Strengthening Public Health Systems: From Global to Local

Wednesday, May 11, 2022

If the COVID-19 pandemic has taught the world anything about public health, it is humility: the United States has as much to learn about public health practices from its foreign counterparts as they have to learn from the United States. This symposium explores ways in which global public health systems can be strengthened, discusses lessons learned from public health officials, and provides a path forward for practitioners and the public during the pandemic and beyond. The full agenda is available here

The Global Health Symposium is made possible through the generous support of Bloomberg Philanthropies.

Session I: Health System Strengthening and U.S. Pandemic Preparedness

BOLLYKY: (In progress)—this program at the Council on Foreign Relations. And it’s my great pleasure to welcome you to our Third Annual Symposium on Health and International Economics, this year entitled Strengthening Public Health Systems—Global to Local. The COVID-19 pandemic exposed profound weaknesses and disorganization in public health systems in the United States and abroad. It exposed gaps in human and financial resources, and in our data infrastructure. It amplified profound underlying inequities in health status and in the drivers of health that could be negated by a better-functioning local and national public health systems.

Those failures have contributed to a decline in trust in public health institutions and, in the U.S. especially, has contributed to a rash of litigation against public health emergency powers and those who exercise them. That lack of trust and limited public health authorities will only exacerbate the risk of future health threats to the public. If COVID-19 pandemic has taught us anything on public health in the United States, it’s humility. And this symposium will explore the ways in which the global public health systems can be strengthened, discuss lessons from public health officials abroad as well as at home, and hopefully point towards a path forward for practitioners and this public in this pandemic and beyond.

I will leave it to the moderators of each of our panels to make the necessary introduction of the speakers. But I will say that we are truly fortunate to have a terrific lineup of both panels today. You’re in for a real treat. The first session this morning will be moderated by my good friend John Monahan. And it will be on Health System Strengthening and U.S. Pandemic Preparedness. The second panel, which will follow that, is entitled, Strengthening Health Systems on a Global Scale and it will be moderated by Susan Dentzer.

Just two quick notes before we proceed. First, I want to thank by thanking Bloomberg Philanthropies for their generous support in making this symposium possible. And second, I want to thank Kayla Ermanni, Cooper Wright, Samantha Kiernan, and Sarah Nance who did all the hard work of organizing today’s event and making the rest of us, who have done very little, still look good. So I look forward to today’s discussion and thank you all again for being here. And with that, I turn it over to Dean Monahan.

MONAHAN: Thanks, Tom. And before I start with our panel, I want to just say thank you to you and your leadership at CFR during—well, throughout this period, but particularly in the last two years. Your contributions, the creation of the blog and the post—the site for Think Global Health is really a contribution to the field. So thank you for all you’ve done.

As Tom said, I’m John Monahan. I’m in the interim dean of the School of Nursing and Health Studies at Georgetown University. I do think we have a terrific lineup—a terrific panel today. Let me—let me just quickly—I think you have access to the longer bios of each of our four speakers. Suffice to say, if I went through all of them, we would occupy our entire time. We have truly distinguished people here.

So first, doctor—we’ll have, first, Dr. Sara Cody, who is the health officer and director of the Santa Clara County Department of Public Health in California. We also have Dr. Jeff Levi, professor of health policy and management at the Milken Institute of Public Health at the George Washington University. We have Donna Levin, who is the national director of the network for public health law. And Anne Schuchat, who is the former principal deputy director of the Centers for Disease Control and Prevention, and a retired rear admiral in the U.S. Public Health Service.

I think you’re going to find today’s speakers to be really incredibly illuminating as we look, as Tom framed, this first panel will be looking at the U.S. angle, if you will, on this global to local challenge. And I think you’re going to find that the speakers are really fascinating. I’m going to ask each of them to take a few minutes—to take three or four minutes to described what they have been doing during the course of the pandemic, and offer some lessons learned and ideas going forward. But before we jump in, if I might just frame a couple of issues that I think I would encourage the CFR members to think about as we—as we go through the discussion.

You know, we’ve just passed this tragic million death mark in the United States from the pandemic. And as Tom noted, I think it’s fair to say our system has under-performed beyond even some of our worst fears, in many ways. While we've also had clear successes, there’s clearly areas where I think we need to rethink things. And perhaps, you know, much like the national security infrastructure or the intelligence community had to think post-9/11 of how do we do things differently going forward, I do think the public health community is in a similar moment right now.

So as we look ahead, maybe just a few issues that I think that you’ll hear from our speakers, or I’d ask you to consider. Is, one, you know, we don’t really have a national public health system, as such. Federalism, while a strength in many ways, also presents real challenges when addressing our national and global crisis. Third, as Tom referenced, we are seeing a scaling back of public health authorities around the United States, which is going to lead to even a greater patchwork in our public health laws. We’re experiencing an erosion of trust in public health as well as larger institutions in our society. There’s a host of data issues of which our panel will be quite expert in helping us think through.

And I’d say, in addition, there is a—we’ve seen a continuing set of difficulties in terms of public health communications in a polarized and complex communications environment, like the one we live in. And then finally, taking the theme of the global to local, and maybe particularly from the Council on Foreign Relations perspective, one question to think about is, given what the U.S. will need to do going forward in terms of our own public health system, what do we need in terms of international cooperation to succeed—from our international organization partners, from other counties? So those are sort of themes I’d just encourage you to front of mind as we go through the discussion.

So with that I want to just start us off. And again, I’m going to turn to Dr. Levi to kick us off and share with us what he has been thinking, what he’s doing, and some lessons learned going forward. So, Jeff.

LEVI: Thanks, John. Although that was almost a perfect overview, and we can sort of start diving into the details. And so a lot of what I’m going to talk about is what didn’t work and what needs to be fixed. But I actually want to start with a few things that did work, at least one thing in particular, which was the incredible success in being able to develop a vaccine so quickly. And despite some fits and starts, our ability to get it into as many arms as were willing to take that vaccine.

There’s a separate issue around vaccine hesitancy, but the fact that the science had advanced so far that we could produce a vaccine that quickly is something that we sometimes forget. And that takes us, I think, to having a much longer-term vision, whether it’s about public health or about science. The ability to develop that vaccine so quickly was built on decades of investment in NIH, in particular actually in trying to, unsuccessfully so far, an HIV vaccine, that then provided this opportunity—this springboard for having a vaccine against COVID. So I think that’s an important starting point.

You know, there are a whole bunch of lessons or challenges that we faced. And a lot of them had to do with leadership. And I think in all of the pandemic planning people did, in all of the tabletop exercises, I don’t think there was a single one where we assumed that the president of the United States—there was always a president in these tabletop exercises. But I don’t think anyone assumed that the president of the United States would actively undermine science and would actively use a pandemic to polarize the country and ignore the recommendations of his own appointed and career officials. So that was a real challenge.

And in fact, you know, a lot of planning had gone into pandemic preparedness. And Anne was probably part of many of those exercises. And there was a playbook. And that playbook was thrown away or ignored—actively ignored. And, you know, it’s hard to know how you prepare for that kind of eventuality. That said, you know, the politicization of science and the polarization in the country really was tragic. And the public health community struggled, and I would say unsuccessfully, to overcome that in communicating both about the science and our evolving understanding of what was happening in terms—with the pandemic.

We also ended up with—and this was not just a political issue. I think it was also an issue in the media and in other types of discussions, of creating this false choice, that we had to choose between public health and the strength of the economy. And we actually saw during the pandemic that when you have so many people ill and are unsuccessfully in mitigating the impact of the pandemic, that harms the economy as much as anything else.

And I think the last thing I would say before I get to sort of solutions and how do we move forward is that, you know, we really—you know, and this was reference in the beginning—the structural racism in our society really played a role. We, in a sense, reaped the whirlwind of that, because, you know, the under—the who was most affected by this pandemic really was driven by the social determinants of health. And because of poverty, because of racism, because of, you know, the types of jobs people had, we were seeing a really disproportionate impact on minority populations in this country.

I would say, sadly, you know, one of the complaints is that our data systems didn’t track race and ethnicity as well as they might have. And I would say, sadly, this is a very sad observation, I think, politically to make, once we started having that data, I think that’s when President Trump stopped paying attention to this problem and wanted to move on, because it was affecting communities that were not part of his constituency.

So John indicated that in fact we don’t really have a national public health system. I think a lot of Americans assume that CDC, Centers for Disease Control and Prevention, are perceived as the voice of public health in our country. That we must therefore have a national public health system that is led by the federal government and driven by the federal government. In fact, we have 2,800—or, almost 2,800 local health departments across the country. And there is no formal structure for knitting them together and making sure that they are adequately resources and that they are working in—at least from a similar playbook and driving in a similar direction.

And so what we saw in the pandemic was the result of this. We have a federal system where public health powers are held by the state. The authority that the federal government has to influence what state and local health departments do are through voluntary cooperation and through the power of the purse. So a lot of money does go from the federal government to state and local health departments. And conditions of award can be placed. But this does not give CDC or any part of the federal government the authority to set minimum standards for what a local health department needs to be able to do.

And so that, I think, is the fundamental lesson coming out of this pandemic. I’m fortunate enough to be staffing a—the Commonwealth Fund Commission on a National Public Health System, which is going to be reporting out in June. It’s chaired by Peggy Hamburg, who is probably familiar to a lot of CFR people. And we are—you know, the commission is going to be recommending that we need to change our lens and really think about public health as a national imperative.

Staying within the confines of the Tenth Amendment, and the constitutional restrictions, but using the leverage that the federal government has to lead by really providing resources to state and local health departments to meet minimum standards, and to work hand-in-hand—federal government, state government, local government—to earn trust and re-earn trust among communities that are most at risk for everyday health problems, as well as pandemics. To really come up with new approaches to deal with both misinformation and disinformation. And to come up with strategies to strengthen the integrity of science in public health.

So those are the kinds of issues that we are going to have to face. Those are, as John mentioned, sort of the post-9/11 assessment that we need to be doing to really think about public health as truly a national problem. You know, whether it’s domestically or globally, viruses don’t observe borders. And we need to create a public health system that reflects that.

MONAHAN: Great kickoff, thank you. And I’m going to—just apropos to your point about thinking about communities—next I want to turn to Dr. Cody. And let me—before I do that, though, I meant to do this in the introductions both for Dr. Cody and for Dr. Schuchat, is I think we all owe those who’ve been in public service during the course of this crisis a special acknowledgment and thanks. So both to Dr. Cody and to Dr. Schuchat, I really—I think, you know, it’s one thing to comment and review and do the sort of things academics do. I’ll just speak for myself. But it’s another thing to be working through a crisis and serving our community. So thank you, both.

Let me turn it now to Dr. Cody for remarks from her perspective. So, thank you.

CODY: Good morning. Thank you so much. It’s really wonderful to be here. And I think Jeff’s comments are right on point. So I’m a local health officer for the largest jurisdiction in northern California, in Santa Clara county, just to sort of set the scene and tell you a little bit about my experience and my take-home lessons. I think California may be a little bit unique. We’ve not had our public health laws challenged, at least not yet. And the state gives quite a bit of authority to the local health officer. And in California, the local health officer must be a physician. And every county must have a local health officer.

There are—and the health and safety code and other laws on the books in California actually give quite a bit of power and authority to the local health officer. And it’s by design that it’s given to a health officer and not to an elected official because, as you can imagine, we had a lot of tension between the local health officers and—as well as—and local elected officials. The remedy that the local health—electeds have, of course, is to remove the health officer. And some health officers were certainly removed or pushed out during the pandemic.

