Report Launch of CFR Independent Task Force on Preparing for the Next Pandemic

Thursday, October 8, 2020

President, American University; Former U.S. Secretary of Health and Human Services under President Barack Obama (20142017); Task Force Co-Chair; Member, Board of Directors, Council on Foreign Relations

Vice Chairman, General Counsel, and Chief Administration Officer, MacAndrews & Forbes Incorporated; Former Assistant to President George W. Bush for Homeland Security and Counterterrorism and Chair, White House Homeland Security Council (2004–2008); Task Force Co-Chair; Member, Board of Directors, Council on Foreign Relations

Senior Fellow for Global Health, Economics, and Development, Council on Foreign Relations; Task Force Codirector; @TomBollyky

Stewart M. Patrick

James H. Binger Senior Fellow in Global Governance, Council on Foreign Relations; Task Force Codirector; @StewartMPatrick


Host, Weekend Edition Sunday, NPR; CFR Member

The United States and the world were unprepared for the COVID-19 pandemic, despite decades of warnings highlighting the inevitability of global pandemics and the need for international coordination. The crisis is not yet over, and has already exacted a heavy human and economic price. Improving Pandemic Preparedness: Lessons From COVID-19, the report of a CFR-sponsored Independent Task Force, outlines a strategy to ensure the United States and the multilateral system perform better in this crisis—and when the next one inevitably emerges.

GARCIA-NAVARRO: Welcome to today's Council on Foreign Relations, “Report Launch of the Independent Task Force on Preparing for the Next Pandemic,” but of course we will be talking about the one that we are currently experiencing. I am Lulu Garcia-Navarro, host of Weekend Edition Sunday on NPR, and I will be presiding over today's discussion. We have more than, I think, 760 registered for this virtual meeting and we will do our best to get to as many questions as we can during the period. But now a little bit about this event. The Independent Task Force Program at CFR began in 1995 analyzing issues of critical importance to U.S. foreign policy in a non-partisan way. Once launched, Task Forces are independent of CFR and are solely responsible for the content of the reports. In the Task Force Program's twenty-fifth year, CFR is launching its seventy-eighth Task Force report. And I would like to welcome you to this discussion of the report and it's called Improving Pandemic Preparedness: Lessons From COVID-19.

A brief introduction of our panelists. We have Sylvia Mathews Burwell. She is the cochair and the president of American University and she was, of course, also the former U.S. secretary of health and human services under President Obama. Welcome to you. And also joining us is Frances Fragos Townsend, also a cochair. She was a former assistant to President Bush for homeland security and counterterrorism and is currently the vice chairman and general counsel and chief administration officer for MacAndrews & Forbes Incorporated. Welcome to you. And Thomas Bollyky is a codirector and a senior fellow for global health, economics, and development and director of the Global Health program for CFR. And finally, we have Stewart Patrick, he is the James H. Binger senior fellow in global governance and director of the International Institutions and Global Governance Program at CFR. So let's jump right in. There is a lot to get through. This was a hefty report with a lot to say. And I'm going to start with you, Sylvia. Why issue the report now during an election and in the midst of this pandemic? Sylvia, are you there? Fran, are you there?

TOWNSEND: I am. There’s Sylvia. Sylvia’s back.


BURWELL: I’m back.

GARCIA-NAVARRO: All right, so why issue the report now before an election in the midst of this pandemic?

BURWELL: And I apologize, couldn't hear with it directed in general?

GARCIA-NAVARRO: I do, I do, Sylvia.

BURWELL: Thank you, thank you, sorry about that. In terms of that now, we wanted to get this report out as quickly as possible. The information from the report is something that we believe is relevant in terms of pandemic preparedness for the future, which we think is extremely important to focus on and be ready for. But it's important for now, as we are continuing in the pandemic that we're in. And so now was the time as soon as we were able to do the assessment with the group of experts, and we want to thank those experts. The four of us are part of this, but there was a whole team at the Council on Foreign Relations supporting the effort, and independent members of a bipartisan Task Force were part of this and we wanted to get the information out so that it could be used to improve the conditions and situation, both in health and economics in our nation and prepare for the future.

GARCIA-NAVARRO: Fran, I'm going to bring you in here, give us the big picture, what are the report's sort of main messages about how we're managing this pandemic, and how we can better prepare for and prevent the next one?

TOWNSEND: Well, the next one is inevitable. And I think that's the thrust of why we wanted to get the report not only out, but could it add something to the current pandemic and the current pandemic response, as well as preparing for the future. And the fact that another pandemic is inevitable is key to why this, I think, this report is so important. I want to take the opportunity to thank Tom and Stewart, who did the lion's share of the writing here and were able to pull together this phenomenal group of folks—policy folks and experts—some of whom have joined us today. The idea was, what could we do better the next time? We have an obligation, for example, to protect vulnerable populations who are particularly hard hit. Sylvia mentioned the economic impact of the pandemic, and what we found, I think everyone agreed was that preparedness is the key to blunting that impact and to reducing the enormity of that impact on populations on the economics. And so what we looked for was common ground, but preparedness is the key here at state and local levels, at federal levels, testing, contact tracing, and being prepared to do those things in a national and global way is key both to preparedness and response.

