Demetre Daskalakis, deputy coordinator of the White House national monkeypox response, and Jeremy Youde, dean of the College of Arts, Humanities, and Social Sciences at the University of Minnesota Duluth, discuss the emergence of monkeypox and other diseases, international responses, and messaging around health issues that especially affect the LGBTQ+ community. Jennifer Nuzzo, senior fellow for global health at CFR, moderates.
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FASKIANOS: Thank you, and welcome to the Council on Foreign Relations Social Justice Webinar series. The purpose of this series is to explore social justice issues and how they shape policy at home and abroad through discourse with members of the faith community. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR.
As a reminder, this webinar is on the record, and it will be made available on CFR’s website, CFR.org, and on the iTunes podcast channel, “Religion and Foreign Policy.” As always, CFR takes no institutional positions on matters of policy.
We’re delighted to have Jennifer Nuzzo, senior fellow for global health at CFR, to moderate today’s discussion on infectious diseases. Dr. Nuzzo is a senior fellow for global health here at CFR. She’s also a professor of epidemiology and the inaugural director of the Pandemic Center at Brown University’s School of Public Health. Her work focuses on global health security, public health preparedness and response, and health systems resilience. In addition to her research, she directs the Outbreak Observatory, which conducts operational research to improve outbreak preparedness and response. And she advises national governments, and for-profit and non-profit organizations on pandemic preparedness and response, and worked tirelessly during the COVID pandemic to advise and tell people what was going on, to the extent that we knew, as we made our way through this two-and-a-half-year pandemic.
So, Jennifer, I’m going to turn it over to you to introduce our speakers.
NUZZO: Great. Thank you, Irina. Thanks for that introduction and thanks for organizing this webinar today. I’m very glad that we’re having this conversation. As someone who’s worked in infectious diseases for my entire career, I have found the last few years to be particularly staggering. I was looking, and as of today there are more than 616 million cases of COVID-19 that have been reported globally, upwards of 6.5 million diagnosed deaths that have been reported worldwide. At the same time, we are also seeing a global surge in cases of monkeypox, a disease that many hadn’t heard of prior to this past year. And now we are over 66,000 cases that have been reported globally, more than 25,000 of those reported here in the United States alone. At the same time, successive outbreaks of Ebola have been occurring, and we have measles once again on the rise. And now vaccine-derived polio circulating in countries where the virus had been previously thought to be eliminated.
So it’s really a staggering list of infectious diseases that have been occurring and continue to occur. So clearly, we’re at an important crossroads in terms of how we respond to these recurring hazards and infectious disease emergencies. But today we get to zoom out a little bit, and to examine factors that they may have all in common, and to try to understand what may be driving these—the recurrence of these events over and over again. So over the past few years we have seen the consequences of social, economic, and racial inequities play out center stage. These factors have underpinned not only our underlying vulnerabilities to infectious diseases, but also how effectively we respond to them. So that’s what we’re going to talk about today. And to help discuss these issues we are joined by two globally renowned experts who have a long history in working to address infectious disease threats and the disparities that accelerate them.
Our first panelist is Dr. Demetre Daskalakis. Dr. Daskalakis is the deputy coordinator of the White House national monkeypox response. Prior to this role, he served as director of CDC’s division of HIV prevention. And prior to that, oversaw infectious diseases for the New York City Department of Health and Mental Hygiene, which is one of the largest health departments in the nation and rivals the WHO in terms of staff and budgets. So Dr. Daskalakis is a leading national expert on many things, but also in particular health issues affecting the LGBTQIA+ communities. And he has worked clinically for much of his career to focus on providing care for these communities.
We are also joined by Dr. Jeremy Youde, who is the dean of the College of Arts, Humanities, and Social Sciences at the University of Minnesota Duluth. Previously, Dr. Youde was an associate professor in the department of international relations at Australia National University in Canberra. Dr. Youde is an internationally recognized expert on global health politics. And he is a very prolific writer. He has written five books, and many chapters, and countless articles. I recently read a very compelling blog post by him on our own CFR’s Think Global Health. So really excited to get both Dr. Youde and Dr. Daskalakis’s perspectives on the issues in front of us.
So I will get the conversation started. We have a lot of great attendees, and we’ll have time for questions. But just to get the conversation going, let’s see here. Maybe first, if I could turn to you, Dr. Demetre. For those who haven’t been living in the monkeypox data as much as you have, perhaps you could just give us a quick summary of where we are and where you see us being headed.
DASKALAKIS: Thank you. And thank you for having me. I’m really excited to join Jeremy and to be a part of this discussion. So living in the data is, in fact, what I do. So I’ll tell you, so monkeypox—I’ll give a little key bit of background just for everyone to be level-set—is an orthopoxvirus, that is a virus that causes disease, transmitted usually from animals to humans. Usually, traditionally, not a lot of human-to-human transmission. This current outbreak in 2020, global in scale, with 66,500 cases reported internationally, actually demonstrates pretty good human-to-human transmission, often in the setting of close contact, often associated with sexual activity, and the majority of cases being among men who have sex with men—the vast majority, over 96 percent.
