Lessons on Reopening in a Pandemic From Around the World

Tuesday, September 22, 2020

Health Policy Research Analyst, Princeton School of Public and International Affairs, Princeton University; Cofounder, The Princeton Conference; Adviser, China National Center for Health Care Research and Development, National Health Commission, China

Author, Which Country has the World’s Best Health Care?; Vice Provost for Global Initiatives, Co-Director, Health Transformation Institute, University of Pennsylvania; Member, Council on Foreign Relations

Professor of Health Economics and Clinical Epidemiology and Director, Institute of Health Economics and Clinical Epidemiology, University of Cologne, Germany; Member, Deutsche Bundestag; Adjunct Faculty Member, Department of Health Policy and Management, Harvard School of Public Health

Nick Schifrin

Foreign Affairs and Defense Correspondent, PBS NewsHour

Speakers discuss the challenges other countries in the Middle East, Asia, and Europe have faced in reopening workplaces and schools during the COVID-19 pandemic, as well as the lessons to be learned from these experiences around the world for the United States.

SCHIFRIN:  Sam, thank you so much and thank you to CFR for this fantastic panel: “Lessons on Reopening in a Pandemic From Around the World.” We're joined by Tsung-Mei Cheng, Ezekiel Emanuel, Karl Lauterbach, and I am Nick Schifrin, the foreign affairs and defense correspondent for PBS NewsHour, and I'll be presiding over the discussion. And so briefly, let me introduce our panelists. Tsung-Mei Cheng is a Health Policy Research Analyst at the Princeton School of Public and International Affairs and an advisor to China's National Health Commission. Ezekiel Emanuel is the Vice Provost for Global Initiatives at the University of Pennsylvania and the author of Which Country has the World's Best Health Care, and I imagine we'll get to that question later. And Karl Lautenbach, Lauterbach, sorry, the Director of the Institute of Health Economics and Clinical Epidemiology at the University of Cologne, Germany, where he joins us and of course, a member of the German Bundestag. So welcome to all of you. It is my pleasure to have all of you here.

And I think our goals today, just to lay out a frame for our discussion, is to examine some of the challenges, successes, perhaps failures, that other countries have experienced while dealing with COVID. And other countries are dealing with as everyone tries to reopen, whether it comes to workplaces, schools, society as a whole, and to try and talk about some of the lessons that should be learned, should be shared, and perhaps some of the experiences that should be avoided. And so where I want to start is with a couple of success stories. So Karl, Karl Lauterbach, let me start with you. Germany, has the lowest death toll in all of Europe. How did it achieve that?

LAUTERBACH:  Thank you, Nick, for having me on this panel. First of all, first of all, we were lucky. I mean, we did a number of things in a good way, I think, but we were lucky. I was involved from the very first minute and we were lucky to learn from other countries, basically how severe the disease is. So we, for example, so the horrible videos from Northern Italy, showing let's say, how the healthcare system there, which is a good healthcare system, Northern Italy, a good healthcare system, how they were struggling. We saw the major losses that were sustained in some of the regions, which we are closely connected to. So we were, first of all, very keenly, early on aware that this is a major disease, a major issue coming on, not comparable to the flu or anything.

Number two reason, let's say mounted a fairly massive response immediately. And I think in retrospect, what made it different is that we immediately accepted that this is only to be dealt with successfully if scientists, physicians, virologists, epidemiologists, and politicians work very closely together and do so in a transparent way. So what we basically did is we had a group of people, which was highly visible publicly, and which would, on a daily basis, meet and we would basically come up with measures, or they explained these measures to the public in a very open and transparent way so that the public was aware of the, let's say, sincereness of the situation. And would also be able to understand what we recommended, for example, when we came up with an early lockdown, we were able to explain to the public quite openly, that there was no alternative to this. And we were able to explain, in numbers, what the alternatives would be if we were, let's say, postponing the lockdown for a couple of weeks.

So we were very open and transparent about this. And we permitted questions from the very beginning. So that was, in my opinion, is the best part of the public health response, that we were, let's say, sharing our knowledge, which was limited knowledge at the beginning, but we were sharing that limited knowledge, we discussed it openly. And we were extremely transparent. And there was a group of, let's say, five to ten, virologists and epidemiologists and a corresponding number of politicians who basically, put it bluntly on the show, literally 24/7, and we were able to explain to the public what was needed, so we had a fairly, what you would call in medical terms almost, we had a fairly good compliance, for better word, for better for, for lack of a better expression.

We had a very good compliance in the population, so our measures were, our measures, our lockdown was not the toughest lockdown in town. Many of the other European countries had a tougher lockdown than we had. We had a fairly lenient lockdown, but we had a fairly high compliance and commitment to the population that those measures that were recommended was and also were, were followed. That's my take on that one. And we were lucky, again.

