The Latest Developments on COVID-19

Monday, October 4, 2021
Eloisa Lopez/REUTERS

Senior Principal Scientist and Chief Medical Officer, COVID-19 Response, Amazon; Major, United States Air Force Medical Reserve Corps, Critical Care Air Transport Team; Pulmonologist and Affiliate Faculty, University of Washington, School of Medicine; Medical Analyst, NBC News; CFR Term Member

Senior Fellow for Global Health, Council on Foreign Relations; @JenniferNuzzo

Director, Center for Infectious Disease, Regents Professor, McKnight Presidential Endowed Chair in Public Health​, Distinguished University Teaching Professor, Environmental Health Sciences, School of Public Health, Professor, Technological Leadership Institute, College of Science and Engineering, Adjunct Professor, Medical School, University of Minnesota; CFR Member


President, American University; Former U.S. Secretary of Health and Human Services under President Barack Obama (2014–2017); Co-Chair, CFR Independent Task Force on Preparing for the Next Pandemic; Member, Board of Directors, Council on Foreign Relations

Our panelists discuss the latest COVID-19 developments, the risks of the Delta variant, mask and vaccine mandates, booster shots, and the possible ramifications of many students and workers returning to in-person settings.

BURWELL: Thank you so much and welcome to today’s Council on Foreign Relations virtual meeting on the latest developments on COVID-19. I’m Sylvia Mathews Burwell. I’m president of American University and a CFR board member. And I’m going to be presiding over today’s conversation. I want to thank you all and thank our panel—our great panel of experts for joining us. We’re going to do some conversation and discussion, and then we’ll get to your questions at about 1:30. So we’re going to focus on some big-picture issues in COVID and then turn to areas where I think it will be an interesting conversation about change that is happening and will happen.

Let me introduce our panelists. First, let me start with Vin Gupta. Vin is a senior principal scientist and chief medical officer and overseeing the COVID-19 response for Amazon. He’s a major in the United States Air Force Medical Reserve Corps and does critical care air transport team—he’s part of that team. He’s a pulmonologist and affiliate faculty at the University of Washington School of Medicine, and a medical analyst at NBC News. He’s a CFR term member.

Jennifer Nuzzo is the senior fellow for global health at the Council on Foreign Relations. She’s a senior scholar at the Johns Hopkins Center for Health Security and an associate professor in the Department of Environmental Health and Engineering and the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.

And Michael Osterholm, who is the director for the Center for Infectious Disease Research and Policy, the regents professor and the McKnight presidential endowed chair in public health at the University of Minnesota. He’s also the distinguished university teaching professor of environmental health sciences at the School of Public Health, professor in technological leadership at the College of Science and Engineering, and adjunct professor of the medical school at the University of Minnesota.

So we’re going to start and dive in in terms of COVID and the big picture. And as each of you all respond to these questions, you wouldn’t mind thinking about how to incorporate conversations and information about boosters, the new therapeutics that many of us read about last week in terms of therapeutics and treatments, masks, and testing. These are all questions that I think our members are very interested in.

But, Michael, why don’t we start with you? And if you can help us make sure we’re all sort at the same level of facts, talking just a little bit about the past, the present, and the future. Before this session started you were sharing, I think, some very helpful and important information about different places in the country and things that we’re seeing there. So if you’d focus on the domestic situation, that would be great.

OSTERHOLM: Well, thank you very much, President Burwell. It’s a real honor to be with you, and with my distinguished colleagues, and with all of you today.

Let me begin by providing one disclosure. And that is, I probably know less about COVID today than I did six months ago. And the more I learn, I think, the more often I challenge just how much I know. I do know that getting out of bed every day I try to scrape the five inches of mud off my crystal ball, and that some days is hard to do. I think one of the challenges is that we all want to ascribe some kind of method to the madness of how this virus spreads, where it’s going to show up, how many cases are going to occur, and over what time period. And you know, as I’ve said many, many times, I feel like, you know, we’re not driving this tiger, we’re riding it. For example, when Delta became the prevalent variant, we saw this major increase in transmission. And yet, if you look at the United States today, we’re kind of a microcosm of what’s happening on a global basis.

We initially saw the activity of this particular surge start out in mid-June in the Ozarks region of the country, southwestern Missouri/northwestern Arkansas. And if you actually follow what happened here, is we then saw shortly thereafter the Southern Sun Belt states light up, for which then we went from there to the Southeastern states of Georgia, South Carolina, North Carolina, Kentucky, to some degree Tennessee. And then within about the two months of when the virus first showed up somewhere we saw a major decrease of cases. So we had this kind of unfolding ongoing activity.

Shortly after the Southeast lit up, we then saw areas like West Virginia—which had actually had very low levels at the time that the Southern Sun Belt states lit up—became the number-one state in the country in terms of progression of illness. We then saw it move into Southern Ohio, into Pennsylvania. And at the same time, we saw in the northwest initially activity starting particularly in the western part of Oregon and Washington. Over a period of the better part of a month and a half we saw it move, in a sense, through Alberta and Canada, and then into Wyoming, Montana, Idaho, northern California and northern Nevada. And at that point then, again, that two-month cycle.

And now we’re seeing it in the Northeast—Maine, Vermont, and New Hampshire, to some degree. We’re starting to see increased activity in the Boston area. The upper Midwest right now is getting hit the hardest it has in the entire surge. North Dakota just announced today that they would likely be rationing care with this—with this week in terms of case numbers. We’re seeing major challenges here in Minnesota, particularly in school children, and the northern peninsula of Michigan, northern Wisconsin are all lit up in levels that we had not seen since the surge of a year ago.

Meanwhile, we see places like Southern California and the New York metroplex area which have very little activity relative to the fact that we know that there are many individuals who are not vaccinated in those settings. And so this isn’t making sense in many ways as to why it does what it does. I can’t tell you that there’s human mitigation that is involved with why we see this two-month cycle we see with Delta, but it’s happening. And clearly the pandemic remains largely a pandemic to the unvaccinated. I would add one caveat to that, the breakthroughs are starting to have some impact in terms of case numbers, workforce issues, et cetera. And I know we’ll be talking more about this today, but I think the whole issue of our relationship with vaccines, protection, immunity, and the variants is going to be a complicated one.