In the U.S., at this moment, we have 25,300 cases. I can tell you right up to the moment. And so we continue to see increases in cases in the United States, but we’re seeing a deceleration in the rate of increase. So cases are stilling being logged. We used to see kind of around four hundred cases per day. We’re now more on the order of two hundred or below and continue to see that trend going in a good direction with more data imminently coming to the website of CDC later on today.
Again, just briefly, the demographic, majority male, mainly men who have sex with men—the gay, bisexual, other men who have sex with men. Looking at the demographics, at the beginning of the outbreak in May, the majority of cases were among white men. And now we’re seeing about 68 percent of those cases are happening in Latino or Black men. From the perspective of that measure as well we’ve seen a significant increase in vaccinations. So we can talk—we’re going to talk more about that, I’m sure. But really with lots of strategies to increase vaccine supply. We are now well over eight hundred thousand vaccines administered. There is an inequity there as well. The majority of vaccines are going to white men. And we’re seeing Latino men and Black men in second and third place, respectively, in terms of vaccines administered.
Jennifer, I hope that that’s a good situation summary to start off with.
NUZZO: Yeah, great summary. Thank you so much. That helped kind of bring everybody to the same—somewhat same level.
Just a quick follow-up question for you. There have been a lot of headlines about the important progress we’ve made, and the fact that the global monkey—or, sorry—the monkeypox cases seem to be coming down in terms of numbers. Question: Are you seeing similar trends for all demographics? Or are you concerned that perhaps the large numbers are hiding increased transmission in other groups?
DASKALAKIS: I had to fix the mute. There we go. So I think what we’ve seen is that the declines are looking to be even across population. So that’s good news. Again, the vaccine equity is our main issue right now in terms of where we’re—where that’s stubborn right now, and really thinking about strategies to improve that. We had a lot of news today, which I’m sure we’ll be able to talk about some of the strategies that we have to address that. But so I think there’s no clear sign that the deceleration is different in different populations. Geographically, however, it is different. And so that’s, I think, one place where—the jurisdictions that have had the greatest and longest experience with this outbreak, so the most cases, are also the jurisdictions that have access to the most vaccines.
So whether it’s because of behavior change that we’re seeing, which is definitely something that we, I imagine, could talk about here as well, or natural infections plus vaccine-induced immunity, I think the places that have had more experience are showing deceleration faster. So New York, California, Texas, and Georgia are looking down, while some of the places where the outbreak is newer and they’ve also had less access and time for vaccines, those places are showing an increase. We’re going to get an update of this, this week. So this is based on data that’s about a month old. So soon we’re going to have a new view into how this deceleration or acceleration looks like, jurisdiction by jurisdiction.
NUZZO: Great. Thank you.
Maybe turn to you, Dr. Youde. You’ve been an important voice about the global dimensions of the monkeypox crisis. And I’m just curious where you think we are globally. And I referenced in introducing you that piece that you wrote on Think Global Health that I thought was—made a quite compelling argument about the role of WHO and where you see the response needing to go. Do you want to maybe elaborate on those points for people who haven’t had a chance to read your article?
YOUDE: Sure. Thank you for the question, and thanks for organizing this. I’m honored to be part of this event.
And, picking up on some of what you were talking about and what Demetre was just talking about as well, we do see these inequities that exist, especially when we’re looking worldwide. The World Health Organization did declare monkeypox a public health emergency of international concern. And while it doesn’t necessarily come with automatic funding or programmatic resources, it does raise the profile. It does put this on the global health agenda and say: This is something we need to be paying attention to. In the piece I described it as the WHO’s bat signal. We’re sending out the message: This is something that we need to pay attention to.
But one of the things I think is frustrating about the WHO response, and just sort of the global community’s response to monkeypox in general, is that monkeypox isn’t a new disease. This is a disease that we’ve known about in human cases since 1970. Laurie Garrett in her book, The Coming Plague
, which came out in ’94—which is one of the books I think a lot of us who are probably about a similar age read in our early, formative days as we were coming into global health and global health politics—she talks about it in that book.
And if you look at the data that we have, we’ve been seeing increases in monkeypox cases in humans in countries where monkeypox was endemic for about the last decade or so. And so—but what really caught the international community’s attention was then when it came to the Global North, when it came to the industrialized countries. And that helps to reinforce some of these questions about what is the nature of our real concern about global health? Is it about health in this very broad mandate, like the World Health Organization has as part of its constitutional mandate, to be this international coordinating body? Or is the sense that we, in the Global North, want to keep the diseases from the Global South coming to affect us?
And there are similar sorts of issues when we’re looking at vaccine equity and vaccine access, when we’re looking globally. And, there have certainly been some problems here in the United States, getting access to the vaccine. But, I was able to get vaccinated against monkeypox. Yeah, I had to drive two and a half hours to Minneapolis to do it, but I was able to do it. And I was able to arrange it. People in countries where monkeypox is endemic have little to no access to these vaccines.
And it raises some of the questions then, again, about how the international system and the global health governance systems that we have in place—how they can address some of these equity challenges? Because in many ways, outbreaks like monkeypox, they glom onto the societal and social cleavages that exist, and help to reinforce and exacerbate them, but also provide this opportunity for us to really put some of our ideals and our promises around social justice, around a cosmopolitan view of understanding that we are all healthier if we are all healthier. And really put those into practice, if we have the political and economic will to do so.
