One Year Later: Global Health Lessons From 2020

On the one-year anniversary of Think Global Health, CFR’s website devoted to global health, our panelists discuss how the COVID-19 pandemic has changed the way we think about the role of global health in shaping economies, societies, and everyday lives.

This meeting is cosponsored with CFR’s Global Health Program.

HAASS:  Well, thank you and good morning to one and all on this snow day that, in this virtual world, somehow doesn't quite feel like a snow day. Somehow I feel we've been a little bit cheated out of our normal day off. Hope everyone is well and safe and healthy. And welcome to today's meeting. It's an exciting, proud day for us at the Council on Foreign Relations because we are marking and indeed, celebrating, the first anniversary of Think Global Health, the Council's website devoted to examining ways in which changes in health are reshaping economies, societies, and really, the lives of people in this and other countries around the world. We have a case study, shall we say, going on right now, so we hardly need to underscore just how important and relevant this is. I want to begin with three sets of thanks before we get to the events of the day. One is I want to thank Tom Bollyky, who really is the driving force behind Think Global Health, but also some of his colleagues at the Council—Shannon O'Neil, Lisa Ortiz, Maria Alzuru, Joel Bousley, and Karen Mandel—it takes a village and it really is an extraordinary daily set of productions that goes into the site. Want to thank our partner here at the Institute for Health Metrics and Evaluation at the University of Washington for their contributions to this initiative. And I want to third, but not least, thank the Bloomberg Philanthropies for their support in making this site possible.

Just to give you some sense of how busy Tom and his colleagues have been—TGH, as we call it, has featured nearly 300 articles from nearly 300 authors from over fifty countries in this first year. And the authors really run the gamut from public health experts to medical professionals, academics, what have you. The site has published more than, has had rather, more than one and a half million pageviews. And it's really become a go-to source for all sorts of news outlets—digital, print, electronic, what have you. In some ways, it's the natural, but it is an outgrowth of what we began at the Council seventeen, eighteen years ago in 2003. And what we decided to do then was to increase our focus dramatically on global health issues. And the goal was to integrate it, to mainstream it, into the fields of foreign policy and national security. For too long, it had been, to some extent, siloed, looked at by health experts. But my goal, because I am anything but a health expert, was to get people like me who had been working on foreign policy and international issues, just to get smarter about it. So we could appreciate its importance. And maybe the two-way conversation would be practical, both for health experts and for foreign policy generalists. We focused on both infectious disease, but also on non-communicable diseases, on NCDs. The feeling was that that had been under-looked at and underappreciated part of the global health burden and the global health challenge.

We've had two task forces—one recently that Peggy was involved with on the pandemic and preparing for the next one, also one on NCDs. We have, I think, four or five now, fellows working on this set of issues, we have more meetings than I can count, we've got the website Tom and others have produced, books on the subject, and it's really become a big and I believe, for better and for worse, permanent part of the Council's agenda. It's also reflected in our board composition, and we have Peggy Hamburg, but we also have at least one former secretary of HHS and we have Tony Coles—obviously, I meant, I was referring to Sylvia Mathews Burwell, but we also have Tony Coles, who's someone who works in therapeutic business. So again, it's central to this institution and I hope many of you have already received your CFR 100 mask, and that you make good use of it. And as my grandmother used to say, may she rest in peace, may you all wear it in good health. Today we have an extraordinary panel, great experience, great knowledge, led by the former FDA Commissioner herself. Peggy, over to you.

HAMBURG:  Thank you. Thank you so much. And I do have to observe that I remember well those days prior to 2003 when the Council was not deeply engaged on matters of health, and going to my first couple of CFR meetings as a term member, now many decades ago, finding it a terrifying experience where everyone was, at least twice my age, all were men, all were wearing dark suits, and nobody cared about what I did at that time. I was Commissioner of Health in New York City, where I was engaged in the intersection of public health, with many broader issues of safety, economic security, and also working at the gateway of so many issues of travel, trade, urbanization, that we know increase opportunities for infectious diseases to emerge and spread, as well as seeing the growing burden of chronic disease. So it's been wonderful to see how the Council on Foreign Relations has expanded its focus on global health, and the centrality of health, not just as a humanitarian focus, not just a concern about health of individuals and communities, but also how it is intimately intertwined with so many important aspects of our lives, well-being, and our future. And today, this panel is really intended to look one year later—global health lessons learned from 2020, but also to try to look forward a bit, in terms of what will be some of the challenges of the future and how can we better apply lessons learned and evolving science to the challenges before us.