GARCIA-NAVARRO: Sylvia, you worked on Ebola in the Barack Obama administration. Fran, you played a role during the SARS and avian flu outbreaks under the George W. Bush administration. I'd like you to first both give a grade to how you think not only the United States, but the international community—obviously we will dig into some of the disparities there—have dealt with this pandemic at this time.

BURWELL: So I think I'm not sure that right now a grade is what is most helpful. I think what the report does that is helpful is assess the things that need to be done better. And that is what we focused on in the report. And I think it's clear in terms of the U.S. response, and we discussed that in the report, that a national strategy is needed. And a national strategy would include a national approach to testing, a national approach to contact tracing, and real clarity of communications that's scientifically based. And I think what we've tried to focus on are what are the things that can move us forward right now and could make sure we're in good stead for the future.

GARCIA-NAVARRO: And Fran, one of the big takeaways, as you've just mentioned here, is the very idea that there needs to be a plan in place for the next one coming along. Generally speaking before we dig in, what does that look like?

TOWNSEND: I think certainly at the federal level you need a single point that coordinates, you know, you look now at how many departments, not it wasn't just health and human services, right, but all of the expertise that had to be brought to bear across the federal government—CDC and FDA—and so it really does require a single point of contact in the White House to coordinate the interagency, but also you know, to be effective it's got to be a global effort. And so you also need someone at the ambassadorial level of the State Department to really coordinate the international response that I think all of those pieces lead to a quicker, more effective, and efficient response.

GARCIA-NAVARRO: So we should say, I'm going to bring in Tom right now, that there is some very strong language in this report about the various failures across the way. And before we get to the other part of the report, which is moving forward with what specifically should be done, there is a lot dedicated to why we are in the place that we are now. And I want to start with China's performance and lack of transparency early on in the pandemic. What are some of the key takeaways there, Tom?

BOLLYKY: Thank you. Well, first, I'm really pleased to be here with you, Lulu, I'm grateful for your willingness to do this event. I also want to express my gratitude to Sylvia and Fran for the tremendous job they did sharing this Task Force. I'm grateful to have had the opportunity to work with them and the other Task Force members as well as my colleagues, Stewart and Anya and a large team at CFR that is responsible for this large report.

So the report, you're right, doesn't pull any punches in assessing what has happened globally. With this pandemic, the Task Force is quite clear vis-a-vis China, that China covered up over a crucial two-week period in January early cases, and delayed sharing material information with the WHO and partners. That has contributed to the early spread of the virus, both domestically in China and internationally. WHO in terms of its response, lots to say that's heroic about it, given their limited resources and authorities, but praising China for its transparency did not help. And they were a week late in declaring this a public health emergency of international concern.

GARCIA-NAVARRO: Yes, I'm going to quote here from the report: "WHO's tendency towards deference has manifested itself in some inconsistent communication, a credulous public stance toward Chinese government claims, and unqualified praise for China's response."

BOLLYKY: That's right. It's understandable—WHO has limited resources and authority, it has to work with affected states. It's understandable that they need to maintain a relationship with China that affords that. That said, the communications from WHO went a bit further than that, in the early days of this pandemic where they were praising China's transparency, and that certainly hasn't helped matters. That said, I think what sometimes gets confused, including by the U.S. administration is this is not particular to this pandemic, or to China. WHO has exercised the same deference in previous outbreaks, epidemics, and pandemics with affected member states. It's a member state organization, it is ultimately as strong as its members make it

GARCIA-NAVARRO: So the U.S. has severed its relationship with the WHO for now. This report makes recommendations about that—is it worthwhile to remain in the WHO? What are the risks of leaving in your view?

BOLLYKY: Absolutely. WHO is not a perfect institution, many of its imperfections in terms of its processes, its bureaucratic nature, have been well displayed in this particular pandemic. However, there is no alternative on the multilateral level to working with WHO on international health crises. And ultimately, you know, what WHO has primarily been doing these last months, of course, is coordinating internationally the response to this pandemic, particularly in low- and middle-income countries. For the most part in low- and middle-income countries, this pandemic hasn't been quite as devastating as people expected. And in my view, WHO deserves, and I think in the view of the Task Force, WHO deserves some credit for what we've seen in that regard.

GARCIA-NAVARRO: What countries did better and why? In the report, I'm going to quote again: "The single most important determinant it turns out has been the quality of political leadership and execution." Right?

BOLLYKY: That's right. So let's use an example. South Korea and the United States experienced their first reported case within twenty-four hours of each other. South Korea having learned from its experience with MERS—Middle Eastern Respiratory Syndrome—another coronavirus, moved quickly, rapidly and aggressively, tested three times as many citizens on a per capita basis than the United States in the early months of the pandemics. And they deployed public health fundamentals, exhaustively testing, identifying those who are ill, isolating them, tracing their contacts, quarantining those contacts, and they exhibited a high rate of mask wearing. Again, for the most part, not rocket science what South Korea did, but they responded aggressively. Today, South Korea with a population of fifty-two million, has twenty-four thousand roughly reported cases of coronavirus—420 deaths. The United States has 7.3 million cases of coronavirus and 211,000 deaths. This was not inevitable. Preparedness has made a difference, preparedness and the ability to execute has made a difference in how nations have done in this pandemic.