I think it's also important to know sort of the theme that I have. My experience throughout the pandemic was the pandemic was the importance of trust and the importance of having built trust and built relationships far before the disaster began. And there are two different relationships that I think were most important for me in being effective and protecting the community. One was an association of health officials around the San Francisco Bay area. We’ve known each other for decades and worked through many difficult public health problems together. We trust each other and we know each other well.

And that trust in that group is what allowed us to act very quickly and very nimbly to order a shelter in place for our entire region. So even though we’re all from different counties, very different structures, and different politics in each of our counties, the relationship that we had with each other enabled us to act together.

The other relationship that was so important was the relationships that we had built with all the various sectors in the county and that’s something, I think, that only local government can do. We know the community leaders, the resident leaders, and all the community organizations in various sectors, and to the extent that we had strong relationships before the pandemic, those served us very well, particularly in extraordinarily difficult, difficult times.

I would, certainly—my experience throughout the pandemic was how chaotic and difficult it felt to be responding to a pandemic in what felt like a county by county by county fashion, and in the Bay Area we started out as being a very united block. But as the pandemic wore on and there were different dynamics in each county, it became very difficult to hold a coalition together.

So even within the Bay Area, which looked very united and we are one large metro area, we were not allowed to—we were not able to continue to do things in complete unison, and then, of course, across the state and across the country every county was doing something quite different and messages were often different, and I think it became very, very confusing and difficult for the public.

So many lessons learned, and I wouldn’t argue with a single thing that Jeff offered as the lesson learned. But from the local perspective, what I see what’s been incredibly challenging, public health infrastructure is so fragile, so fragile. I often describe it as like matchsticks and scotch tape is what’s put our infrastructure together and just sheer grit of the individuals working in the structure. You know, we soldier on.

But that’s not the way that we can best protect our communities, of course. Having resources that are sustained and robust and not categorical, of course, would be the most helpful from the local perspective, and the infrastructure—the glaring lack of a robust data infrastructure really came home to roost and I think we also—the pipeline for the workforce and for trained public health professionals, I feel, is also rather fragile and may have become more fragile during the pandemic when local health departments and local leaders endured a lot of backlash for public health work. So I think those are, certainly, risks for going forward.

We also—you know, as you mentioned in your opening, it’s not really a system that’s well knit together, and I think that despite so many years of work we really do not have a clear definition of roles—the local role, the state role, and the federal role—and those definitions are often different state by state and county by county.

So very, very challenging. So I’ll stop there, and delighted to participate in the discussion. Thank you so much.

MONAHAN: Thanks so much, Dr. Cody. That was terrific. And maybe to go to the other level from national experience, Dr. Schuchat?

SCHUCHAT: Thanks so much. It’s a real pleasure to be part of this panel and sort of a PTSD experience to join you right now. (Laughs.) I served as the top career official at the CDC from 2015 until the end of June 2021, which, you may recall, was right before the Delta wave hit the country when everything was looking wonderful and I thought I’d be able to retire with things in—on a great trajectory.

So I’d like to emphasize something that, I think, Tom stressed early on, which is humility, and I think that’s got to be our number-one recommendation in thinking about pandemics of the future. It’s going to be easy for us to fix—not easy to fix—it’s going to be easy for us to identify everything that went wrong this time, but overcorrecting for those things may or may not anticipate what’s going to be the problem next time.

You may recall that after the 2003 SARS pandemic a critical part of the update of the international health regulations was that, you know, you never want to induce travel restrictions because those are always too—more burdensome than helpful, and I think a key benefit in this pandemic was the restricted mobility that people had, voluntarily or not, that slowed some of the global spread and, potentially, gave us more time for that great scientific production of a—of the effect of vaccines to take hold.

I think the second overarching theme of my recommendations is empathy, you know, at every level, obviously, you know, for Sara, who had protestors on her lawn, you know, while she was doing an incredibly great job of promoting health and protecting the Santa Clara County population. But I think also with the public and with every country involved, despite our playbook, despite our drills, whatever the politics were, the duration of this particular pandemic has been extraordinary. And I think most of our playbook and most of human behavior and most of good communication and messaging has a shelf life, and even in New Zealand they found protests eventually with, you know, great communication and great interventions.

So I think we have to recognize that when you have something that will go on this long you need to be nimble and you need to be capable, but you also need to be empathetic—that there’s going to be a whole lot of issues that emerge, and that brings me to, really, emphasize the lessons that Jeff and Sara have mentioned about our federated system and our fragmented—it’s not just a fragmented public health system. It’s fragmented health care and public health, and the two don’t really talk to each other on a good day and we haven’t had a good day for a couple of years.

So when we think about data systems, when we think about workforce, and when we think about the laboratory needs, we have to recognize we’re starting both with fragmentation and we’re starting with, you know, legalized fragmentation that, I think, Donna will go into, and we’re starting with a public—you know, a very broad part of the public that has zero interest in weaving together those fragments or strengthening the authorities.

So I think we—with our humility and empathy, we also need realism about what are the improvements, that there’s going to be political, social, and financial will to take on. And so I put my recommendations in the categories of the data where it’s both authority—you know, all the desire for CDC to have a national picture relied on completely voluntary reporting and data use agreements with the jurisdictions, which were based on their data use agreements with all the health care entities, which were based on, like, you can’t share this with anybody, the missing race and ethnicity, the—you know, just overwhelming challenges to get timely, accurate, complete data when you need it so that there can be nuanced heterogeneous interventions, because if the San Francisco Bay Area can’t agree, believe me, the Midwest was not happy when there was a national shutdown because of the Northeast.

So I think we need to improve data at every level. And a lot of that is not political. A lot of that is advanced agreements and getting the private sector that believes they own all the data to get in line and actually in emergencies make it available where it needs to be or accessible where it needs to be.

Similarly, with our laboratories, we need to recognize that best case of sustainable funding public health laboratories are a tiny piece of our laboratory system. Commercial labs, clinical labs, academic labs, and public health labs need to be connected with an enterprise approach, and the federal regulatory view of laboratory-developed tests for an emerging pathogen of pandemic potential need to get real and not be a barrier to scaling up new laboratory tests when something is in that acceleration phase, which was a challenge even with the tests that worked well.

I think—I’m glad Jeff talked about the vaccine and vaccination effort that worked well. We need that same kind of approach for all of the countermeasures if we’re developing and scaling up diagnostic tests, developing and scaling up treatments and, similarly, with the medical supplies, like personal protective equipment, we can’t have states competing with each other and, you know, it takes a federal level investment to get the supply that a nation needs.

So I think my final comment will be that this is a national security issue. It needs to be resourced the way that we resource the defense issues because, clearly, the loss of life and the economic impact of the pandemic is greater than wars that we’ve experienced. So we need to be investing in public health for the long haul, recognizing that there’s not necessarily agreement about what that is going to look like.

So probably too long, but those are a few of my thoughts to start things off.

MONAHAN: Anne, thanks so much. Appreciate it. That’s very, very helpful.

Donna, I was going to ask you to give us some of your perspectives. So thank you.

LEVIN: OK. Thank you very much. Very grateful for the opportunity to join the discussion.

So my background has been as a public health lawyer my entire career for the past forty-two years. So ten years right out of law school as a staff attorney for the Massachusetts Department of Public Health Office of General Counsel and then the next twenty-six as the general counsel, and for the last eight years I’ve been the national director of the Network for Public Health Law.

So that is an organization of public health lawyers who provide real-time legal technical assistance, resources, training, across the country, health departments—to health departments, public health researchers, advocates, others in the public health field, and most of our assistance is free, thanks to the RWJF—RWJ Foundation and other funders.

So I’m going to put a link in the chat to the network because I will be mentioning some resources there. I appreciate the shout outs so far from the other panelists to the incredible dedication and resilience of public health officials. Those are the people that we’ve been working with—public health officials, public health staff on the frontlines, associations that support them—and part of the work that we’ve been doing, unfortunately, is providing resources on how they can counter the threats and harassment that they experience. So that is some of the work that we’ve done. That’s on our website.

The two points that I wanted to make on lessons learned during the past pandemic—two and a half years—are some base legal, and then I’m going to move to trust. And everybody—I think we can’t emphasize it enough. So I will still move there, as it is in my notes.

So, first, we’ve learned that trying to protect the public’s health can result in an unfortunate backlash that is going to be very dangerous to the public’s health, moving forward, and we’re seeing this play out in legislation and litigation around public health measures.

Part of the lesson here is waking up to and acknowledging the effectiveness of a concerted and long-term anti-regulatory and preemptive campaign, and it’s found that this time is an opportunity for that agenda. So there’s a current onslaught of—to public health authority in the legislature and we can see some of that anti-regulatory model language in some of the bills. We can see it verbatim. So I would just say people should check out, be aware of the influence and reach of the American Legislative Exchange Council.

So I’ve been involved in public health, like I said, a long time. Through 9/11 we saw states passing or modifying emergency public health acts to ensure that the executive branch and public health agencies in that branch had the requisite authority to take necessary measures.

For the past two and a half years as the pandemic went on, we’ve seen that problems encountered with the use and implementation of legal measures were not a matter of lack of legal authority on the books. It, as others have mentioned, been a lack of coordination, a lack of transparency and trust, misinformation, lack of consistent messaging and as well as a political climate that has tilted the balance of what is perceived as the right to individual autonomy and the greater good in a way that doesn’t foster public health and protection for communities.

So I wanted to mention that at the network we’ve been tracking the last two years of legislation that seeks to limit public health’s authority to act. There have been over a thousand bills at last count this last past March, and we haven’t—we’re still updating, but as of mid-March about eighty-five had been enacted in various states across the country, shifting authority to legislators and legislatures from the executive branch, meaning delay, et cetera, limiting the scope of emergency orders, prohibiting mask mandates, vaccination requirements, isolation, and quarantine requirements, even establishing being unvaccinated as a protected class under the Constitution.

So there will be a link I can put in the chat on this survey of bills for you to take a look at and keep abreast of as we keep updating it. So and, similarly, as Jeff mentioned, there’s been extensive litigation challenging almost every aspect of the exercise of public health authority.

So I mention this to make the plea. It’s important to know this is going on and we can’t shy away from this battle to defend public health authority. Public health needs some political muscle. Public health is political.

The second briefer comment, John, is about trust. I’m glad trust and humility has been mentioned. We’ve had focus groups, we’ve had town halls, and that’s what we’re hearing from public health officials and from the community. So I think this battle is, in part, about trust. We need to rebuild trust in public health.

Jeff, I think you said we have to look at public health and recognize public health as a national problem. I think it’s also we have to look at it as a national resource. So we have to build that trust and we have to frame public health in our own narrative.

People don’t know what it is, and waking up to how we’ve had to exercise those authorities in the past two and a half years hasn’t given them a full or accurate or comfortable picture. So relationship building, consistent communication, trusted messengers. I want to leave it at that for now and hand it back over to John.

MONAHAN: Thanks, Donna, and as—thank you all for, I think, a great way to set up the conversation. There’s so many places to go. But let me—let me start where Donna finished, because it does seem to me that trust is implicit and trust in public health institutions is implicit, moving forward, trying to build the kind of systems we hope are in place.

