Thomas J. Bollyky, Bloomberg chair in global health at CFR, discusses recent changes to domestic and international health policies and the implications of a U.S. withdrawal from the World Health Organization (WHO) on global health programs and international health coordination. Manisha Juthani, commissioner of the Connecticut Department of Public Health, discusses how state health systems might be affected by changes in federal policies, trusted resources for public health data, and how state and local officials can respond to promote health and safety in their communities. A question-and-answer session follows their opening remarks.
TRANSCRIPT
FASKIANOS: Thank you. And welcome to the Council on Foreign Relations State and Local Officials Webinar. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR.
CFR is an independent, nonpartisan membership organization, think tank and publisher focused on U.S. foreign policy. CFR is also the publisher of
Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy.
Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments by providing background and analysis on a wide range of policy topics. We’re delighted to have you with us for today’s discussion. We have more than 580 state and local officials confirmed to join us from forty-nine states and two U.S. territories. So, again, this webinar is on the record. The video and transcript will be posted on our website after the fact, at CFR.org.
We are pleased to have Tom Bollyky and Manisha Juthani with us to speak on recent changes in public health policy and implications for state and local governments in the United States. We’ve shared their full bios with you, so I will just give you a few highlights.
Thomas Bollyky is the inaugural Bloomberg chair in global health at CFR and director of CFR Global Health Program. He is also a senior fellow for international economics, law, and development, and a senior consultant to the Coalition for Epidemic Preparedness Innovations. Tom Bollyky is the founding editor of Think Global Health, an online magazine that examines the ways health shapes economies, societies, and everyday lives around the world. And prior to working at CFR, he served in a variety of positions, including at the office of the U.S. Trade Representative and as a staff attorney at the AIDS Law Project.
Manisha Juthani is the commissioner of the Connecticut Department of Public Health. Commissioner Juthani previously served as a professor of medicine and infectious diseases physician at Yale's School of Medicine and currently serves as an adjunct professor there. During the COVID-19 pandemic, Dr. Juthani was a leader in the COVID response at Yale, which led to her appointment as commissioner of the Connecticut Department of Public Health in 2021. So thank you both for being with us today.
Tom, I’m going to first turn to you to talk about the most significant changes that we’ve seen to U.S. public health policy in the last month, and what you see is the implication of these changes for future international health coordination and data collection efforts.
BOLLYKY: Great. Thank you all for joining us. Thank you to Irina and her team for coordinating this. The state and local network that her team operates is really one of the most useful, I find, resources at CFR, particularly on public health where battles are won at the state and local level. And it’s a privilege to be able to engage with you and learn from what you’re hearing on these issues as well.
There's a lot going on, of course, on U.S. public health. So there's a good bit we could talk about. In my initial remarks, I'm really just going to focus on three areas. To start, I'm going to talk about vaccination. And there has been an unfortunate consequence, the cumulative effect of some of the early actions taken over this last month to perhaps undermine the support for vaccination, at a time where we have a quite a large measles outbreak ongoing, the potential emergence of dangerous avian influenza. These are risks not just for a loss of life. On measles, of course, it's also just a huge expense if it shows up in your part of the country.
This is new. Vaccination for decades—U.S. immunization efforts provided immense benefits for health and had broad bipartisan support. Underlying these efforts were policies rooted in science that have been adapted and improved over time. Support for that vaccine policy framework is just as important today as it has been ever before. But it really has taken a hit, particularly after the COVID-19 crisis. To see how far we’ve traveled on measles, it was just in 2000 that measles was officially eliminated from the United States—meaning there was no measles spreading in the country. That was driven by vaccination. Typically, you need about—vaccine coverage of around 93 to 95 percent to have a sufficient level of population immunity to prevent outbreaks. There are currently, out of the forty-nine states reporting vaccination rates at the kindergarten level, thirty-one states are below the lower band of that threshold of 93 percent for coverage for the MMR vaccine.
In terms of the outbreak, I’m sure most on this call are aware. Yesterday the tragic news was reported of the death of a child from measles in west Texas. An unvaccinated child is the first death from measles in the United States in ten years. Officials have reported, by last count that I’ve seen, 124 cases in Texas, mostly west Texas, since late January. Nine cases in the neighboring New Mexico county. Eighty percent of these cases involve children, who are more susceptible to this vaccine-preventable disease. Vaccination rates in the most affected county, rural Gaines County, at the center of the outbreak, are quite low.