We do have an extraordinary panel, as was noted. First, Tom Bollyky, who I think is well known to most everyone on the call—the Senior Fellow for Global Health, Economics and Development and Director of the Global Health Program, the vision and energy behind Think Global Health, and also the vision and energy behind the extraordinary strengthening of global health programs at CFR and the vast productivity that we've all been the beneficiaries of in recent years. We also are joined by Christopher Murray, who has been a very important researcher and voice on global health issues for now many decades. Importantly, he is now the Director of the Institute for Health Metrics and Evaluation at the University of Washington, a partner in Think Global Health, and a partner in so many activities of CFR and other public health organizations that are committed to matters of global health. And our third panelist is Natalia Kanem. She's a medical doctor who currently serves as the Executive Director of the UNFPA, the United Nations Sexual and Reproductive Health Agency. I believe that in this capacity, she's the highest ranking woman at the United Nations, and we want to recognize that, and the first Latin American to head UNFPA and has had many other important roles as well. So we want to have a discussion. I'll start with each of the panelists, just making some brief observations on the topic of the day. But I also want to introduce the panel with a short video, a brief greeting from the Director General of the World Health Organization, whom we call Dr. Tedros. And I think, you know, his voice, you know, adds and underscores the importance of global health, the importance of different institutions and organizations coming together with different perspectives and different mandates to help advance health for all. So with that, let's have the video and then we'll start the panel.

DR. TEDROS:  Dr. Richard Haass, President of the Council on Foreign Relations, dear Natalia, Peggy, Chris, and Tom, dear colleagues and friends—thank you for inviting me to this one year anniversary of Think Global Health. It's also one year since I declared the public health emergency of international concern, the highest level of alarm under international law over the outbreak of novel Coronavirus. Some countries heeded that warning and have money to prevent or contain widespread transmission. Others did not.

One of the key lessons of the past year is that strong leadership, including at the highest levels of government, is essential to the fight against COVID-19. There can be no question that the politicization of the pandemic weakened the global response and cost lives. That's why throughout the past year, we have called for global solidarity in our fight against the virus. COVID-19 has shone a bright light on the inequalities of our world, between and within countries. Now, the very tools that could help to control the pandemic, vaccines, could exacerbate those inequities. That's why we have called for vaccination of all health workers and older people to be underway in all countries in the first 100 days of this year. The pandemic will recede, but we will still be left with many of the same challenges we had before it struck. There is no vaccine for poverty, climate change, and inequality. WHO remains firmly committed to serving all countries to control the pandemic and to build the healthier, safer, fairer world we all want. I thank you.

HAMBURG: Okay. Well, and with that, I will turn it over to our first panelist. Tom Bollyky, who I think deserves, you know, really a lot of praise for what he has brought to the Council on Foreign Relations—the perspectives on global health, the importance of global health, and the content that he has been able to put forward engaging scholars and experts and practitioners in this country, and around the world, to write articles, join panels, and be part of the global health program. And congratulations on the anniversary of Think Global Health, Tom.

BOLLYKY:  Great. Thank you, Peggy. That's very kind and generous of you. Let me start by thanking Richard for his nice introduction and expressing my gratitude to Dr. Tedros, for sending those kind and thoughtful remarks as well. It's always a pleasure to participate in any discussion with Peggy, Natalia, and Chris. So I'm glad to have this chance to do so today. We are proud of what we've accomplished with Think Global Health and grateful for the generous, generous support of Bloomberg Philanthropies to do so in the collaboration we've had with Chris and his IHME colleagues.

As was mentioned, this is an anniversary, a birthday of sorts, and I think it's fun to see this website out in the world and people interacting with it. But I do want to point out I am, by no means, rearing it on my own. And I want to thank the CFR staff that have helped me and worked tirelessly to do this, Caroline Kantis, Sam Kieran, Jason Bardi, Maria Alzuru, and Ted Alcorn, for all their work on this site as well. When we launched this site a year ago, the novel coronavirus was just emerging in China. Many saw global health still, as primarily a humanitarian concern, a field about solving the problems of other people, largely poor people. The mission of this publication is and was to try to help reconceptualize global health as an investment that shapes all societies and economies and everyday lives. That case is easier to make these days a year later. COVID-19 has cost more than two million lives worldwide, sickened many more, and done an estimated twenty trillion of economic damage. Over one and a half billion children have lost time in the classroom, many of whom may not return. Our daily lives from graduations to weddings to funerals have been disrupted over this last year. Even nations that have done a good job in containing the spread of this virus have suffered previously—economically and otherwise. Even with the global COVID-19 crisis raging, there has been a reappraisal of global health, that’s indeed occurring, but it's not clear how far that transformation has gone.