Maybe just to push this a little. It seems to me one of the challenges of trust has been communications and how public health officials have communicated the complexity of this pandemic as it’s evolved over time, and I guess I’d like to ask if—you know, what do you think we need to do to better equip not just people who are, quote, “public health officers” but also the broader community to educate the public about the risks and the steps that people need to take to protect themselves?

You know, we learned that uncertainty is really hard to communicate, that communications gets siloed, as each of the speakers talked about, and sort of the frame—whatever ideological framework or partisan framework people bring to these issues, whether it’s masking or vaccines.

So, I guess, what do we do next? I mean, we are where we are. So what do we do next? How do we—how do we strengthen public health communications going from today? I don’t know if—who would like to start. Jeff, looks like you’re about to—

LEVI: Yeah. So I sort of feel like—I’m going to sound like a broken record but it really comes back to rebuilding trust or earning trust because it’s not—we had positive experience—H1N1 was one example—where it was possible for CDC and public health leadership to communicate to the public and for the public to understand that in an evolving situation our understanding of the science would shift.

But when you are trying to practice sound public health communication and the president of the United States is actively undermining those messages that’s a losing battle. The president of the United States has a huge megaphone, that no matter how brilliant the director of the CDC is or how brilliant a local health official is you can’t compete with that.

So that’s the starting point, and so what do we do now? So we now have to dig ourselves out of this hole so that the next time there is an emergency there is some trust, and I think that becomes very much a ground game, much more at the local level than even at the national level.

And, you know, one of the reasons Sara Cody was so successful was she had built those relationships over the time, and if you look across the country, even in, you know, supposedly polarized communities, health officers who had built relationships with the community, which meant with residents, with the business community, with the education sector, with the health care sector, they were able to sustain public health interventions longer than those who had not created those relationships.

And so we really now have to invest the time, the resources, and, you know, the energy in recreating those relationships.

SCHUCHAT: I think there’s also—I agree completely with you, Jeff, but I think there’s also the way that each of those people communicates and I think Sara is a good example of it. But I think that you really have to start with empathy.

We had brilliant people all over the place, you know, whether they were experts or public health or health care leaders. But people will increase their trust when they know that you actually care about them. They’ll accept that you don’t have all the answers, that it’s going to change, that tomorrow you may have to tell them something different, and that, you know, patience might be all everybody needs to do. But if you don’t start with the empathy—and it’s really easy for people to focus on the data and the technical and the, you know, I know everything, but those relationships are built on trust, and trust is often built on, you know, the empathy that people have.

So I think, you know, after—again, after the bird flu, you know, we trained the world on risk communication. Everybody at CDC got trained on how to do risk communication, and then, of course, when this pandemic really took off we weren’t allowed to communicate. (Laughs.) But I think that I agree with you that we aren’t starting in a good place right now to earn back that trust.

And so one of the things that I believe CDC has been doing has been funding a pretty large-scale effort at community health workers where it’s not at the governmental public health level but it’s people within a community in peace time, in disaster time, to be of the community, with the community and, hopefully, a resource to them.

CODY: If I can—if I can—

MONAHAN: Please.

CODY: —jump in. I completely agree with everything that’s been said, and it’s both what we communicate and how we communicate because I think that there was so much, you know, really absurd information that was circulating, you know, from the president. And so we had to get the facts straight that we wanted to communicate, and that was uncomfortable to say, well, actually, it’s not that, it’s something else.

The other thing I would say about what we’ve experienced building trust in the community is it’s not just—it’s don’t tell them, show them. So we have to demonstrate that we’re trustworthy, and a lot of the work that we did during the pandemic and prior to the pandemic was more based on power sharing with communities.

So, for example, is we said we need to do increased testing in this community that’s been hard hit—how do we do it. Then we collaborated with community to co-design whatever the intervention was going to be, and sometimes it wasn’t what—it made us a little uncomfortable. It wasn’t quite what we wanted to do. But we wanted it to be community led, and those types of—all of those little actions and little iterations served to increase the trust, and then we were able to say things and communicate things even when people didn’t quite want to hear it. They trusted us and were able to able to hear it. So and I think that the investment in community health workers and that kind of investment is very, very important because it’s really where public health meets the community that we serve and that’s exactly what we need.

MONAHAN: Well, Donna, did you want to jump in?

LEVIN: Yeah. So we had a suggestion come for sort of reconciliation tours where there’s listening going on when this is calming down and people can—public health can listen to the community, listen both ways, and try to sort of learn from what happened, going forward, which will build trust.

And another idea is on a larger or smaller scale, given county, local, state, to have an advisory board that’s not regulatory in nature but is comprised with stakeholders. So community leaders, voices, Chamber of Commerce representative, business, employers, who are briefed on the day-to-day—you know, the issues that are coming up for public health, what public health does, and they, in turn, become your trusted messengers. And as my panelists have also said, you need resources to do this. I think Sara can tell you it’s hard to pick up your head to do anything else but, you know, your incredible array of responsibilities, and you need the time and resources to work on this communication and it’s so important.

LEVI: John, if I could just add one thing—

MONAHAN: Go ahead.

LEVI: —just to emphasize what Sara said about co-decision-making, because it is more about—it’s more than just information exchange. It really is about trusting communities to make decisions, and that is not in the DNA of public health people, to be perfectly honest. Public health people are used to being the experts. You know, we know the right path, and we may know some of the science but we don’t necessarily know how to get from point A to point B when it requires the real cooperation and support of entire communities.

And so building into—you know, I talked a lot about a national public health system but all politics, all public health, is local, and building into the local public health infrastructure a shared decision-making process is incredibly important. And, you know, Sara reaped the benefits of sharing that kind of power even if it wasn’t the direction that one might have assumed we would go.

MONAHAN: Well, I think one thing—we’re going to open up questions now to our members who are online, but I just—just maybe take a pri. I just want to underscore in my experience, you know, as hard as it is to build those kinds of relationships for government agencies and health agencies, it’s vital. If you want people to be messengers and part of your network they’ve got to be part of the process.

And the other—maybe it’s more of a small p politics observation—you want to have those conversations and build those relationships before the crisis, right. And so that, it strikes me, is an opportunity here.

But let me turn to Sam, I believe, who is going to be our—is going to make sure that we pull our questions here from the listeners.


OPERATOR: (Gives queuing instructions.)

We are still waiting for some questions to come in so I’m going to turn it back to—oh, actually, we have one right now. Our first question will be from Tom Bollyky.

BOLLYKY: Great. I, actually, felt bad being—I wanted to ask a question and then felt bad getting to speak twice. So I’m glad that I’ve gotten the chance.

I had two questions to ask. The first is that, obviously, we’re in a very politically polarized moment, and I was part of an event that had this debate as to whether or not the polarized nature of mask wearing or many other recommended public health behaviors is a byproduct of how those authorities, those recommendations, were made, or simply a matter of public health being elevated to an issue of national prominence and it becoming polarized in the same way that many other things have become polarized in our society at this moment. It’s important because it gives us a sense of what’s the realm of the possible in fixing this. Is this a deeper issue in our society around political polarization, or a particular way that we exercise authority? That’s one. The other is that—a question I had is, to tie to Anne’s great point, that we did develop the playbook for risk communication for the world. And I would love to hear about how you think that playbook needs to change in light of what we’ve seen in this pandemic. Obviously, we didn’t exercise—we didn’t use it the way we would have liked to. But based on what we’ve seen, what needs to change about that playbook? So not only that we use it in the future, but that it adapts for what we’ve learned over the course of this pandemic.

MONAHAN: Thanks, Tom. So do want to take that—there’s two important questions there. Anne, do you want to—maybe the simplest would be, Anne, if you want to start with the playbook, and then we’ll turn to the sort of what came first, the public health crisis or the polarization?

SCHUCHAT: Well, I think we need to put masks a little more prominently in the playbook—(laughs)—like, maybe combine the two answers. You know, masks were always there for a severe pandemic. And we’ve learned a phenomenal amount about the direct and indirect benefits of barrier protection. You know, that it didn’t have to all be the perfectly fit-tested N-95. That you could get a lot of bang for your buck with a reasonable-to-produce masks, and both protecting the individual and those around them. You know, the playbook wasn’t written for something that spreads asymptomatically—that asymptomatic people are that effective at spreading. And so the issues of ventilation, the issues of, you know, just what can be achieved with some of the mitigation measures. You know, we weren’t—we did have aspects of severity, but I think our transmissibility projections underestimated, you know, this particular kind of threat.

And I do think that revisiting all the roles and responsibilities of federal, state, local, and across the federal government—you know, the—(inaudible)—was essentially developed in order for this kind of event. And there was supposed to be a federal leader, you know, at the NSC that was bringing all of government together. And we exercised and drilled that. But there, even absent politics, even with good drills, there was a reluctance for any department to really share with any other department and, you know, some reluctance for HHS to give up leadership when it was appropriate, which it was appropriate in this particular pandemic for this to be an all-of-government response.

So I think we really do need to revisit who’s doing what and, again, with a countermeasure enterprise. You know, learned a lot about what the DOD and FEMA are really good at in this response, and whether public health can get as good at those things or we need to be working together more effectively. You know, the logistics and the large-scale work that both those groups were—have authorities for. You know, we need to assess that.

I do—just to comment on the mask issue. I think it’s hard to—clearly, it was politicized from day—you know, the initial day that the mask recommendation was made. Even before that, the mixed messaging about, you know, don’t wear them versus health care needs them. And don’t panic versus, look, everybody in Asia’s already doing this and it seems like it’s probably a good idea. You know, we had mixed messaging before. And then when we officially recommended it we had politicization instantly. So it is hard to separate. You know, is it because it was a public health recommendation or is it, you know, how the whole thing started?

But I would say that, you know, some—you know, the comfort level and familiarity of masks in the U.S. was so low, compared to places with bad pollution where, you know, they were a big reach for us versus it was an instant adoption in many of the Asian countries. So I think there were—you know, we can’t blame everything on politics. There were—there were other things here. Although, it’s tempting to blame everything on politics. (Laughs.) We just can’t.

OPERATOR: We will take our next question from Patricia Rosenfield.

Q: Thank you very much. And thank you for this profoundly important panel discussion. I really appreciate what everyone has said, and particularly the emphasis on trust and empathy. Lessons learned from those—I worked at the World Health Organization for many years, and now currently head of the Rosenfield Fund—where you learn that when you work in marginal populations in developing countries.

But my question is about a sector of American society that no one has mentioned. And that is the role of journalists across the spectrum in helping to spread misinformation and then try to counter misinformation. And I’m just wondering if you could all talk about the role of journalists in reinforcing some of the problems that we confronted during the last two and a half years, and how to bring journalists front and center into the public health process, so that they understand better the role of uncertainty, and how to communicate uncertainty, along with all the other important recommendations that you have emphasized. And their training and engagement, and how to—not just science journalists, but he regular journalists across the spectrum.

MONAHAN: Great question.

LEVI: I think—yeah, I think one of the big challenges we face is there are fewer and fewer health beat journalists than we used to have. You know, I got into public health at the very beginning of the HIV pandemic. And almost every newspaper, including small newspapers, had a health reporter. And that’s much less the case now. And so you weren’t starting at sort of ground zero every time a new issue arose. I think the fact that so much of the briefing around COVID occurred at the White House press room really affected who was covering this. The White House reporters are not health reporters. They are political reporters. And so they always look to these issues through a political lens. And the fact that CDC was shot down in doing their briefings and was not able to reach perhaps some of the press that would normally cover these stories also, I think, undermined what was happening.