GARCIA-NAVARRO: Well, this brings us to the United States. And I'm going to bring in Stewart now. The report calls what happened here "the consequences of a failure in political leadership." It also notes pandemics are not random events, as we just heard earlier, they are predictable. They do happen. We know another one will happen. The United States was unprepared Why?

PATRICK: Well, the United States was unprepared and then this a problem that goes back certainly prior to this administration. We'll get to the administration's response as well. But for years lots of blue-ribbon commissions, frankly like this one, and official U.S. government documents have outlined the imminence and threats to human life and to the economy and political stability of international pandemics of this sort. And yet, what we found consistently is a pattern of complacency in which, even asked, are some of the emergencies that we've had, there's just has been very little investment at the national level, as well as at the international level in pandemic preparedness. So a lot of it is just sort of a structural inability or unwillingness of the U.S. political system to treat pandemic preparedness as the national security threat that it is on a par with national defense. Every year we budget over $700 billion on the Pentagon and U.S. military spending, and yet what brought the United States to its knees in 2020 was a pathogen. And I think we need to recognize them.

In terms of getting beyond just the long-term lack of preparedness that has afflicted the United States, we've already pointed to a few of the major failures on the part of the United States once the pandemic was upon us. The lack of a comprehensive nationwide system of testing and tracing meant that too often elected political leaders, whether in the White House or in governors' mansions, or in city halls, were flying blind about the trajectory. And so you either had to have blunt-force responses to this public health emergency, or you took a cavalier attitude because you didn't really know which way it was going. Another thing that I think has been really debilitating, and there are others, but I'll stop with this one is the lack of clear public health guidance from leaders. I think too often, much of what we've heard from the president on down and often by governors as well, is a lack of willingness to put science first. And so it's sort of contradictory, unclear, or incoherent and sometimes politicized public health guidance, which doesn't provide American citizens with what they need to know from their elected leaders, which is, what's the risk here, and what are some common sense precautions that you and I can take to protect our families and communities. I think those things have been lacking in this pandemic.

GARCIA-NAVARRO: The report also, before we move to some of the recommendations moving forward, but the report also makes quite an important point that the response was slow and that cost lives, that the government seemed to have known much earlier on what was going on, and yet, it wasn't until mid-March that actually anything was really mobilized.

PATRICK: You know, I'm not sure that I personally can add much more to revelations in Bob Woodward's book and other press reports in this regard, but the Task Force does make the point, and has charts to this effect, that if interventions had occurred, say one week earlier, or even hopefully even two weeks earlier, that there would have been a lot lower loss of life. And Tom's discussion of the Korea case I think is highly indicative here. We have a death rate that is eighty times that of South Korea, and an infection rate that is fifty times greater, and yet the first infection was within a day of when the United States had its first infection. And so it suggests that, while China and the WHO have some answering to do, there are obviously failures in the way the United States responds to this at a national level.

GARCIA-NAVARRO: You mentioned the essential role of communication and chain of command in disseminating information and how that really struggled here. So moving forward, how should the federal government better work with state and local entities to convey information? Whose responsibility is to ensure accurate information is being shared with the public?

PATRICK: Well, one of the things that we do point at as a real imperative is to try to get some level of clarity about roles and responsibilities among the federal government, state government, and municipal authorities. So we don't have what, as one of our task members described it sort of a caricature of the Articles of Confederation in pandemic response where you have sort of fifty flowers, at least at the state level blooming, and people are adopting quite different approaches. And so we call for the executive branch to lead an inquiry in a study in terms of trying to remove some of those ambiguities, including over the use of the Strategic National Stockpile, which became something of a political football as you recall early on in the pandemic.

GARCIA-NAVARRO: I'm going bring Sylvia back in because we've got a little bit of time before we open it up to questions. Horrific death rates among Black, Latinx, indigenous populations in the United States from this disease, as well as essential workers, the elderly—how can we better protect vulnerable groups?

BURWELL: I think as we think about the vulnerable populations in our country, that we need to focus on two things. We need to focus on the here and now, in terms of where we are in the pandemic, and the things that can be done right now to help. Some of that's about making sure we have the right data and information. Some of that's about communicating clearly the scientific information to these populations to make sure that they know and have the tools that they need to prevent it at the citizens' level. The third thing are policy things that you can do to make a difference. We know that these populations in these vulnerable populations have certain types of social determinants that may prevent their ability to prevent spread. For example, we know that certain populations may be living close together. So how do you provide policy options for people if they need to isolate so they don't spread the disease further to their family if they don't have that ability to do that in their own home? We have to then focus on the longer-term issues that have created some of that disparity and inequity that we see. The underlying health conditions of people of color in our nation and minority populations result from years of structural issues, and so that's the other thing that as we come out of the pandemic, we need to focus on why is it that there are more of the pre-existing conditions that make this disease worse in those populations. And whether that's access to health care, we know the number of uninsured is again, another place where there's an equity in the country. While the Affordable Care Act made great progress against that, it's not enough and it still exists. We also know that there are inequities. And when we're doing trials, in terms of who participates in those trials for drugs, for vaccines, for all kinds of things. So there are issues now, and then there are issues in the longer-term that really need to be focused on so the next time that this happens, we're not in the same place, and as we move through that we do everything we can to take care of some of those inequities that exist.