SCHIFRIN:  Yeah, no, luck, luck helps, as any poker player would say—I‘d rather be lucky than good. Tsung-Mei Cheng, we all know where Taiwan is. And we all know that millions of people travel between Taipei and Wuhan. When COVID broke, Johns Hopkins predicted Taiwan would have the second most cases in the world. And I think by my count, there are some ninety countries and territories with more cases than Taiwan and perhaps it's even larger than that. It seems that Taiwan successes also come from some of the points that we heard from Karl, lessons learned, massive national responses, scientists working really with priority and a level of compliance in Taiwan as well.

CHENG: You are exactly right, Nick. Taiwan's success, by success, let me just give you two numbers—to date, yes, I mean, Taiwan was expected to be a very, very severe case of COVID-19. But that didn't happen. As of today, they have 509 patients that are confirmed cases of COVID-19. And in terms of death, they have seven, seven people died. When you think of, you know, our country, the U.S., in the New York state alone, something like 33,000 people died. And it has, sure, the population is smaller than Taiwan, which is twenty-four million. Now the, I would say, the key to Taiwan's success is that they were prepared. They, when they first heard about the one case in Wuhan, on December 31st, 2019, and immediately the government sprang to action, because they have learned from SARS. They say yes, I mean, this is a new virus. We respect it. We fear it, we respect it.

But they were also prepared, because they learned from SARS, which happened to Taiwan when they were totally unprepared, and one in three people died. So mentally, they are prepared. And, I would say that, so they had laws, they had infrastructure capacity building to meet this challenge. But I would say here that it was the early action that the government took, that really made a difference. You say that necessity is the mother of all inventions and Taiwan feared this massive onslaught of COVID-19. Because, you know, they didn't have enough ICU beds, they didn't have enough medical personnel, if this wave should hit Taiwan.

So they say, all right, so what is our strategy? All right, let us keep the virus out. So that was the key that I, you know, a former health minister gave this to me personally, that was our strategy, keep the virus out. And so, they're, it's a two pronged approach. Under that strategy, it is prevention and control. So the actions they took early, early on, starting on December 31st, is they put on travel restrictions. Anything from Wuhan was very, very closely monitored, people tested, and then the other actions are isolation, quarantine. And then they also did, you know, immediately the whole, the whole island, everybody just started wearing masks. It did social distancing, and hand hygiene, and get their temperatures checked judiciously.

See this because, the Taiwan as a population, they could do this because they're mentally prepared. They were humble enough to say, “okay, what was our experience? What is the science, what is the evidence that could protect us?” And so these are all the things they did. So as a result of the effectiveness of the measures it took, it never had to do, resort to large scale testing. Because, you know, first of all, it was very expensive. And, as you know, that Taiwan is a single payer system operating on a budget. And so they say, “all right, let's just, you know, do the prevention and control.” So the, and then the cases were so few, that there was no need to go for large scale testing. And so far, that hasn't worked. And I don't know whether later on, you know, we'll get a chance to talk about, you know, the specific factors that helped Taiwan succeed. It's not just good luck. It's a lot of things together.

SCHIFRIN:  Luck never hurts, I suppose. Ezekiel Emanuel, I know you want to compare this to the United States. Just to go over though what we've heard—we’ve heard lessons learned, whether that's immediate from Lombardy or from SARS years before. We’ve heard about prevention in both cases, whether travel or mass. We’ve heard about compliance—a population actually listening. And in some cases, Taiwan included, certain aspects of society, perhaps it would be allowed there that wouldn't be allowed here. But I know you want to compare that to the U.S.

EMANUEL:  Yeah, I think these are two excellent examples. The first is preparation. I don't know that we didn't have preparation—the United States. We certainly had a CDC that understood how to battle infections and potential pandemics. It had been through a run through in H1N1 in 2009, 2010. What wasn't prepared is a national government to actually exercise national leadership on this. And I think that's a major difference between Taiwan, Germany, and the U.S. I know for a fact, because I was on a call with—many calls actually, with the president. He was told, he was warned—we now have Bob Woodward saying “he was told, he was warned, he understood how bad it was. And national security peoples told him how bad it was.” And yet the resolve to take immediate and stringent action was lacking.

Second of all, we had a haphazard—different regions doing different things in the United States that even Germany, a country of more than eighty million people, did not have. They had a strong leadership, we tended not to learn as quickly as, for example, Germany did about the lessons from Italy, and I'll talk about that in a second.