And then, you know, this—you know, and because it was mostly covered more by political people, it’s always on the one hand, on the other hand. There is always two sides. There’s the Democratic side and the Republican side. Well, you know, it’s a virus. There are—you know, there aren’t two sides to this—to certain elements of this story. And yet, it was often presented that way. But I think the other part—of which—about which I have absolutely no expertise, I will just observe—is, you know, this is the first public health emergency where social media was so incredibly important in spreading information and disinformation. And, you know, that’s where I think a lot of the playbooks need a lot of upgrading, so that we’re better able to communicate and reach people.

MONAHAN: Anyone else want to jump in?

LEVIN: I think there’s—we have to keep in mind that local news is disappearing. It’s not just that there aren’t health reporters, and you’ve got people watching their own version of the news. And it’s more and more national in that way. And I think it goes back to trust, and facts, and people who are in the media being accurate and trusted messengers. So I think that when you’ve seen these deserts for news created more and more in this country, you’re going to see more and more misinformation. So I don’t know if it’s such—we’ve had great reporters reach out to the network and try to—and they’ve written great pieces on this. I just despair that the markets are becoming more and more polarized and less and less available.

SCHUCHAT: Just a comment—


SCHUCHAT: Yeah, thanks. I agree with you all. I wanted to say that I think there’s been some excellent journalism during this, you know, just as there is about Ukraine right now. There’s some people who weren’t even health reporters who have really taken this on in a good way that’s been helpful. But the bigger problem is the fragmentation of the audiences, and that a lot of that good reporting is being read by people who already get it, versus the places where poor reporting or misinformation is being spread.

Just a comment about the local because, of course, the pandemic, you know, happened locally—you know, what your area was going through. You know, one thing was I do think the voices of the—you know, the overwhelmed emergency room or ICU health care professionals were very compelling in those local stories. Of, you know, you might not believe anything that’s happening nationally but, you know, the morgue is overwhelmed here. That was—that was important and, of course, a late sign.

Then I did want to mention, I heard a really interesting proposal or perspective from a Swarthmore College student who thinks that in the absence of local media, college and university newspapers and workers could really be filling a gap and be part of the public service. You know, they did that to some extent with the outbreaks that were happening on campus. I know we’ve had some big stories where the news was broken by some, you know, college reporter. But I think harnessing that was part of the public health system more as, you know, the people to educate.

We did—even the political reporters at the White House, you know, in 2009 with the H1N1 pandemic, Secretary Sebelius and I did a whole session with the White House reporters about what’s a pandemic, and how does it evolve, and what should you expect, and what are the—what do we know is going to happen that is not a story but, you know, all the stuff around vaccine safety and the signals. So you can do it. It’s just—and I think out of this experience, all the journalists have lived during—you know, the surviving ones have experienced a pandemic, and are much more knowledgeable. So I think there’s a lot to work with there.

MONAHAN: I don’t know, Sara, if you had anything you wanted to add before we go to the next question.

CODY: My experience, again, is the better relationship you have with your local journalist, the greater the chance that the story they’ll produce will get your message out. And just like any other relationship, they take time. They take time to build. So really simple things, like responding to them as quickly as you can always, and being consistent, certainly helps.

Actually, one thing that surprised me during the pandemic—and I didn’t—this has taken me a long time to understand. I always think that I am communicating to the population of Santa Clara County. Very focused on the community that I am serving. And many times, not realizing that what I said about Santa Clara County then became a message that went to a different audience, to a broader audience. Which was, I found, sometimes challenging, because it wasn’t necessarily as relevant for a large audience as it was for a local.

So I do think that the—you know, in the bay area we still have, you know, a fairly robust team of journalists that are interested, that have continued to cover the pandemic. And that’s not true—you know, not true in many parts. So I think it’s an excellent point.

MONAHAN: Thanks, Sara.

So, Sam, another question?

OPERATOR: Our next question will be from Daniel Spiegel.

Q: Yes. Hi. Thanks for this very interesting conversation. I’m a lawyer at Covington in Washington.

I certainly agree with Jeff’s analysis about the harmful role that Donald Trump played. Let’s also remember that it was not only Trump. He was also able to really harm the credibility of both CDC and other institutions, including HHS. And it just wasn’t the White House that played a harmful role here. Now, the Biden people have tried to right this ship, but it’s interesting. If you were to ask, who was the spokesman at the federal level today for public health? Other than CDC, you know, you really couldn’t say. Maybe the secretary of HHS. But the fact is that there isn’t a public health expert sitting in the Cabinet with the president.

And I’m wondering whether we should think about, in terms of strengthening public health, making a statutory change and requiring the secretary of HHS to be a physician. This secretary has no experience in public health. He was a member of Congress. He’s a very intelligent man. He was an attorney general of California. But he has no experience in public health, and rarely speaks unscripted about public health. And I think—I think, I’d like to get your reaction, the need—if you want to strengthen public health and fight politically in the Cabinet and against many of these state regulatory impediments, you’re going to have to—you’re going to have to perhaps change the role of HHS, sitting above CDC, NIH, FDA, et cetera.

MONAHAN: Well, Jeff, do you want to-

LEVI: Yeah. I think you raise a really important issue, and it’s something this Commission on a National Public Health System is actually wrestling with as we speak, in terms of how do you provide more focused leadership from HHS for public health? I think we’re all a little bit leery at the moment of statutory changes, just because statutory changes are getting harder and harder to make. I am not convinced that a physician has to be secretary of Health and Human Services in order to provide the kind of leadership that you want.

You want the secretary of Health and Human Services to empower the public health leaders. But, you know, some of our most successful secretaries have been former governors who know how to communicate to the public and know how to represent the interests of their agency in a political climate. We are never going to totally depoliticize policymaking because, you know, it’s not just science. Policymaking is a combination of science and small-P politics—ideally, small-P politics. And you need someone who can play that synthetic role. And that’s the kind of leadership that’s needed, I think, in any Cabinet agency.

MONAHAN: Anne, I want to ask if you wanted—anything you wanted to add to that.

SCHUCHAT: Well, I think—I do think in a number of public health emergency or crisis responses, you know, the CDC director or delegate has been in the Cabinet meetings or been part of that conversation. And the scope of the secretary of HHS is pretty broad, and particularly with, you know, CMS and, you know, that entire enterprise in there. So I think that there’s a different—you know, it’s worth thinking through how is the public health voice united versus fragmented because there are multiple agencies that deal with some part of public health.

But I think there’s a way to get senior level, credible information to—you know, across government. And I know that, you know, it’s under discussion about making the CDC director a political appointee that’s Senate-confirmed, versus not Senate confirmed. And obviously, the HHS secretary is—requires Senate confirmation. I think just remembering how pandemics don’t really respect calendars, and the 2009 pandemic started before we had a HHS secretary and before we had a CDC director.

So you got to figure out who’s going to be in what chair when. And, you know, obviously, during the Trump administration, they were mostly acting people by the point that the pandemic emerged, in all of the departments. So I think, you know, just to be careful in those—in what you plan for to be resilient to the whims of the calendar.

MONAHAN: I might just take my presider hat off for a second, since I’ve worked for the HHS secretaries during these different crises. I’m not persuaded either that being a physician in and of itself is the essential qualification. It seems to me really effective HHS secretaries partner with their public health agency leadership, as Anne suggested. And that’s a really combination, especially if the HHS secretary brings a type of experience that’s not part of the public health community. Whether it’s a governor, or an elected official, or whatever. I think part of the issue from the last administration as that there wasn’t that kind of coordination between political and career officials in this crisis.

But, anyway, I’ll put my presider hat back on there. But I think we have two more questions, if I understand. So let me ask Sam if he can queue them up for us.

OPERATOR: Our next question is from Scott Holcomb.

Q: Hi, everyone. Thank you for this very compelling presentation. I’m a state representative in Georgia, so I’ve been in the mix of a lot of these issues for the last couple years. And what you said, I think, is exactly spot-on in terms of the symptoms of what we’re dealing with—fragmentation, extreme politicization and polarization, and just a lot of challenges across the board that are not going to be easy to solve. And one quick rebuttal in terms of the issue about the news. I certainly agree with that, that we need more health care coverage. But at the same token, all too many people aren’t reading the news at all to be informed. They’re just being informed by social media, period, without that even being news articles coming to them. So that’s not an easy part to fix.

And I’ll share just one quick anecdote. A constituent of mine is thrilled that our neighbor to the north, Tennessee, passed a law to allow ivermectin to be purchased over the counter. And he’s excited about this. And the sponsor of that bill even said that no matter what people believe about ivermectin, his bill should improve public safety. And so I responded and said: I suggest you talk to your doctor. But this notion that there’s a massive audience in this country that isn’t informed by science and, even more problematic, many policymakers are not informed by science. And if we could just get the science to inform policymaking, we’d be in a much different place. But that’s just not an easy place to solve.

So where I find some encouragement, though, is I think a lot of public health people recognize that they need to get involved. And we’ve had people who are M.D.s and Ph.D.s run for office in Georgia. And I think that’s wonderful, because they’re adding new voices. But my question is, where do you see other opportunities, in addition to what you’ve mentioned? Other interventions, with the private sector, perhaps, that we can push? Because I’m not saying we’re not in the public sector really leading here. And I wish I had a different view, but I don’t.

MONAHAN: Thanks. Thanks so much, Scott. Who would like to respond to that?

SCHUCHAT: Yeah, I think—just, quickly, I do think the private sector has a huge role, a huge opportunity as major employers, as, you know, advertisers, as, you know, people who get eyes on their work more than, you know, public health anyway. I know CDC and probably other agencies have tried to tap in, you know, to Business Roundtable, Chamber of Commerce, and to really have robust relationships, partnerships, and feed, you know, information that’s vetted or that’s accurate to those groups.

But I think we could do a lot better. You know, I think, in a way, CDC had so many of these efforts, but they needed to be on steroids for the level of magnitude of this pandemic. So we’re not doing things big enough, often enough, with enough penetration. But you’re absolutely right that the social media—you know, the influencers are not the official media right now. And getting to those influencers, whether they’re private sector or, you know, the mommy bloggers that we were—we were reaching to around vaccination, I think is very important.

MONAHAN: Thanks, Anne. Anyone else? All right. Well, thank you. So we’re coming close to the end of our session, believe it or not. We knew we’d have lots of questions. I don’t think we have any more questions at this point. Maybe invite—I’d invite just some final thoughts that the panelists would like to share. And it looks like, Donna, you have one. So maybe I’ll start with Donna, and we’ll go in reverse order. How does that sound? How we started. So, Donna, you wanted to say? Donna, I think you’re on mute still.

LEVIN: I wanted to say that a pandemic meets its host as it finds them, right? And the virus in this country—found this country in a weakened condition. So it’s not just about public health resources, coordination, fragmentation. You know, vaccination, not the only route to immune response. So as we, as lawyers, looked at this—and I’ll put this in the chat too—of COVID-19 policy playbook, you know, you need that robust infrastructure to support people in a pandemic like this, right, when it’s long-range like this and people can’t work. And so you have to look at taking care—and this is a big ask, right? But in our country, we need robust protections for workers, families, and children. And that has to happen in normal times, and it will protect us in emergency times.