Now, take what I just said about the United States—and, by the way, I should have added a very sober note that last week Alaska hit the highest level of cases per incidence per 100,000 we have seen in any state through the duration of the pandemic. They hit over 176 cases per 100,000 population. So here’s our fiftieth state up there that basically is severely challenged. On a global level, this is exactly what’s happening. It’s like whack-a-mole. We see between 2.5 million to 5.5 million cases occurring around the world. And it’s up and down and up and down, much like we see here in the United States.

BURWELL: Michael, thank you very much for that view here. And, Jennifer, why don’t we turn to you and do a little bit more focus on the international situation and what we see abroad right now, as well as an epidemiologist what do you think are the clues to this two-month trajectory that we heard Michael describe? And are there any things that we are seeing that we can learn from this? As you are the type of person who follows those clues quite closely.

NUZZO: Well, thank you so much. It is also my honor to be here with these esteemed panelists, as well as those who are listening.

And it has been a really long and heartbreaking road tracking the COVID data. One of my other roles at Johns Hopkins is I’m part of the Coronavirus Resource Center team. So that’s the map and all of the ancillary data that goes with it. So every day I’m in the data and I’m looking at the data, and trying to understand what the trends are, and trying to discern where we’re headed.

So where we are today is that reported across the globe upwards of 235 million cases, and more than 4.8 million deaths globally. That is obviously a really startling number, certainly. We have continued to meet and exceed very grim milestones. We met and exceeded another one this week when the United States eclipsed more than 700,000 deaths reported in the U.S. Throughout most of the pandemic and still today, the United States has accounted for the largest number of cases reported. And so what we’re seeing in the global numbers is very heavily influenced by what happens here in the United States.

So the global numbers are starting to look better. The numbers are coming down. But I have to caution that, you know, as of about a month ago, about 20 percent of the cases being reported globally came from the United States. So when we see a downward trend in cases in the U.S., that can make the global numbers look a lot better than they perhaps really are. The fact of the matter is I am still very, very worried about a number of places in the globe. I have on my watchlist, you know, about fifty countries that are experiencing very high levels of case increases for two or more weeks.

So that means this pandemic is very much not over. It’s not over until it’s over for all of us. But certainly, there are countries that are still in the very acute phases of the response. Right now where the trouble seems to be is a lot going on in Eastern Europe and in the Caribbean, South America, a number of countries in Africa. But there’s also a limit to what we’re able to say, because one of the things that’s become abundantly clear in tracking the COVID numbers is the inadequacy of our surveillance for COVID.

So one of the things that we also track in addition to the reported case numbers is the amount of testing that countries do, the extent to which those data are available. And it is abundantly clear that countries are employing very different tactics to look for COVID, to find the virus in people, to even track who is hospitalized and who dies. And so the reported numbers, I very much have to caution, do not represent complete reality. In fact, they’re very much likely undercounts.

We know that some countries, for instance, only test those who are traveling to that country. So if you just looked at those testing numbers, you know, the percent positivity, the numbers of cases may look quite reassuring, when the reality is there have been a number of studies that have found COVID among deaths that hadn’t been previously reported. And this is reflected in an increasing number of excess death analyses that are looked—basically looked at the number of deaths being reported by countries worldwide and compare that to what has been reported in previous years, finding that the discrepancy observed in the pandemic years are likely directly or, in some cases, indirectly attributed to COVID, and that those deaths far exceed the numbers that are reported by countries. So don’t assume that a country that isn’t reporting high numbers isn’t being hard hit or that it won’t be hard hit. And also I think we should take very much with a grain of salt that where this all falls in the end is still very much being written.

That gives us an opportunity. And that gives us an opportunity to respond in a way to continue to save lives. But we have to act with urgency. And so increasingly the story of COVID, particularly in 2021, is one of whether or not there is access to vaccines. We are seeing even in countries that have been previously quite adept at slowing the spread of the virus, keeping their case numbers low, through all the traditional public health measures are being basically outrun by the Delta variant. It has a shorter incubation period, and a case can result in more secondary cases than what we’ve seen with earlier forms of the virus, and it makes it very, very hard to control through the public health measures that perhaps worked better in the earliest stage of the pandemic.

So when I see countries entering the watchlist that had been previously the COVID exemplars, that’s when we know that we really have an urgency to act, and particularly to act to increase the availability of vaccines. There are about more than six billion vaccinations that have been administered in the world to date. And about fifty or so places in the world have administered enough vaccinations to cover about 60 percent of their population. These countries are, by and large, high-income countries. And in low-income countries, the percent coverage of the population is incredibly low, in some cases less than 1 percent, in some cases less than 2 percent. In fact, most of the continent of Africa is probably about less than 5 percent coverage of the population by vaccines.

So this is a real challenge, one, because it will really exacerbate the already hideous tolls of COVID as countries continue to accumulate them. Even if they’re not showing up in the numbers, they are happening, and they will happen unless we act and we act quickly. It also—you know, I think it’s epidemiologically perilous for even high vaccination countries because the more we let the virus spread unchecked in parts of the world where there’s low vaccine coverage, particularly among immune-suppressed individuals, we could see the emergence and spread of variants that, you know, render our vaccines less effective.

So one of the—this urgency I feel is that the conversation around doing whatever it takes to improve global access to vaccines, while I think there’s high level of appreciation for the need at all levels of politics—all the national leaders are talking about, the WHO talks about it, there have been lots of pledges made to date—the urgency with which we’re acting is not matched to the epidemiologic situation. So you have countries pledging donations, and the pledges never—haven’t come. They’re really slow. And you have proposals for increasing access to vaccines that span into the years. We have probably a good year or so to act to save the most amount of lives. So we need to do whatever it takes right now to make sure we expand access to vaccines.

