profound understanding for me at that moment. And I think that needs to be elevated as we go forward. And

so to your point, it is—if you go to a COP, there are many women, but you will notice that the leadership is primarily male. So, yeah.

Q: How do you change it?

HILL: I think that we need to call attention to it. And I think that for many professional women, it’s a difficult road to call out your own sex, in a way, to call attention to a problem. Frankly, I think the most powerful thing is for men to call out this problem. And that’s the same for other issues, so for marginalized communities, that those who have the power make sure that they share the power. And so I think that it’s a matter of continuing to draw attention to the issue. And I think that we have excellent institutions trying to do that, but we’re not where we need to be to keep women and girls safe in the face of changing climate. And that’s just what my own research taught me.

KICKBUSCH: Thank you, Alice. And I think, of course, that is the case with practically every global threat. And we live through it with the pandemic as well, as to who was the most vulnerable, who died. We lived through it with the health workforce, which is mainly female. So I think, you know, it’s a very general thing that if we do talk global health threats and collective response to it, then that collective response needs clearly to have an understanding of the gender dimension of this. And despite the fact that gender has been much discussed in global health, we are not there, either with the awareness nor with the leadership, I would think.

There’s a question here, please.

Q: Hi. Thank you so much for doing this. This has been a great panel and a great symposium. I’m Shannon Kellman. I’m the senior policy director and co-chair of the Global AIDS Policy Partnership, at Friends of the Global Fight against AIDS, Tuberculosis, and Malaria. A little bit of a mouthful.

I wanted to ask, both in terms of financing and in terms of political will, how we keep individual crises from suffering what I call the shiny object syndrome, which is the immediate often crowds out all of the other issues on the table. We’ve seen this with disease, after disease, after disease. And I am concerned we are seeing it now with COVID. And this symposium, bringing us all together to talk about the lessons learned from the COVID experience, I wonder how we can think about the future of challenges that we all see on the global health space, certainly, but how we can take the lessons from the past going forward.

And I bring that up because as I’m sitting here, I just literally just received a notification that the Senate Foreign Relations Committee will be holding a hearing next week on PEPFAR at twenty, how do we achieve epidemic control, featuring none other than Ambassador Nkengasong. So wondering if we could get some preview thoughts.

KICKBUSCH: Preview, John.

NKENGASONG: You’re more privileged to that information than I am, so thanks for sharing. (Laughter.)

KICKBUSCH: You heard it here.

NKENGASONG: (Laughs.) Thanks for sharing that. I think—let me say—I’ll repeat what I said earlier. Twenty years ago was remarkable. PEPFAR was created and Global Fund. I always think of that moment like the moment. Where is that leadership, as I think somebody said about leadership, when its present you know that leadership is present. There was leadership there. There was political leadership. But we should also remember that HIV/AIDS have a lot of advocates and activism behind it. I think that we can never underestimate the power of activism, advocates. That’s why in the session I just had with U.N. AIDS a few hours ago, I started off by recognizing the so many parents that PEPFAR has. And as the saying goes, success has many parents and failure you are alone. So PEPFAR is a success, with 25 million lives saved.

It couldn’t have been just the Office of the Global AIDS Coordinator doing that. It’s all of you. I mean, I look in the room and I see so many parents of PEPFAR. Where are those parents for the Pandemic Fund? You have to have those parents for Pandemic Fund that are advocating every day, educating, informing, and make sure that agenda item remains on the radar screen. In 2000, I remember vividly we had an AIDS conference in Durban. And former President Mandela, or late President Mandela, was at that meeting. Those of you who were there, we were all on the streets marching, whether you’re a scientist, a lawyer, a policymaker. We’re all on the street protesting and asking for a way out of this, right? That kind of activism, don’t underestimate the power of that. We need that kind of movement if pandemics or health security needs to be taken seriously.

I would just end by saying that the way I process health security is—and the question that people always ask—is what is the return if I invest in the Pandemic Fund? What are you counting and what is the return on the investment looks like? My answer to that is that we should look at health security from a lens of military, like, a defense, right? You do not invest in those planes, warships because you’re at war every day. You may actually spend a lot of money buying that expensive piece of equipment and you don’t use it for twenty years. That’s your insurance. You should look at it as insurance. What are the insurances that we have for our own—to guarantee our security, health security, in the future. You may not use it, but it already has to be there, not in the lens of return on investment, if I put $10 billion a year, what am I getting in the return. So I think—I don’t think I know the answer to that, but that’s the way I think about these issues.