MONAHAN: I hate to do this, but I’ve been kindly reminded by our colleagues at CFR that we’ve—I think Donna’s point is really a good way to end. This virus found our country and our public health system as it is. And I just want to say thank you to the panelists. As I think I promised everybody, this was a rich and an incredibly robust discussion. So thank you all. If we could do a virtual applause, I would. But thank you.

And then really, for the rest of the audience, just a reminder that the next session, Session II of the Global Health Symposium, which is about “Strengthening Health Systems on a Global Scale,” will begin at 11:30 a.m. Eastern time, after this break. And you should see the link in the chat. I would just urge everybody to think—if you’re going to both of these sessions—think of what you heard today and think about what is the United States? We are—all health is global. How did what you hear today about our challenges—what do we need from our global system? Not only what does the rest of the world need, but what do we need?

But I want to say thank you to the panelists and thank you to CFR. And I encourage everyone to join the next session. Thank you.


Session II: Strengthening Health Systems on a Global Scale

DENTZER: Thank you very much, and hello to everyone joining us for this session today on “Strengthening Health Systems on a Global Scale.” We’re going to be discussing lessons from national health agencies and international multilateral organizations working to alleviate health disparities and global challenges and how we get ready for the next series of public health emergencies that the world will undoubtedly face.

I have the pleasure now of introducing our distinguished panelists.

First with us is Agnès Soucat, who is the head of the Division of Health and Social Protection at the French Development Agency, the Agence Francaise de Development. Agnès was previously director for health systems governance and financing at the World Health Organization in Geneva, and before that held senior positions at the World Bank and the African Development Bank. So, Agnès, welcome to you.

We’re also joined by Chikwe Ihekweazu, who is assistant director general at the World Health Organization where he leads the WHO Hub for Pandemic and Epidemic Intelligence. He was previously the director general of the Nigeria Center for Disease Control and CDC. And welcome to you as well, Chikwe.

We’re also very happy to be joined by Vernon Lee, who’s deputy director for communicable diseases at the Singapore Ministry of Health. He’s also head of the Singapore Armed Forces Biodefense Center and adjunct associate professor of public health at the National University of Singapore. He was formerly adviser to the assistant director general for health security and environment at the WHO.

And finally, we’re very happy to welcome Natasha Bilimoria, who’s deputy assistant administrator in the Bureau of Global Health at the U.S. Agency for International Development, USAID. She has more than twenty years of experience working in multilateral institutions, nonprofit organizations, and government, and most recently was the director of U.S. strategy for Gavi, the vaccine alliance.

So Natasha and Vernon, welcome to you both as well.

We’re going to divide our discussion today into two sections. In the first we’re going to discuss strengths and challenges in the state of global health system preparedness and health system response to the COVID-19 pandemic. Obviously, this pandemic continues in most of the world and we continue to reap lessons from this. Those are the ones we’re going to start with today. In the second round of our discussion we’re going to talk about preparedness for the future. What needs to be done in terms of discerning the lessons from COVID-19 and getting ready for the next series of public health emergencies and other global health challenges—for example, related to climate change? So those two blocks of time will take us up into about forty minutes or forty-five minutes of the conversation, at which point we’ll be opening it up to questions from all of you, and the operator will be able to instruct everybody how to pose a question at that point.

I do want to take a moment to mention that Natasha will unfortunately have to be leaving early to get to another urgent meeting, so she’ll be signing off at about 12:10 or 12:15 or so.

With that, let’s go to the first round of our discussion, which, as I said, is on the strengths as well as the challenges that we’ve seen in global response to COVID-19. And again, I’ve asked each of our discussants to offer several minutes of comments. We will by no means exhaust all of the lessons learned in that several minutes, but hopefully this will set us up for a very good discussion about how we need to get ready for the next set of emergencies, as I mentioned earlier.

So, Chikwe, I’m going to start with you. As we look back on our experience to date and continue to think about working our way through what remains of the COVID-19 pandemic, and we don’t know what the dimension of that will be, what do you think are the primary strengths of the response and the challenges of the global response that we’ve seen to date?

IHEKWEAZU: Excellent, and thanks for having me. I think I’ll flip the question and start with the challenges and then move to the strengths. It just makes the framing a little bit easier.

You know, I think there are three broad challenges that we in the emergencies program of the World Health Organization are kind of trying to deal with. One is the one I’m directly responsible for, the—our global capacity to detect and to use information to inform the decision making. And we’ve seen our political leadership struggle with this across the world, north, south, rich, poor. Our leaders have struggled to make use of the information that we have tried to provide to them to make those decisions. And we have been challenged in our ability to rapidly access, analyze, and offer them the data to make decisions. In the past decisions relating to the health sector that our leaders had to make were maybe around vaccination policy, maybe around outbreak response, but now we saw our political leaders across the world having to decide on whether to shut down their economies, whether to ask people to change their ways of life completely. You know, so these were decisions with huge societal implications. It also means that the infrastructure that we have to enable our leaders to make those decisions has to exponentially improve. So we saw a big, big mess in the data systems; we’re now working very hard, and that’s the raison d’être for the—a new WHO Hub for Epidemic and Pandemic Intelligence, to make sure that, yes, we cannot—our leaders will ultimately make the decision they need to make. They are elected to do that. Our responsibility is to make sure they have the best information possible to do that.

Quickly, to touch on the two other important areas. 2005 the world came together and agreed on a framework called the International Health Regulations to guide the way that we work. Through this response we found that there’s some deficits in that in terms of how we hold ourselves accountable to do what we need to do, given that there’s no world government and we live in one world, so we have to have framework through which we agree on what we need to do, and therefore we are now working through a new set of agreements, the member states into a new instrument, the legal instrument that hopefully will improve the governance side.

So, firstly, I talked on operational ability, operationality. Secondly, on the governors. And thirdly, on financing. If we want this place to improve our space, we have to devote more time to it. If we really think the health security is an existential threat, one; but secondly, if we calculate the cost to the global economy that we’ve gone through this pandemic, then we will change the mind frame with which we invest in this. And so in those three areas, those are the three kind of big gaps aggregated for this combination in terms of the tools and the systems, the governance and the finances that we have available to address these very hard challenges that we face.

DENTZER: Well, thank you very much. And I noted very little discussion about strengths in there, but that’s all right. We can come back and build on that later.

So with those three challenges that Chikwe has laid down now, the challenge of getting information and making use of it, the challenge of having any kind of a global governance structure, agreed upon set of ways we’re going to proceed through the next global health emergency and then, the third, financing.

Let’s go, Agnès, next to you, building on what Chikwe talked about. What do you see as the predominant challenges going forward that we have discerned from the COVID-19 pandemic?

SOUCAT: Thank you. Thanks for that question. And I think I’d like to start by saying that, interestingly, what this pandemic has shown is that the issues were the same for all countries in the world, so whether it is France, my country, or countries that are much lower levels of income, they all had to face the same challenges. And this talks a lot about the challenges of globalization. And I think vis-à-vis those questions, there are three fundamental questions that lead us to revisit how we were handling those common global health issues. First the response—the prevention and the response to the COVID-19 pandemic is a tragedy of the commons and this is well documented throughout the history of modern societies is this difficulty we have in handling those functions that cannot be handled by the markets because there are market failures. Those functions that need collective action; we need to all work together as citizens. And definitely those core public health functions are commons, they are common goods, which means they are either pure public goods and global public goods or they are functions that have market failures that markets don’t deliver on. And as the world experienced globalization over the past decade, there hasn’t been a parallel development of the functions and the institutions that need to handle the failure of this global market. And this has failed everywhere. This has failed in France, in European countries, in northern America. In all countries we have, over the past decades, underinvested in surveillance, in regulation, in coordination. We know in animal health and environmental health programs we had public health agencies that were defunded. That was the case in several countries. So this realization as a body of citizens that we need to prioritize investments in what cannot be purchased with a fee, but that we need, actually, to fund collectively through a taxation mechanism is absolutely fundamental, and it is true at national level, but it is also true at global level. And we will meet to find a way to fund those global functions.

The second lesson learned, and I think, again, is universal, is the fact that our public health framework is outdated and the way what we call global health or global health initiatives have handled global health issues has been very much on the disease, per-disease line. So we have basically addressed the issue of global health one disease at a time. And this doesn’t work anymore in 2020, in this onset of the twenty-first century. We know the pandemic has shown that what has led to the pandemic is the same kind of system and particularly food systems and environmental management that led to both the emergence of epidemics and this pandemic and is also responsible for the growing epidemic of noncommunicable disease. It’s about our food systems, it’s about our environment. So we really need to embrace now a new public health framework that is around one sustainable health, bringing together these functions of surveillance and regulation with the key public health programs that address not only human health through infectious disease and noncommunicable disease but also animal health, environmental health, and address the fundamental issues linked to environment or degradation that is—whether it is climate change, pollution, biodiversity laws, or the consequences of our food systems, such as AMR, for example.

And the last lessons I think that this pandemic has taught us in France, in Europe, and everywhere is a governance lesson. We’ve really learned very painfully that we need to have different spaces for the science discussion and for the political discussion, and wherever these two are mixed under the same governance it is not working very well. We need autonomous, independent, transparent science institution. We’ve seen during the pandemic the incredible response of science institutions everywhere in the world, you know, South Africa, the U.S., Europe, Asia. Everywhere you had the science institutions communicating in real time, publishing preprints before this could even be envisioned. Immediately data being available, being made public, being exchanged, being discussed.

We need to foster this kind of collaboration, horizontal collaboration between independent, autonomous institutions that are not under political control. And in the same way, the political space needs to be better organized to be able to listen to the scientists but also to listen to all segments of society and particularly to have an approach of participation, to listen to citizens, to listen to the economic sector, to see what is—how to develop policies that are acceptable to people and are in line with the science guidance. And in France we had really a fantastic experience with that, with the scientific council, which was fully independent, with academic experts but also autonomous institutions contributing, and then we had the security council that was political and was making the decision. I think we really need a world in which the scientists do the science and the politicians do the politics, and there will be tension, there will be a lot of discussion, but this is what is needed if we want to have the best response possible. Thanks.

DENTZER: Thank you very much, Agnès. And you’ve built on Chikwe’s comments in a very wonderful way, drawing the thread of the problem of governance; as you said earlier, the need for developing a new public health framework that is much broader than the one that we’ve had and not as disease-driven, as you said. And then this last point about letting the science advance while the politicians, frankly, listen more to the science. I think obviously we’ve seen the need for that play out across many countries.

All right, we’re going to now move to Vernon. Vernon, your sense of the strengths—and I’ve noted—(laughs)—almost no one was able to talk about strengths. That says a lot. But let’s continue this discussion about the challenges that we have seen through the pandemic and how we envision, as we will talk about in our next segment, how we envision building on whatever strengths do exist to have a better response to public health emergencies to come. But looking back on the pandemic to date, Vernon, challenges that you’ve seen.

LEE: Thank you so much. And maybe I’ll just add a few strengths to this mix as well, because I think with every challenge there are also a lot of strengths, a lot of opportunities that we have seen during this pandemic that we can really learn from. And to me, building preparedness and also resiliency, not just in countries but as a, you know, global community is not something that can be done overnight. It is something—there’s an iterative process that requires planning, responding, learning, and revising all over again. So the COVID-19 pandemic to me is a good opportunity for us to learn as a community to build upon the strengths but also to look at the challenges and try to address them so that we can better prepared for whether it be a new variant of COVID-19 or a new disease X in the future.