That is what’s going to ultimately be in our best interests in terms of not wanting to track, you know, all of the variants—the Greek letter-named variants that are—that are to follow. Right now Delta’s the biggest one on our list of concerns, but there could be more. We’re not going to see an end to that unless we, you know, make sure that more countries have the ability to vaccinate their highest-risk populations. So I just have to stress that where we are right now, there are no guarantees by any means. When we see downturns, it doesn’t mean that we’re not going to see upsurges.

And to your earlier question of why this two months? I feel very strongly that it’s likely behavior. And behavior that changes, I mean, there’s flux. When people start hearing about a rise in cases, they change. The start putting on their mask again. They may not go the crowded indoor environment. They may stay closer to home. But after some time with the case numbers going down, what we’ve seen time and time again is that people do other things, including go and travel and see relatives and friends for the holidays, et cetera. That’s often why I think you see a surge in the later winter months.

I expect we will see another surge of cases in the later winter months. I think in the United States we’re in much better circumstances than many other parts of the world, and so I don’t think we’ll be as hard hit as other places will. But I think that a temporary decline in cases seen globally is not one that should necessarily convince us that the pandemic is behind us.

BURWELL: Thank you, Jennifer.

Vin, can you jump in and talk about where we are and where we’ve been from the perspective of the health sector in terms of health-care workers, a place that I know you are particularly personally close to, and in terms of what you do every day. So can you speak to it from there? And the other thing, Vin, if you want to touch on, or we can come back to others. Jennifer mentioned the question of the incubation period and the transmissibility. I think it’d be helpful for our members that are listening to understand that actual change that has occurred in terms of what is the timeframe that we now believe for Delta is the incubation period? And putting numbers to transmissibility in terms of our first variant that we knew about to this variant, the Delta variant, which is so dominant, in terms of its increase in transmissibility? I think it’s important for people to understand those two things, because then they can understand the exponential growth that we can see in case quickly. But, Vin, why don’t you talk to the health-care workers?

GUPTA: Absolutely. President Burwell, thank you. It’s an honor to be with you and with Dr. Nuzzo and Dr. Osterholm, and with the CFR community.

I’m going to—I’ll try to touch on just a few different points. I’ll try to keep it brief. First and foremost, from the health-care worker perspective, this concept of staffing. I know we—many on this call probably have heard about hospital surging. Michael talked about crisis standards of care. What does that actually mean? Often a hospital—ICUs that I’ve worked in across the country will have open beds. They will not have staffed beds. And this is emblematic of the larger crisis here that’s going to play out over the course of the next several years, which is we are not—we don’t have enough trained health-care workers. And I know this is something we’ve been beating the drum about and sounding the alarm. But we’re expecting a third of nurses to leave the workforce by 2030, 40 percent of physicians to leave the workforce by 2030. And right now, that is the rate limiting step.

That’s why you’re seeing this progressive militarization of our response from the health-care worker standpoint. On any given shift in an ICU, I’m probably working—I’m working with nurse, for example, from Charleston, South Carolina, or from Nevada. I mean, literally we are having traveling nurses fill hot zones across the country. It is a mobile health-care cadre now. I just got back from a few week deployment from my annual tour with Air Force. We were using C-17s to move patients that needed really advanced ICU therapies from Tennessee to the Cleveland Clinic, elsewhere in the heart of the country. This is what is happening right now. And I think that is—that reality sometimes does get lost in the American public. The degrees to which we are trying to respond to this crisis by moving health-care cadres across the country.

I’d also say that rationing is here. And it’s really difficult for everybody in the health-care system to wrestle with it. That this is not some future dystopia that we thought we would never have to face. We’re facing it as we speak. In every ZIP code across the country, lifesaving decisions are being made one way or the other about who gets access to a dialysis nurse, much less the machine, who gets access to cardiopulmonary bypass machines called ECMO, which is something that rarely we need to utilize in the worst of the flu epidemic in any given year. We’re utilizing—we’re giving consults for this service—multiple consults a day in places like Seattle, that cares for a five-state region. It’s really unheard of. And we just don’t have the specialty staff.

To get to your question, just since I know this is top of mind for everybody on the call, what about this crisis of communication and all the ways in which the Delta variant is changing, all these new therapeutics we’re hearing about? This crisis of communication, getting clear information to the public, it’s something all of us in health care have looked at. And we’ve said, you know, maybe we can do better.

First, I’ll say as a pulmonologist, just using clear, concise visuals conveying why you should get vaccinated—that it’s to keep you out of the hospital, that it’s to keep your lungs from looking like lungs ravaged from pneumonia. That type of paradigm we used for the anti-smoking campaign, and yet we haven’t really dived deep into that very clear, concise, blunt messaging. We’re getting there. But I think if we had started about what is the purpose of vaccination. It’s not to prevent you from testing positive. It’s to keep you from hospitalization. And back that up with simple images. That could have been helpful.

To the point about boosters, it remains that two shots of the vaccine—if you’re less than 65, otherwise without significant medical conditions—that two shots of the vaccine still appears to be very durable at keeping you out of the hospital. Yes, it’s true, and Michael mentioned that breakthrough cases are happening. Some cases mild symptoms are occurring in those breakthrough cases. And yet, the actual incidence of people ending up in the hospital if they got two shots of any vaccine approved in the U.S.—soon that’s going to include Johnson & Johnson—the actual incidence of people ending up in the hospital without high-risk medical conditions or if they’re not above 65 years of age, is extremely low.

Lastly, I’ll just quickly say about these new therapeutics and also a brief comment about monoclonals. This new therapeutic, this pill that Merck developed that many may have heard of in the last week, it’s a great news, especially from the global landscape when we think about ways in which we can reduce death tolls globally. It’s a pill that you take. You take four pills twice a day for perhaps up to five days if you come down with COVID. You’ve been early—you’ve been diagnosed early in your course. It’s a 50 percent chance, especially if you’re high risk, it could keep you out of the hospital.