We've seen cases in seven other states—Alaska, California, Georgia, New Mexico, of course, New Jersey, New York, and Rhode Island. The total number of cases being just over 130 cases actually is more than we've seen in eight of the last fifteen years. And that's just in the first two months of this calendar year. There are probably more cases than that than we know about. We don't know how large this is going to get, but the rate of increase or the force of infection, as you might say, is strong. For reference, the last major measles outbreak we've had in the United States was in New York in 2019. That hit over a thousand cases. This could be worse. Now it is not too late. With the—with the potential for vaccination, behavioral shifts, tireless work of public health teams we could slow the spread of this outbreak. But it is concerning. At the federal level, we've not seen the type of support one would typically see for vaccination.
The CDC has—itself, has been quiet on these issues—relatively quiet. We've had a number of important vaccine advisory committees postponed. The National Vaccine Advisory Committee was meant to discuss the strategic plan for national vaccination in February. That's been postponed. The Advisory Commission on Childhood Vaccination was meant to discuss the vaccine Injury Compensation Program. That's been postponed. There's been questions coming out of—at the secretary level about potential conflicts of interest among the Advisory Committee on Immunization Practice, that considers clinical information on immunization practice. Its findings influence the compensation program. Their credibility has been put in question. We had a Cabinet meeting yesterday at the White House where a reporter afforded an opportunity both to the president and the HHS secretary to speak on this, and although they did, we didn't see the call for vaccination that you would ordinarily see. We also saw in the early days of the administration an executive order restricting any federal funding to states or schools that required COVID-19 vaccination. So a broader—the cumulative effect of these actions, intended or otherwise, diminishes support for vaccination at a point where it's more critical.
The second thing I would highlight is the firings of U.S. public health officials as part of the broader reduction of government workers. We’ve seen the National Institutes of Health, the nation’s premier biomedical research agency—we’ve seen an estimated number of a hundred—oh, I’m sorry—1,200 employees, most of them promising young investigators slated for larger roles, have been dismissed. Many of them have specialized knowledge that can’t easily be replaced. The CDC has seen a reduction of around 1,100 individuals. Four hundred of those are people that took the voluntary retirement in response to the request from the Office of Personnel Management. About 750 have been fired. There had been views that we might see a reduction in the Emergency Intelligence Service. Not yet, although that’s still possible. But we have seen significant decreases in personnel in the Laboratory Leadership Service Program, the Public Health Associate Program. And these are linkages between the CDC and states and locality that provide important resources in emerging outbreaks and crises.
The last thing I will say is these, of course, also link to what's been happening at the international level, and the information sharing that can go on there. On the first day in office, the president, as many expected, withdrew from the World Health Organization. He did so in a manner that he renewed the withdrawal notice from 2020, suggesting it may be immediate. U.S. officials have already stopped participating in many of the networks that exist around surveillance of emerging infections and around influenza. USAID last night had 580—I’m sorry—5,800 out of 6,200 contracts terminated, in terms of its programming. There’s an expectation that the workforce there will be reduced from around 10,000 to 1,000. And, of course, they provide our eyes and ears with other countries in terms of emerging infections, as well as the good work that USAID does around HIV, malaria, and other concerns.
What this boils down to is, you know, frontline public health workers here in the U.S. and abroad provide our network that we detect emerging diseases, prevent and respond to these threats, and protect everyone. That system may be unraveling. The risk of doing so is that we create blind spots, where emerging health threats incubate beyond our knowledge and provide an illusion of safety in public health that we don't—that we don't have. And that is our greatest threat potentially moving forward. So let me stop there. Lots more we can talk about. Looking forward to this exchange.
FASKIANOS: Thank you, Tom. And we’re going to go to the commissioner to talk about how you are adapting your health systems in Connecticut to the federal public health policies that are obviously shifting, and the challenges that you’re facing, and where you see the opportunities, so we have a little bit of optimism. (Laughs.) So over to you.
JUTHANI: Thank you very much, Irina. Thank you for the opportunity to speak with all of you today. And thank you for laying that foundation, Tom, so that I can speak to how we are dealing with things at the local level and at the state level.
So what I would like to start with is that, as we entered these last few months and have seen a number of different orders and actions come through, it has been a time period of uncertainty and a time period of unrest, a bit, in terms of staff in a public health department, and state government writ large. So for us in the Department of Public Health in Connecticut, we have 154 different grants that we receive, largely from the federal government, spanning potentially up to seventeen different agencies at the federal government. And I believe that almost all of them received some sort of cease order in terms of work, initially. Half of my department is funded through federal dollars. And so where we are right now with different temporary restraining orders that have been put in place is that, in fact, at this moment, right now today, we do not have any specific grants that have been given specific terminations or reductions. We also have CDC employees—for example, the EIS officer, CEFOs, which are epidemic field officers that have been positioned in Connecticut—we had threats that they would be fired but they have not, up until this point.