The United States and other wealthy nations share, with all of humanity, an interest in scaling up the manufacturing of safe and effective vaccines and expediting their widespread deployment. It is the fastest way to control the spread of this pandemic, and to reduce the emergence of dangerous new variants. But seven weeks into that vaccine rollout, four nations—the United States, the United Kingdom, China and Israel, and the EU, are responsible for 84 percent of the vaccines administered globally. Only one low-income nation, Guinea, has administered vaccines at all. And just six lower middle-income nations have begun administering vaccine doses. There are just three countries in Sub-Saharan Africa that have administered vaccines—fewer than 32,000 doses. So it’s unclear how well we have taken the lessons from this last year about the importance of global health to all societies. And it remains unclear whether that reappraisal extends beyond pandemic threats.

We have, hopefully, set the stage to mobilize effectively, not just against future pandemic threats, but other collective action challenges that constitute the world's greatest global health threats, from non-communicable diseases, which Richard mentioned, that are leading killers of people under the age of sixty worldwide, to pollution and climate change, which have historically rated low on the global health agenda despite the daily evidence of their debilitating health toll. So we started this site, it has the tagline of “Better Health Begins with Ideas.” We're hopeful that the small silver lining of this terrible, terrible past year has been that there might be more of a market for those ideas and a broader appreciation of why global health matters. I appreciate the panel's involvement in this discussion and all the support from the members here today.

HAMBURG:  Well, thank you, Tom. And I'd like to turn now to Chris Murray, who, you know, really has been very busy this past year, as the modeling that he's been doing has had great influence on the shaping of public understanding and policymaker insights into the nature and scope of the COVID-19 challenge. But he also has had great influence over many years in how we think about the burden of health in countries around the world and how best to address it. So we'd welcome your thoughts, Chris.

MURRAY: Thanks, Peggy. And first, let me congratulate CFR and particularly Tom for Think Global Health—great idea, great execution. We've been very happy to help in some way in this effort and look forward to it continuing. I wanted to make four points. Looking ahead to you know, what did we learn from 2020, and what's coming in 2021. The first one is, you heard it even in Dr. Tedros’ comments, this idea that we're going to get the pandemic behind us. And up until about a week ago, I would have agreed.

What we got was some very bad news out of South Africa last week that hasn't really penetrated the general consciousness. And it's not, there was the fact that the two vaccines, the Novavax and Johnson and Johnson, were much less effective against the South African variant. It was buried in the placebo arm of the Novavax trial, namely that they enrolled people that were previously exposed—seropositive and seronegative. And the attack rate of the new variant was exactly the same in people who had previously been infected with those who had not. Meaning if this holds up in the J&J results, which we're waiting for this week, there is no cross strain protective immunity, meaning we will never have herd immunity, meaning that COVID will never go away—that COVID is now going to be a super flu, that is going to be a seasonal affliction, but the death rate will be ten times higher. That's a pretty grim bit of data, which will ripple through everything we think about global health, if it holds up, right.

So luck, you know, it's early days, it's one data point, people have gone back and looked at the the subsequent analysis in the Pfizer trial, and they show the same thing, if you add an extra month of observation. So, it probably will hold up. And I think it's going to make us think about many other things around global health once we think about COVID as a, essentially a seasonal challenge. I think it'll lead us to pay more attention already from COVID, because of the importance of, you know, oxygen and basic treatment, you know, delivering steroids to the sick, we're going to end up, I believe, wanting to spend much more time thinking about health systems and, you know, really nitty gritty things like logistics and health systems in low- and middle-income countries. How, if the only way we deal with a chronic version of the COVID pandemic, is to anticipate variant change, and use the new platforms around vaccines to, sort of, keep ahead of the variance, then the speed of both the research, but also the delivery to around the world, will become really quite preeminent.

So I think we will want and see much more interest in the details of health systems. At the same time, I think the economic effects of the pandemic in the high-income world may do what we saw with the great financial crisis, you know, we had this great expansion of money for global health from in the north, in development assistance for health, it went flat after the great financial crisis. And we, you know, really need to worry quite a lot about well, this second major financial challenge lead to development assistance going down. We've seen what the UK has done. Is this something—what can we do collectively to try to make the strong case that would be not in everybody's interest to see that start to happen in two or three years from now?