GARCIA-NAVARRO: Fran, I'd like to ask you your thoughts on really the state of public health in the United States. I mean, that is an issue that the report really talks about being a need to provide this sort of safety net for the country in times like this.

TOWNSEND: Picking up on where Silvia left off, frankly, what you find is as you look across the fifty states, the capability in each of the states is quite different, right, and nowhere is it adequately funded or staffed. And this is where the federal government can really provide sort of funding. You know if we funded this, I think it was Stewart who referred to sort of budgeting, if we really believe that this is a national security threat, then we need to fund it like it's a national security threat, not just talk about it. And when you look at the impact the pandemic has had, you realize why it's so important to have a comprehensive federal health security budget that is a funded and regularly supported and replenished, you know, part of our federal procurement system. The Strategic National Stockpile, because of the inequity among the states, can be the central procure of PPE so that there is adequate supply, even in states where the public health system is weaker than other parts of the country. Part of the federal government's responsibility here is to be able to even out the inequities that exists among the states. But back to Stewart's point about roles and responsibilities, the federal government isn't going to be able to solve this for everyone, and the states do have a responsibility to prepare themselves, or to identify their shortfalls so that the federal government can help them meet those shortfalls.

GARCIA-NAVARRO: I'm going to bring you in Stewart and also Tom, if you can speak to this as well, we are going to see a vaccine, probably several at some point—how do you ensure equitable access to a vaccine within the United States and globally?

PATRICK: I will be very brief here because the expert on this is Tom Bollyky. He is the expert on vaccine nationalism. But our report does talk about the importance of supporting an international mechanism that actually has that position of equity built into it based on public health, and not simply trying to lock up supplies for own citizens. But Tom, I think you're the man.

BOLLYKY: Well, thank you for that. And it's a great question. So we are weeks and potentially months away from a vaccine, there is a multilateral initiative that the report speaks to supporting to share vaccines. It is being led by the World Health Organization and partners. That said, many wealthy nations are in engaging in advance purchase agreements, which are inherently rivalrous with that initiative. They use up resources the initiative needs to succeed, and they use up scarce vaccine manufacturing capacity. If that is the case, we will have a situation where we have medical intervention in the midst of a deadly pandemic, the worse in a century. It's in everyone's interest to share it because it would bring the pandemic under control faster, and we may add a scenario where wealthy nations effectively hoard it first. So that's something that is important to avoid. What the report recommends is that instead of trying to build the airplane while flying it, which is what we have had to do in the context of this pandemic, is setting up an international initiative is important to do this in advance. It's also important to address the fact that what we've also seen in this pandemic is countries have hoarded supplies, personal protective equipment, ventilators, other essential medical technologies. If that happens on vaccines, you're going to see a breakdown there as well. So we need an agreement where nations, at least in the context of a pandemic, and particularly this one, forego those types of efforts with vaccines. Otherwise, you'll see a breakdown of the system.

GARCIA-NAVARRO: I mean that's a very dire prediction. Who should broker that agreement? Is that something the United Nations does and WHO—what are the mechanisms for that?

BOLLYKY: So historically, this is where U.S. leadership has played a role. The U.S. was a crucial partner in setting up the Global Fund to Fight AIDS, Tuberculosis and Malaria. The U.S. was a crucial partner in setting up Gavi and ensuring it has adequate funding, which provides primarily pediatric vaccines throughout the world to millions of children. The U.S. should play, and needs to play, more of a role in this effort. There are a number of entities including the Bill and Melinda Gates Foundation, and as I mentioned these international organizations that are doing their best to pull this together, they need some support from large vaccine manufacturing nations, and currently they're not getting it from the U.S., they're not getting it from China, and they're not getting it from Russia, and other big players in the space and that needs to change before we can see a different result.

GARCIA-NAVARRO: And this is just, before we turn to the questions, this is just to the group, clearly one of the main issues for the next pandemic is how do we sort of improve our national and international disease surveillance for the next time, because you've touched on China's lack of transparency during the early stages of this pandemic, and it had devastating consequences. So what needs to be put in place for that not to happen again?

PATRICK: I think Tom is probably, in the first instance, because this has been a big issue for him, the sentinel surveillance issue.

BOLLYKY: Yes. So if one lesson that clearly comes out in these pandemics, we cannot be entirely dependent on the transparency and self-reporting of nations in future outbreaks of dangerous disease—we need other sources of information. So that doesn't mean not supporting the International Health Regulations and WHO in their role, but we need other sources of information. So what the report recommends is a sentinel network based on health care facilities that regularly voluntary incentivize by partners but reports regularly hospitalization data so you can identify unusual trends. That may have made a difference in this case, where it appears, at least according to Lancet's analysis, cases were showing up for the better part of a month in China before anyone recognized or at least recorded the pattern. So having that early surveillance, having it tied to public health agencies that can assess it and act upon it, including the World Health Organization, is one way to make us better prepared and less reliant on the honesty of world leaders because they haven't exercised it in this particular pandemic.