So what this has created, though, is a lot of uncertainty in terms of where we are going to be able to move forward, where we are going to potentially have to cut back, and where our work will continue. I think the second point on uncertainty is that, as with all administrations, there's an opportunity to decide what communications should go out, what needs to be paused, what can be resumed. And there was a lot of uncertainty in the first several weeks in terms of what information we would be able to get. And for example, there was the Morbidity and Mortality Weekly Report. The one that was put on pause in the first week after Inauguration Day had three different reports on H5N1 or avian flu. Since then, those have all been published, and we do have that information available. Today another MMWR came out as expected. So that is hopeful, that we have been able to see some resumption of communication that had been paused in the first several weeks.
I would also comment that we’ve had a few emergent situations where we’ve had to call the CDC for emergency input in terms of how to deal with potential threats. And we were able to get in touch with officers who were working on the ground and be able to help provide us with guidance. As Tom mentioned, a lot of public health—good, old-fashioned public health is done at the local level, at the state level. But where we do really rely on federal partners is for expertise in areas that maybe we only interact with or have exposure to on a one-off basis and not on a regular, standing basis. And that is one of the challenges that we have seen, that we anticipate, and then we worry about in terms of where that is going to take us going forward.
Tom mentioned a little bit about vaccinations. I mean, this is a foundational component of our public health advances over the last century. I’ve been talking for the last several months about a Morbidity and Mortality Weekly Report, MMWR report, from 1999 talking about the ten landmark achievements in public health over that previous century. And many of the things that are in there, with vaccinations being one of the top of the list, are the types of things that we worry about every day. If you look back to the early 1900s, influenza was a leading cause of death in this country. Today, we look at diseases like heart disease, and stroke, and diabetes, and cardiovascular disease taking a higher standpoint than influenza. But that is something that can backtrack very quickly. Something that gave me pause today was when I heard that VRBPAC, which is the federal committee that meets to determine which strains of influenza will be in the next season’s flu vaccine, that meeting was canceled.
I hope that it is a postponement. I hope that we have an opportunity to see that those particular candidate selections of what should be in next season's flu vaccine are determined pretty quickly because this takes time. When the flu vaccine is identified what should be in the next season, that has to be done in the spring. It takes time to manufacture these vaccines. And this could be threatening to our pharmaceutical industry. This could have impacts on people showing up for work. The impacts of health are so vast. They impact business every single day. They cannot be separated. Health and business go hand in hand because in order to be thriving members of society we need to be healthy and we be able to—we need to be able to live, and work, and participate with each other.
So these are some areas of concern, but I am hopeful that we’ve seen some changes where, for example, MMWR did resume. I am a member through the Association of State and Territorial Health Officials on the ACIP, which is the immunization practice committee that evaluates all—you know, all vaccines that come forward to be able to help create that schedule of vaccines. That meeting was postponed. I am hopeful, again, that ACIP will resume and that we will have an opportunity to be able to resume those types of, really on a regular basis, meetings that help inform these things.
In Connecticut, we have been fortunate that vaccine uptake is something that has always been strong in our state. Going back to 2014, since we were talking about measles, the measles, mumps, and rubella vaccine, we had a 96.65 percent uptake for kindergarteners with the MMR vaccine. We hit a low during the pandemic in 2020 of 95.28 percent, with 95 percent often being a quoted number for achieving herd immunity. But now in 2024, we are actually higher than we were pre-pandemic, at 97.7 percent. And so we have a lot to, at least, hope that, at least, we’ll be able to, hopefully, avoid a measles outbreak. But we do have under-vaccinated populations, even within that—within our state. Which is true across the country. And so this is something we worry about, and we prep for, and we try to be ready for.
The other thing I want people to just be aware of is that vaccinations are a critical thing, but there are so many areas of public health that we often don’t even think about. And I often say this comment that was said to me once, which is that public health saved your life today, you just didn’t know it. So, for example, safe drinking water. If we take our foot off the gas on regulations for drinking water, whether it be toxins, whether it be chemicals, whether it be infectious agents, these are foundational things that we maintain safety in our country. That is something that is under our purview in the Connecticut Department of Public Health.
Another example would be food safety. We’ve heard some concerns that there may be less oversight or regulation in terms of food safety. We know right now, for example, there’s a listeria outbreak that’s going on around the country. This is particularly concerning for women, for babies. And we’ve had two cases here in Connecticut. But this is true at our restaurants and at our distributors of food, right at the ground level. For example, our state health department has secret shoppers that go out and buy different types of meat, or dairy, or produce, and do testing to ensure that food that is out in the public that people can purchase is safe. And we get funded, often through collaborations with the federal government and with our state partners, for that type of safety.