But the other thing I would say is a word that I don't think either Karl or Mei used, but is basically trust in expertise. And that I think is a major difference. We in the United States, unfortunately, are in this mode of populism. And one of the hallmarks of populism is the denigration of expertise. And the not trusting it. We've recently, yesterday saw that, you know, even someone at the NIH was attacking the NIH and leadership anonymously, using pseudonyms, undermining the message, you know, it's hard to have a population that gets a single message and gets it over and over and gets the data behind it and understands it, when you have a leadership that is directly undermining it.

But let me say, which I think is a really important, you know, Germany learned from Italy, we were a week or two behind Italy, certainly in the New York area, the, the lesson of Italy, as just an example, not the only country, but it shows you that they went up, they had a, sort of, you might say chaos in the healthcare system, but then they responded and they responded quite systematically and effectively. They locked down the north first, then a day later they locked down the country. And you can see, if you look in the data, very consistently that happened, the middle or the second week of March, and by the end of May, so roughly eight to ten weeks later, their case load was very, very far down—a couple or three cases per hundred thousand. So an effective response sustained over time, brought them way down.

We in the United States have never done that. The president not doing leadership, leaving it to the states, having governors, like in Georgia or Florida, just flouting public health measures, then people from Florida or Georgia moving around the country, taking cases with them, has meant that we've, sort of, the lowest we've gotten is 30,000 or so new cases per day, we've never gotten down to the low, one, two per 100,000, that other countries have achieved. And that makes a huge difference as to how you can open up. And so one of the things we have failed to do is to act in a unified manner, follow the actual recommendations of experts, and follow the public health measures. I would say one big difference is we are not a face mask culture, the way Taiwan is.

We had to learn how to do face masks. But it's quite clear from the data, overwhelmingly clear from the data, that wearing face masks work. How it works—do you get a small inoculum? Do you get no inoculum? We don't know exactly. But we know it works. And the inability of the country to systematically implement that and people to flout it on, with encouragement from the president, is really, really one of the reasons that we can't seem to get our arms around this problem.

SCHIFRIN:  So we now have a baseline—it’s 10:45. For the next 15 minutes, I want to go through reopening and at the very end, I want to look into the future and talk about vaccines. And, so let's try and get to multiple aspects from each of you in short bursts here. So, Karl Lauterbach, take us through what seems to be a major second wave in Europe. And what are you advocating for? What are you looking at? Especially when it comes to schools, how they should reopen, the nature of testing in public. Those seem to be two of the things that you're looking at today.

LAUTERBACH:  Yes, indeed, thank you. We are currently, in all of Europe, at the start of a second wave and we have high new case-loads in many of the surrounding countries in Spain, in Italy, in France in particular, but also in Austria and Germany, we start seeing more cases as well. All of these countries, Germany included, currently have in common that the new cases are mostly among young people. But if you look at mortality and do an age adjustment, it appears that let's say the age adjusted mortality and also the severity of the cases is comparable to what is was the first day, so we do not see strong evidence so far. Let's say, mask-wearing will make a big difference in terms of, let's say, the mortality that we would have to expect if the older age groups were targeted by the disease. So that is where we currently stand.

What we are currently preparing is, and we are in the process of speaking about it as we speak, as a matter of fact, even tonight, after the session, I will be involved in that again. But we are very likely to come up with measures that, in public places, mask-wearing, even outside will be mandatory. In particular if, let's say, distancing is not possible because if you are outside and there is many people and there is lack of possibility of distancing, and loud speaking is commonplace, and the louder you speak the more likely it is that you transmits a virus. So therefore we will, in public spaces, we will most likely come up with a measure of mask-wearing. We will also, let's say, deal with schools, we prepare, let's say, school social distancing, perhaps halving classes, we are also looking into, let's say, air filtering machines, mobile air filtering machines, standard fourteen filters that will take out airborne transmission by aerosols to a higher degree. We will limit private festivities, private meetings to twenty-five people as an upper bound.

This is what I expect us to do. Again, these are measures that are not currently taken, but I expect those to come about in the next couple of hours because we are meeting for this in the next couple of days and we are preparing to respond. So in that sense, we will most likely come up with what I would call, let's say, a soft response. But this soft response, we will again explain to the public very, in a very detailed fashion. We will explain what measures we take, what measures we do not take, why we made that selection, what we expect, and what numbers we expect to come about if we are successful, so that we go about this in a transparent way again. So we will basically try to repeat what we have done in the first wave, but with different measures. We are not looking at a major, immediate new lockdown. So we look at a microsurgical and arthroscopic COVID response here, but that has to become, that has to be decided in the next couple of hours.