That’s not terribly different from the way in which we think about Tamiflu. For those who may have had flu on this call, if you’re diagnosed early with flu—and we’re entering flu season so get your vaccine—but if you get flu, regardless of whether you’re vaccinated and were diagnosed within the first forty-eight hours, you can get something called Tamiflu. It’s an oral pill that can reduce your risk of ending up in the hospital by 50 percent, in some cases. But it is not a substitute for a vaccine that is 90-plus percent effective at doing the same exact thing. I’ll layer that on to say monoclonal antibodies, now we’re moving towards subcutaneous formulations of monoclonal antibodies, much more effective than this oral pill. But we can inject it now. And so these therapeutics do have a role as part of a broader toolkit, but they’re in no way a substitute for two shots of the vaccine.

BURWELL: Vin, thank you so much. And I want to—as a former secretary of health and human services, I do just want to empathize that flu shot point in terms of everyone on here. Please do go and do it. It’s extremely important in any year. It’s very important now, especially in the context of when people become symptomatic. Running a university, you can imagine trying to separate these things out, and what it means trying to keep populations safe, and trying to keep people healthy.

We just heard a pretty dark picture of where we are. And that may not be felt by everyone, because I think the situation, as Michael started us, it moves. The situation moves. And for those that are not coming in contact with the health-care system or the international situation that Jennifer described, just really coming to grips and understanding the extreme nature. Seven hundred thousand deaths. I just think pausing for a moment and thinking about those numbers relative to the numbers of deaths that we have from cancer, from heart disease, the other top killers in our nation. Michael, you looked like you were going to jump in on that point. Did you want to jump in?

OSTERHOLM: No, no. I’m just agreeing with you. I think you said it very well.

BURWELL: You know, it is something that we all want to focus on. I want to take us a little bit further down the path that Vin started us on, which is about workforce. And, Vin, you were talking about the health-care workforce. And right now, the situation and the challenges that we are facing right now and are going to face in terms of our health-care workers. Michael, would you jump in on this topic from the perspective of broader issues in the workforce and what we’re seeing in terms of what COVID is causing, and what kinds of impact that could have throughout everything from health care, to just about our food, to everything?

OSTERHOLM: Well, let me start out by just addressing one professional area that’s near and dear to my heart, and that’s public health workers. You know, I spent twenty-seven years at the state health department in Minnesota here, state epidemiologist for a number of those years. And I remain very actively involved in state and local public health practice. This pandemic has been devastating to the public health practice. The number of people we’ve lost because they just could not continue to deal with the very negative and, in some cases, literally threatening kinds of behavior issues that come in. And the whole situation in terms of salaries and so forth.

And I think that we, in public health, for many, many decades have enjoyed a certain sense of, you know, we are the good people. We are the ones there to try to maximize on good health outcomes and minimize the bad things that happen to people. And today, we see in many instances the public—at least a segment of the public—not agreeing with that. That we’re part of a conspiracy, we’re part of a cover-up, we’re part of doing something to take away their rights and freedoms. And frankly, we’re at a really major crossroads. So how will public health move forward from here? How do we gain trust back?

And we can’t get people to buy into the fact of the safety and the effectiveness of our vaccines, despite the incredible body of data. Yet, we can show people who are desperately seeking ivermectin for treatment for their loved ones who are not vaccinated based on data that, frankly, shows that this drug does not work. Well, carry that through to public health. Many of the recommendations we’re making today are not only not agreed with, but they’re also seen as almost a poisonous situation. So I worry about the future of public health and who will still be here to turn the lights on and off in the near future.

But as you pointed out, President Burwell, this pandemic has had an implication of professional needs and requirements unlike anything in modern history. Case in point, we have never seen the kinds of disruptions right now of supply chains that are occurring globally, in part because plants manufacturing certain things in Vietnam—I can go through the world—are closed down or have limited activity. We’ve never seen a shipping situation, sixteen major freighters sitting outside Long Beach today waiting to unload, something that’s never happened before. Why? Because they can’t find enough workers on the docks to help speed this forward.

And I can go through a number of areas. Today in long-term care—I just want to point out not only are we talking about our hospitals, our medical clinics, but long-term care for this country is hanging on by a thread in terms of the number of employees. And so one of the things that we now have to understand is why we can’t have pandemics in the future, why we must make it our job to do whatever we can, through research and development and so forth, to limit the impact of whether they be a coronavirus or an influenza pandemic, because the collateral damage that occurs with the pandemic is so much more than just makes the everyday headlines of cases and case numbers. And I think that people are now beginning to understand that.

I would just conclude by saying that a Nobel Prize laureate economist said to me a few months ago—he said, lookit, if you’ve got something that costs trillions of dollars but could have a major impact on this pandemic, we’ll buy it right now because it will save many, many more trillions of dollars and lives that otherwise wouldn’t happen. So I think that this is going to be one of the take-home stories of this pandemic, is why did we see the impact on our lives across the board beyond the medical care system? And what can we and must we do to better prepare for that for the future? Because there will be more viruses that will challenge us, just like SARS-CoV-2 has done.

BURWELL: Michael, thank you. And I want to bring your point that you just made to a point that Jennifer made earlier, and this question of spending the money in order to stop what we see continuing to happen in terms of the impact of COVID, especially the hospitalizations, the impact on the economy, and workers broadly. Jennifer, you had a point that you made about the importance of vaccinations, the importance of vaccinations worldwide and getting those vaccines worldwide. And as we think about that question, I’d love to hear from you, Jennifer, what do you think is the critical path issue? Is it actually the dollars, or is it the production capacity that could—that could come back to dollars? But what do you think right now is the critical path issue as we think about getting more and more people vaccinated from a worldwide perspective?

NUZZO: Sure. So we just simply don’t have enough vaccines to do everything that we want to do. There are projections of more that will be made but, again, I underscore that the time to act is right now. And that’s why I think you’re hearing some concerns—deep concerns that although, you know, things like third doses might be nice to do in countries when we can’t even use vaccines to prevent deaths in, you know, the most vulnerable people, in health-care workers worldwide which, were we to lose them, would set back a generation already weak health systems. So we don’t yet have enough vaccines to cover all of the highest priority boxes. And so that’s why you’re hearing calls for either a redistribution of what we have and, crucially, making more—but making more with urgency. Those—that has to be fixed, first and foremost.