These are basic things that public health does. And so I'm hopeful because I've seen some things improve over the last several weeks. But I have areas of concern. And it is our goal to work with our federal partners, that we rely on to be able to help provide us expertise and make these broad decisions that implicate all of us and have potential impacts on all of us. And I really hope that going forward we'll be able to continue to work together with federal partners to ensure the safety in our states. Thank you.
FASKIANOS: Thank you very much to you both. Let's go now to all of you for your questions and comments. And you can also use this forum to share your experience and your best practices.
(Gives queuing instructions.)
And nobody’s put up their hand yet. Oh, we do have the first hand. Jennifer Herring.
Q: Good afternoon. I’m Jen Herring. I’m from Doylestown Township, Pennsylvania. I’m the chairman of the Board of Supervisors there.
My question is, generally speaking we know that there’s—it looks like there’s some limitations on communication between the federal authorities and state and local authorities, as far as health is concerned. And I’m fearful that it’s going to increase—or, actually, decrease—less communication. Where would you recommend we get our information from, if we don’t have access to the information such as, like, a department—the CDC?
JUTHANI: I can start with that, at least. I would say that I would lean into your state public health department. One of the challenges that we all face is that state public health departments and local public health departments often rely on the CDC for more expert guidance. But, you know, we're doing the best we can with the information we have, at least at the local level, for what we can communicate out. And so I think as it relates to what's happening right in front of you, and in probably your day-to-day life at a local level, your state health department is probably a good place and a good resource to be able to lean into.
One of the challenges we have, to Tom’s point earlier, is we don’t know what we don’t know. When you don’t have eyes on what’s happening on a more global landscape, or potentially even at the federal level, we just may not know it. But one of the things that I would say is that a number of us, as state health officials, do get together on a weekly basis. We do share information with each other. And we may need to do that a little bit more organically. We have sent out statements as we’ve received them. I’ll give an example.
Today's MMWR did comment on severe influenza in children resulting in encephalitis and more severe neurologic complications. Before I heard that in the MMWR, I had heard that from some other state health officials. And so that was something we actually also ended up sending out a notice to providers in Connecticut to let us know if they had children who were manifesting with those types of symptoms. I was glad to see that it showed up in the MMWR as well, and I was able to get a better sense of what is the CDC seeing right now in terms of how that relates to what's happening now as opposed to historically.
And some of the information shared there is that right now it seems to be 13 percent of children who died from influenza this season had that presentation, historically that was 9 percent. Again, is that outside of the range of variation? We don’t really know, but that was at least helpful for me to be able to read and understand that that was something they were able to share with us. But I would very much lean into, at least from a day-to-day standpoint of your life, leaning into your local and state health departments.
Now, if you’re traveling somewhere else often we might have relied on the CDC to be able to see are there certain health advisories or other things like that that may be out there. I have not seen that that is not there. So that may still be available. But I would say also looking at those specific countries and seeing what they may be reporting out on—and, you know, WHO does have a website, it has information out there. Those would be the types of things I would lean into.
FASKIANOS: Tom.
BOLLYKY: Great. In the arena of more positive developments, after a few weeks where much of CDC’s website, in terms of data and pages, were shut down, there has been a return of much of that information. Now, depending on the area looking there are some concerns that some demographic information has been stripped out, which, from a public health standpoint, is not always helpful. But a lot of the data that had been missing, and some of the advisories that are posted on the CDC website, have returned. So that is, depending on your area, a resource. So, for instance, when I was looking for how many states are below the threshold, at this point, you can get that information from the CDC website, whereas just a few weeks ago you could not. So you’re starting to see some of those resources come online.
The only thing I'll say on the WHO side, there are concerns—leaving aside the issue of collaboration with U.S. officials and, you know, a significant number of U.S. public have health staff had been seconded to the CDC—or, to WHO, so it was a real resource there, this will be—the United States was the largest donor to WHO, representing around 16 percent of its overall budget. So they have stopped international travel by most staff unless you're locally there. So to get back to the point that we don't know what we don't know, there is going to be some diminution of the international information we have, simply by reducing the reach of the world's health agency. So that will come at a cost. And part of that cost is the collaboration and the movement of staff.
FASKIANOS: I’m going to take the next question from council member Barbara Leary from Folsom, California.
Q: Yeah, I’m wondering if there’s—and I don’t know what can be done about this—any movement to reinstate a lot of the research? I know, you know, that you’ve talked, you know, about the MMWR being re-released, but I guess I’m concerned about a lot of scientists and other people who have been let go or who are not being able to pursue their interests in research, tracking problems, et cetera. And does anybody have any idea about how that might be addressed or changed? I think we’re in uncharted territory at this point, so just looking for some other thoughts on that.