GARCIA-NAVARRO: All right, at this time I would like to invite members to join in our conversation with their questions, a reminder that this meeting is on the record. The operator will remind you how to join the question queue.

STAFF: (Gives queuing instructions.) Our first question will be from Leslie Roberts.

Q: Hello, panel. Thank you so much for this report. I thought it was wonderful. I appreciated especially the part that was criticizing WHO that Thomas summarized, and I wondered why that logic didn't apply to the CDC. And so my question is, can we get an independent CDC again? I say this because the CDC seemed to sort of not be there in the beginning, everyone was going to the New York Times to get the most recent data, not the CDC. And now in retrospect, we understand that the White House was manipulating them on a level we've never seen before. AP wire service released on Saturday that the CDC was ordered to close the board. It was almost universally opposed by CDC scientists, but it was written by the White House. We learned last month that their MMWR, the Morbidity and Mortality Weekly Report, the main mechanism for half a century, they have released scientific findings, was being edited to not allow them to say, for example, that children were transmitting this disease.

GARCIA-NAVARRO: So wondering—

Q: Is there a way to get the CDC's independence back, which has just been sort of a hallmark of them? They've been like the Supreme Court, sort of independent, you don't touch them on abortion, on gun control. The White House has put pressure on them, and they've never given in, and we're just in completely new territory. And do you have any thoughts on how to regain CDC's independence? Thank you.

GARCIA-NAVARRO: Sylvia, I'm going direct that question initially to you. And then Stewart, if you want to join in on the role of the CDC in this.

BURWELL: So I think in the report, one of the recommendations is an independent review of the CDC. And I think, at this point, what we do need in order to rebuild that confidence is an independent review that looks at the question of what types of influence, as you described, occurred at the CDC and where there are other issues. And I think that will be an important part of rebuilding the competence in the CDC, an organization that I had the opportunity, as you described, to work with and depend on in Ebola, in terms of the incredible work and the work around the world. We used South Korea as an example, that MERS outbreak that they learned from, that we talked about, part of how they learned was they depended on our CDC experts. That was at a period in time where those were the largest cases of the Middle East Respiratory Syndrome outside of the Middle East. And they called upon CDC to be partners in developing their response. And so I think we have to return to the place that you have described. It's an important place for us as a nation in terms of how we depend on scientific fact-based information. And the CDC has historically been a place where we can turn and I think what we have to do is assess what happened, understand it, and rebuild that confidence.

STAFF: Our next question will come from Kathleen Hunt. We seem to be having technical difficulties. Our next question will be from Mark Lagon.

Q: Stewart and Tom, good to see you. Thank you all for this. So I have a question about how the language of health security is likely to unfold in the political system. We don't need to make prognostications about the results of the election, but how do you think health security is going to be defined? I work at Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria and we see an opportunity to discuss these things, but if we think back to how the U.S. government responded to 9/11, and how it produced the Department of Homeland Security and a lot of reliance on contractors, what perils might there be in efforts to sort of fight the last war as our political system tries to take on some of these issues? What are the biggest mistakes we could make that are errors of commission, rather than errors of omission? Thank you.

GARCIA-NAVARRO: Fran, do you want to take that one?

TOWNSEND: Sure. I mean and I invite the others to chime in here, I really do think that, you know, it's the old saying, "an ounce of prevention is worth a pound of cure." The lesson in this is the investments, whether it's CDC and building their capability and resources as part of this independent review that Sylvia was talking about, or investing in the public health at the state and local level. When you have that capability and the bench is deep enough, your response capability can adjust to whatever, whether it's, you know, it's a COVID pandemic, or it's a very bad seasonal flu, or MERS or Ebola, but what you need is the expertise and you need it sufficiently deployed and with a deep enough bench to be able to respond. And it's the resilience, it's the capability to me that I think is the key, Mark, to being prepared not just to fight the next COVID, right, but to fight whatever the next pandemic, whether it's, you know, this was a naturally occurring bio incident, but it could be, you know, you mentioned 9/11, we were very much in the wake of 9/11 of a bio weapons attack. And so regardless of what the causes, if you've got the capability and the depth, you can adjust and respond to whatever the next war is.

PATRICK: I might, Lulu—


PATRICK: —If I might just offer observations to my good friend Mark Lagon's question. You know, I think you do put your finger on an important issue which is the tendency, obviously, to wrap many foreign policy and even domestic concerns in the mantle of national security does sometimes carry risks. I did a bunch of work on fragile states in the past and to frame that as a security threat risk, which they can be also, often worries development actors, right, who are worried about sort of poverty alleviation, etcetera, and you wonder what the instrumentalities are, you're going to, right, in instruments you're going to actually bring in tools, you're going to bring to bear on these things. That being said, I think that our Task Force tries to sort of have it both ways, in a sense. We talk about it as a national security threat, but we also talk about particularly when it comes to vulnerable populations, we think about it as a question of human dignity and also a matter of social justice. And because, to the degree that we, for instance, don't do well by our most vulnerable citizens, we’re letting them down from a perspective of justice, but we're also creating vulnerabilities for ourselves as a nation. So that's, I guess the way we would try to frame it.