And the last reflection is this issue around whether the experience on COVID will change the focus from what I would think of is the traditional Millennium Development Goal agenda. To have more focus on the expanded SDG agenda, because even, look where money goes, where policy is focused, despite the SDGs, most policy discussion for low- and middle-income countries, has remained focused firmly on the MDG agenda. Will the interplay between COVID and background risk from NCDs? For example, change that I think the answer is yes, in some places, Latin America, I think very much. So I think we might see that in South Asia, Southeast Asia. And we may still not see that for Sub-Saharan Africa, but time will tell. So I think we're going, you know, rather than this sort of, this metaphor of, you know, getting to the finish line. I think the fact that there won’t, that finish line will keep moving away from us and the pandemic, is going to really have an awful lot of knock on consequences that we will only start to make sense up in the next weeks or months. Thank you.

HAMBURG:  Well, thank you. Not an entirely cheering set of observations on the state of the world. But you know, important and grounded in in data and science. Well, let me now turn to Natalia Kanem, who, as I mentioned is the Executive Director of the UN Population Fund, has worked on global health for throughout her career, and also importantly, through a gender lens as well. So we welcome your thoughts and comments at this time, Natalia.

KANEM: Well, thank you very much indeed Dr. Peggy, and thanks to Richard and Tom and the Council at this one year anniversary of Think Global Health, excellent task force report, and outstanding leadership on foreign policy matters that really are vital for our community to address. I'm also happy to be back with Chris Murray, his Institute partners with UNFPA, and we really could not ask for a better strategic partner.

 It's been said that COVID is exposing huge fault lines. And we are witnessing what years of structural inequality, racism, discrimination, and institutional neglect have brought. Lack of access to quality health care, chronic disease, economic hardship, unemployment, and certainly housing insecurity. And once again, what we're seeing is the poorest and most vulnerable people who are older persons, communities of color, people with disabilities, and those of us with mental health needs, these are the people hardest hit. And there is a gender dimension because as always, in times of crisis, women and girls are bearing the brunt. The rights of women and girls are not negotiable. These are human rights enshrined in the United Nations Charter and in so much policy all over the world. So why are the rights of women and girls constantly on the negotiating table? For too many women and adolescent girls, because a lot of the people that I advocate for are labeled a woman but they are a girl, they are a girl that was married at the age of twelve, or fourteen, or whatever, they’re somebody who might be subject to FGM, whatever it is, for too many of them, reproductive rights and choices, that are really essential for them to be able to achieve full equality and empowerment, it’s still an elusive dream. And this should outrage anyone who is paying attention, because now with COVID-19, the threat to women being set back is even bigger. Everywhere in the world, whether rich or poor, it’s women and girls who are experiencing a shadow pandemic of sexual and gender-based violence. With UNFPA projecting that this pandemic is likely to reduce by fully one-third the progress towards putting an end to gender based violence and female genital mutilation before the 2030 Sustainable Development Goal deadline. It's concerning. COVID is disrupting the interventions that we would use to end child marriage, and the economic consequences that Chris has just spoken to, could result in an additional thirteen million child marriages in the next decade as families scramble and try to figure out how to marry off their daughter, which happens every day to the tune of 33,000 girls.

So yes, with COVID, health systems are overstretched, and here, scaling back sexual and reproductive health services, which are often not deemed essential, is pretty drastic at a time when movement restrictions, and fear of the Coronavirus, for example, a lot of women are not going for their prenatal car, right, they’re not seeking this care, because of the checkpoints and everything else that they have to go through. And this puts their life and the life of the newborn at risk. So again, I think the potential in low- and middle-income countries for women being unable to access modern contraception, at the beginning of a pandemic March last year, we estimated that a staggering seven million additional unintended pregnancies could occur for every six months of a lockdown type of situation. And now a year on, we're seeing a lot of the predictions that we made around the world come true. Yes, there have been spikes in teen pregnancy. Yes, there have been increased maternal mortality because of pregnancy-related complications. And the global surge in gender violence is astronomical. So gender has influenced the pandemic in so many other ways because women represent 70 percent of the health workforce. They're the ones who we imagine when we think of that nurse or midwife, that janitor in the clinic is often female, and they're risking their lives often without adequate PPEs, and it's been a logistical nightmare for you UNFPA and other UN agencies to assure that we can get this personal protective equipment moving across borders all around the world. So I'm quoting James Baldwin for you as I just summarize our three takeaways: “not everything that is faced can be changed, but nothing can be changed until it's faced.” And this is why I'm highlighting inequality, because a year into the pandemic, the clearest takeaway for me is that sexual and reproductive health services are essential. This is what women care about. And we should defend them, we should defend them. And it's high time to stop politicizing women's rights and women's health.