BOLLYKY: So just a little bit, and then—I'll start. I think there has been some effort for them—in terms of the cuts—at the federal level to U.S. public health employees because it was done largely around probationary employees—so less in a targeted manner and more where there might be the legal flexibility to pursue those reductions in force—you've lost a lot of people with particular expertise. So this was famously, has been reported, you saw that at USDA that the office that they had assembled around tracking the avian influenza outbreak had been gutted. You saw that at parts of the FDA, where, you know, we had brought in—or, the FDA had brought in, rather, people with particular areas of expertise that they've had to now try to hire back. EIS is an area that had been on the chopping block and, at least as of yet, given the outcry about the important role that that program plays, that has not happened.
So I do think, in terms of communication, particularly from the state and local level, the importance of programs to the good work that you all do can have an effect when people have a greater appreciation of the value. I do want to point out one thing, though, that I am concerned, particularly as this has largely fallen on probationary government employees, that we are really eviscerating our next generation of public health experts and scientists. And that will have an effect not only, of course, on these people’s careers, but also on people who are considering entering the field. And it comes at a time where state and local—the state and local public health workforce has already been under stress due to the pandemic and is at low numbers. So really, the combination of this disincentive, losing potentially a generation of people, with some of the fatigue that is going on at the state and local level is really quite damaging. So again, you’ve—if you value these programs and particular areas of exchange with the federal government that are important to you, then don’t be quiet about it.
JUTHANI: If I can just add one other piece to that, which is in my former role in academia the cut to indirect rates in terms of NIH funding, which funds many different types of support of research in academia, it has also had a chilling effect in the academic world where some academic institutions are not taking on graduate students in a variety of different areas. And in terms of the pipeline you talked about, of people doing research and not being able to pursue that research, some of that is because academia is feeling the pullback, whether it be from NIH dollars, a little bit different than some of the other public health funding that we’ve been talking about, more about scientific research. But really, this is an ecosystem and a continuum where people train in academia and then enter the private sector, enter the public sector, and really continue great scientific work. And it has been the stance of the United States for many, many decades that we wanted to invest in science, and scientific development, and that scientific pipeline. And so I do have concerns and worry that not only are we taking a hit to the public health workforce and generation of public health workers, but also to the scientific workforce writ large.
BOLLYKY: Irina, I'm just going to add one quick thing, if I may, on that point. I have a particular concern about infectious disease research. One change, that there's proposed legislation in Congress but also apparently some support of the incoming team at the NIH, is to split NIAID, the portion of NIH that focuses on infectious diseases, into three subgroups—infectious disease, immunology, and autoimmune diseases. The thought is that this might build on some comments made during the campaign to defund or decrease funding to infectious disease research. And it really couldn't come at a worse time, given the range of things we're following. But it is not a lucrative area of medicine, to begin with, and to limit the research opportunities for people in this field is going to be a real disincentive to people pursuing it.
FASKIANOS: Thank you.
JUTHANI: As a—I’m sorry if I could just say one other thing.
FASKIANOS: No, go ahead.
JUTHANI: As an infectious disease doctor, I can attest to the fact that it is not one of the most lucrative areas of medicine. But I can also say that when we talk about public health we often think about communicable diseases, and infectious diseases being a large part of that, and the noncommunicable diseases. And we—because we've been able to have great scientific advances on the communicable diseases—in our vaccine programs, and antibiotics, and treatments, and antivirals—we've been able to focus on the noncommunicable diseases, meaning heart disease and cancer, and the things that take many, many decades to get worse in order to then cause worse morbidity and mortality. But if we don't have control of the communicable diseases that generally have morbidity and mortality more immediately, we will be losing decades of progress that we've made in public health.
FASKIANOS: Thank you. I’m going to go next to Bill Taupier, who’s the director of administration and safety, in Massachusetts.
Q: Oh. Thank you for having me.
My question has to do with a little bit about USAID, and where it has been essentially eliminated, for all intents and purposes. My question is about, you know, outbreaks overseas, and how we can—you know, we learn a lot from those to fight diseases at home. But what is your opinion going to happen now with outbreaks of things like Ebola or Hantavirus, or other places—other diseases that could go unchecked?
BOLLYKY: We’re going to be at greater risk. I think there might be a perception among some in the U.S. public that because of the struggles we saw around the COVID response, not just in the U.S. but other countries as well, that we really don’t know or are unable to contain—prevent, detect, or respond to outbreaks of dangerous diseases. And it’s not so. If you just take viral hemorrhagic fevers, things like Ebola or Marburg, you think about the Ebola outbreak in West Africa in 2013 to 2015, a little bit in ’16, that took 20,000 lives, or more. It costs billions of dollars in terms of the response. With each subsequent outbreak of Ebola virus, as well as other hemorrhagic fevers, we have gotten much better, even in low-resource countries, in containing this. The reason why you do not hear about these outbreaks in the same way that we heard about that particular West Africa Ebola outbreak is because of the build-up of these systems.