SCHIFRIN:  Tsung-Mei Cheng, what are the specific steps that the Taiwanese government continues to take in schools and workplaces to maintain the successes that we talked about? And quickly, as I mentioned, you're an advisor to China's National Health Commission. We have seen the Chinese mobilize in response to small outbreaks. Do you believe that's been successful?

CHENG: I do think so. I do think so. Because if you have targeted response and evidence shows that it works. So China is, I would say, it has controlled the situation. In fact, if you look at how its economy is doing, it is one of the few economies in the world that is actually growing. You can see that, because of the disruption caused by COVID in the rest of the world, that a lot of the interest in business investments, etc, have had moved to, to say, China, China and Singapore, which also has COVID under good control, they are now doing big, big business. So I would say that the situation in China is under control.

But that really took very, very stringent government policy, and also the cooperation of the population, which is, by the way, also the secret to the success of control and containment in Taiwan, where people have the proper respect for evidence, for science. And they understand that the government policy is science led, evidence based. And so when you put the two together, first, you have leadership at the top, which is crucial, critically important, which I'm afraid to say that in the United States, we have not seen that. So far, the efforts have mostly been at the state level because that is our national policy, the states shall take care of its own COVID problems. But in China, and in Taiwan, it's government at the top that has taken charge, and we see the results produced, and what the government does is not just arbitrary, it is, I want to emphasize for American viewers, that what they do is fully science and evidence based.

SCHIFRIN:  Mei, can you respond quickly, in terms of what we hear from the U.S. government, that you use the word cooperation when it comes to Chinese. What the U.S. government depicts, is a society in which people don't have the choice. That they have to follow those government restrictions, regardless of the success. So just quickly respond to that.

CHENG: Yes, you say, President Ronald Reagan, this famous saying that comes to mind, “trust, but verify.” So you have a set of orders from the government, but then, you know, whether you monitor it and watch it, whether people observe it, and obey, makes a big difference too. So, you take Taiwan, for example, they have very, very strict rules about isolation, home isolation, or quarantine. And if you violate that, they have the technology that knows how you move about and then they will contact you to say, “oh, you have left home or you have left your hotel room, where are you?” And so then there are consequences if you violate the orders. Very, very big fines. I think the last I heard is that the fine could be as high as one million NT Taiwan dollars. Divide that by thirty. So it's 30,000. And they really, yeah, so it's a carrot and stick kind of thing. And it so far has worked.

SCHIFRIN:  So Zeke, we've got about five minutes left and I want to touch on two points. So quickly, if you could, can you engage with that idea that Mei was just saying, that there is an obane of the population, but also techniques that the governments, whether we're talking about Beijing or Taiwan have used—would those techniques be acceptable in the West? And I know you want to talk about the principles of reopening, the need to get the rate down, and for example, bars and restaurants closed. So take those two things, are some of the principles that Mei just described, are those possible even in the West? And then this principle of reopening, what needs to happen in order to reopen successfully?

EMANUEL:  Yeah, let me begin with what we know and what that shapes our reopening. So you know, the transmission as Karl has laid out, you know, transmission of this virus happens by going through into enclosed spaces with lots of people for a prolonged period of time, where there's a forced exhalation, whether it's shouting, yelling, or other things. Outdoors helps because it's not an enclosed space, but it's by no means perfect, especially if you're right near other people. That tells you how to reopen, it tells you that enclosed indoor spaces where you're likely to be for a long time, where shouting, yelling, or sneezing is going to happen—indoor bars, indoor restaurants, indoor gym facilities should be the last places you open up. If you need to be indoors with a crowd for prolonged periods of time, i.e. schools, you need to space people out, you need to have windows open and ventilation, you need to have wearing masks mandatory. And that's the way we need to think about the opening and get people trained.

Now, let's talk about how would we get compliance with these kind of behaviors, like mask-wearing. You know, the analogy—first of all, we need to understand if you don't do those things, you're endangering not only yourself, but someone else. And we know from this virus, not everyone knows when they're infected. 40 percent of people are asymptomatic, may have the virus and don't know. So we really need high compliance. High compliance can be done by—part of it, by social pressure. And we've advocated that to have a sort of social norm. But that requires leadership. It requires someone who's in the presidency and in other places of power, actors, influencers comply, but also penalties to reinforce that, right?

We don't say you shouldn't drive and drink at all, right, and not have a penalty. Why do we have a penalty for DUIs? We have a penalty for DUIs because you're endangering other people. You can injure them and you can kill them. By the way, the same thing is true of COVID. Right, you can endanger other people. So when we think about, well, we would never put up with that. We put up with it in terms of DUIs because we realize you harm other people, you're a member of the community, we need you to comply with certain rules that minimizes the risk to others. COVID is actually no different in that regard. Do I favor that? Absolutely not. I think it would be much better if we could get compliance by social norming it and incentivizing it.