But, you know, were we to have an abundance, you know, I think that would ease some of the debates on how we should be using vaccines, et cetera. It won’t totally eliminate distribution and uptake problems. You know, the world is besieged by vaccine hesitancy. And, you know, sometimes this is used to justify keeping vaccines from other countries, suggesting that there’ll be limited uptake. You know, I fundamentally reject that argument because, you know, we have an enormous problem with vaccine uptake here in the United States, despite the abundance of the vaccines that we have. So I don’t think we can necessarily point fingers abroad. But we have to fix this misinformation/disinformation environment that’s driving a lot of the hesitancy, absolutely.

I mean, if you’ve ever been involved in conversations with people who are not yet convinced of vaccines—I hope all of us are because it really, truly will take a village, and people probably want to hear most from their friends and loved ones than experts. But if you’ve ever involved—been involved in these conversations, you’ll understand that people are not making these decisions without information. They have plenty of information; it’s just the wrong information. They’ve been besieged by lies. They have tried to do their research but can’t separate fact versus fiction, in part because we have an information environment that allows lies to travel further and faster than the truth. So we have more work to do on that front, but urgently we need to fix the supply problem because there’s just not enough to do everything that all the countries want to do.

BURWELL: Jennifer, we could go deep in that manufacturing challenge. And we know how—you know, that is not a simply a problem in terms of—we’ve seen what happens in terms of manufacturing capability. It’s a very delicate thing to get the vaccines right. But I’m actually going to take us back to another point. Vin, it’s a point you’ve made and a point that Michael’s made. And Michael talked about the workforce and public health workers. Vin, you talked about our health-care workers, that we tend to think about in our personal health-care system. Can you speak a little bit to are there any positive lessons that we need to learn about bringing together public health and individual health as we think about what Michael said, which is we will have more pandemics, we will have more challenges? Are there any—(inaudible)—you’d like to share before we get to folks’ questions?

GUPTA: Absolutely. I do think there are a lot of silver linings, President Burwell, from this experience of the last twenty months, from the health-care workforce perspective. Number one, we’ve developed models across the country when it comes to command control establishments and health-care systems for ICU triage. So now we do a lot of tele-consultation. We have more eyes on more patients within the health-care system so that we can we understand who may or may not need care, be able to predict it, be able to load balance within a large city.

For example, the city of Chicago—to give a concrete example to everybody on this call—they have data. They’re harmonizing data across the entire city about where are there ICU beds available, where there are not. They’re using predictive tools upfront in the emergency room to understand who is likely to need ICU-level care. These are all innovations and all collaborations, and the use of data and sort of a virtual type of environment, that has gained greater traction over the last twenty months.

I’ll say, from a public health—the interaction between public health and the health-care system, we know that we spend $11,000 per capita on health-care delivery. So per individual, we spend a lot of money just on the provision of health-care services. Three percent of all health-care spending is dedicated towards public health works, public health projects. And I do think things are going to change, though, because now we’re moving towards different types of innovation. So we’re moving towards over-the-counter, at-home, non-prescribed tests for COVID, soon for flu. That’s going to off-load our public health system. That’s going to help with contract tracing.

We’re obviously dedicating more—there’s been more money put through some of these recent bills in Congress towards buttressing departments of public health across the country. We need more of that. But there are some silver linings here. I will say that there are persistent challenges, just to talk about our way forward here over the next ten years. We need greater incentives to get more people in careers in public health, in health care, educational incentives, more scholarships. We need loan forgiveness not to just be a buzzword but a reality for more schools across the country—both nursing schools, schools of public health, medical and allopathic and osteopathic schools. More incentives. Just it’s a gauntlet right now to become any type of health-care worker, whether it’s a public health worker or a provider of health-care services. So that’s number one.

Number two, I’ll just say quickly—since we didn’t touch on this yet—something that seems so basic and fundamental to the provision of health care. Oxygen is going to be—we need to think about ways in which we provide more of these basic services, like oxygen, to the world. When I talk to pulmonologists across the world in India, in Indonesia over just the last few months, one of the reasons why people were dying in mass to a respiratory pandemic was the inability to move oxygen—in large tanks, that often cost $1,000 to refill and an additional thousand to ship, whether it’s in a C-17 or by FedEx—from point A to point B.

And if we think that the next pandemic—I’ll defer to Michael and Jennifer on this—but if the next pandemic is respiratory, I think it’s going to be respiratory, if we don’t have something fundamental like oxygen that we can scale the delivery of cheaply, then everything else that we do doesn’t really matter. And so there are things that—I do believe that there have been silver linings. There’s been innovation. There’s been a regulatory environment from the FDA here in the U.S. that has allowed for that innovation to reach people at home. And yet, there’s some critical roadblocks here, whether it’s getting more people into these health-care cadre and to these schools of public health, or just figuring out how we scale delivery of oxygen, that pose continued challenges.

BURWELL: Thank you, Vin.

And we are going to turn to moderated questions. And I’m going to turn it over to our moderator, who can help us receive your questions right now.

OPERATOR: (Gives queuing instructions.)

We’ll take our first question from Krishen Sud.

Q: Yes. Hi. Thank you for taking my question. So this is a question for Jennifer.

So a lot of the world has been vaccinated with vaccines from Russia and China. And so my question is, are those vaccines as effective as the mRNA vaccines or J&J’s vaccine? Or will we have to ultimately vaccinate all those populations with an mRNA booster or something like that?

NUZZO: Well, so the first question is effective against what? And, you know, I think if our goal is to prevent severe illness and death, I think the vaccines that are on the table still give us decent protection against that. That said, there are vaccines out there that do a better job. And so you’ll see that countries are preferentially trying to now use those vaccines, particularly the mRNA vaccines, for purposes. It’s also one of the reasons why it’s not just the U.S., it’s not the U.K. and Israel that’s talking about boosters.

Many other countries are talking about boosters too. And so that is creating an even larger demand. In fact, my colleagues Tom Bollyky and Sam Kiernan at CFR did an analysis of all the countries—and this was about a month or so ago—that were talking about using boosters. If they all follow through with what they were talking about doing it would amount to about a billion additional vaccines that would be needed. And so that’s why these decisions are not made in vacuum.