So countries that have responded and learned from previous pandemics, epidemics, and other health emergency crises I think have been placed in quite good stead in responding to the COVID-19 pandemic. Singapore is one such country. I mean, we have responded to SARS in 2003, pandemic influenza, and many other epidemics in between, and that has helped to shape our preparedness and response plans and programs, and so when COVID-19 hit, of course it’s a different disease; there are a lot of curveballs that COVID-19 threw at us, you know, and as a pandemic is extremely long-drawn and a lot of these things were not in, I think, most countries’ preparedness plans. But because we had that tool kit, we had the building blocks that we were able to mobilize. We were able to then respond flexibly depending on the nature of the situation.

One of the things that went quite well for us and I saw it went quite well for quite a number of countries as well is a whole-of-government approach and collaborations across countries as well. And this is very important because the pandemic is not just a health sector issue; in fact, a lot of responses were way beyond the health sector—the lockdowns, border restrictions, the need for, you know, financing of many of the measures that were rolled out, surge capacity were not just some things that the health sector or the ministry of health and so on could deal with it alone. You have to bring in the whole of government to support, for example, the flexible deployment of capacity to deal with surging cases, distribution of vaccines, and even things like the socioeconomic impact of the public of interventions, which in many cases were necessary to slow down the spread of the virus but creates a whole different set of issues. And I think this whole of government and also multilateral collaborations helped to achieve and to lessen the impact of many of these public interventions.

The other thing also is a whole-of-society approach. We saw this in many cases in Singapore but also in many other countries where the collaboration with community—whether it’s community leaders and members of the community themselves to good communications and other engagement platforms have identified, for example, groups at risk of health issues so that we can target interventions towards them and also social-economic issues so that we can deal with them and that those social-economic issues will not become an impediment, for example, to access to health care and so on.

So I think there were a lot of strengths that could be gleaned from this. Of course, some of the challenges on this front were, for example, the unexpected and, in many instances, uncoordinated responses, especially, for example, in border control. If you recall in the initial phase of the pandemic there were a lot of different types of border controls that people had rolled out and travel and trade at one point in time dropped to levels not seen in the past fifty years. I think this was extremely detrimental on many fronts, not just on the health front as well.

The other issue is, of course, the equitable and sustainable development and distribution of many resources, and I think it was mentioned by our colleagues earlier, and it includes important supplies like stocks of masks, test kits, vaccines, therapeutics, and so on. I think the world needs to invest more in terms of the sustainable development of such technologies and resources and also the equitable distribution such that more people can have access to these critical resources as fast as possible.

And then, of course, there’s the local responses. So I mentioned earlier lockdowns, and while I think quite a number of countries that managed a lot of their non-pharmaceutical interventions in quite a good way with the whole-of-government and whole-of-society approaches, the lockdowns and a lot of the non-pharmaceutical interventions created a lot of issues, not just with health access but also social-economic issues and mental health issues that I think were not in a lot of the preparedness plans, because a lot of preparedness plans, like I mentioned, were trying to deal with the health problem, whereas COVID-19 really showed that it is not simply a health problem, it’s actually sort of a whole-of-society and a global problem that needs to be tackled with a lot of collaboration across different sectors.

So these are the challenges that I think, while we have dealt with—at least in Singapore we think that we have dealt with in quite a good way, we have been collaborating with a lot of the different sectors, collaborating with different parts of society. We have tried to minimize impact of the pandemic as much as possible. But at the same time, there are a lot of lessons for us to learn, especially in areas of sort of faster-response collaboration, not just within the country but across countries as well, and this is another, I think, success stories that we could share, which is the rapid collaboration and information sharing both on the risks and effectiveness of different responses. I think there’s a mention about, you know, countries sharing data preprints on the effectiveness of different interventions and how different countries have dealt in their own way to slow down the spread of the pandemic. And also vaccine development was another, I think, very good outcome of this pandemic. I mean, we managed to develop a new vaccine, brought it to market in less than a year. The distribution and the subsequent supplies of those vaccines of course can be improved upon, but it is still no mean feat to be able to develop, you know, all the research, clinical trials, licensing approvals within such a short period of time. So I think on the—if you look at two sides of the coin I think there’s a lot of things that we can be proud of during this pandemic, especially in the rapid sharing of information, the collaboration within and across countries, but also a lot of things that we can strengthen, especially, like I mentioned, the coordination of responses at a global level and also sustainable, equitable development and distribution of resources.

Thank you.

DENTZER: Great. Thank you, Vernon. And thank you for acknowledging that at least some things went right, as you have just said, the very rapid science, development of vaccines and therapies that really has broken all kinds of—(audio break). As you said also, the ability of many countries to have learned from previous public health emergencies—(audio break)—have the building blocks already—(audio break)—as you had mentioned or had done, as well, as much of—(audio break)—particular coming out of the prior SARS pandemic. So at—(audio break)—things to look back on, really, or build on for the—(audio break).

So now, Natasha, let’s go to you. Your sense of the challenges and the strengths surfaced in the COVID-19—(audio break).

BILIMORIA: Great. Thanks so much, Susan, and it’s great to be here, and I will just apologize up front for having to leave a little bit early but I’m really glad to be part of this conversation.

It’s always tough to go last after having such a really rich discussion. And I’m going to add a couple points but I think a lot of what has said is—you know, I think it’s a common theme from all of our experiences. And you know, what I’d like to say, to start with, is obviously what we’ve all gone through in the last two and a half years has exposed every challenge and weakness within, you know, global health and development, but when I think about looking at it from a very specific health space, I think the most prominent thing that was made clear in everybody’s mind was the systematic weaknesses in health systems around the world.

You know, Agnès said that no country, rich or poor, you know, U.S., Malawi, no one was exempt from these challenges, and you know, even our country that spends more on health care than anyone else in the world, we were ill-prepared, and as was everybody, on how to really deal with, you know, what we were going—what was coming down the road and what we have been dealing with. And, you know, then when you add fragility that so many countries around the world are facing and additionally these, you know, conflicts that we are seeing pop up day in and day out around the world, all of these things really put health systems down a very, very difficult road and, you know, severely impact people’s abilities to access quality health care.

So when I was thinking about this question, you know, what really came to mind in all of this was I think what this pandemic exposed for me was the total lack of connection between a country’s public health system and its health delivery system, and this was a huge failure around the world. You know, a public health system that is chronically detached from the system that is actually built to deliver lifesaving interventions and services to implement them, you know, that’s really the divide that we saw and, you know, in a lot of places, including low- and middle-income countries, you know, there are surveillance systems in place, lab capacities, and strong public health programming that provides critical commodities and services. But what the pandemic showed was that the broader health delivery system was not able to meet the needs in a time of crisis. And so I think COVID really exposed this failure, but to try and be a little bit of a glass-half-full, I think it also really has provided all of us in the global community to create a lifesaving connection between those two areas, the public health system and the health delivery system, to ensure that we are able to overcome, and in my view that is really where the hope and opportunity lies in what we’re going through.

And, you know, in my tenure at USAID, which is just a little over fifteen months, you know, I’ve been heavily involved in the agency’s response to the pandemic and also working closely with countries to rapidly respond at the time of deadly surges, and, you know, we’ve seen that they have, in some cases, the capacity to test and treat and in some places they don’t. Where the oxygen needs are and where it is just nonexistent. And we’re also seeing who is getting vaccinated and who isn’t. And, you know, we’re really learning firsthand about where the capacity exists and where the gaps are. And we’ve been really working through our COVID response work to work with countries to meet their immediate needs to vaccinate their citizens, provide critical testing opportunities, and really ensuring that the public health system has the critical therapeutics, including oxygen, to save lives and really decrease severe illness, wherever possible.

And what I would also say, and I think one of our former speakers brought this up too, is that, you know, the need for strong coordination and planning are really the foundational elements to this response or any response. And, you know, investments—as we think about what comes in the future, and I know we’re going to discuss this shortly, we do want to ensure that the investments that we’re making in these areas have lasting effects on the government’s capacities around the world. Because this is not going to be the last time we see an outbreak, but we really do need to make sure that it’s the last time we see something like this for a very, very long time.

And, you know, I—look, a couple of others points just to make is that I think that strengthening partner government capacities to coordinate and plan has been a core area of USAID’s support. This, again, has had lasting benefits on the government’s coordination and response capacity moving forward, and it also ensures that the ministry’s partners and the funding is also really aligned in the future to address a public health emergency.

And so, you know, I want to—I guess I’ll leave it there. But again, I think a lot of what my fellow panelists have said, you know, really show the challenges. But I think this disconnect between these two systems is something that’s been exposed, and something that I think we need to work to bring closer together in the future.

DENTZER: Great. Well, thank you so much, Natasha. And thank you for adding and underscoring—(audio break)—Agnès said earlier, that we see the same weaknesses around the world, that all countries share similar—(audio break)—of the same set of challenges as you and our other speakers have said. And this issue that you just identified, the lack of coordination, cooperation, and even ability to work together of public health systems of various countries, with the health-care delivery systems in those countries, has been particularly pronounced, as you said.

So, staying on that point and the point that you just made also about—(audio break)—have even better coordination and planning between those sectors, as well as among nations with respect to those sectors, I’m going to give you the first crack at this next phase of our discussion, which is: What do we do now to be ready for the next set of public-health emergencies? And to tie in what you—what Agnès said earlier, we saw—we have—(audio break)—dramatic underinvestment around the world in public health, and this tragedy of the commons that—(audio break)—has been true around the world.

How do we think about addressing that, when it really is going to come down to the political environment in every country? As she said earlier, it’s going to require—(audio break)—an investment in sectors to—(audio break)—deal with the—(audio break)—to deal with the tragedy of the commons, to create health investment. How—(audio break)—will we make a difference in that as a world going to come down to a country-by-country challenge, do you think?

BILIMORIA: Yeah. So, you know, I think this is—this is really the crux of the matter. And, you know, what I want to focus on, actually—again, just continuing on with the—with what I’d said earlier—is really, I think, this is a critical time to ensure that as a world we are looking at health systems. You know, we—over time, we have had—you know, again, I think we’ve had a lot of success in our global health programs, but they have been very siloed in nature. And I think, again, when we look at what we’ve seen over time, the common denominator is a weak health system. And I think if there was ever a time to focus on strengthening health systems around the world, this is it. This is our moment.

And so—and we’ve seen that when countries actually consistently invest in their health systems, they lower the direct and indirect impact of emergencies like COVID-19. And they also improve their chances, moving forward, to be prepared to respond more quickly, and also maintain the essential health services that their citizens need. Because that’s another piece that we saw, that, you know, in every health area, you know, services were stopped. And we’ve seen a huge backsliding in decades of global health success. And, you know, speaking on the U.S. side, you know, bipartisan success. This is something that has been supported by both sides of the aisle for, you know, double decades. And I think we have to do everything we can to ensure that we don’t lose out on those successes.

And so I want to frame kind of how I see the future with health systems in sort of three key buckets. I think one is, is how our COVID funding is not only working to support the immediate response to the pandemic in countries, but also building and strengthening broader health systems in countries. So it’s not a one and done thing. What we are really trying to do is ensure that the funding we’re using right now actually builds something that can be strengthened and—well, it’s either strengthening something that’s there or really building something that needs to be there as time moves forward. You know, and with that, I think that helps reduce that gap that I talked about, between the health—public health system and the health delivery process moving forward.