BOLLYKY: If I may, I was going to quickly just say one thing, if it's okay? I think there are three reasons why it's really important to sustain our global health programs. The first is that this pandemic has exposed the fact that it reveals pre-existing weaknesses, both in terms of individuals' health, as well as health systems. In that context, these programs reduce potential comorbidities, that makes the pandemic worse, but they also, as we've seen, where you see immunizations drop and health systems affected in these cases, if there's not a robust capacity existing in a pandemic, that's going to make that worse. Second, what we've seen is a lot of the nations that have been targeted by these global health programs have actually done reasonably well in tackling this pandemic. And I don't think that's accidental. Third, the important issue here is that historically, it's been difficult to get low- and middle-income countries to support global health security because what's in it for them, if it's primarily about protecting high-income nations. Having a balance in how we engage with countries in global health will be really important to maintain their interest in engaging an agenda, which frankly, the countries that have been hit the hardest in this case, for the most part, are wealthy nations.

STAFF: Our next question will come from Katherine Hagen.

Q: Thank you so much. This has been a fantastic program and an excellent report—very timely and very good to have it. My questions are very much oriented to the global focus that I think is very good to have in there, because so much of it is so oriented to what's happening in our own communities rather than thinking broadly. But clearly, the American engagement in this has been lacking at one level, but not at all levels, since there have been so many different research efforts that have been going across the globe with Americans very much involved in them. Certainly, the Bill and Melinda Gates Foundation is one of those. But the fact that there's so much going on with civil society groups and private sector entities, raises the question of how can you more effectively integrate these efforts into the kind of global coalitions that you're talking about? And secondly, related to that is can't there be enough negotiating power, even without the U.S. or other manufacturing countries to have some clout to make it in fact a global focus in terms of addressing the treatment and the vaccines and the prevention strategies? Those are my questions.

GARCIA-NAVARRO: Tom, I think this one's yours.

BOLLYKY: I'll take the second one, perhaps I don't mean to put her on the spot but Sylvia with her, I think, might be better on the role of philanthropy and broader actors in the space. But I'll talk about the vaccine issue. It's important to understand that vaccine manufacturing is not like small drug manufacturing. This is a fundamentally different crisis than what we saw two decades ago around HIV. The manufacturing capacity is scarce. If you're talking about the active ingredient of vaccines, antigens, you're really talking about a dozen, historically a dozen producers worldwide. So that capacity is very limited, there's efforts to ramp it up. It will not get there when we first have first doses of vaccines. So the real issue is, if that is locked up in advance, which currently it is being so locked up by wealthy nations, the multilateral initiative by the time it gets the resources to compete will not have it. So the challenge we have is, most of the vaccine manufacturing in these advance purchase agreements are in those large, by primarily wealthy nations, but not exclusively. If they aren't willing to play ball and sharing early doses, the rest of the world will wait potentially months or a year or longer to receive the vaccines they need to protect their health workers and most vulnerable populations. And that will leave a legacy that isn't just about this pandemic, it will undermine global cooperation on a host of other issues. If we can't cooperate in this situation on sharing a vaccine, what hope do we have to cooperate on climate change? What hope do we have to cooperate on other global health problems? With that, I'll stop and let Sylvia talk about the other aspect.

BURWELL: And I think that's a transition to the question about the rule of philanthropy, and how do we make sure that we get the most of that in terms of both private sector entities and philanthropy. And I think right now, the Bill and Melinda Gates Foundation is very engaged in ensuring that that vaccine access can occur in the developing world, that is a part of what they're doing. And I think one of the things when one thinks about the role of philanthropy and philanthropic organizations is it spreads across a number of different elements of fighting a pandemic. When one talks about the issues of the previous questioner in terms of global health—when Ebola, when we found that there were cases of Ebola in Nigeria, it was one of the darkest days for me, knowing the density and the challenges that one would face in a country as populous as Nigeria, also with the economic anchoring that it does in West Africa. However, what happened was, they were able to control and they controlled it on the backs of the polio work that had been done because basic public health, things had been put in place that were what they used to do the contact tracing to do the other things, that what happened was they controlled, and those things were investments.

The Gates Foundation had invested in polio in Nigeria in terms of trying to wipe out polio for many, many years. And so it's everything from the vaccines and the scientific knowledge. You know, the Gates Foundation and others have invested in the production of both vaccines and therapeutics, and parts of the science that we're using, philanthropy does that, places like the NIH [National Institutes of Health] do that, and I think your question of how you bring it all together is an important one. And one of the things that as the WHO moves forward, as we said, there were things that were challenging and things that they did right, one of the places where the WHO needs to, I think, continue to improve is a willingness to think about partners that are broader than the governments that are those that mainly fund them. Although philanthropies also contribute, the Bill and Melinda Gates Foundation has historically also supported the World Health Organization and making sure that it does have capacity to do things. So I think what we need is we need places where those conversations can occur with the private sector, with philanthropy, and with governments at the table about important issues from vaccine—

GARCIA-NAVARRO: We seem to have lost Sylvia for a moment. While we wait to get her back, let's go on to the next question.