And that’s where—that’s one of the areas where I get a bit concerned right now. I know we’re all exhausted talking about COVID-19 and about monkeypox, and all of these sorts of outbreaks. Jennifer, I know you’ve been doing a lot of this. Demetre, obviously, you’ve been on the frontlines. I’ve been doing some of this work as well. But when we lose that attention, sometimes we lose then that motive—that momentum in the political system to try to address some of these challenges and these shortfalls that we have identified.
So, I can be a critic of the World Health Organization, but I also recognize that the World Health Organization is a creature of its member states. And so, it’s really incumbent upon the member states to really put some action behind their words. And to say: If we want to have a more effective response, we need to build systems that are going to be able to respond better than this.
NUZZO: Thank you for that. It’s a good segue to what I wanted to talk about next, which is the title of this webinar being about social justice. And those who’ve worked in public health, the notion that social justice has a role to play in reducing our vulnerability to infectious disease is quite clear. But I’m aware, particularly over watching—(laughs)—the national political debate over the last several years that those outside of public health may not recognize the connection between our vulnerability to infectious diseases and social justice. And they may be dismissive of the idea that public health authorities should be engaged in the work of social justice.
So this is actually a question for you both. And maybe reflect on monkeypox or your long experience of other infectious disease threats that you’ve worked to address. And what would you say to folks that just don’t understand why public health should be concerned with social justice, and what role do you think it has to play going forward? And maybe we’ll turn back to you after Demetre.
DASKALAKIS: Do you want Jeremy to go or do you want me to go first?
NUZZO: Go ahead.
YOUDE: Go for it. Go for it. I’ll let you start.
DASKALAKIS: All right. So I’ll put my very strong HIV hat on, because that’s sort of where I come from. And I’ll start that this is a forty-one—a forty-two, almost, year-old lesson that I think we’ve seen play out over and over again, which is that really the social determinants of health are actually what drive infection. So there are countermeasures that can work. There’s vaccines. There’s drugs. There’s pre-exposure prophylactics, post-exposure prophylactics. It doesn’t matter. The social determinants are really what ultimately ends up blocking us from being able to implement the full vision of what we know we can from the perspective of medical technology and public health. And so I think that at the end of the day that implementation piece is so critical.
So much technology can exist, so many interventions can be designed, but they sit on the shelf unless there’s both the political and social will to move them forward. And so I think I should put that HIV hat there for a second, because in environments where there is less political and social will we tend to see HIV flourish. And in places where there is social and political will, we tend to see HIV not do so well from the perspective—or, in other words, we will do well because of less incidents and prevalence. So I think that sort of looking at that will is so critical.
I’ll give you a story from monkeypox which I think is really important, that is about the sort of CDC response. I got pulled in really early on, before the first case actually hit the United States. One of the very early conversations that we had with the response is that we need to expect that we’re going to have inequities that are going to be a part of this. And I think that’s based on lessons from COVID, and lessons from HIV, and lessons from so many other infections. I think we really worked to make equity the cornerstone of the response. But even when you do that, it is an all-of-society thing that needs to happen, and not just something that is mediated simply by a public health department or a public health agency. Over.
YOUDE: And if I can take that public health hat and HIV hat that you had on, and I’ll wear it myself. I got into this line of work through working on HIV/AIDS issues in Zimbabwe and South Africa, and seeing how those sorts of societal cleavages played a role, but then also how infectious disease outbreaks, and the spread of HIV was glomming into these other issues around democratization, around building societies that were going to be equitable, that were going to be able to fulfill the promises that governments had made to their populations. And seeing how a disease like this was thwarting that progress.
So it’s something that is not just unique to the United States. It’s something that we see globally. From a very instrumental perspective we can say, look, public health is ultimately a weakest link public good. Everyone is still at risk, so long as risks still exist. So we need to reach out to those places which might have fewer resources, which might not have the same sorts of ability to implement these sorts of programs, because ultimately that’s going to make us all healthier. And I think there’s elements and an important role for those sorts of instrumental views of public health.
But I also think about the recently passed Paul Farmer, and his notion of public health, especially his idea around the preferential option for the poor, which was kind of a double-edge sword. Because on the one hand he was saying, look, the people who are disenfranchised within societies, those are the people who are the most vulnerable to these infectious disease outbreaks. Those are the people who are at the greatest risk.
But also, we need to think about our programs, we need to think about our interventions putting those people first, thinking about equity. Putting that not as an afterthought or something that we think about five, six, seven steps down the road, but it needs to be central, and it needs to be core. Because, again, if we’re not taking equity seriously and we’re not really putting this into everything that we’re doing, then we’re just reinforcing these sorts of divisions and, again, providing these opportunities and these outlets where diseases can thrive.
And so, to just cosign what Demetre was saying we can have all the technologies we want. And I have all my criticisms about the way that the access to pharmaceuticals and drug interventions exist on a global level, and questions about compulsory licensing and all these sorts of things. Those are all important, but those are secondary in a lot of respects if we don’t have the underlying core infrastructure in place. And that core infrastructure, even if it’s not touching us in a direct way, does have an effect on our ability to stay healthy.