But, you know, and one of the incentives we might use—and the government had plans to do this, but then scraped them—is mail every household, have the postal service deliver five masks to every household, maybe do it monthly. That's a really good, set message about social norming incentives and giving people the method by which to adopt these practices, but we didn't do it. And again, I would rather the social norming. But if the social norming doesn't work, and we're still having 1000 deaths a day as a result, we might have to go further. And again, I think the analogy is best done by driving under the influence. We don't just leave it to people's discretion. We actually have rules about it and laws.

SCHIFRIN:  Zeke, we need to move to questions but I just want you to give us a very quick headline on the role of vaccines when it comes to reopening and how important it will be and how important you believe international cooperation is on those vaccines.

EMANUEL:  Well, let me just say two things—we are going to, you know, a vaccine will help dramatically, a lot will depend upon its characteristics. You know, is it effective at 75 percent rate or 50 percent rate? 50 percent rate actually makes it really difficult to just rely on a back seat to reopen. Is it durable? Does it last more than twelve months? Because if it lasts just six months, it's also going to be hard, hard to imagine that you're going to give people two shots twice a year to maintain. And it's got to be safe because it's not safe, as we know, certainly in the U.S. and I think in many countries, people will stop taking it. I do think both Russia and China have decided to begin mass vaccination without reliable data that it's actually safe and effective. They don't have effectiveness data, they began to distribute after phase two rather than really finding out—does it prevent and how well does it prevent, vaccine?

And there's been recent studies that look at comparing, sort of, what you might call, each country trying to do its best with a cooperative effort. And it turns out, the cooperative effort actually reduces mortality much more than the haphazard method. Which cooperative method you have, I think there are different ones and I think you can do even better than the calculations suggest by really focusing the vaccine on places that are hotspots and not distributed evenly across the world because, you know, some places like Taiwan, evenly, if you're not going to prevent any deaths, they've had seven deaths, and they've had seven deaths for weeks and weeks and weeks. No new deaths, giving them vaccine is not going to prevent any death.

SCHIFRIN:  And I'll remind people that as we speak, Presidents Trump, Bolsonaro, Xi Jinping are all speaking at the seventy-fifth UN General Assembly, which because of COVID is virtual for the first time in history. And this is a big topic. All right, well, lots to talk about but I want to get to your questions. So just a reminder, we see a few questions already, but in the participants tab, you can raise your hand and I turn it over to Sam, who's going to start calling on all of you to ask questions.

STAFF:  Our first question will be from Laurie Garrett.

Q:  Thank you very much and thanks for organizing this. My question is to Karl. Here in the United States we have a very toxic atmosphere. Everything about dealing with the virus has been politicized so that people are taking sides—red, blue, mask, no mask, etc. In Germany, you said that you've gone to great lengths to create, a kind of, unified response. But we do see that you have demonstrations against lockdowns and against masks and they tend to align with the far right. Do you think that this could become, reach a kind of dangerous point in Germany, similar to what we have in the United States, with a politicization that goes along with right wing objection to social distancing measures?

LAUTERBACH:  Thank you for the question. No, I don't think that this will happen. First of all, we allow these demonstrations because the right to demonstrate is very important to all of us and this is a constitutional rights that we honor under all circumstances. And the spots effect that this is a very, let's say, visible and radical groups that is demonstrated here. It is a minority in the country. And we have bipartisan or multiple partisan consensus in Parliament. That includes to some degree, even the AfD, which is our far right parliamentary group, to some degree, that we go along with the measures that we as a government think are necessary.

So looking at the demonstrations, yes, we do have a far right movement, and we have some, let's say virus deniers, denialist on the street, but there are strict management problem, there is no way that you can convince these people of let's say, the hazards of the of the virus. And I think we can manage to deal with that—it will not become a mainstream movement. It is not, say, splitting the party into groups. So all things considered there's a nasty, very visible, and unpleasant far right group, which let's say, uses the antivirus people for their for the political purposes, also far right, but it is not a big hazard to our public health policy which will not be endangered.

STAFF:  Our next question will be from Joe Nye.

Q:  I have a question for Zeke. The United States is an outlier, both in number of cases, but also in remedies, domestic and international. Recently, the Trump administration refused to join the COVAX facility for development and access to vaccines. But a lot of other countries have joined. And indeed a majority have joined. What difference would it make if the United States doesn't join? Can the U.S., basically—will the other countries be able to make COVAX work without the U.S. participation? In other words, do we have an effective veto power on this set of remedies that other countries have suggested? And is are isolating ourselves going to kill it? Or can they go ahead without us?