USAID funding is responsible for the identification of the first COVID case outside of China. It is responsible for the development of the vaccine that we now have against mpox, and the world uses. I mean, the list just goes on and on and on of how these have kept us safe. And I do have concerns in these environments that—with the cutting of these programs, that we may not see that persist. If you had asked me even at the start of yesterday I would have told you that I think that some of the treatment programs around HIV or malaria, around in terms of the use of insecticide-treated bed nets, that those programs will probably survive in some form, even at the State Department. But we did learn overnight, with the cutting of these programs that I mentioned, or these grants, that many of the programs that had received waivers, the grants supporting those programs have been cut anyway. So I don't—I really can't say what's going to happen, but your question raises a real concern that gets at the heart of safety for all Americans and people worldwide.
FASKIANOS: A question from Laura Bellis, Tulsa City Council member.
Q: Hello. Yeah, I'm a Tulsa City Council member here in Oklahoma. And I also work in maternal-child health. And obviously, just geographically proximity-wise, too close to Texas for comfort. And our vaccine rates are also, as anyone can imagine, low, relative to where they should be. And so I'm curious if you all have any advisement, when we look at—whether it partnership, as Manisha has mentioned, with, you know, our state or local health departments, just what we can proactively do, acknowledging that we are likely to see a measles outbreak here? That we are in a certain type of policy and health environment that is not always very pro-public health. And just curious if there's anything you all would recommend trying to proactively do in the time we have prior to an outbreak.
JUTHANI: Yeah. What I would recommend is, first, getting some knowledge with your local health department and state health department on areas that may be under-vaccinated right now. They should have eyes on that. They should know where those pockets exist. And, you know, like you said, proactively doing some of those interventions. And we do get funding to do this type of work, where we go within communities, identify what some of the barriers to vaccination may be, try to do that type of ground-building and communication with communities in terms of helping to overcome whatever vaccine hesitancy may exist, and then have vaccination campaigns to be able to, in fact, allow increases in vaccination rates. That’s some proactive work that could be done right now.
Of course, you know, many health departments are stretched thin as is. Of course, we are dependent on our funding to be able to do that kind of work. But right now, I would say that that type of work is possible, and I would encourage you to connect with your local and state health departments. You know, every state is a little bit different. Connecticut is a home-rule state. We have fifty-nine local health departments and/or districts. I know that there are states like Massachusetts that have many more. There are others that have county-level government, and so there is a lot more economies of scale. But that's where I would really lean in and start there, to try to prepare yourself for what you've identified as a potential risk.
FASKIANOS: Tom, do you have anything?
BOLLYKY: Yeah. The only thing I would say here is part of what’s been hard about this first month is that, you know, vaccination rates have gone down. I think there is an important national conversation to be had. The part of the secretary of HHS confirmation hearings that resonate with me is being transparent that vaccines have a balance—all medical products have a balance of benefits and risks, and talking in those terms. I think it’s important that we engage in populations in a respectful way. I thought the advice that was just provided is very useful in that regard.
I think there is work to be done. I think the fact that we did see a death, tragically, yesterday, hopefully provides an example of what the cost of under-vaccination might be. And there may be more receptivity to these vaccination campaigns than we might otherwise find. So I think looking for a way to have respectful, transparent conversations at this moment, given the national attention to this issue, is important. So I thank you for worrying about it. And, you know, the support you might be able to—or, the partnership you might have with your state and local officials.
FASKIANOS: Great. I’m going to go next to Destini Cooper. If you could identify yourself, please.
Q: Can you hear me?
FASKIANOS: Yes.
Q: Hi. This is Destini Cooper. I’m a policy analyst at the Legislative Council here in Nevada.
And we're actually in our legislative session right now. I have a public health background. And I kind of want to know what you think the kind of pushback on public health will be when we're already in the world of vaccine hesitancy and things of that nature? And I just feel like in a world where we're trying to restore health—trust in the health care system or in the public health world, do you think that this will have some type of backlash? Because, as we know, as funding goes down or funding is taken away, then we lose services and we lose—you know, vaccine accessibility goes away, and people get sicker because we have more uninsured. And then the blame is, oh, well, vaccines don't work. Now we have more sick people. And now things that we made great strides in are now going backwards.
So do you think that public health will kind of get the blame again when, how do I say it, basically options are taken away? Like, when we have to pull back on services and stuff, do you think the increase in health outcomes and, well, the lack of health outcomes—I guess, the decrease in health outcomes, do you think that public health will get the brunt of that again? Because COVID was our fault, right? Nobody believed in public health until COVID came, and then it was, oh, public health is here, and it’s terrible. So do you think that it’ll kind of be our fault again when we lose funding and we have to roll back these programs and the world gets sicker again, for lack of a better term?