DASKALAKIS: Could I—this is a fun one. Could I keep going a little bit longer on this?
NUZZO: Please do, yeah.
DASKALAKIS: This is a great, stimulative conversation on this. And along with what ends up being both the foundation of the issue as well as the deeper foundation, the way that all of these social issues interact with stigma, like I think we’ve seen in fast-forward with monkeypox. Like all the things that we saw with HIV and other infections and COVID—today, for instance—this is a really good example. So, we’re giving the vaccines and right now they’re going on people’s forearms. Which means that literally some people will have a mark on their forearm. So talking about stigma—literally stigma.
And so, we changed it so that individuals can elect to get the vaccine on their shoulder or on their back. So we have people who want vaccines but are saying, I don’t want to be marked by this. I don’t want to have the sort of—someone know that I am someone who’s potentially identifying myself as part of a group at risk. And so it interacts exactly with the social determinants.
Whether it’s poverty, transportation, racism, all of it interacts in a way where these sort of more brass-tacks economic issues interact with these very profound stigma issues and create barriers where even if you do have great access—I’ll give an example again. [The] Ryan White [program] is really great access for people for HIV medication, but we still don’t have everybody in the country—(inaudible)—right? So why is that? It’s partially access, but it’s also that the systems are built to sort of maintain structures of stigma and structures of inequity that are really hard to overcome, even with things that provide access.
NUZZO: So I was actually going to ask you about stigma. So thank you for segueing to it. And I seems to me that—and I don’t have the HIV hat to wear, like you both do. But studying events that we typically think about in the field of health security—which is a field that sort of struggles to incorporate the forty-plus year lessons that HIV has learned—is that it is clear that stigma is an issue in nearly every single event. Any time we have particularly a new infectious disease, or something that’s unusual, society seems to look for some group to blame.
But what it seems, though, is that while there’s an increasing recognition of the importance of stigma, it doesn’t seem like we have great strategies for addressing it. And I guess I’m wondering, do you agree? And also, what practically can and should we be doing to address stigma? I really saw us struggle with this. I mean, we had a recognition of it as being important in monkeypox, but I feel that the absence of clear ways to deal with it really led us to struggle to talk about monkeypox, and who was at risk, and how people could protect themselves. So what should we be doing going forward not just for monkeypox but future threats, so that we don’t get hobbled by—first of all, that we can minimize or tackle stigma, but also don’t get hobbled by it? Whoever wants to chime in. (Laughs.)
DASKALAKIS: So this is back to the HIV hat. This is the tightrope that we walk every day in HIV. And I think that the lesson actually—well, one of the first lessons that’s important, sort of sitting on the government side of the world, is that government needs to lead, and governmental public health needs to lead, so that its messaging does not propagate stigma. That’s very important. Because whether people like governmental public health or not, or have complaints about it, ultimately people do look to governmental public health—like CDC, local health departments—to really fine-tune their own messaging, and then translate that messaging not just to another language but translate it so the populations that people work with actually understand.
And so I think monkeypox was actually a kind of exciting example, where from the very beginning of the response it was a how can we take an anti-stigma stance in how we messaged it? And so the balance really then depended on the data. And so that’s what was really important. So it was starting with imperfect data, and as the data became more and more clear, making sure that the messaging evolved in a way that addressed what you were actually seeing epidemiologically without necessarily—without creating a scenario where you’re pinning infection, a virus, on a population.
Let me give you an example since, Jennifer, you say your HIV hat isn’t as strong as ours. So in the ’80s, when HIV started, before it was HIV it was gay-related immunodeficiency. So that lesson was the lesson that was so important in the work that we did with monkeypox, to start off by saying: This is a virus that can affect anyone. But we’re seeing this virus more in this population. As opposed to saying: This is this population’s virus. And so it’s leading by that example. And it’s one of those things that we can raise up and say: We have learned the lesson from this forty-two years ago, and we’re not doing it this way again.
And so with that said, I think that there’s a lot of strategies that can address stigma. And a lot of that has to do with communications, using trusted messengers. So, that has been a really important part of this as well because, again, working in public health I would love if everybody listened to public health data. So providing good communications to individuals who are trusted messengers is really important. And also, part of the propagating stigma is also being clear about what data is, things that we fully know and things that we’re still learning. Because that really allows that risk communication so that you don’t over-select or too rapidly move a response into what population, as opposed to being broad.
So as you learn more data—so, for us, our guidance started off in one place about safer sex and safer gathering. As we were seeing that this was not moving throughout the different populations, it got stronger and stronger. And we really started the conversation by saying that this is guidance that’s going to change as we learn more. I think that we do have stigma mitigation strategies. But stigma’s a stubborn thing. I’ll give it over to Jeremy.
YOUDE: Yeah, I would agree with everything that you said. And especially being—having that level of humility. We are still learning about this. Things are going to change. Things are going to evolve but building those sorts of trusting relationships. The other things that I would emphasize, and I think these complement what you were saying quite well, is empowering communities to speak to each other. I think one of the things that we’ve seen here in the U.S. around access to the monkeypox vaccine, and the relatively high rates of vaccination that we’ve seen, has been people talking to other people. Men who have sex with men talking to other men who have sex with men, and this becoming part of the conversation.