But the question is, for those countries—all countries, even in the United States. I mean, it’s a fair question of if we have to give another dose, what do we give another dose with? Right now, the data that we have are for people, say, who have received Pfizer getting a third dose of Pfizer, and not necessarily getting other vaccines, including vaccines that are not yet on the market but may become on the market soon but that maybe work in slightly different ways. And perhaps that would have some additional benefits than just receiving a third dose of a vaccine that you’ve already gotten.

So I think there’s still a lot that needs to be sorted out in this whole third dose environment, including how we manage the kind of global ramifications of individual countries’ decision making and where are the additional doses most needed.

BURWELL: Thank you. Next question.

OPERATOR: We’ll take our next question from Susan Purcell.

Q: Hi. Thank you very much.

I’m a political scientist, so I have a kind of political question. Why is it that—I mean, one of the things that’s undercutting the desire to—and the rebellion against vaccine mandates is that the United States has just about a totally open southern border. And tens of thousands of illegal—people from other parts of the world, often from developing countries, have been admitted illegally. And yet, when asked recently, Dr. Fauci says—it was explicitly the question that I’m asking now. When Dr. Fauci was asked this question as to how come no one is focusing and examining and mandating vaccines for the illegal—people who are entering illegally, Dr. Fauci just said categorically: They are not the problem. But that’s absurd. I mean, there’s something wrong with a policy where the vaccines are mandated only for U.S. citizens and they’re not mandated for people who are entering illegally which, if we were serious about this pandemic, we wouldn’t allow. We’d close the border again. So it’s extremely hypocritical of the administration.

And I can understand perfectly, because related to this is the issue of censorship. Why is—you know, several of you have been talking about the fact that there’s misinformation and there are all these lies, et cetera. But there’s also no debate allowed. I mean, there are other points of view which are not tolerated, whether it’s on mass media TV stations or on the internet. And so until we get those things straightened out, there’s going to be a lot of opposition to the vaccine mandates. And I speak as someone who’s—

BURWELL: Can you help us—can you help us with your question? Want to make sure we get to your question.

Q: The question really is, if this is—if we are serious about, you know, making sure everyone’s vaccinated and helping people to understand why it’s necessary you have to end these kinds of political policies, such as censorship of doctors who have a different point of view, and also letting in—you know, mandating that Americans get vaccinated—

BURWELL: Can we just get to the question?

Q: That’s it.

BURWELL: I want to make sure we have time for others. So can you get to the question?

Q: No, but that’s the question. I mean, what do we do? I’m sorry. What do we do about the hypocrisy and this big problem with the way public policy toward different classes of people, or censorship, are affecting the desire and trust of people to go and get—

BURWELL: Jennifer, do you want to—Jennifer, you want to hop in? Thank you.

NUZZO: Yeah. So I’ll hop in on this, because I was the one who brought up misinformation. So I will start there. I will, first of all, say that my preference has not been vaccine mandates. I have hoped that people will willingly see the value of and benefits of vaccines. I have worried that government-initiated mandates would entrench people who are not yet convinced of the benefits of vaccines, have absolutely fair concerns that, in my view, stem from misinformation but need to get connected to the right information. And, you know, I have felt that one of the most common things I hear—and I do a lot of conversations with vaccine-hesitant individuals and groups. I mean, tons of conversations.

And a lot of themes—similar themes come up. And one of them is when I ask people, they often talk about not knowing where to go for the right information. And I will say, well, could you talk to your health-care provider? And quite commonly many of the people that I talk to do not have a health-care provider. They do not have somebody they can go and talk to, to get answers to their questions. And, you know, that is probably symptomatic of where some of the concerns are coming from and where some of the kind of self-guided research has to happen in the absence of having, you know, access to trusted experts that they could get faster answers from.

So that is a challenge. And when people are in those circumstances, if they don’t regularly avail themselves of the benefits of medicine because they have not had access to it, I can understand certainly why people may be very skeptical that suddenly medicine has a tool for them. So I have worried about the need to overcome that hurdle. Of course, I completely understand that private businesses have to run, and run with—you know, run with consistency, and so there has been interest in vaccinating individuals to make sure that the businesses are capable of running.

But nonetheless, one of the concerns that I have had about the flow of misinformation—and I, as, you know, many public health people at the onset of this thought that this was this huge, amorphous problem where there’s all these people with lots of different beliefs that’s really hard to control and hard to get our handle on. And all we can do is just try to combat it one person at a time. The reality is the groups that have actually mapped out the flow of disinformation online have found that it’s not that way.

It’s actually probably about a dozen or so individuals who are responsible for the spread of about almost two-thirds of the lies about vaccines online, for profit. (Laughs.) Not beliefs, but they are selling something else or they are directly profiting from the clicks that the disinformation that they put out there provide, to the tune of $36 million per year. So it’s an enormous business. So for me, seeing it in the context of this is a—this is an unregulated business was much different than thinking of it as, you know, these individuals who are just expressing their views being censored.

BURWELL: Thank you, Jennifer. Let’s go to the next question.

OPERATOR: We’ll take our next question from Krishna Guha.

Q: Thank you very much.

So as I think at least one of the speakers already mentioned, we see countries that have been successful in the early stages of the pandemic using public health strategies—shutdowns, test and trace, high levels of mask wearing and so forth—to suppress the pandemic finding it increasingly difficult to do so in the current Delta phase. And we’ve seen a number of countries—I would single out Singapore, Australia, and now New Zealand—starting to move away from zero tolerance strategies as a result. The standout is China, that continues to look as if it’s following a zero-tolerance approach and trying to use the authoritarian power of the Chinese state to implement draconian, you know, regional lockdowns to suppress the pandemic.

So my question to the group is really: Does China have a workable strategy here? Or is China’s strategy running out of road? And if so, what is the prospect for this hugely important part of the world economy and our global supply chains migrating to a more hybrid approach that accepts some level of transmission? Thank you.