STAFF: Our next question will be from Brad Tytel.

Q: Yes, hi, thank you. But I should maybe note that I'm actually with the Gates Foundation. But my question is also about financing. I'm actually curious to hear your perspectives on public financing. I haven't had a chance to read the full report yet, but I appreciated noting that COVID-19 has highlighted that this is more than a health crisis and requires more than health and traditional health sources of funding, particularly globally looking at how we can move pandemic preparedness response away from being seen as an overseas development assistance issue, and also how we can mobilize more resources, both globally and domestically from other public financing buckets to be able to support what is truly a whole of society response. So just be curious to hear your thoughts on that and how you think we can do that more effectively. Thank you.

GARCIA-NAVARRO: Thank you. Who wants to take this one?

BURWELL: I'm happy to. In terms of a number of different places in ways as we think about the public financing of the effort and the preparedness, I think what Fran had said earlier and others have said, it is the importance part of taking this to the level of it as a national security issue. It is a national economic security issue. And the resources that we put against those things on a regular basis, we need to as a federal government put those resources against those. The same thing needs to occur at the state and local level. We know that the spending on public health has gone down to a place where most of the funding for public health issues all comes from the federal government. And even that money has been reduced over periods of time in terms of the priority. And so one of the things that we need to do is we need to have a system that is funded at the federal level, but also state and local communities need to because what's different in terms of one of the things that's different is we compare these things to defense issues and national security in this way.

A pandemic is thought at the government level, at the state level, at the local level, and as we all know as citizens in the middle of this, we all need to do our part and I would recommend everyone gets their flu shot as a part of that part. But we all have to do our part. So as you think about the funding, you need to think about it at all those levels, and you need to think about the base and the core of what's happening in public health, and that's the health of different communities. And that brings us back to some of those disparity issues that we were talking about, or the issues in an international scene that the gentleman, Mark, raised the question about the broader global health. When we have a strong platform of health across countries, whether it's the U.S. or in the developing world, that is a part of the funding when you describe it because you have that base to build on.

PATRICK: If I might—go ahead, Tom,

BOLLYKY: I was looking at some numbers to illustrate Sylvia's already great points. We have never since 1995, spent more than 1 percent of global assistance on pandemic preparedness just so that people know this. People talk about a boom-and-bust cycle of engaging on preparing for pandemics, it has been consistently on the international level—bust. We have in terms of the support federal government has given to states on pandemic preparedness—that has gone down from where it was in 2005. Public health departments, local public health departments cut 56,000 positions in the years before this pandemic. So when we have spent trillions of dollars in responding to this pandemic, I think it's fair to say that Sylvia's point about federal governments worldwide, you need to spend more in this space as well, well demonstrated, given how little we have spent in the past. That said, the report does put forward some ideas on other sources of financing as well. It does talk about leveraging more international finance institutions, whether it's the IMF's special drawing rights or looking at possibilities mobilizing innovative resources around the fact that clearly so many of our international economic activities are tied to adequate pandemic preparedness, whether that be travel or so forth, this case may provide the momentum to actually mobilize some of those potential sources of financing as well.

PATRICK: If I might just briefly just add on just the sort of relative modesty of U.S. and international funding for global health in general. The report does note that the $5 or $7 billion annual budget of the World Health Organization is smaller than the budget of New York Presbyterian Hospital. And obviously, there's a lot of discussion in the global development arena about the importance of domestic resource mobilization to make sure that international assistance and external assistance does not crowd out domestic resource mobilization, and obviously when it comes to pandemic responses, that should be or pandemic preparedness that should also be on the table.

STAFF: Our next question will come from Gregory Treverton.

Q: Thank you very much and thanks for a great conversation. I want to ask about early warning. It's striking in this case that lots of groups and lots of people, including me, have said for a generation now that pandemics were one of two existential threats out there—the other being climate change. We had H1N1, we had SARS, but we still didn't have very good warning in this case. As I read the record, the first warning sign was done by ProMED, an NGO, at the end of December. That was probably two months after we should have noticed something happening in China. So my question is, do you all suggest major changes in the way CDC works, the way the National Security Council approaches these issues, the way the intelligence community works, or the way all of those interact with the private sector?

GARCIA-NAVARRO: Thank you. Tom?

BOLLYKY: I can start, I imagine Fran might have some views on this, too. So I'll just quickly say that on this issue as we talked about before, there does need to be other sources of surveillance that can bolster the system other than nation self-reporting. It is unfortunate that we went through a revision of international health regulation to address a past episode in which China was late in reporting and not sharing information only have had that happened again. You don't need to make that mistake twice. That said, I do want to be clear here, you know, the WHO did declare an international health emergency on January 30. Every nation from that point on was dealt the same hand and many nations dealt with it better. So surveillance can help, early warning can help. I'm really looking forward to hearing Fran's thoughts on leveraging the private sector in that regard. But we also do want to recognize that the fundamental failings for most nations, particularly in the West, was they didn't respond in the same way to the information that was available to everyone else. And that's not just a matter of reporting.