Even if it is something at the level of, where were you able to get access to it? When supplies are limited. Just building that sort of awareness within a community can be incredibly important. I think it’s also important to make sure that we do have targeted messages. Not blaming messages, but understand that the message that just says, everyone is at risk for HIV or everyone is at risk for monkeypox, ends up falling flat and doesn’t really strike anyone. And so having that sort of targeted outreach plays an important role.
But going back to this point about empowering the affected communities, one of the most powerful things that I think that I’ve seen in the work that I’ve done is looking at the Treatment Action Campaign in South Africa, and the work that they did, especially in the late ’90s and early 2000s, with the T-shirts that just in huge, bold letters across the chest said: HIV positive. And just having people going out there, wearing those T-shirts. The image of Nelson Mandela wearing one of those Treatment Action Campaign T-shirts is just incredibly important because, again, it’s helping to remove some of that stigma. It’s getting people who are trusted, who are respected, coming into the conversation.
OK, if he’s involved in this, if he’s saying this is an important issue, maybe this is something that I need to be paying attention to. But also just trying to make that sort of availability, so that people are willing to share their experiences, or talk about what’s going on, or what worked, or what didn’t work for them. Again, these all play really important roles. It’s never going to be perfect. It’s something that we do need to keep at the forefront when these sorts of outbreaks happen. And you see some of this in some of the broader conversation around even what we call diseases, the names that we use.
The fact that there is a very strong move away from geographically located names for diseases, because we don’t want to stigmatize those particular communities or people who happen to be coming from those areas. Even something like that can play a really important role in helping people to think, this is something that I need to take seriously if I’m in the United States, I need to take this seriously. Even though we’re talking about something like monkeypox, which isn’t a geographic designator but there aren’t a lot of monkeys roaming around in Minnesota. But it’s something that they should be taking seriously, because of these effects and these sorts of community-based responses that help to try to destigmatize things, encourage people to get access to vaccines, or treatments, or other sorts of options that are available to them, and start to have those conversations to empower communities.
NUZZO: That’s great. I’m going to turn over to questions. And maybe participants can start putting their hands up. But while that’s happening and before I turn it over for that section of the conversation, one last question to you both. Which is, I am deeply worried that we respond to these events as these one-offs. We have an emergency, we get emergency funding, then perceptions of the emergency being over, the funding disappears, and it’s gone. And we saw that happen with COVID, where the money went away and then states had to let go their pandemic hires. And guess what? They weren’t there when monkeypox happened.
So I guess the question is, how do we move away from sort of seeing these as just one-off emergencies, and moving towards a role where we create a durable sort of permanent system that’s in place to snap into action anytime there’s an event, which is happening—which we’re seeing—these events are happening with an increasing frequency?
YOUDE: I’ll jump in first, Jennifer. It’s like you’re reading the paper that I’ve been working on throughout the event today. And that’s part of my concern about WHO designating this to be a public health emergency of international concern, when we’re talking about monkeypox or COVID-19 for that matter, is the emergency framework. Public health, when it’s doing its job, we don’t know about it. It’s something that—where we’re essentially trying to stop things before they reach that level of public consciousness, or stopping it really, really early in the process.
And so the emergencies, they get the attention for global health but they don’t necessarily get the long-lasting system. It becomes, like, OK, whew, we got through that. We can move onto the next thing, or we can just not pay attention to global health again until the next system comes up. But at a very fundamental level we have this organization. We have the World Health Organization, which has this constitutional mandate to act as this international coordinating body for health—cross-border health issues. And it has a smaller biennial budget than many large hospital systems here in the United States.
So how is it going to be able to do that sort of work when it has so few resources? Plus, given the way that the WHO is funded, it only has control over about 20 percent of its budget. The rest of it is coming through these voluntary contributions, which are generally specified for specific purposes, which may or may not align with the purposes that the WHO itself would put in place.
So I think that one of the things that happens there is it behooves us, it behooves the member states to actually—to put some diplomatic and political capital behind this, to actually move on this. I have no doubt that in a few years’ time we will have some sort of after—some sort of response that will look at the response that WHO made to COVID-19. And it will bemoan the failures. And it will talk about all the things that need to change. And then it will gather dust on the bookshelf. And we will get similar sorts of things for monkeypox.
And what we haven’t had is a country or a group of countries, or some sort of person with high stature, really glom onto this and be like, yes. We need to do this. This is our potential roadmap for trying to address this in the future. I—nerding out in the global health politics world—I had this idea that someone like a Helen Clark, or an Angela Merkel, someone who knows international politics, who knows the systems, who has that sort of diplomatic experience, but also is concerned about issues around health, that could be the person who could help to inspire some of these actions, and could get the attention of world leaders in a way that civil society organizations often aren’t able to do. Which is not to say anything bad about those organizations, just that there are structural problems getting the attention of world leaders, and having that sort of concentrated attention.