BURWELL: Krishna, thank you so much. And, Michael, I’m going to turn to you. And as we talk about this question, I think one of the important points that Krishna’s question has raised is the question of what is the appropriate measure? And we touched upon this a little bit in terms of is it case count? Is it hospitalization? Is it mortality? And how do we think about that? So, Michael, with that as a little bit of more content, why don’t you dive in?

OSTERHOLM: Well, first of all, we have to understand we’re on a journey with this vaccine and this virus. We’re learning. You know, when we first came forward with these vaccines in the earliest days of research and development, I remember the FDA made statements to the effect that if we could get vaccines that were even 50 percent effective, we’d get them licensed and get them on the market. And then we saw that initial wonderful data that came out with the early studies, particularly of the mRNA vaccines, with 90-95 percent protection against clinical disease of any kind, et cetera.

And what we didn’t realize at the time—when we set up our dosing for time—day one and then three weeks or four weeks later, that was really set up to get data as quickly as possible. It was not really based on what we might think of with a maturing immune system and the fact that possibly a second dose at ten weeks later might very well provide us with the most important protection. But what we did in those earliest days is we came down to two different buckets. One was safety and one was how well do the vaccines work, what can we do to make them work better?

We’ve established the safety. The safety is not a question. It is answered, done. What we’re still trying to figure out is how do we use these vaccines going forward? And just by chance, for example, if you look at the U.K., because they were concerned about the Alpha virus spread early on, they said: Let’s get a single dose into as many people as we can, and then ten weeks later we’ll give the second dose. They now have data that supports that that is probably a much better way to use the one-two dose vaccine approach in terms of immune response. This all leads up to the question that is: I do believe that one day this will be a three-prime vaccine. I’m convinced of that. I think that it’s ultimately going to take that to get the kind of protection that we need.

The second question, though, on that is: Well, will we need more? We’re already hearing some of the companies talking about, well, this is probably going to be an annual-ish immunization to provide protection. And so to answer your question, it’s going to be will in fact China, or any country like that, be able to achieve a country of protected people from vaccine, where they didn’t have to pay the price to get there by so many of them acquiring their natural immunity through infection, as opposed to vaccine, and then the vaccine was able to continue to support that.

Until we know that, we can’t say is the Chinese plan appropriate. They may find that they will have leakage that will occur well into the future of this virus into their country, doing a whole series then of these lockdowns, et cetera? And will that be what works? And the same is true for us. You know, Singapore, you gave the example. Here was a country that had mastered, you know, the ability to get more than 80-plus percent, almost 90-some percent of certain age groups vaccinated. And yet today, you see what’s happening in Singapore. So I think until we understand more how well these vaccines work long term, what do they do, what will we accept? As you asked, President Burwell, is it going to be about just preventing hospitalizations and deaths?

I hear that now. Well, these vaccines were never intended just to prevent mild illness, only hospitalizations and deaths. Go back and look at the rhetoric that came out when the first mRNA data came out. Everybody talked about we want a vaccine that covers the whole spectrum, OK? So we’ve kind of changed our attitude, you might say, about what we want from these vaccines. And that’s not a problem. That’s OK. But the question is, what are these vaccines going to do in the future? If we do need annual boosters, will we be able to supply the world, you know, with billions of people with annual boosters? I don’t think so.

So the challenge is going to be down the road, when these vaccines and their performance are more clearly understood, I think we’ll be in a better position to answer what a country’s approach might be. Is it appropriate or not? Is it sustainable or not? And we don’t know right now. We just don’t know.

BURWELL: I think the other thing—before we turn to the next question—that we will all—we’ll have to consider is the question of the more cases you have, the increased likelihood of variant change and variant change that could break through. So as we think about answering the question of what we want to measure of success of different approaches—vaccination and other approaches—you want to consider both the public health impacts—in other words, do we have more dangerous variants that come—at the same time you consider the public health in terms of how many people within communities and parts of the world, including our own, are sick, hospitalized, and die. And then—you know, so I think there are going to be things that we consider as we get more information.


OSTERHOLM: Can I just—could I add a piece on that? Because I think that’s a very important point you’re raising. And I just have to say right now that we have to keep our eyes wide open. God knows what a new variant could bring. But if you look at what we’ve seen so far, I mean, there really are three categories of variants we have to be very mindful of. Are they more transmissible? Do they cause more serious illness? Are they capable of escaping immune protection from either the vaccines or natural infection? And what we’ve seen so far, of course, from a concern standpoint, has been that third category—whether it be Mu, or Beta, or Gamma. But what we’ve also seen is that first category of more transmissible. And Delta is the king of the block right now. And transmissibility appears to be probably the most important of those three categories.

And so I don’t want to ever say that I don’t worry that a vaccine—or, a strain may evolve that—a variant that could evade immune protection. But I think it’s going to be transmission, transmission, transmission. And I can’t imagine any more transmissible than Delta. If it were, we’re in trouble. And I think that that’s—we’re in bad enough trouble now. So I think that’s what we want to keep mindful of too, is we’re so fearful of the—of the vaccine or natural infection situation that we forget that the only thing that would probably beat Delta right now is going to be a more transmissible virus.

BURWELL: And that makes sense, because the thing the virus wants to survive is transmissibility.


BURWELL: The virus itself doesn’t care about how damaging it is. What it cares about is can it survive? And its survival is transmissibility, which is why Michael’s point, I think, is what most of us all believe is what will be the dominant thing, is transmissibility.

Let’s go to the next question.

OPERATOR: We’ll take our next question from Kelly Atkinson.

Q: Hello. Thank you all so much for the work that you’re doing on this very important effort. I’m also a political scientist, and I hope that we can explore issues of public opinion and misinformation without otherizing populations that are involved in this ongoing effort.

My question is for Dr. Gupta. I heard you speak about the impact on health-care workers from this pandemic. As an active-duty military member, I’ve seen firsthand that our services on base have reduced drastically over the last year and a half. So I’m interested in, first of all, what’s the impact on local populations who are losing access to health-care workers? But, secondly, what’s the long-term impact on health-care workers? Do you think ten or twenty years from now are we still going to be feeling the impacts of this pandemic? Thank you very much.