FASKIANOS: Who wants to start? (Laughs.)
JUTHANI: I guess I can start. You know, I—Destini, I appreciate that comment. I don’t know that I would have thought of it that way, but I guess anything is possible. I would not have predicted the way the COVID pandemic happened and the divide that we ended up in after seeing a remarkable development of a vaccine that has saved millions of lives. So, you know, I think, to your point, is there a narrative or dynamic that has been set up that that could happen? I guess it could. You know, I guess I would have liked to think that with a reduction—and more health care problems, with a reduction in public health and preventative measures, that people would see that difference. But, you know, I guess we don’t know.
My perspective in general is to try to work within my circle of influence, figure out where I can actually try to make a difference, and make a difference there, in that circle of influence. Because otherwise these questions become existential and feel like we’re never going to be able to make progress. But if I can look at—for the state of Connecticut, can I try to show people that I genuinely care, that I have read the science, and that, in my medical opinion, this is their best path forward, and try to bring people along and meet them where they’re at, then I’ve done my job for the day. And I think that that’s all we can each try to do. I hope we don’t end up in a place like you’ve outlined. Is it possible? I guess it could be.
BOLLYKY: Two things, just to say quickly. We do a lot of work—have done a lot of research here on the drivers of differences between countries, how they did during the pandemic, controlling for relevant biological factors, and at the state level. And what a lot of that research has shown—and I’m happy through Irina to circulate the
Lancet studies we’ve done on these things—is that, you know, trust—social trust, how communities interact with one another, played an outsized role in the differences between outcomes. There is actually a fair amount of research on how to engage with people who may not be trusting of public health or more inclined to blame public health for the problems. It is leveraging local—the people that are more trusted in those communities, physicians and nurses, the people that you engage with every day, the institutions you engage with every day, maintaining those relationships even in between crises, I think, is honestly one of the major lessons of the COVID pandemic for me, at least. And I think one that is going to be important in this moment.
The second point I would make is I read an op-ed by a former Democratic political operative in the
New York Times that talked about one strategy around this moment, from that political perspective, is waiting for the consequences of some of these actions to manifest, and therefore pointing out the folly of them. And I will say, from a public health standpoint, I don’t want that. I don’t want to wait that long. (Laughs.) I think we really need to be clear about what the consequences might be and try to engage with communities in an open and transparent way up front. And, you know, I think it’s really incumbent on all of us to do as much of that as possible.
FASKIANOS: Thank you. There’s a raised hand, a number begins with 856, no name. So you’ll have to really help us identify yourself, your name and affiliation, please.
Q: Yes. This is Laurie Lehmann. I’m City Council, Cape Coral, Florida.
And I just want a clarification. You know, obviously, no one has mentioned Florida. Would my best bet be to talk to the county-level or the state-level public health departments to find out where we are lacking and what we can do about things?
JUTHANI: Your local health department is always the group that is the most close and proximate to the conditions of what's going on, on the ground in your situation. So I think that that would most certainly be what I advise anybody, honestly, in any state, because they really know what's going on, on the ground most close to you. They can reach out to experts, whether it be at the state level or at the CDC level, to get additional information should it be necessary. So I think your instincts are correct to lean on the people who are closest to the ground where you are.
FASKIANOS: Great. There are no more raised hands, but just a question about sources of good data. At the state level are there other organizations who are compiling the data that you could commend to people?
JUTHANI: I would say that I think that this is a fluid and evolving situation. I think, to Tom’s point, we know that a number of CDC websites came down, and then now are back up. There are other things that are coming down and are—look to be permanently down in other agencies, as he mentioned the most recent changes that we’ve heard from USAID. So I think we’re going to need to keep on evolving and reassessing as time goes on. You know, I think there is the opportunity that maybe there will be other organizations, whether it be foundations, whether it be independent organizations, whether it be philanthropy, whether it be academia, whether it be partnerships of the like, who may try to fill voids that may develop, but I think we really don’t know what those voids are just yet. And trying to figure that out is, I think, where we are right now.
FASKIANOS: Great. And, Tom, how would you say that other countries are beginning to fill the void of the leadership role of the United States in the global public health space? You know, with the exit from WHO, I mean, what is on the horizon here?