So I think we—ultimately, we need a champion. We need a person, or a country, or a group of countries who are willing to really champion this, and go to the mat for trying to make these sorts of changes, so it isn’t just emergency, after emergency, after emergency, but something that is going to be more long lasting, that is going to provide that sort of infrastructural support, and make sure that we aren’t just lurching from here, there and everywhere, but actually can have some sort of coordinated response and something that is a bit more forward-thinking. But it’s a challenge.
NUZZO: Demetre, the bullets of your bio—(laughs)—are a list of the emergency, after emergency, after emergency. So I know you have first-hand perspectives of this. So any hope we can fix it?
DASKALAKIS: Sure do. (Laughter.) So, my perspective may be very domestic, but I actually think it’s not. I think when I start talking, I think it’s going to seem as if there’s also infrastructure that needs to be leveraged internationally that’s similar. Which is, I always think about what actually worked. And so one of the things that I think we’re seeing over and over again, whether it’s COVID, or monkeypox, or other outbreaks, is leveraging systems that already exist, and really figuring out how to support those systems during peacetime as well as wartime, so that it stays warm for a response. And that’s a very public health—it’s a very sort of operational, public health example.
So I’m talking HIV. I’m talking chronic infections. I’m thinking domestically, we have this excellent—I think the HIV Epidemic Initiative, it’s not nationwide yet. It hasn’t been resourced to do that. But, if it were, that is a really sort of important way to be able to create and maintain an infrastructure. So thinking about sort of chronic diseases like viral hepatitis, having an infrastructure that could potentially lead to curing more people with viral hepatitis creates a system that then could be used for care and other public health delivery of countermeasures.
So thinking about things that—what can we do to sort of do our peacetime work, which is around chronic infections like virus hepatitis and HIV, and what can we—and STIs, which are out of control in the United States, mainly because they’re under-resourced—but what can we do sort of to maintain sort of those systems, so that when we flip the switch from peacetime to wartime that we can pivot those resources to do the work? I’ll give an example from the research universe—monkeypox, as an example. Right now, there are studies that are going on for monkeypox vaccines and for monkeypox therapeutics. And they’re built on the networks of HIV investigators. So, HIV Vaccine Trials Network and AIDS Clinical Trials Group are currently the people that are doing those studies. And sort of research funding potentially being a bit more flexible, that pivot is possible.
But what if we had similar models sort of in the operational world of public health, where you have sexual health clinics or STD clinics that are doing HIV/STD work during peacetime, but can flip into monkeypox vaccines and testing in wartime? And so it’s investing in a chronic infrastructure to be able to make it translatable into an emergency response, in a nimble way, I think is really important. And of course, I back up Jeremy. That idea of political will and leadership is really important in making sure that this sort of moves forward in a way that works. But, I mean, I say this domestically, but then one can conjure PEPFAR in terms of an infrastructure that works.
So that—they have been leveraged. And so what if we worked harder to make sure that they were resourced adequately during the peacetime, so that during wartime they flip and are flipped more effective? And by the way, that HIV positive T-shirt has influenced my career, Jeremy, in terms of seeing people who were willing to put on a shirt that really works against stigma. My favorite being Annie Lennox, who I met with that T-shirt on, and I was very excited, as a fan. But definitely an important thing to reclaim that stigma. Jennifer, thank you.
YOUDE: And if I can build on what Demetre was saying, think about the Ebola outbreak in West Africa in 2014, and the cases that popped up in Nigeria. That led to all sorts of concern. Now you’ve got someone who has Ebola in Lagos, a city of twenty million people, and just not a city that necessarily has the sort of infrastructure in place that you’re going to think, oh, we’re going to be able to contain this. But they were able to repurpose existing programs. They were able to use measles control programs and other sorts of programs. And, using the word that we have all become way too familiar with over these past two and a half years, they pivoted, turned that into doing the surveillance and doing the contact tracing for Ebola, and were able to stop the spread, and being able to prevent that from spreading rampantly throughout one of the largest cities in the world.
And I think that’s the sort of thing, you know? If we have these sorts of structures in place, we can adapt them. Even if they are for one purpose, they can be adapted for other purposes. And so it’s not that we need to recreat the wheel each time, it’s that we need to figure—we need to make sure that we’ve got enough wheels out there, essentially.
DASKALAKIS: And that goes for surveillance. Maintaining good surveillance systems for chronic things means that when an acute thing comes up, that good surveillance already exists there. So not only for an operation, but also for being able to understand what’s happening with the threat. I like to call it keeping the system warm, if you think of sort of the stuff that’s happening. So when you have to heat it up, you’re not starting from—it’s not a TV dinner you’re taking out from frozen. It’s thawed already. You can move quickly.
NUZZO: It’s really hard to build capacities in the midst of an emergency. So thank you for those thoughts.
I am going to give others a turn to ask questions and turn it over to the question-and-answer session now.
OPERATOR: Thank you.
(Gives queuing instructions.)
Our first question comes from Mark P. Lagon from Friends of the Global Fight against AIDS, Tuberculosis, and Malaria.
LAGON: Hi, there. Thank you for this really thought-provoking forum. I come from a perspective working in the health field, but also background in human rights. I was an adjunct senior fellow at CFR, and president of Freedom House.