EMANUEL:  Joe, nice to hear from you and as usual—a very difficult question. This is a moment that requires world leadership and world leadership by a superpower. We are the natural group to step in, and lead COVAX and demonstrate that cooperation by the world is better, it's better for everyone in the world, and in particular, it'll certainly benefit the low and middle income countries that are having, that have difficulty affording a vaccine that need a vaccine. I am quite dismayed that we are not stepping up. One of the things is just from a practical standpoint of, you know, what you talk about, soft power. Being a leader really entails joining the facility and contributing money to the facility, that's what we would need to do, and to steer the facilities' allocation in the right direction.

This pandemic has cost trillions of dollars in the United States and the amount of money that the COVAX facility needs to get going and really distribute vaccine is in, you know, the seven, I think it's eighteen billion dollars is what they're looking for vaccine alone. Right? That's a trivial amount. It's a rounding error. And we have traditionally, we the United States, have traditionally been the largest supporter financially. And in terms of leadership, of worldwide responses in global health and providing global health assistance. We should step up and write a check for, you know, eight, ten billion dollars and show the world that we are serious about being leaders, that this is an effective way of reducing the pandemic.

Will this humble it? It depends whether the other countries that have joined like the UK, like Norway, are going to be able to raise the money and make the distribution effective in reducing the mortality rate. Without the United States it's much more improbable, with the United States it would have definitely happened. And, you know, all I can say is I hope for an administration change, because I think this is one of those pivotal areas switches that really will make a difference to the worldwide, how much the world suffers from this pandemic, whether it will continue for years and years, or whether we can actually effectively address it in the next fifteen months.

STAFF:  Our next question will be from Shaarik Zafar.

Q:  Hi, this is Shaarik Zafar, formerly at the State Department. Can you—I would love to get the panel's view on how, with your respective countries, how's the view of the United States changed? Is it irreparably damaged? You know, the average citizen in your countries—what do they view about U.S. leadership and the U.S. government? And is this something that they think is temporary? Or do you think there's been laughing then—

SCHIFRIN:  We lost you there at the end. Mei, why don't you start?

CHENG:  Yeah, I happen to see a study. I think it was the Pew poll, that says that how other countries view the United States has changed significantly downward, unfavorably. I didn't see one single country where the view is favorable towards the United States above 40 percent. There are more in the 25-38 percent range. So there's no question that, that the image of the United States has taken a beating. But I understand that, this is from talking to my international friends, that it's recoverable if the administration changes hand in November. So it's not a hopeless situation but it's fairly precarious at the moment. So it's recoverable, but it depends.

SCHIFRIN:  Karl, why don't you take us to Germany and Europe, quickly on that?

LAUTERBACH:  Yeah, quickly, I would agree. And I travel around in Europe a lot and speak to many people in Germany about the U.S. since, as an adjunct at the Harvard School of Public Health, I travel to the U.S. all the time. And I'm asked and so forth. I would also agree this is a temporarily beating, but no more than that. Most Germans and most people in the surrounding countries can make a clear distinction between the current administration and the administration that we have seen before. Many people in Germany believe that, for example, former President Obama was a particularly successful and also admirable person. So that is still in our minds, as a matter of fact, is part of a view which I personally share. So I would not think that any permanent damage will last here. If we see things to change. And that is my personal view, I hope that things will change. I agree with Zeke on that particular point. That is not our government's official position. Needless to say, I think I speak for many Germans here, at least one out here.

CHENG: Can I add, the Pew poll showed that the Germans are most critical of the United States at the moment with favorable views at 25 percent.

SCHIFRIN:  We've got about sixteen minutes or so, we've got two more questions. I think there's time for me to take a moderator's prerogative and push back a little bit on this consensus of change and election, obviously, which is not something that I can engage with. But I want to suggest that Zeke, respond to what the administration would say, if we had someone on from the administration right now, to a couple of points—one, the level of money that the United States is pumping into the vaccine development cause, operation warp speed is in the billions and is the leading number in the world as far as what the administration says, and that the scientists who are participating in that effort, whether American or European, supported by this administration, will be the leaders going forward on vaccines, and that that will represent the success thanks to this administration. So why don't you just respond to that quickly?

EMANUEL:  Well, yes, we are leading and we are contributing heavily to vaccine development. And the underlying science, the mRNAs, the adenoviruses, and even the older technology are things that the United States, Britain, and other countries pioneered, for sure. That's our role. That's part of what makes us a great country, or has made us a great country, is advanced scientific research. But we should also be a little humble here. We're not the only people who are in this game with research. The Chinese have a couple of vaccines in phase three, the Russians have their own approach, as well. And we don't know who's gonna win.