The second is really around how are we looking at global health security and pandemic preparation, and how this also works to build countries’ health systems moving forward. And the third is—and definitely not least—is what we are doing, again, as it relates to health systems writ large. And USAID about a year ago published a vision for health system strengthening. And it’s really a framework that shifts the focus away from disease-specific interventions on health systems. And we’re really looking at strengthening health systems in a way that is much more holistic in nature. And with all of these categories, everything we do is looking at the quality of support, the equity that’s being provided, and really looking at resource optimization, so that we are assisting and partnering with countries to do what’s best—to work with them on what their priorities are, and hopefully have a real ripple effect across the entire health system, and not just specific stand-alone functions.

And so an example on the COVID response would be, you know, one of the areas that we have supported is regulatory systems reform. This is actually a foundational investment that we’re making in health systems, and that can really mitigate medical product shortages, facilitate expedited, timely introductions of safe and effective medical products, and really identify and remove falsified products from the market. And time and time again we are hearing that this is really a critical strength that is, again, needed across a number of different areas within the health system, and can really ensure that countries are able to deal with a number of areas with this—with this sort of—with this sort of help.

The second, again, around the global health security area, is really strengthening systems to prevent, detect, and respond to emerging infectious diseases. And that’s really a critical part of the broader global health investments that we are making. And, you know, we’re doing this in a variety of ways, working to support partner countries, to prepare and respond for things in the future that are happening. And also realizing, as was mentioned earlier—and we’ve been doing this for quite some time—is really looking at it from a multisectoral approach. It’s not just about, you know, diseases in humans. It’s looking at, you know, the overall environment where diseases can exist, and really looking at it from a one health approach standpoint.

I also just want to add that I think this is also a good moment to add about an initiative that the United States and a number of different countries have been really advocating for, which is the creation of a financial intermediary fund to really look at the broader strategy around pandemic preparedness. It’s been said here a few times that, you know, we always deal with what’s right in front of us, and then when the—when the issue, you know, dissipates, we sort of go on as we did before. And I think, again, this is absolutely the time to be doing this work now to ensure that, you know, all of us around the world are set and ready to prepare and prevent and detect and respond to things that may happen in the future. And I think the FIF really allows for a global partnership amongst countries to really do this together, and really prioritize investments to strengthening countries’ capacities, including surveillance and pandemic preparedness, for emerging threats that may be coming down the pipe.

And then lastly, just to say a world on the vision for health system strengthening, you know, again we—this is a critical part of what USAID has been doing, you know, overall on health systems. And the vision is really aligned with a new initiative that was actually just launched this morning with the White House on global health—a Global Health Workforce Initiative. And, again, it’s really looking at what are the things that run across these areas of health that are required to really strengthen systems and programing overall? So I guess I’ll stop there. But again, I think that we really do have an opportunity at this moment to focus on systems in a lot of different ways and ensure that people around the world are getting quality care and also getting it in an equitable fashion.

DENTZER: Well, thank you, Natasha. And I know you have to leave shortly. But let me just ask a quick follow up. For—(audio break)—for health system strengthening that you said USAID had released, is that still available on your website? Could those in the audience who want to learn more about that access it there?

BILIMORIA: Absolutely. And we can probably share it with you all, but yes. It’s called the—it is on the website, and in a lovely PDF format. And so you can read it online or print it out. But it’s really actually, I think, in many ways, very groundbreaking and really looking at things in a more holistic way.

DENTZER: And then secondly, you mentioned the proposal for a financial intermediary fund. People who want to learn more about that, could they find that on your website as well?

BILIMORIA: Muted. So that is something that can be found on the White House website. And again, happy to, you know, share some information separately. It is something that’s actually being focused on within the G-20 process as well, so.

DENTZER: Great. OK. Thank you for that. And again, we know you have to go. Thank you for joining us today.

All right. We’re close to the period of time when we were going to start to take questions from the audience. Let me just ask the operator to come on and let everybody know how to pose their question. If there are questions, we’ll go ahead and take them. If not, we’ll resume some of our conversation about preparation for the next set of public health emergencies. So, operator.

OPERATOR: Thank you.

(Gives queuing instructions.)

We’ll take the first question from Katherine Hagen.

Q: Thank you so much. I’m based here in France, and I’m very impressed with what, Madam Soucat, you’ve been discussing on this. And I would like to raise a question about the way in which that approach could be globalized. I know there has been a lot of initiatives with the Gavi program that are oriented to trying to bring multistakeholder groups together. But there is also a very interesting proposal that Bill Gates has proposed in a recent publication. The acronym is GERM, Global Epidemic Response and Mobilization team.

It would be interesting if you and others in this panel would comment on the way in which a global approach that would combine a parallel approach of experts with politicians making policy decisions could be adapted from what the experience is that you’ve had here in France. I’ve certainly benefited from what you’ve done here and do appreciate very much how that is being developed and how the French have been very active in supporting a global responsive strategy. And I would be interested in your reflections on these particular proposals that have been coming forward in recent days.

DENTZER: Great. Agnès.

SOUCAT: Thanks. That’s a super interesting question. And I wish I had the answer. I think it’s the conversation that is taking place now to see how are we going to reform the global health architecture to be better ready for the next global health threat? But generally, for all the health threats that are going to be linked to the looming environmental challenges, particularly global climate change and biodiversity, that are spread. I think that the—to give you a quite clear answer, I think the very first point is to have independent science. So how to go about it? I think that probably if we learned from the pandemic, and everybody recognizes the success of the lateral—the horizontal approach—is to have a network of networks, and really bring in all the national CDCs. I mean, Chikwe was heading one of them until recently.

The CDCs have done generally an excellent job, but also academic institutions, science institutes, and really invest in their capacity to research, but also their capacity to communicate and develop some level of coordination. But that coordination should really be having a science governance or should be under some kind of consortium of academia or a consortium of scientists. And that’s something that needs to be created. It just doesn't exist now. It’s just that kind of a free exchange. So certainly, in the European Union we are moving towards that and having that network of scientific advice. We now have Professor Peter Piot as the scientific advisor of the head of the European Commission. But this is really a very first priority.

The other part which has really not worked that well during the pandemic is the financing, purchasing, and distribution of products. And there, Natasha was mentioning the FIF, the Financial Intermediary Facility for Pandemic Preparedness at the World Bank. I think it’s really a first very significant step towards improvement in global financing for preparedness in pandemic, first because it focuses on preparedness. So it is about financing public health institution, financing health systems, like Natasha said. It’s not about buying products. It's about financing institutions at national, regional, and potentially financing these networks of science.

And what is fundamental, what we’ve learned, what has really not worked with COVAX and ACT-A is that too many functions were in the same—in the same, small public-private partnership at global level. And it was—it was raising funds. It was identifying the distribution formula. It was purchasing and it was distributing. And this was very, very centralized. And it really did not deliver for certain regions, particularly the Africa region, which found itself at the end of the queue. So for that, what is important is the unbundling of functions.

So we need—we need purchasing functions that are probably more in the hands of regions and countries, so that they can purchase what they need, and they can develop mechanisms to invest in the production of medical products that they will need. So there is now a whole line of support to vaccine production, and potentially pharmaceutical production in Africa. It’s really the lesson learned about the market failure of global supply chains during a pandemic. During a global crisis we saw that what happened was that when you have a shortage, then the market is—takes time to respond. And the fact that the global supply chains were essentially very concentrated in a few countries left some regions of the world with no access to products.

So there is really a need to underline that. And when it comes to financing, financing actually in this crisis was quite a success. So science was a success. Financing was a success. Massive amounts of financing have been mobilized during this pandemic in hundreds of billions. There was mostly—it was mostly through borrowing, guarantees, credit lines. There’s been really a response in terms of economic response, in terms of social protection response, protecting households, protecting businesses. So financing has been a success, but when it comes to financing health and pandemic, in fact there was no—again, no connection between the financial institutions, with very big capacity to finance and very deep pockets, and the funds that were funding the response and the vaccine.

So you had two kinds of response. You had the response from the financial institutions—the World Bank and my institution and all the different financial institutions. But that response was not fully articulated with the global response. So there, there is really a need to structure financing around the FIF in a way that mobilizes all the financial institutions towards financing both pandemic preparedness by providing incentives. That’s what the FIF at the World Bank is supposed to do, is playing a level effect. Providing incentives to countries to invest more in public health institutions, in surveillance, in regulation—in pharmaceutical regulation. And also, being the facility that allows the mobilization of large amounts of financing in times of crisis. And that can be done only by financial institution.

And of course, ultimately, at the end, the World Health Assembly in the WHO is the political organization. So it is naturally the space where the global political discussion is taking place. And then they would have to find—we would have to find a way to see how the exchange takes place between the network of science institution and the political body that is—that is the World Health Organization.

DENTZER: Thank you so much, Agnès. These are incredibly robust subjects. We could spend a lot of time on all of these. In the interest of time, since we have only about twenty minutes left of our conversation today, may I ask both our questioners to be crisp in their questions and our discussants to be as crisp as possible in their responses so that we can get to as many questions as possible.

Operator, let’s go to the next question, if we may.

OPERATOR: We’ll take the next question Daniel Spiegel.

Q: Yes. Thank you. I’m—my name is Dan Spiegel. I’m a former U.S. ambassador to the U.N. in Geneva.

We’ve been talking a lot about strengthening health systems and pandemic preparedness. But don’t you think—do you really think the WHO is fit for purpose today? I see it as too political, too bureaucratic, too over-mandated. And I’m wondering whether we need a real reform of WHO, more like turning it into an organization that looks more like UNHCR in terms of focused on strengthening health systems and pandemic preparedness, with offices and operations in developing countries, rather than this huge headquarters in Geneva? And so I just ask that question, because I’ve been troubled by some of the impediments that are clear at WHO.

DENTZER: Well, I think we have to put that question to you, Chikwe. What do you think?

IHEKWEAZU: Thanks, Daniel. To answer that question honestly, I want to take off my WHO hat, because I’ve only worn it for six months, and put on the hat of leading the Nigeria Center for Disease Control for the last five years and working in this space for the last twenty-five years. And WHO takes a lot of criticism, but I tell you, most honestly, working in Nigeria over the past five years—now, Nigeria is unique. It has 200 million people. Tough socioeconomic circumstances. Right on top of the equator. The highest population density, in addition to population, on the continent. So there couldn’t be a better place for viruses to emerge. And they do emerge all the time.

The support that WHO gives to member states in every country is unique because it doesn’t come with an agenda, right? We can rely on this organization that has country offices in Nigeria to support us, but also global expertise to support their country officers to support us. So I think—and, in a way, to solve the problems that we have all been part of in the last twenty years, we have created so many other organizations, given them a lot of money. They don’t have the accountability to member states. So they appear to be more agile, more flexible, because they don’t really have the governance mechanism and the requirement to be accountable to the people that they serve.

So I think we can’t even judge WHO at the moment, because we have never resourced this organization to deliver on its mandate. I think for the first time in—at least, in my lifetime—there’s a real opportunity to not only provide WHO the financial resources but also the encouragement, the support, and galvanize around it, so that we can carry out this critical mandate we have for the world. Within the organization, I have met a set of incredibly hardworking colleagues with very few resources, thinking very hard every day how to work. Whether it’s Ukraine, whether it’s for COVID, whether it’s in Tigray, colleagues are putting their lives on the line every day without asking questions.