Secondly, as our Secretary General Antonio Guterres put it in his Nelson Mandela lecture, multilateralism is more important than ever. We belong to each other, he said. We stand together or we fall apart. And there are plenty of examples of that. And my last observation is that as UNFPA leads with UN Women and other parts of the UN on upholding women's rights, sexuality is an intimate part of everybody's life. And women and girls actually depend on policy for protection from intimate partner violence. They depend on a fair shake in employment, and with so many women unemployed and unlikely to regain their jobs, this is a concern that we share. With the new news of the Biden-Harris administration in the USA recommitting to global health, we do have an expectation and a hope that the U.S., which is actually a founder of UNFPA, will take up that historic role of leading when it comes to women's health and reproductive health, in particular, because these times demand unity of purpose. Dear friends, I think our biggest takeaway is that we are all connected. So you can't solve the pandemic problem in one location when mobility is going to erase that achievement in very short order. So thank you, again, for engaging with this, because publicly funded health care as a human right, has been the cry, and I think now it's time to make that a reality. Thank you.

HAMBURG:  Well, thank you. Very, very thoughtful presentation of an important set of issues and issues that, frankly, have not gotten adequate attention over a long period of time. And certainly, during this past year, with all of the focus on COVID, across many domains, that both you, Natalia and Chris, have raised, along with Tom, we, you know, have to be sure that we keep recognizing the broad spectrum of issues, concerns, and factors that influence health, but also how health is so intimately interconnected with so many critical aspects of our life, our work, our economic futures, and our security.

I note that the time has been going by swiftly and I think, although I have many questions and would love to engage more deeply in discussion with the three of you now, I think I will open it up to Q&A as promised, since CFR audiences always have great questions and want to be engaged. So at this time, I'd like to invite members to join our conversation with their questions. And I want to remind you that this session is on the record. So, the operator will remind you how to join the question queue and I open it up now for members and their questions. Thank you,

STAFF:Thank you. Ladies and gentlemen, as a reminder, to ask a question, please click on the raise hand icon on your Zoom window. When you are called on, please accept the unmute now button and proceed with your name, affiliation and question. To view the roster of CFR members registered to attend this meeting. Please click on the link in your Zoom chat box. We'll take the first question from Mary Lake Polan.

HAMBURG:  Can you unmute, Mary?

STAFF: Miss Poland, please accept the unmute now button.

Q: Yes, I have just unmuted. I have a question about the Novavax data. Could you expand on that, and talk about the possibilities of both of the mRNA vaccines, in terms of efficacy with the South African variant?

HAMBURG:  Chris, I think that goes to you.

MURRAY: So in the Novavax trial, on the placebo arm they enrolled both seropositive and seronegatives, that is COVID seropositive and seronegative, the trial started at the point where b1351 started to take over as the dominant strain. So the test was basically for the previous variant, and then people are being exposed during the trial period to 351. And the attack rate was 3.9 percent in both arm, in both the seropositives and seronegatives, meaning previous infection didn't give you any protection from the new variant. So, if that turns out to hold up, and Johnson and Johnson's the timing is about the same, so they should have the same data, that would really change how we make all our models. Where we had been assuming that you accumulate herd immunity and eventually you'll get to herd immunity, that now means that wouldn't happen, you would have strains-specific or variants-specific herd immunity.

So then the question comes, you know, you've already heard, I'm sure, from Moderna and Pfizer that they believe with their mRNA platform that, in quite short order, maybe two months, they could revise the vaccine to adapt to these mutations that are in spike protein in 351 and P1 in Brazil, for example. So that holds out the promise that, you know, maybe it takes longer than they've said, but that in some shortish time, without having to go through the whole process of a phase three trial, we might have a revised vaccine. And so then you get into this, you know, essentially long term game of anticipating what the new variants that might come, and trying to get a vaccine ready in time, and then there'll be a big premium on the platforms that can do that the fastest. Now, some of the other platforms also argue that they can do it not quite as fast, but they can also adjust their vaccine, such as the adenovirus platform from Johnson and Johnson.

HAMBURG:  You know, I just have to add—thank you, Chris, but that, I think we do have to underscore that the emergence of these variants, and the growing understanding of their potential impact, really means we have to double down now though, on our nonpharmaceutical interventions. We have to recommit to the basics that we know can make a difference—of the masking, the social distancing, avoiding large gatherings, especially indoors, etc. And I think it reminds us of the interconnectedness of all nations and that we also do need to recommit to working together to ensure that we can support public health measures, including vaccine around the world and also strengthen our capacity to actually identify and rapidly respond to emerging concerns through improved and more integrated surveillance, including genomic surveillance as well. So I think many of the themes that have been part of the global health discussions at CFR and elsewhere, you know, really are reinforced, by what is disturbing news, but important news for us to address. Let's take the next question.