And it's not—I keep saying this, it’s not who gets the first vaccine, but who is going to get the best vaccine. And remember, what we're trying now, clearly aren't going to be the best vaccines. And we can say that for one overwhelming reason—they require two shots. And two shots is a very complicated, logistic thing. And the Pfizer vaccine requires minus seventy degrees Celsius temperatures, which make it very difficult to distribute, and logistically a big challenge. So we're going, you know, it's not clear who's going to come up with what is a one-dose vaccine that, even better if it can be done orally, Merk's working on that, but we should also remember that all these companies are not, they're multinational. And a large part of both their research and facilities are, you know, the Pfizer vaccine is a collaboration between the United States and Germany. The AstraZeneca vaccine is British. Right? Sanofi GSK, European.

So it's not just the United States. Yes, we are pumping money in but these are, you know, in the scheme of the economic impact of COVID. These are trivial, trivial amounts of money. You know, if you're talking, I don't know how you want to calculate it, but if we're talking 569 trillion dollars wiped out because of this, you know, even if you're talking one trillion, ten billion is 1 percent. It's a penny on every dollar. That's not a big investment.

STAFF:  Our next question will be from Don Stroeve.

Q:  Hi, thanks for the very interesting panel. I have a question, probably mostly for Karl, on the role of partial herd immunity. I realize herd immunity is not a binary concept, and also depends on social behavior. But one interesting observation is that the number of new cases remains relatively low. For instance, in places such as New York, New Orleans Lombardi, and now also Arizona, places where seroprevalence studies have shown pretty high shares, perhaps Madrid could be a counter example. And so my question is, do you have a good sense of what the relative contribution from prior infections is relative to social control measures on the declining base, or just a low base of new infections in those places that got hit very hard previously?

LAUTERBACH:  Thank you, I personally believe that situation is as such a herd immunity. There is, let's say a range at which studies assume herd immunity to take off the lowest number being 20 percent, let's say higher numbers 70 to 80 percent. I think the best studies basically range somewhere between 50 and 70 percent. But to have, let's say, slow down of new infections, because, let's say, 15 to 20 percent of the population has been infected already, it is very unlikely to materialize. Therefore, from the studies that I've seen in my own reading of literature in that field, in particular, the experience in New York, but also in some of the regions in upper Italy, where you have, let's say, a fairly high zero prevalence in comparison to other places, I would assume that most of what we currently see is simply that, let's say, new cases are still down because a lockdown measures, that the public has measures are still in place.

This holds, for example, in particular for New York, where I have very good friends who are, let's say, working in the field. So my assumption is that currently herd immunity, nowhere is really playing a big role in holding down cases. And I also assume from let's say, what we currently know about COVID, in particular, long COVID, a long term disease even in, let's say, intermediate cases, not only is a very tough cases, but the intermediate cases that are not even in need of, let's say, ventilation support, these long COVID cases would make it almost unacceptable to let's say, target herd immunity. So I think that herd immunity from an epidemiological perspective does not play an important role. And it cannot be reasonable public health target.

SCHIFRIN:  Zeke, do you want to take that on as well?

EMANUEL:  I basically agree with Karl. The evidence, you know, you've got New York, New Jersey, Connecticut, and you have effective public health measures put into place. Now some of them are going to be tested when we do things like go inside in November. We've also seen in places like Italy, and other places where, you know, if you ignore these measures, the rates do go up. There's not been a clear case of herd immunity in those countries. When we ignore the social distancing, the hand hygiene, the face mask-wearing, you do see a rise, you know, parties have an implication and an effect. So I think Karl is right.

You know, the best state of the best epidemiology is we need minimum of fifty, maybe higher, to really get effective herd immunity, and no place that I have seen has reached that level. And by the way, some of the states that you mentioned, in the United States, again, we're also beginning to see uptick in cases. And I think it's just a matter of time if we ignore these public health measures.

STAFF:  Excellent. As a reminder, to ask a question, please click on the raise hand button on your zoom window. Our next question will be from Lori Zimmerman.

Q:  Hi, it's Dr. Zimmerman, I'm the medical director from Citigroup. And thank you very much. This has been excellent. You know, with the guidance that came out yesterday from the CDC, and then was pulled about the concern about aerosolization, you know, as we think about bringing our employees back into the workplace, and obviously, social distancing, good hand hygiene, and mask use, I'm wondering if you think that you need to be wearing masks all the time when you're in the workplace, or if you are socially distanced at your desk, you can take them off. I know this is a big concern, you know, we've definitely targeted keeping employees that are in offices or in conference rooms with more than one person, they must wear it. But what about the idea that if you're sitting at a desk in a large room, you know, in a large, big space where you're greater than six feet, about mandatory mask wearing?