So I think the world has a unique opportunity to stand up and support this organization to deliver a critical mandate for the world. At the same time, we need to be open to the criticism of areas that we can improve absolutely. And I think the group I lead right now, the new WHO hub for pandemic and epidemic intelligence, is a real indicator that we are listening—that the organization is listening and responding to the critical challenges of our time, knowing that we have to kind of work a little bit differently and respond to the critical needs at the moment.

So that’s my short response. Just recognizing that we don’t have too much time left. I just noticed that Vernon has had his hand up for a while. Maybe we can let him come in as well.

LEE: Yes, thank you so much, Chikwe. In fact, I wanted just to add to what you had mentioned as well, because what you mentioned is very important. And I just say, from a member state’s perspective, I think there have been enough sort of discussions and also enough platforms that have been created. And what we need to do is not to create more platforms. What we need to do is to strengthen the existing ones that we already have. And we have seen them actually been quite effective on certain fronts.

Of course, can they, you know, be better? Sure. But I think exactly like what, you know, Chikwe mentioned, this is where WHO as a global convener can come in to do a few things. Not just for, you know, individual countries like Singapore, but also for the global community. And these things include obtaining early information and also providing risk assessment. Because that’s what we really need. And I think the new setup that you’re heading, Chikwe, I think is a huge step into doing this so that we can have better information globally to be able to make the right responses that are proportional to the threats that we face.

The other, of course, is also coordinating global responses so that we can enable the best measures that can be brought to bear. Whether it be to contain a disease that’s containable or, if a disease is not containable, to see what can we do as a global community to mitigate the impact collectively not to have sort of, I guess, actions where some countries may benefit more than others, and so on. I think one of the things that have been touched on earlier by Agnès would be the sustainable distribution of resources, whether it be supplies, therapeutics, funding.

And this is where I think WHO, and of course countries, will have to come in as well. Because it’s a two-way street. No global organization or donors can come in and say, you know, let’s address this in a specific country, if the country themselves do not want to invest resources. And resources might not just be money or financial resources. It will be manpower, effort, and so on. So we cannot rely solely on donors. Countries have to put their resources into this and also work together with others in sharing of best practices.

And this is where I think the last thing that WHO and other global platforms can help, is to help countries in building capacities through their lessons learned from other settings in other countries. We don’t have to always go through, you know, a crisis ourselves to have to learn things the hard way. Of course, there are countries that have already done so. And by putting all these best practices, and really stringing all these together into a toolkit that can be shared, I think we would be in a much better place.

So I would strongly urge, I think, everyone to really work together, and also work together with WHO and with all the existing platforms that are available, and there are many of them, to make the preparedness and response for the next pandemic a much better one. Thank you.

DENTZER: Great. Thank you very much, Vernon. And thank you, Chikwe, also for your earlier comments.

Operator, let’s go to the next question.

OPERATOR: We’ll take our next question from Thomas Bollyky.

Q: Hi. Thanks so much to a great panel. I’m Tom Bollyky. I direct the Global Health Program here at the Council.

I had a question for Chikwe and Vernon in particular around metrics. There had been a number of efforts put forward beforehand to pull together measures of a public health system’s capacity to respond to a dangerous disease event. There’s been some speculation on how well those metrics have performed in this particular pandemic. And I was curious, from your two respective posts on the global side and on the local side, how you would like to see those metrics adapt to what we’ve learned in this pandemic.

DENTZER: Vernon, why don’t you take that first? And then we’ll go to you, Chikwe.

LEE: Sure. You know, I think, you know, there are always pros and cons of different metrics. And where we try to score something, you know, with whatever metric, I think, you know, there will aways be some advantages but also some shortfalls in that. So I don’t think we can say using a certain metric to say we rank countries, or that we say a country is prepared or not prepared. A lot of times the, you know, proof of the pudding is actually eating it. So you have to actually go through a certain crisis to see if you have the capacities and you have the resources to actually respond to it, and then to improve on it. And that’s part of the whole exercise.

I think metrics are a very good assessment of how we’re doing. And it will change across time as well, both the measurement metrics and also the country response to those and the scoring because as you go through different crises you will improve on your sort of capacities and, of course, scoring on those metrics as well. So I think in a nutshell for Singapore, I mean, we have gone through, you know, various things. For example, the joint extended evaluation for IHR capacity building. We’ve gone through other different exercises in trying to find out if we are able to handle different emergencies, and so on.

And I must say that while we have scored reasonably well on these indicators, we have also realized that when we have responded, for example, to different crises—whether it be SARS or the COVID-19 pandemic—there are certain things that the metrics do not actually measure. And those are a lot of the coordination and operational issues that we are faced with. I think one of the earlier questions was about, for example, the coordination between scientists and the politicians and other sectors, for example.

And this is where I think it’s not such a simple question as to whether should we let the science lead things or should we let the politics lead things or should we let the policy aspects lead things and so on, but it’s really how do we collaborate closer together to develop more evidence-based policies, to really hear what the population wants, and how the population’s affected by different things that we do. And all these are very difficult to measure on certain metrics. So in a nutshell, I’ll say that metrics are good for us to have assessment. It's like going to school and getting an A grade, you know, at school. But actually, when you go into the job getting an A grade doesn’t guarantee that you will be good at doing the job. But it’s a good start. And then you build on your résumé and so on and so forth along the way. Thank you.

DENTZER: Great. And, Chikwe, briefly, your—(audio break)—about metrics.

IHEKWEAZU: I’ll deal with it very briefly, because I think—I love Vernon’s last analogy. It gives me something to use in the future. But to be honest, think just—Thomas, it’s a good question, right? But I think we must all hold back a bit in judging our countries based on this pandemic. You know, we were struck by a very bad virus. Could we have done certain things better at certain points? Absolutely. But should we throw away the baby with the bathwater? I really don’t think so, right? We’ve worked—these metrics have driven a lot of investment in many countries around the world on health security, on preparedness and response, and have pushed our leaders in many countries that previously did not take this work seriously at all, we’ve all developed national action plans for health security. So really how you judge the metrics is really what do you want the metrics to do?

If you’re judging the metrics on its utility in defining how each country responded to this outbreak, then that’s one point of view. I would argue it’s too narrow, but ultimately that’s one of the—part of the responsibility that I have now with many colleagues to really develop the whole analytic space, to move from a kind of static measurement of once every five years, or whatever, to a much more agile way of defining vulnerability and risk that really would give us—and the tools to do that exist. Only that to a large extent we are lagging a little bit behind in our public health utility of many tools that exist and are being used in many other parts of daily life. So I think there will be a lot of improvement in this space. Ultimately, do I think that there’ll be perfect metrics that will work in every country of the world? I don’t think so.

DENTZER: Great. Thank you.

We have a couple more questions in the queue. We’ll try to get to them both, but let’s at least take the next one, Operator. And, again, encourage our discussants to keep their answers crisp. Again, understandably there is so much to say on these topics, but we’ll try not to say it all. All right. Let’s go to the next question, operator.

OPERATOR: Thank you. We’ll take the next question from Patricia Rosenfield.

Q: Thank you very much. And thank you so much for this important and provocative discussion. I’d like to return to what Agnès talked about at the beginning in terms of global public goods and the building of horizontal networks. And I’d like to extend this from the pandemic issues to other existential crises that the world is facing, namely the climate crisis, and now the impending food crisis.

And so I’d like to ask the panelists how—what kind of horizontal network can be built across those groups, both scientists and global organizations, as well as perhaps—going back to Vernon’s comment on whole of society and whole of government approach—to build a connective response? Because we know the intersectoral nature of those crises will have tremendous intersectoral impacts. So I’d like to know what—really looking toward the future, we know these will all be affecting human health and wellbeing, how do we go forward to build the kind of sense of global public good, connectiveness, and institutional arrangements that will make—that will enable us to deal with those crises?

DENTZER: Well, I think we have to give that one back to Agnès. Agnès, would you take that on? And we do have just several minutes left, so please give it your best shot.

SOUCAT: OK. (Laughs.) Thanks. Yeah, thank you very much. Well, a couple of quick point I think is in today’s world—and we see now I think everybody’s pretty cognizant of what is coming our way in terms of changes in the world because of the environmental challenges, but also because of the profound changes in demography and in relationships between countries. And clearly, multilateralism is evolving very fast, and multilateralism we have, which is a heritage from post-World War II, is no longer fit for purpose.

And what we see emerging is really, I would say, something that is more like plurilateralism and those networks. And an example is really the amazing institutional construction in Africa that emerged from the crisis with the Africa CDC, with the African Union, with the role of institutions like the Nigeria CDC. What we see emerging is much more a world in which there will be a lot of information sharing that will be informal, that will not be necessarily controlled by governments. But that will probably be more like networks of networks. So countries, regional economic communities, would be a first network. Another network would be continental, clearly emerging in Africa, in (Asian ?). Certainly the case in Northern America, certainly the case in the European Union. So we have political spaces—regional political spaces that post-COVID are organizing themselves very rapidly. So that’s one way this can be organized.

And then with a global—a global role that would be a role of coordination of these—of these regional roles. So something that is much more—much more horizontal, much lighter at global level, and probably something that is much less centralized. You know, when some countries—some middle-income countries who ordered vaccines from COVAX received only 20 percent of what they ordered, it’s not because COVAX did not do its best. It’s because it’s just a centralized unique mechanism to purchase vaccine at global level is not going to work in today’s world. We all wish the world would be different. But this is not working. That’s what we sometimes trouble with, with the old public health paradigm, because the public health paradigm is quite centralized.

And we love having a strong ministry of health, and we love having clear instructions and clear central planning. But the fact is in today’s world is going to be evolving very fast. It will require much more interaction with civil society organizations and people responding to a pandemic, we’ve seen. You need to bring your people on board. So it will require networks that have different levels and different dimensions. And this is why it’s quite clear that global organizations will need to focus on their core mandate. They will have to evolve. So I really fully agree with what Chikwe and Vernon said about the important role of WHO. WHO is a political organization, and we need a political organization.

We need a conversation in which the different regions and the different countries have a conversation. And we need much more of that. It didn’t happen much during the pandemic. We didn’t have a lot of conversations of counties exchanging political experiences. And that’s—part of the reason is the current global political economy, which is, as you know, not very conductive to dialogue. And we face the same problems in the G-20, because there are very—a lot of tensions between different regions, different countries. But we need to continue to try.

Now, the key question—I mean, to just respond to the question—is whether we need a centralized organization in Geneva, an organization that has 8,000 people? Maybe not. Maybe we need something lighter, maybe we need something more decentralized. That’s where—other member states will have to decide how big a political organization should be.

DENTZER: Well, as I said earlier and as we have amply demonstrated over the last hour and a half, amazingly robust conversation among all of our discussants today. And I really want to thank all of them. Agnès Soucat, Chikwe Ihekweazu, and Natasha Bilimoria, who of course had to leave us a bit early, and Vernon Lee. Terrific conversation. And I think just putting it all down on—in plain view for all of us that the key challenges here really do revolve around governance and financing. Those are the paramount challenges that the world will need to take on as we get ready for the next set of health emergencies.

Again, I want to thank our discussants. I want to thank those of you in the audience today. We’ll end it here. Thank you very much for joining us and have a great day.


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