I wonder, to take some of the points that Jennifer Nuzzo has been making and posing to you, to move to pandemic preparedness. If you have—we’ve seen that AIDS confronts one with very clear human rights and equity issues, particularly for stigmatized populations. You have a kind of a reprise with monkeypox. There was a lot of discussion about in terms of the impact of COVID and equity on vaccines. As the international community has moved to form a fund housed at the World Bank, how do you embed preparation for pandemics to have a human rights or social justice perspective? Activists really had to push hard to get two voting seats for civil society on the governing body of that fund. Thank you.
NUZZO: Anyone want to take that on? (Laughs.)
YOUDE: Sure. I’ll offer a few thoughts. I think this is something—again, this is something to be thinking about at this early stage. As these sorts of systems are being designed, as they’re being set up, keeping these sorts of elements important and at play. But I also think it’s important to make sure that there are multiple channels for this communication to happen. That there’s one thing to talk about formal board seats, and those are obviously important to have people at the table for these pandemic financing facilities through the World Bank and other sorts of organizations. But also make sure there are other opportunities, because new organizations may pop up. They may change. Depending on the particular circumstance or the particular outbreak that we’re talking about, there may be other groups that are being mobilized and being affected by this.
And so, there needs to be a certain level of nimbleness that needs to go into this. I think it’s also something that puts a lot of—we need to put pressure on our leaders to really put their promises into action, to make sure that this isn’t just something that we have as a tick box exercise. Oh, yes, equity is important, we need to address this. But actually, that there is this ongoing pressure and this sort of check of what are we actually doing here? Are we reaching out to these communities that are being affected? How can we better do this? And so I—again, there’s an interesting moment right now that we can hopefully seize to make sure that this is something that really does get instantiated within these systems. And I hope we don’t let that moment pass. I hope we don’t decide to just we’ll go back to existing systems.
Because that’s the other thing that goes along with this. It does challenge the status quo. It does challenge the sorts of standard operating procedures that we have in these organizations. And that can be challenging. That can be a difficult sort of conversation to have. And we have to be willing within our international organizations and other sorts of responses, we have to be willing to have those conversations. We have to be willing to challenge ourselves and to criticize ourselves, and to then make changes that are going to be effective.
LAGON: Thank you.
DASKALAKIS: I don’t have almost anything to add to what Jeremy said. I think there really—again, the political will is important. And just we’ve all experienced that U-shaped curve of concern, right, where when things are very exciting everyone is very worried and engaged, and then when it fades away, resources fade away. And what that means is the infectious disease comes back. And so it’s really—whether it’s the same or a different infectious disease, sort of keeping that momentum and having it really come both from the political piece, from organization, but also from the side of advocates and activists is really critical to keep the—to keep the energy moving and the momentum moving. We have to make sure that we come to a better place.
Every event, you learn more. And so I think that even if we take a quantum leap in what preparedness looks like, whatever the next event will challenge that level of preparedness and will require us to then—to really develop systems that are—that are updated based on the experience. So I think moving the needle anywhere, but moving it in a coordinated way because of that will and that strategy is the most we could hope for and the most we should expect. Or the least that we should expect, the minimum, of being able to move to a place where we have something that is better than how we found it, and potentially more resilient in terms of a—monkeypox is minor compared to COVID, after COVID.
NUZZO: Yeah. I mean, I think the more we have these events the more we learn, though it does feel to me a little bit like the more we have these events, the more we learn the same things over and over again. (Laughs.) And particularly when we’re talking about these inequities. And Jeremy pointed out about the stark inequities in terms of who’s able to access vaccines in the globe. And that was clearly something that we saw throughout much of COVID-19, still see it today. We saw it during the 2009 H1N1 pandemic, in terms of who had vaccines and who didn’t.
So I guess the question—and I recognize that we have just about ten minutes left, and the CFR rule is we always end on time. So I’m going to—(laughs)—I’m going to be aggressive about that. But just on that point what do we need, I think, to put into place? We talked about how there’s a pandemic fund now, which is important. But aside from money, and maybe it’s just money, what else do we need to kind of create structures to address these inequities globally? Given, Jeremy, you also made the important point about—I’ve been struck by how hard it’s been to contain monkeypox here in the U.S.
But let’s say we’re successful, we’re still going to have challenges as the virus continues to circulate. So we need to make progress globally. And we need to have systems in place such that every time these emergencies happen, we don’t keep learning these same lessons over. So maybe just two or three minute each, your takeaways on what you would do to fix these problems if you were deemed in charge of the world.
YOUDE: A little new world, just like that. Money is obviously important. The amount of money that we spend on development assistance for health has gone up dramatically since the early 1990s, but it still pales in comparison to the level of need. So there is just a basic resource need. The second is that we need to make sure that systems that we are building are not for specific diseases, but are things that can be flexible, things that can be adapted. We don’t want to just say: Now we’re going to set up all these monkeypox surveillance systems, when that may or may not be what is going to be the next big outbreak. So we need to have things that are going to be able to be flexible like that.