KICKBUSCH: Over there, please. It’s coming.

Q: Hi. My name is Digvijay. I am the cofounder of Drizzle Health. We make $2 diagnostic devices for global health and one health.

We talk—

KICKBUSCH: Please put the mic closer, yeah.

Q: Sorry. Can you hear me now?

NKENGASONG: Yes.

Q: Yes. My name is Digvijay. I am the cofounder of Drizzle Health. We make $2 diagnostic devices for global health and one health.

So, Juan touched on this a little bit, but I wanted to go to Ramanan and ask, if you look at tuberculosis, the problem of molecular testing and how it’s being rolled out, it’s still dependent on aid and how concessional pricing has been used to, like, test all these populations. What can be done to ensure that LMICs, or low and middle income countries, participate early when it comes to one health, as opposed to as a laggard population when the problem is already upon us?

KICKBUSCH: Go ahead, Ramanan.

LAXMINARAYAN: You know—thanks, Ilona. And thanks, Digvijay, for that question. You know, I think you sort of alluded to the answer yourself, which is that even for things like tuberculosis, our ability to provide diagnostics at scale and to get people to understand when they have the disease has been a long, you know, road. And we are so far away from it. And I’m delighted that you have a $2 diagnostic for tuberculosis. That sounds—that sounds really promising.

Now, I think, you know, in every other place it is a challenge to be able to get LMICs to be ahead of the game in terms of adoption. Some of it is being made possible because of increased manufacturing capabilities or, as we saw with COVID, you know, in the case of vaccines for instance, some countries, like India, which have the

capability to be able to step up and also carry out innovation, not just on, you know, responding to innovation that happens in high-income countries, to be able to move the needle.

And I suspect that that will happen even more going forward, just because science and technology capability in countries, like, you know, South Africa, or India, or Brazil, or China—is certainly—the gap between the West and these countries is a lot narrower than it used to be in the past. And, last but not least, the markets that are available in these countries are tremendously large. If one is able to innovate on diagnostics for one health, in a country like India or like Brazil, then that company would certainly be well-prepared to take on any sort of challenge in the U.S. or in Europe, both in terms of pricing as well as anything else.

So I am optimistic that a lot of innovation will now move to the so-called developing world. And that can only be good for everyone as a whole because then the price would be right, and the ease of use and adoption will also be facilitated through that.

KICKBUSCH: Thank you. I understand we have a virtual question, please.

OPERATOR: We’ll take the next question from Bruce White.

Q: Oh, hello, there. Bruce White, director of the Organization for Identity and Cultural Development, oicd.net.

In line with what’s been said here on inequality, the importance of working at the grassroots, and the interconnectedness of problems, we’ve been working on building a social and psychological resilience to polarizing, divisive, and harmful misinformation, such as on climate and health science. And my question is really for anybody’s who’s interested in taking it. How can we spur the necessary investment in ensuring that localized identity and values structures can resist dangerous manipulations of identity and culture? And is there a way to embed this grassroots cultural resilience into health systems? Thank you.

KICKBUSCH: Thank you. And that’s partly related to the trust issue that was also raised earlier. Juan, is there something you can say about this in terms of, you know, the investment—well, it’s investment in people and their trust.

URIBE: Well, Ilona, you know, I don’t—I need to be very frank. I don’t have an answer for that. I think it’s going to be very difficult to really have an answer that can be applied across so many different scenarios. But you already responded what I would have said, and it’s a matter of—really of trust. And, again, trust, you have to—you have to earn it almost day by day. I think we’ve seen very different responses in terms of hesitancy, for example, and the interventions end up being very specific for that locality.

By the way, I don’t know, by the way, how this scenario will unfold in the future, in the near future, with digital developments like AI and others. By the way, I think that question is extremely good because this matters of public health and trust and relations will all get, you know, more complex. Not necessarily for the worse, but for sure much more complex than what we can envision right now and that what I can understand right now.

KICKBUSCH: Thank you. And so it’s just a plea also in all our discussions to keep this deep digital transformation in mind, because it’s going to affect and change everything we do in the next ten years, quite surely.

There was a raised hand back there.

Q: Hi, I’m Maria Freire.