SCHIFRIN:  We're gonna turn to the doctors there, Karl, you want to start?

LAUTERBACH:  Yes, thank you. It's very important question. I personally believe that it will, depends on three things. Number one, what's the likelihood of someone being infected sitting there. So if there's a high likelihood, if that is, let's say, a high prevalence region, it is more worrisome. Number two, it depends on the size of the rooms, the volume of the room. So if that is if there is a high volume room, and you do have good natural ventilation, or good air conditioning system, and which does have, let's say, ventilation from the outside mingling with the air conditioning, so that it is not simply let's say, a system which does not replenish air, then it's also again, a more difficult issue and I would therefore think that, on average, the risk becomes higher, the more people there is in the rooms, less ventilation you do have, and the more the higher prevalence is in the region.

In particular, in school buildings, I think that this will be a major issue. I do assume that in the wintertime, when we do have very high numbers, I assume the numbers will increase in the wintertime very considerably. Unfortunately, this is my take on the literature, I expect major increases in the numbers in Europe and also in other countries in the Northern Hemisphere. So if we do have very high numbers, I would assume that in many buildings, where you do not have good ventilation systems in place, with let's say, filter systems like standard 14 filters and so forth that take out airborne viruses, that indoor mask wearing will definitely become an option, if not a necessity.


EMANUEL:  Yeah, I think you know, I would agree with everything Karl said. Low prevalence, are you testing people before they come in? So you've, that doesn't get it to zero for a variety of reasons. Certainly the point of care tests are good, but their sensitivity is still a little less. And I do think how frequently the ventilation, how frequently you exchange the air, you know, on airplanes it's every three minutes you're exchanging the air, that's a kind of issue and do you have the right filters in place? Nonetheless, I do think if you're going to bring people together, you've got to expect an increase, especially as we do get into the colder weather because you're going to have more sneezing and coughing with that colder weather. And if you separate people and you're trying to have a meeting in a room, the voices are going to get louder the exhalations.

And so I think if you're going to bring people back, even if they're wearing masks, you got to expect some frequency. And the last thing I would say is it depends how well those rules that you have are being enforced and people are actually able to adhere to them. I've been advising some, you know, TV production, movie production, and one of the problems is getting, you know, getting the guidelines, they got great guidelines, and getting them actually adhere to in practice over eight hours. That's a big, bigger challenge than many people, I think, appreciate.

SCHIFRIN: Mei we've got four minutes in. Yeah. And I just wanted to turn to you because I don't think there's any more questions. Just quickly describe what you've seen from Taiwan, about how businesses are reopening and the individual lessons that Taiwan or the lessons that we should take all over the world about how Taiwan is reopening right now.

CHENG:  I will just say this—everything is open, fully open. Students, kids are back in school 100 percent. And restaurants are busy, and touring tickets are hard to come by. So people do go out and enjoy life and life is normal. Having said that, I want to mention also that people do take precautions to protect themselves, but also to help protect others. What I mean by that is people do wear masks, whether they're indoors or outdoors. So that that is one thing. And other measures, such as hand hygiene, is very, everybody does it and they make it easy for you to do. And also when you go into public places, they take your temperature, so all these precautions are still in place, but then because of the consistent application of this whole range of measures—that containment and control has been successful. And so people go about their lives normally.

So I would say that for, say for Americans, and certain Europeans who think that mask-wearing is infringing upon their personal liberty—I would say that, well, an ounce of prevention is what is important that you know, protect yourself and protect others by doing what is, what is the new normal. That mean, the Western world has learned to eat and like Chinese food, Japanese food. So I mean, when you go to these places, you see people wearing masks, even say in summertime without any pandemic going on. So maybe buy and buy, through this painful experience of the COVID, that more Americans, more Europeans will say, "well, what's the big deal, you know, wearing a mask?"

EMANUEL:  I mean, that's what you do with 500 cases over six months and a population of twenty-four million. That's not what we can do. I mean, even New York City doesn't have that, now, doesn't have that result. It just shows you that when you have suppressed the virus so substantially, life can return to normal. That's the key and you don't need a vaccine. Taiwan doesn't have a vaccine. It has very good compliance with the public health measures as Mei have said.

CHENG: You're absolutely right, Zeke. Attitudinal change takes time. It takes years.

SCHIFRIN:  And on that note, I do see a last minute question. But unfortunately, we are out of time. So I want to thank all of you, the members who joined us today, I want to thank Karl Lauterbach, Tsung-Mei Cheng, Ezekiel Emanuel, all of you for your fascinating contributions and for having a conversation for taking my questions. And just for everyone who's interested, an audio version and a transcript of the meeting will be posted on the CFR website later today. And thank you very much.

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