STAFF: We'll take the next question from Donna Shalala.

Q: Hi, hi Peggy. Rapid response is not a characteristic of either the international organizations or even the United States government, though local governments, local health departments may be faster. What does rapid response mean, in terms of restructuring some of the global institutions? Not just the World Health Organization, but are we, I've seen some of the international reports, but they don't look to me like they're creating nimbleness. And I'd love to have the panel's comments on that.

HAMBURG:  Thank you, important question. Why don't we start with you, Tom?

BOLLYKY:  Great. Thank you, Donna, for the great question. As was mentioned at the outset, Peggy, Chris, and I were on a CFR task force that looked at these issues, and what could be done to try to address pandemic readiness and implementation which, from the view of the task force, really what was the deficiency exposed in this pandemic. There is a lot of nascent capacity that government simply didn't use and didn't use aggressively or on time.

So we had a couple of recommendations here that I think might be responsive to what you've just described. The first is that we can no longer be beholden to the transparency and self-reporting of directly affected states. The task force endorsed the creation of a voluntary, hospital-based sentinel network, to try to identify signals of outbreaks earlier. That might have helped in this pandemic, where you had coronavirus cases hitting the Chinese health system considerably earlier before the government and certainly any other governments recognized it.

The second area that we've talked about is that we need to have a coalition of states that help address the non-health elements of pandemic response, such as the proliferation of travel bans and trade restrictions, debt relief, and the sharing of essential medical supplies. WHO has an essential role to play on the public health response, but pandemics aren't just a health crisis alone. There are security, economic, and trade implications to the reoccurrence of pandemics. There's an opportunity, we think, for a collaboration between a smaller group of nations to collaborate on addressing those issues. Finally, we also discussed linking the sentinel surveillance system directly into public health departments, as well as the World Health Organization,  and have that system tied also to regular rehearsals of pandemic response via triggers or mitigation guidelines that states can use to guide their responses. If pandemic response depends on perfect leadership from our national leaders, or is a question of who responds most aggressively, we will be building a system that's destined to fail. So those were the ideas we had to advance a more nimble, aggressive response to future health crises.

HAMBURG:  Thank you. Anybody else want to jump in? Or should we go to the next—Natalia?

KANEM: Yeah, actually on both points. And thank you so much, Dr. Polan and Dr. Shalala. The question of how we coordinate has certainly been called into question by the pandemic. And I think even in the best of hands, we all have to admit that the cross-border nature of this issue has complicated it beyond belief. But I would like to say that, under the leadership of Secretary General, the guidance from UN came out actually faster than ever regarding the protocols that people depend on, in terms of what to do. With others, UNFPA did the one on violence, and it really made a difference to remind people that you need to have a hotline, you need to have a shelter for the women to go to, or a way of dealing with issues like that. The guidance issues also, very early on, dealt with the economic impact of the pandemic, because there is a fairness issue in terms of vaccine distribution. As of last week, the entire African continent had vaccinated 20,000 people. So, taking lessons from other public health crises, like the HIV situation, where we did have to advocate for equitable drugs and equitable services. This is something that needs to be hit head on. Thank you.

HAMBURG:  Thanks very much. We have quite a number of questions in the queue and not much time left. So maybe, would it be possible to sort of take them in groups and let the panelists try to provide some coherence in their answers? But maybe we could get the next three questions teed up quickly, and then see if there's some continuity.

STAFF: Sure. We'll take the next question from Kenneth Bernard, and then Vanessa Kerry.

Q: Hi, can you hear me okay?

HAMBURG:  Yes.

Q: I've been working in this area for a long time, and it was really interesting what Secretary Shalala just said about, that she's on the line here and she's talking on these issues. I wanted to go back to what Richard Haass said at the beginning, which disturbed me a little bit, Richard, if you're still listening. You talked about how important health was, but you then talked about the experts you have in the Council, etc. I think that's part of the problem here. And it's part of the problem we're seeing, is that national security people have a tendency to view health security as an add on, as the new thing. It's a bit like climate and health, and climate and security, and I think that that's part of the problem we're in now. Health people have a tendency to say, we're the experts, we should make the policy decisions on these issues. And that's not the way to go. If we want them to solve the problems that Natalia and Tom and Chris are talking about. Health people often don't make the big decisions necessary to fix the infrastructure problems we're talking about. So I'd really like to see people not taking over, the health people taking over the decision-making here. We need to make our bosses, like Secretary Shalala, who by the way, never failed to give her opinion about what should be done, the options to make these decisions, because that's the only way we're going to solve the problems that Natalia and Tom have been talking about.