I have a—I was very moved, Alice, but your epiphany about the impact of climate change on women. Has anybody studied the financial impact, as you take these women and cripple them economically? Have we looked at that the other way around? Because we always—as John said, we’re always looking at the return for the investment. But I wonder what happens when we look at it without the contribution of the women to the economy.

HILL: I am not aware of such modeling. But to your point, I think just stepping back on the modeling about climate change, we have a lot of modeling about the costs of the transition, to the costs of clean energy, the costs of reducing our carbon emissions. I don’t think our modeling is as strong—and I think I’m not alone in this—as to the economic costs and the cascading costs of climate change. Including the cost of health that we’ve just—you know, to human health. That’s a lot of costs in medical bills. But we didn’t even mention here, I didn’t mention, our hospital infrastructure, that is greatly threatened by flooding, by power disruptions. We’ve seen people in nursing homes die because they didn’t have sufficient generation capacity when power was threatened during a heat wave. And that is what happens during a heat wave. And, by the way, our power system is built for the climate that existed about sixty years ago, when we built a lot of it.

And so you may have noticed in your own life a lot more power outages. And that has been documented. And they’re often worsened by climate impacts. And the modeling that we made some of our choices with regard to climate change, I think on a policy basis in terms of the high costs that were projected for the transition, just simply weren’t sophisticated enough, and still was very difficult to do, to really parse out all of the costs, including to your question. What’s the loss to the workforce, because it’s too hot to work? What’s the loss of missed school days to children as we are seeing now in the United States in Philadelphia, because it’s too hot for the kids to be inside schools that aren’t air conditioned and you didn’t need air conditioning in Philadelphia in the old days? And now we do. And we will need it in Boston. And we’re going to need it in Quebec. And we’re going to need it elsewhere. We just haven’t thought through that.

So when we talk about how expensive it is to get to clean energy, we need to think what are the costs we’re not accounting for that we’re already accounting, and will only get worse as we experience more heat? Because these events become exponentially worse as there’s more heat added. And every amount of additional heat from that big blanket of greenhouse gas emissions that now trap heat for all of us, every bit of extra heating brings worsening events. So what is the added cost of not significantly advancing our transition to clean energy? And we don’t have good numbers on that.

KICKBUSCH: What numbers do you have, Juan?

URIBE: (Laughs.) So, Maria, I don’t have an answer either. But I do want to say that in the health unit at the World Bank, we’re trying to develop a country evaluation instrument that starts putting numbers to some of the initial dimensions affected by climate. And we’re talking about NCDs. We’re talking a little bit, Alice, about infrastructure. We’re talking about infectious diseases, of course, some of them. We’re looking into mental health, that we haven’t spoken about it but extremely important. So we have, like, six categories—nutrition or food, for example—that are already being evaluated.

But it’s still very short compared to what Alice told us about the much deeper impact of climate, and health, and that human face, in this case that of women. So I think we are starting. It is very important. We tried to do it, to have basically, as you said, arguments to call the attention at the country level around these policies with so many other competing needs. And we are advancing. We are doing it. But we will need to get much deeper and much longer in terms of embracing so many dimensions, yeah.

KICKBUSCH: Thank you. There was a question here, yes.

Q: Hello, there. I’m Mitchell Warren with AVAC. And I’ll put the microphone close to my mouth.

And a question, you know, Juan Pablo, you talked about community engagement being so central, and thinking about the future. And I’m thinking, John, as I remember 2000, and activism and advocacy from the streets ended up evolving into deep, durable civil society not just engagement but leadership and governance structures. And I’m curious, as we think to the future of global health architecture, what are the lessons, perhaps from the Global Fund and PEPFAR, or the country leadership and ownership, and civil society leadership in the governance structures of the future of the Pandemic Fund and future of global health architecture generally?

KICKBUSCH: Thank you. John.

NKENGASONG: I was hoping that Juan would let me answer that question, so. (Laughter.)

URIBE: I will come up. (Laughter.)

NKENGASONG: You know, thanks so much, Mitchell. We just spent the last few weeks in South Africa for a country operational planning, also called COP. (Laughter.) With about twenty-two countries, planning for the next two years in PEPFAR. And my—as the new head of the PEPFAR, what I am promoting is what I call a tripartite, where the government of the countries that we are supporting leadership, civil society and communities, and partners—i.e., you can replace the Global Fund or any other partner.