GUPTA: Kelly, first of all, thank you for all you do and for that question. There is a lot of worry right now that a shortage crisis that already existed is going to be exacerbated by everything you just mentioned—burnout, the sense of just dire danger that a lot of health-care workers feel, being so just in the midst of fighting this pandemic in an ICU bay, for example. So I do think that this is going to be something that unless we think big on solutions to address the health-care worker shortage we’re going to be in a much worse spot given all the trends mentioned—the demographic trends that we’re going to lose nurses and docs throughout the rest of this decade.

So I think we should make it easier for people to enter the field, number one. So direct from high school, direct to medical school or osteopathic school programs. There are some that exist out there. We need more of them. We need more nursing schools. We need to make it—we need greater education incentives so that we’re not straddled with a bunch of debt well into our late 30s. It’s actually objectively a really difficult path, regardless of what part of the health-care profession you want to pursue to actually pursue it, much less to get a seat. So we need those strategies there.

I’ll say, as a former active-duty doc in the Air Force, now reservist, one of the lifelines I had, Kelly, was being able to get the health profession scholarship offered through our military. I think we need to make that track a little bit more attractive to people finally. We need hazard pay for our respiratory therapists and our nurses who want to lead this field. We don’t have that paradigm for civilian health-care cadres. We do have it bit for the military, but people are wanting to flee right now. So there needs to be a think big, moonshot-type vision on how we increase more—how we drive more people into these professions, how do we keep them there. And what private sector does so well is talent retainment. There isn’t a lot of that happening across health systems in the United States. And that needs to be a big focus.

BURWELL: Thank you. Next question.

OPERATOR: We’ll take our next question from Craig Charney.

Q: Hello. I’m a political scientist also, based in Charney Research. We’ve done some work on COVID.

My question is this: How much would it cost, roughly speaking, to vaccinate the unvaccinated world at this point? And beyond that, is there some scope for a program equivalent to PEPFAR to do it? After all, COVAX seems to be a bit of a flop, or at least operating much too slowly. And the PEPFAR approach, there are so many cases, there are so many countries, how do we get the drugs to them, would seem to be indicated here. So any thoughts on that? Because I’ve been surprised by the absence of such a conversation.

BURWELL: Jennifer, you want to hop in?

NUZZO: Yeah. So the IMF has looked into this, and they have done some analysis of what it would take. They’ve estimated it would be about a $50 billion enterprise, which, you know, is a lot of money, but also very small compared to the stimuluses and other things passed in the United States. And they’re very frustrated, at least from their communications, that there has been less appetite for the proposal that they set forth. It really just feels like, you know, a lack of ultimate leadership. But we need to figure out something. And particularly, you know, one of the—I have two concerns.

One is both the speed with which we are acting, but also, you know, where countries are giving donations it’s largely along preexisting political lines, like trying to reaffirm strategic alliances, and not necessarily targeting where there is greatest epidemiologic need. This idea of using—you know, when we rolled out vaccines to U.S.—you know, to Americans, we did so according to—you know, considerate epidemiology, where we gave it to people that we expected would benefit the most, and also people who were in the greatest of harm in terms of exposures. We don’t have a similar rubric for allocating awarding donations overseas. It’s just a little bit here and there to kind of check the box, it feels like, in terms of reinforcing political allegiances. But there is a—I suggest taking a look at the IMF report on this, because they did some, I think, thoughtful thinking on what it could take.

BURWELL: Thank you. We’re going to try and get one more question in here.

OPERATOR: We’ll take our last question from Jay Markowitz.

Q: Hi. Thank you for squeezing me in. And thank you to all your participants, not just for this call but for everything you’re doing around the world.

Jennifer made the point that it’s not over till it’s over for all of us. And I want—my question has to do with that point. So it’s not just about supply of vaccine. While that’s critical, obviously, it’s also about distribution. So perhaps you could comment on what systems are now in place or being contemplated to improve not just cold chain but getting vaccines into arms. And then also, in the spirit of not letting, you know, a great crisis—a devastating one—go to waste, whether that kind of infrastructure can be done and used for active surveillance not only to find variants of this virus, but perhaps to detect early on next—the next wave of the pandemics. Thank you.

BURWELL: And I’ll let others jump in, but would just start with the idea of community health workers, and the numbers of countries that use those systems, are places that we can build the back on very quickly in terms of both vaccination distribution as well as surveillance. And if you ever got to the stage where you could do the surveillance testing, those would be the places where you have things in place. And your point is very well-taken on distribution, because we’ve had a polio vaccine for well over sixty years now, and we still have it in a number of places. But I’ll turn to my colleagues. Who wants to jump in on this one?


NUZZO: I’ll just say that I think we can also build off of previous—infrastructure put in place for previous events, you know, in terms of cold chain, et cetera. The fact that we’ve been able to deploy Ebola vaccines in remote parts of the world I think holds out promise that we can do it elsewhere. The truth is, probably vaccination programs are more robust in places where there has been a concerted effort to make improvements, as opposed to the United States where we don’t really have a program for vaccinating adults. So anyway, just to say—that’s not to say that there’s challenges—there aren’t challenges. But I also think that there’s a lot more capacity than we certainly give countries credit for.

BURWELL: Michael, did you want to add a last word?

OSTERHOLM: I was just going to say, I think that—remember, we came into this pandemic wanting a vaccine that was quickly available, that could be scaled to a certain degree, and that was effective. Well, of course, this is what we got, which was actually great. But we never really thought about necessarily the cold chain requirements or the challenges of these new vaccines. And I think that the second-generation vaccines you’re going to see are going to be as effective, if not more, but they’re also going to have ease of use, and cold chain requirements are going to be very different, so that they can be more readily moved around the world and made available in that regard.

BURWELL: We could keep going on. I know we didn’t even get to the inequity issues that have been laid bare by the pandemic, a whole ‘nother topic there, and many, many more. But want to just close by, first, thanking our panelists. Jennifer, Michael, Vin, thank you so much. Thank everybody for joining us today for this conversation. Appreciate it. And so you all will know, both the audio and the transcript will be available on the CFR website, if you want to go back to something. And thanks, everybody, for joining us today.


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