Third, we need to have—we need to have a better sense of just our—I guess our international community’s willingness to engage with global health. We have the international health regulations. So we do have an international treaty that’s supposed to govern how states respond to infectious diseases and their outbreaks. But the willingness of states to abide by that varies quite dramatically. And so we need to have a big of a come-to-Jesus moment about what are we actually willing to do, when push comes to shove?
And then last thing I’ll say is that I do think we need to have a conversation around access to pharmaceuticals and vaccines and other sorts of medical interventions like that. Because we know that there are inequities, and we know that oftentimes the communities that have the least access are the communities that have the highest rates of incidence or are in the most need of these sorts of things. And our structures are not really well designed for getting people access.
Even though there are things like COVAX, even though there are things like PEPFAR, and all these other sorts of programs, which have done tremendous work, they are still falling short. And so we need to—we need to have a better sense of what—how do we actually put these sorts of things into practice? How do we actually make sure that these scientific breakthroughs that are so invaluable are reaching all the people that need to be reached?
DASKALAKIS: Ditto, I’ll start off. So that makes my job a little bit easier, because I think what Jeremy said is really important. I’ll say again, I think in my hierarchy the first and most important thing is consistent political will, because I think that that then drives a lot of what happens beyond that. So I think that that really jives really well with what Jeremy said, in terms of that sort of commitment. Money is very important, I think, but it is not the only thing that drives us into preparedness. So I think that having that commitment.
I also would like to think about that investing the money in things that keep the system warm. So I’ll go back to that sort of statement, or like thinking about investing in the diseases that we still haven’t finished. We still are working—we’ve got HIV, we have hepatitis, malaria internationally that we’re worried about. There are a lot of areas that we could invest to create systems that are infrastructures that keep it warm for operation for pandemic.
I cannot say it loud enough that what Jeremy said about flexibility is right. You can’t really build the infrastructure on chronic disease if it’s not flexible to move to another acute event. So it needs to be something that is both creates and maintains the infrastructure, but also has the ability—everyone’s favorite word today—to pivot into the emergency response zone. So very important.
I think also workforce and data. I think that it is important to remember that we talk about giving patients trauma-informed care, but we need to give our workforce trauma-informed care. COVID has been hard. Monkeypox has been hard. Our next challenge will be hard. And sort of how can we support the workforce and then also continue to mentor it to be able to do the work? Data also is so important. A commitment to share data, and to have data that is accessible for decisions, even if it is imperfect.
And then finally, the realization—and it goes back full circle, Jennifer, to your first question—about our—or, maybe second question—about the social determinants. There’s only so much that public health can do. There is an all-of-society need to address the core drivers of so many of the inequities. We can’t solve everything through public health. We can get closer to health equity, but ultimately the goal is that as you access is really to go into social justice, which is not just public health but really an all-of-society endeavor to try to improve the environment so that we don’t have fertile ground for these pandemics to blossom and grow.
NUZZO: Thank you. There’s a question that just popped up in the Q&A box. And we just have a few minutes. It’s about the privilege of good information and how we address misinformation and disinformation, which likely leads to fragmentation.
I will just chime in, having done a lot of communication over the past two years, I think that this is not a problem that public health can solve. I actually think the drivers of this are much, much larger. And I think we need an all-of-government approach to this that includes the potential regulation of the platforms. But I’m curious if you all have any quick comments to add to that.
DASKALAKIS: I mean, I just agree with you. (Laughs.) It’s definitely much bigger. There are things we can do, like monitor social media and make sure that our messaging is one way. But ultimately this is an issue that’s bigger, that requires not just the public health lens to address.
YOUDE: And, at the same time, we also can recognize that those trusted outlets, those can be really important tools. So, churches in sub-Saharan Africa played a really crucial role in many parts of helping to decrease HIV stigma, helping to get access and information out there about testing, about protection, about these sorts of things. I mean, that can also be the flipside, though. If you got these trusted sources that are peddling this misinformation, then it becomes this much bigger issue that goes beyond what public health can do. So I guess it’s—part of it is just figuring out where those allies exist, be they in government or outside of the government, and what sorts of connections they might have with populations.
DASKALAKIS: And to your earlier point about building those connections prior to events, so those relationships exist and you’re not trying to forge them in the midst of a crisis.
NUZZO: Well, really, thank you both. I wish I could appoint you both in charge of the world, because if I was asked who should be in charge of the world you would both be on the top of my list. But I am very glad that you continue to do the work that you do and contribute in important ways. And have both been really guiding voices as we continue to experience these events. So thank you very much for that, and really thank you to our participants for attending and the thoughtful questions.
FASKIANOS: I second that. Thank you all. And we appreciate your taking the time to do this. I hope you will all follow their work. For Dr. Daskalakis, you can follow him at @dr_demetre. Dr. Youde is at @jeremyyoude. And Dr. Nuzzo is at @jennifernuzzo. Pretty easy. So we also encourage you to follow CFR’s Religion and Foreign Policy Program on Twitter at @CFR_religion and write to us at [email protected]
with any suggestions or questions. We want to help support the work that you all are doing. And we hope you will join us for our next Religion and Foreign Policy Webinar on the Politics of Religion and Gender in West Africa, on Tuesday October 11 at 12:00 p.m. Eastern time.
So thank you all again for being with us, and thank you for your public service. We appreciate it.