That we start the co-planning and co-creation early. The co-planning and co-creation early, and have alignments. Where the government sees where this is the direction that we’re heading with their response to get to a common goal of 2030. The civil society comes in and says, well, and they actually develop their—what they call the people’s COP. They are coming with their own strategic plan. And we come in with our five-year strategy. And we try to merge all three, so that we have a common way underneath the banner of one country, one program.

That, to me, I hope will be—should be the direction that, regardless of—or, a model, rather, that defines us as we work together in the spirit of true global health, where it’s bidirectional. We actually lead by respect, bonus, and courage in discussing with each other. And hope that’s a model that once the pandemic fund is established, it should be—I hope we are successful with that, and that we—the new platforms that are emerging could learn from it.

KICKBUSCH: Juan.

URIBE: Yeah, no, and I think there is a lot to learn there. And there has been an incredible benefit coming out of advocacy and that broader support. But I wanted to share something worrying to me at the same time. I’m always—I’m always concerned about voices that are not heard as well. Just to give a particular example that always strikes me, it’s maternal deaths. Why don’t we advocate for mothers, Ilona, when they’re giving birth? Why do we still have this incredible rates of maternal deaths? And I don’t see that noise. So what I want to say is that we need to learn from these very good examples that have been so robust and successful. And then looking to those silent pandemics, into those silent pockets of suffering and disease.

By the way, usually concentrated where concerns and sympathy, as John said, do not reach easily. I like very much that summary, John. And try to bring light to those elements as well. I think that’s extremely important. Of course, that’s the role of governments, by the way, and of the state. But let’s be aware, and the health agenda, that there are a lot of silent pandemics out there, happening minute-by-minute. And we need to also be conscious about it. We need to address them, Ilona, learning from these very good examples of success.

KICKBUSCH: Thank you for that. and we had in another context, you know, this discussion also that sadly, or mainly, we use the word “pandemic,” which scares everyone and motivates everyone for the infectious diseases. And of course, there is the pandemic of the most vulnerable and the pandemic of inequity. And of course, that came to the fore very much with the COVID-19 and, you know, who lived, who died. And, again, a very strong

gender dimension. We already mentioned that. And then, you know, there’s the other silent issues—the silent pandemic, again, that Ramanan, of course, is advocating for.

And could I ask you, Ramanan, who advocates for AMR? Do you have, you know, a really tough civil society group that glues itself to streets and says, fight AMR? (Laughter.) Who fights for AMR? Who fights for your issue?

LAXMINARAYAN: Well, Ilona, you know the answer to that. You know, if you really looked at—you know, if you ask people, nobody dies of AMR, right? They die of HIV, and then a bacterial infection that couldn’t be treated. They die of a road traffic accident where they got an infection where they couldn’t be treated. You know, in India, for instance, the operative word for AMR is multiorgan failure, which means a systemic infection that people could not, you know, treat. So AMR lives under different sort of, you know, definitions and titles, but never as AMR, because nobody dies of AMR. Until you actually realize that it’s our inability to treat bacterial pathogens that causes this.

But I don’t see this as insurmountable. I think that this is just a matter of time before we’ve—you know, we really get people to understand that it’s really the lack of effective antibiotics that’s killing people, lack of effective antifungals that’s killing people. And that’s the work that lies ahead for us. It is a challenge, to be sure. But, you know, just reflecting back—and not to give away anything for how long I’ve been working on this—(laughs)—I remember a time before there was community-associated MRSA, a time before there was (common penicillin ?) resistance.

And all of these were considered, you know, to never be things that would ever happen. But we’ve been proved consistently wrong and caught flat-footed by failures to predict how fast AMR will become a big issue. And, sadly, that means that the next fifteen years or ten years, even five years for AMR, is going to look a lot worse than the previous ten. And so we’re going to end up with a crisis. And to use a Washington cliché, we need to be shovel-ready when the crisis really becomes recognized, to be able to have the plan to deal with it. Because that’s the point at which the political leadership will say, oh, now we have a problem. What do we do about it? And we’ve got to be ready for that.

KICKBUSCH: Thank you. We have time for one more question from the audience, if there is an interest. Yes, please, here.

Q: Hi. Thank you. My name is Katie Kirts and I’m director of global technology at New York Life Investments.

And I was curious, we’ve talked a lot about trust today. Have you seen any improvements with the use of data to tell narratives that are helping generate trust around any health-related issue? Or do we not quite have the data literacy or the media literacy quite yet?