HAMBURG:  Well, thank you. And I might, just as a historical observation, also note that Donna Shalala was the first HHS Secretary to really begin, formalize bio-preparedness programs. And she also put the first, seconded the first health expert to the National Security Council, and that was Ken Bernard. Perhaps we could hear from Vanessa Kerry next, and then let the panelists respond.

Q: Hi, thank you very much for this discussion. And again, I'm Vanessa Kerry, I'm a physician and the CEO of Seed Global Health, that partners with governments to help build healthcare capacity. And I had a different question, but I'm now repondering it a little bit in the context of the question I just heard. It's interesting for me, because I think that one of the things that I wanted to originally ask was the fact that, for me, health has been underutilized, underappreciated, and underinvested in most of the decision-making—decisions have been made on expediency, politically, economically, security, without thinking about all the ways that health actually is critical and fundamental to some of those investments. I'm in agreement, that health folks should not necessarily be making the decisions. But I do think they need to be included in the decisions and to think about the ways that health has been weaponized or utilized for secondary gain, and how it can really be a powerful tool for economic growth for individual and community security.

And with that in mind, and seeing the complete devastation that COVID has brought to us globally, in this moment, is there an opportunity to use this, the lessons from COVID, what this experience is to really think about how to make bigger and more meaningful, deeper, longer term investments to build capacity infrastructure, and fundamentally kind of health and social resilience. Or are we going to use this just to get ourselves out of the moment, and then go back to business as usual. And I would like your perspective on that, please. Thank you.

HAMBURG: Well, thank you. Great question. And I think I'd like to ask all of the panelists to respond to such a rich question. Tom, you want to start? And we'll just go through the group?

BOLLYKY:  Sure. Fabulous question. So thank you both to Ken and Vanessa for them. So, I actually think, Ken, what you described is very much what the model at the Council. We really are trying to embed global health in a larger national security and foreign policy conversation. So whether it's through our task force or meetings, we're constantly promoting a multidisciplinary approach to these issues. So that comment really spoke to me. I agree with Vanessa, it's an interesting debate whether or not the experts have had too much or too little sway in the context of this pandemic. Internationally, the answer seems easily too little. We can debate I guess, about domestically, whether the same has been true and where. I think the part of your comment that particularly resonated for me, though, is that at the end of the day, global health can't be seen as a charitable enterprise and just as a matter of aid. It must be about governments acting in their self-interest and addressing collective action challenges for the reasons Chris said. With the economic fallout, the pressure on governments to make domestic investments in their health systems, the shift of global health needs away from the MDG agenda, I don't know how long our charitable approach to global health is going to last. If we're not moving to a reconceptualization of how to address global health issues, we have a problem. I'd like to think the Council can be part of that reconceptualization, but we certainly can't do it alone. And let me turn it over to the other panelists.

HAMBURG:  Thanks. How about Chris next?

MURRAY:  Sure. Both great questions, I'll—I think Tom's made many comments that I broadly agree with. I just want to focus on Vanessa Kerry’s question-comment. You know, I've been actually, remarkably impressed in the last year at how senior decision makers, not the health experts, but the politicians, have been really reaching out and asking for quantitative scientific input for really tricky decisions around COVID. I would not have guessed this would be what has happened. You know, and some of that happens, as everyone on this call knows, behind the scenes, and some of it happens in the public's eye. I think that opening for the interest in sort of analysis of different options is something that we should try as, as other issues come to the fore, even if COVID stays around with us, to try to cultivate that idea that the, rather than health experts making decisions, that there can be useful decision aids, for some of these broader trade-offs. I think this year is the 100th anniversary of insulin. We know that diabetes is being one of the confounding factors with obesity for COVID. There's a lot of interest in addressing the axis of obesity and diabetes. Can we use this, sort of, new interest and analytics from some of the politicians to broaden the scope of what they're willing to listen to beyond the narrow scope of COVID policy? So I've been actually encouraged by that. And I think that creates some interesting opportunities for us as a community.

HAMBURG:  Thanks. And Natalia, I know you'll have some wise observations on this as well.