BOLLYKY: Great question. I think, unfortunately, the events of the last month have had several knock-on effects. One is that governments who might be more politically aligned with the White House at the moment, some of them have—Argentina withdrew also from the World Health Organization, to emulate the action taken by the U.S. Reportedly, Hungary and Russia are considering doing the same. So this may spur, among some governments, emulation. In terms of the broader conversation about the Ukraine conflict, and indicating a potential need for more of a European role on defense on the European continent. This week, the U.K.—which outside of the U.S. is the largest government donor to global health—announced that it would decrease its foreign aid budget from 0.5 percent of GDP to 0.3 by 2027, so that it could invest more in the military, in response.
Germany just, of course, had an election. There's enormous economic pressures going on in Germany right now. Germany has historically been a supporter of multilateralism, in the World Health Organization in particular. The World Health Organization has an office in Germany that does surveillance, data surveillance. I think there is some risk that you will see a pullback there as well. In terms of in-country, I think there have been some moves by aid-recipient countries to assume more of the burden. You've seen that in South Africa and Ghana, some conversations for that. But right now, the average government in sub-Saharan Africa spends $92 per person on health, which is less than a fifth of what it is in the less—the next lowest region. And their ability to assume some of these programs is going to be limited, outside of a handful of countries that are better resourced.
Where we do see some governments responding has been China, particularly in countries where the U.S. has—or—and China has been grappling for influence, Southeast Asia and some Latin American countries. You've seen China offer to pay for some of the programs. I think in those strategic countries you will see that. I think overall China is not likely to assume the burden for U.S. programs in less strategic regions, or focusing on cross-border health threats. They tend to focus more on infrastructure projects. So we will see less of the focus on global health security and infectious disease or mother-child programs and more focus on healthcare infrastructure and products.
FASKIANOS: Great. Roberta Smith from Routt County Public Health asked about programs like the polio eradication programs and Peace Corps, assuming they are also in danger. And then there's another question from MaryAnn O'Connor, who's the Massachusetts director in the city of Medford. Who's on the ground working on the outbreak in the Congo? So maybe you can just put those together.
BOLLYKY: Yeah. So just quickly, on polio eradication, the U.S. provided money to the World Health Organization in two forms. One, like all governments, it pays assessed contributions, effectively membership dues. And then the other way is voluntary contributions. We, the U.S., historically provided significantly more in voluntary contributions. Much of that money went to two areas—the emergency program of the World Health Organization and polio eradication. So the withdrawal from the U.S. from WHO is going to have a consequence. Another major funder of polio eradication has been the U.K. government. So I don't know what will happen there in this area. It has been a priority for the Gates Foundation, so you may see them step up somewhat. But you may see some consequences.
I have not seen anything in terms of the Peace Corps program. And maybe that will continue, but it’s difficult to know if they just haven’t gotten to it yet or if that’s more of a decision. I just haven’t seen any discussion.
FASKIANOS: Great. Manisha, I wanted to give you a minute just to wrap up, and then I wanted to go back to you, Tom, just to say a few words about Think Global Health, because I think this community, this group could really benefit from it. So, Manisha, over to you before we close. And then we’ll go to Tom.
JUTHANI: I think I would just make a plug to everybody that a lot of public health is local. And we do rely on federal partnerships and, obviously, international partnerships. But all of you are on the ground in your local communities. Advocate for public health locally. Press on and support the public health people that are doing that hard work and getting a lot of, potentially, counter messages to the work that they’re trying to do. And support them. Support the young people who are trying to do this work in that space in your local communities. And don’t be silent if you value public health, because I think that is going to be helpful not only in your state legislatures but at the federal government as well, to be able to show how public health has helped in terms of our society.
FASKIANOS: Tom.
BOLLYKY: Great. Thank you for the kind opportunity just to put in a plug for Think Global Health. It’s our online magazine that looks at how—tries to take—much focus on health is how things affect our—other things affect our health. This website looks at how health shapes economies, societies, and everyday lives. It looks from the other way. It’s a form of investment. I think we saw that in the pandemic. I think some of the political upheavals here are also related to what happened in the COVID pandemic. It is a multi-contributor site, so we do have a fair amount of domestic coverage of what’s happening in the U.S. So I would encourage you all to read it, but also, for those that are looking to write on these areas, we have that opportunity as well, and we welcome that.
FASKIANOS: Wonderful. Well, thank you both for this hour. We really appreciate your taking the time and for the work you are obviously doing. And to all of you on the call for the work that you’re doing in your communities. It does take a village.
We will be sending out the video and transcript. And we can put together some of the resources that were mentioned during this call. And, as always, we encourage you to visit CFR.org, ForeignAffairs.com, and, of course, ThinkGlobalHealth.org, that Tom just mentioned, for the latest analysis on international trends and how they are affecting the United States. And we welcome your suggestions for future webinars. You can email us at
[email protected].
So, again, thank you to Commissioner Juthani and Tom Bollyky for this conversation. And we look forward to continuing it down the line. So thank you all.
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