KICKBUSCH: Thank you.

Q: Maybe Ramanan on this.

KICKBUSCH: Thank you. (Inaudible.)

NKENGASONG: For the work we are all doing, which is global health and public health, we should protect as much as possible that space of leading with data. I think data should continue to remain the radar that guides our work. That is the work in global health, whether it’s pandemic response or the neglected pandemics or the silent pandemics, should always be governed by data. I think we should get that space up tightly, because if we lose that it’s the only currency that I think we have that inspire trust. Probably we have that because it’s so important to even think otherwise, that we would not be leading by data, I think, is the underpinning of everything that we do should be guided by—should be evidence-based, should be data-driven.

KICKBUSCH: Juan.

URIBE: I was going to say that last point, Ilona. We did see, for example, in Latin America that operations that have robust data assistance really made a difference in those countries that were able to make timely, evidence-based policies, from those who were not able to do that. And their results were incredibly different.

KICKBUSCH: So we’re nearly at the end of this panel. Thank you. And what I’d like to do is to ask each of the panelists literally in one or two sentences to say what type of collective action would be most relevant and important for the threats that you deal with.

Ramanan, would you start? What collective action do you want to see?

LAXMINARAYAN: Well, I just also wanted to respond to that previous question on trust, because that also—

KICKBUSCH: There’s no time. (Laughter.)

LAXMINARAYAN: No, no, no, quickly. (Laughter.)

KICKBUSCH: They’re very strict over there. The glances I’m getting are—

LAXMINARAYAN: So if I have the one point, let me make it on trust because it is really so important. I think, you know, what we have learned from COVID is that when countries fail, despite having the technical capability to deal with COVID, it was mostly a failure of trust. And the trust issue was interlinked with the diversity of marginalized populations. In the U.S., for instance, it’s the African American population that were vaccine hesitant, although they were the ones that were also most vulnerable to COVID. So I think the collective action agenda that is crosscutting, that we can put on top is to build confidence in science and scientific processes and global institutions right now in sort of, you know, the peacetime, so that it is useful regardless of where the next pandemic comes from.

KICKBUSCH: So an important message, the crosscutting collective action that, you know, helps us be better prepared for any of the issues. What would you crosscutting collective action be, Juan?

URIBE: So I would love to see a collective action that has a core, strong, real country ownership, comes from belief. It shares—it shares a lot, starting by sharing information and harmonizing those things that can be harmonized. And it has incredible solidarity to address in the collective action, Ilona, the inequity angle behind these threats.

KICKBUSCH: Thank you. John.

NKENGASONG: So because we—the theme was global threats and collective action, listening to the conversation I even got scared towards the end, with the climate conversation. I knew it was bad, but I got scared with that. So it really suggests to me that we need collective action that is underpinned by global cooperation and global collaboration. And it should all be part of foreign policy in all member states.

KICKBUSCH: Thank you. Last word to women.

HILL: Well, this is an issue really—I’m going to focus on climate change—for the last forty years, since we recognized that this was an important issue. The urgent has really knocked it aside, and now it’s become an urgent issue. We aren’t acting like that yet, but we need to. And my—back to the original premise of this, what is the collective action? I think the G-20, if they got together and were really committed to doing this, could get

it done. And that’s a small group of nations, many of whom have had the most responsibility for causing the accumulation of that blanket of emissions. And if they were to act, we could all be a lot safer.

KICKBUSCH: After they have added the African Union to the G-20.

HILL: Well, this is about cutting emissions now. And then we got to work with the African Union about how the power up in a much cleaner way than the rest of the Western world has done to date.

KICKBUSCH: Yeah, but, again, coming back to the foreign policy dimension of it, we will only get the action if we get the geopolitical move in that direction. And, you know, the inclusivity of the G-20 is no longer the case. We have to see that clearly, and just as the Security Council is no longer the inclusive decision making body.

So we’ve had, I think, some excellent positions from our panelists. We’ve had some very interesting questions. We are at the end of our day and our discussions. So I thank you for coming today, virtually and in real life. And I have to tell you that the video and the transcripts will be available and will be posted on the CFR’s website. And I understand you’re all invited to a reception outside, which will give you the opportunity to network. Sadly, not the people on the—online. But we hope that another time you will be able to be here with us in person. Thank you very much, and I hope you enjoyed the whole afternoon. Thank you. (Applause.)

(END)

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