TOWNSEND: Yeah, I'll pick up on Tom's comments. I do think that there is, to Gregory's point, right, there are multiple layers of responsibility in terms of early warning. Do we need a global health surveillance system that more effectively sort of pulls that information together and puts the dots into a picture so that we understand what's happening? Absolutely. The private sector has a role there, right, because of the extended supply chains. We saw the vulnerability of that in the COVID instance. But the private sector can see that beginning because they are responsible largely for the movement of goods and have the supply chain. And then there is, you know, Gregory asked the question about the intelligence community. You know, every year at the National Security Council, you set what are the intelligence priorities and requirements nationally, and this has never been high up on the list. It just hasn't been. And when you see the economic impact that we've suffered as a result of COVID, you realize that's the argument for why health surveillance has to be very high up, much higher than it has been historically, on the list of intelligence priorities for the U.S. intelligence community, because they're really in by and large the ones who will trigger the policy community to begin to think about what a response will look like.

STAFF: Our next question will come from Patricia Rosenfield. Mr. Rosenfield, if you can unmute your microphone.

Q: Thank you very much for this important and timely report. I wanted to pick up on Sylvia's point, just almost as a throwaway point. Sylvia, you mentioned citizen participation and getting a vaccine, the flu vaccine. So I'm wondering about individual and civic responsibility as one of the weak links and how you're addressing that and especially with the future pandemics. Because it seems to me that, as you mentioned, foundations are working at different levels. But there's also a focus now on civic responsibility and democracy. But we have in New York state, for instance, where very good leadership communication and a strong public health situation, we have people who kill other people for asking them to wear a mask—just happened the other day. How do you inculcate a public health understanding and perspective in individuals who feel that their rights are being abrogated if they're asked to wear a mask or take a vaccine or get a vaccine? It's not only in the United States, it's happening in other countries as well. So it just seems to me that this is a weak link that requires some additional attention.

BURWELL: I think that the report takes on this issue in terms of the question of clarity of communication and the question of the rules and obligations of our leaders with regard to clarity of communication about what we know are the basic fundamental public health tools. And you know, in its simplest form, the issue of masks, distancing, the question of making sure if you are sick that you don't go to places and so that basic clarity of communication about those things and those are simple things. And I think, you know, in our country, we do a number of things that are about our health and communicating from a science perspective and a factual based perspective. I think, if you think about the number of deaths that we've had, and as we're inching closer to the number of deaths caused by cancer in a given year, if you communicated clearly to most of the U.S. population, that you might be able to not die of cancer this year, if you took these steps—I mean it is about basic public health communication and connecting the actions with the outcomes and making sure that people have the information and that that information is clear. In pandemic situations and epidemic situations, communications clarity, and this was one of our largest learnings in Ebola, as we did the studies afterwards, that importance of clarity of communication that is fact-based and gets to the public because they do play a role, as you're indicating, is more important than ever. And it's also important not just because of the role that citizens play, but because in pandemics, the information evolves—we learn. These are different and new, the science, we're learning every day more about transmission, we now know that almost 40 percent of the cases are asymptomatically transmitted. Boy, doesn't that tell you about how you should think about your behavior, because you could be doing something unintentionally. And so that clarity of communication is both about that role of all levels of our nation, but it's also about the fact that things evolve and so clarity becomes very important in a world where things evolve, and there's a lot of uncertainty.

GARCIA-NAVARRO: I don't know that we have time for another question. But just briefly to that point, what do you do though in a world where there is disinformation? Actual actors trying to muddy the waters of what could be clear communication. Sylvia?

BURWELL: Fran, do you want to, you know, from Homeland Security—

GARCIA-NAVARRO: Yes, absolutely. Fran?

TOWNSEND: Look, you know, we're suffering this now in the election, right? We did in 2016. We know that Russia, China, and Iran are trying to launch influence operations during the current presidential election. We struggle with this in many contexts, right? And so this is really no different. Part of this, speaking personally, I absolutely believe there's an education component that goes back to early childhood education, teaching children to be critical readers and thinkers. That's much harder, you know, the older we get, the harder it is to learn new tricks. But we ought to be skeptical about everything we read and everything we see in terms of, you know, I think many kids now are relying on social media for their information. And we just have to be skeptical of what's motivating those who are writing what they're writing. These campaigns, the intelligence community would tell you, are very sophisticated. But what foreign intelligence services are looking to do is they look toward to existing divisions in our society, whether that's race, economics, gender, and then they drive a wedge taking advantage of these divisions that exist in our society—they're not creating them. And so I just think we have to be skeptical consumers of information, far more so, and we're on notice of it now.

GARCIA-NAVARRO: All right, I will have to end it there. I want to thank you so much for joining today's virtual meeting. And thank you, of course, to Sylvia Mathews Burwell, Frances Townsend, Tom Bollyky, and Stewart Patrick for that incredibly important and enlightening report. Please note that the audio and transcript of today's meeting will be posted on the CFR's website. I'm Lulu Garcia-Navarro. Have a wonderful afternoon.

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