KANEM: Well, you know, my anxiety—and I need to put this plainly, is that wherever you sit in a time of COVID, there is heterogeneity in what we're addressing, right? So, whether you're in a donor country, or whether you're in the smallest country at the bottom of the health and disease, there is an inherent argument about looking after those who, in SDGs terminology, would otherwise be left behind. So we need to up the level of ambition. I think what we saw, was a fractionated scramble with very little coherence because of politics. So it's important for members of the Council, who do have powerful influence, to be able to engage to defend the rights of women who, after all, when you're talking about surveillance, when you're talking about detection, when you're talking about handwashing, when you're talking about the kid who's home from school and vulnerable to so much else and may never get back, there is a gendered possibility also, of inviting local women to the table, of asking them what they think is going to work, and to work together as governments.

 I think what we've really seen is that no one can go this solo, good luck, it didn't work. And so ultimately, again, our ability to coordinate, to share information as we're doing today, and to also accept that we have to counter disinformation with evidence, and not back down. I mean, even for vaccines, if available, which of course, there's huge inequality there, even in developed countries, health personnel are refusing vaccines based on really calculated disinformation processes that need to be rejected at every point. So again, I think political will, the financial resources, and the disaggregated data so we can track who's vulnerable, how they're doing, and how we got out of this. Thanks.

HAMBURG:  Thank you. Let's try to see if we can squeeze in another question or two, but they'll have to be quick. So next questioner, but please make your question short.

STAFF: We'll take our next question from Willene Johnson.

Q: Thank you very much for this discussion. I'd like to really continue in the same line of questioning, but perhaps be more practical. I'm working with a group of African, not only official representatives, but civil society representatives, who are about to approach the challenge of developing a national security strategy. And we've gone far enough in our discussions to understand that we need to go beyond the whole of government into a whole of society. And that a critical element of the process is to open up the door to those who haven't had voice in the past. So I'd like to know, if you have either seen, or have advice for, how you can have an effective and inclusive process that would help to spread appropriate information, encourage the right behaviors. And so, we've just heard that our non-medical approaches are very important. How can we involve people to both identify the risk properly, because we've learned if you leave people out, that the decision-making process gets blindsided. I think we've seen that here. So, any advice would be appreciated, by me, and I'm sure others.

HAMBURG:  Okay, well, that's a big question. But let’s turn to the panelists. Tom, you want to jump in first?

BOLLYKY:  Sure. So I’ll be very brief, and make sure the others get a chance. I think it needs to be a very conscious and active process to bring those broader voices and sources of data and expertise in. Certainly what we've tried to do with this Think Global Health project is really very much with that goal of diversity in mind.  That is why we've had people from fifty-three countries writing, but we can certainly do better and we'll continue to try to get people across different expertise to write. But it doesn't happen by itself is my experience. And I'll let the others will chime in.

HAMBURG:  Natalia, you're nodding your head, let's go to you.

KANEM: Well, just to add also that what isn't measured is not going to happen. So the benchmarks have to be explicit, for example, on my team, you can’t always, especially in security, achieve gender equality, high panel or something like that. But the question, you know, where is the Native American population on this? Or whatever the appropriate, you know, disabled person's interests. You actually have to ask, in order to glean these answers. And when you look after, you know, having the instructions in Braille or whatever you're going to do, this is also a way of focusing people on differential need. So just to add to what Tom said.

HAMBURG:  Chris, anything further?

MURRAY:  Just that if to have more inclusion, in thinking about the right way forward, one of the things that will help a lot is to have the sort of basic data available to everybody. And despite a year into the pandemic, we still have, you know, a lot of instincts in various governments around the world that they don't want to terribly have made in the public domain. They want to control the narrative. And that really just gets in the way of that more inclusive strategizing and decision-making. And I think, just reinforcing that as we go forward. Because the pendulum goes back and forward, we're back in a little bit into the cycle, I think, in some countries of trying to have less data, not more, and that's not gonna help us.

HAMBURG:  Well, I sadly see that our time has come to the end. I think as we reflect back on this last year, and look to the future, there are many important discussions to be had and much work to be done. I thank the panelists for this terrific discussion—Tom Bollyky, Natalia Kanem, and Chris Murray. I apologize to the members—that we didn't have time for everyone to take part in this conversation. But, to be continued. I thank everyone for joining in today. Please do note that the video and transcript of today's meeting will be posted on CFR’s website and I also have to note that, apparently the groundhog saw his shadow or her shadow, and there will be six more weeks of winter, but hopefully sunnier days ahead. So thanks very much for joining us. And thanks to CFR and its leadership for its terrific work on global health. Bye bye.

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