Public Health Threats and Pandemics

Susan Dentzer, health-care analyst, commentator, journalist, and senior policy fellow at the Duke-Margolis Center for Health Policy, discusses local health systems, including how they are coping with the COVID-19 pandemic and best practices for reporting on the subject. Carla Anne Robbins, CFR adjunct senior fellow and former deputy editorial page editor at the New York Times, hosts the webinar.   FASKIANOS: Good afternoon. Welcome to today's Council on Foreign Relations Local Journalists Webinar. We'll be discussing local health systems and best practices reporting on them during COVID-19 pandemic with Susan Dentzer and Carla Anna Robbins. I'm Irina Faskianos, Vice President for the National Program and Outreach here at CFR. As you know, CFR is an independent, nonpartisan organization, and think tank focusing on U.S. foreign policy. This webinar is part of CFR's Local Journalists Initiative created to help you connect the local issues you cover in your communities to global dynamics. Our programming will put you in touch with CFR resources and expertise on international issues and provides a forum for sharing best practices. So thank you all for being with us. Today's webinar is on the record, and the video and transcript will be posted on our website after the fact at CFR.org/localjournalists. We shared bios with you, but let me just give you a few highlights. Susan Dentzer is a leading expert on American healthcare and policy and a frequent commentator on news outlets including PBS and NPR. She is currently a senior policy fellow at the Duke Margolis Center for Health Policy in Washington, DC. She's held roles as the on air health correspondent for the PBS NewsHour and editor in chief of the policy journal Health Affairs, and she's a member the Council on Foreign Relations. Carla Anna Robbins is an adjunct senior fellow at CFR. She's aculty director of the master of international affairs program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously she was deputy editorial page editor at the New York Times, and chief diplomatic correspondent at the Wall Street Journal. So Susan and Carla, thank you very much for taking the time to be with us today. I'm going to turn it over you, Carla, to get us started. ROBBINS: Irina, thank you, as always, and thank you to everybody at CFR. So Susan, thank you for doing this. You bring multiple skill sets to this conversation. Today I'm reporting on local health systems and the pandemic. You've worked in television and magazines. You’ve edited, what was when you were doing it, the leading public health journal, and you started in the business with local newspapers. So you've done it all. You also have deep expertise not only in public health, but also in economics, and this is in many ways an economic story. So in full disclosure for everyone here, you're also one of my best friends, you're probably my best friend. So we’ve got to be clear on this for full disclosure. So as ever, we're going to start out with a few questions from me and then throw it open to everyone here and I really want to thank all the journalists here because the work you guys do is so incredibly important right now. We know how tough the news businesses is, it isn't? I can't even imagine what it's like to report on a daily basis in the current environment, so thank you for being here. So when we talked about you joining us today, I divided my questions into two areas: getting through the pandemic and digging out afterwards. So, what questions and what stories should we be asking in this stage of the pandemic about our local health systems capacity, even though the infection rates and mortality numbers are rising? We're not hearing about crises so much in capacity or shortages of PPV or ventilators. Is that about to come again? Did we learn some key lessons from the first wave in New York and Washington state or from Europe, that local hospitals in Texas, Florida, Arizona, and Nevada are now following? Is it going to get better, or are we about to get hit by another wave in a really bad way? DENTZER: Well, thank you Carla. First of all, thank you for that gracious introduction and secondly, great to be with all of you to talk about this very important topic. I want to echo what Carla said about the importance of you continuing to do your very important work. So, that was a lot of questions. Let me start to unpack some of them. I divide my thinking up into the viability of the health system to cope with a pandemic into its clinical issues. What is it actually able to do clinically now to care for people with COVID-19? And then what are the financial and operational repercussions on the system and its capacity to deal with this? As Carla said, there's what we care about now and then what is going to happen in the future. So thinking in those different dimensions, clinical versus financial, operational, now versus future, that's kind of how I organize my own thinking. If we just take the clinical perspective right now and ask, you know, how our health systems doing in various areas around the country? The first thing, of course, that I learned long ago as a journalist is that almost anything you say about the US healthcare system will be true somewhere. Because there is so much variation around the country and around the system and among hospitals, and across even within the same metropolitan area. There will be big differences among hospitals, depending on the structure of the hospital. Is it nonprofit? Is it for profit? Who does it serve? Who's its population base? Is it primarily Medicaid patients or public publicly insured patients, or is it a more privately oriented system? All of those variables come into play when we ask any question about what's going on in the healthcare system. But if we basically ask, how is the health system prepared today? We think about sort of three S's: space, stuff, and staff. Okay, so the space is, how much space do they have to accommodate patients right now? That space issue, as we have learned across the country, has really been able to fluctuate, because if you take, for example, New York, the governor of New York told every hospital in the state to double ICU capacity within the hospital. So they had to put hospital beds, including ICU beds, and what were formerly conference rooms and what were formerly closets, etc. So for space, has the current system, does it have the current space? And what space has it created in terms of new beds, swing beds, etc, etc. So that's one really important factor, how much space do they have. And that will not necessarily be a fixed number because hospitals have a licensed number of beds that frankly is kind of a fiction, it's not even clear. They're always operating and staffing their fully licensed number of beds. So you always have to be aware of that. It's a dynamic number that that you have to get your arms around. So that’s space. The next thing is stuff, and of course, the most important stuff in the current environment. People have tended to focus on personal protective equipment, or PPE, and that's extremely important. But it's also all kinds of other stuff. We focused a lot early on in the pandemic on ventilators. As we now know, we probably overused ventilators. It now looks as if we put too many people on ventilators, and frankly kind of killed them faster by virtue of doing that. So ventilators are important but you also want to know, are there also BiPAP machines, CPAP machines, other ways of providing oxygen support for people as well. Then there's just the basic drugs, you know, are there enough medications? There's been a lot of attention obviously on remdesivir capacity, but we care about everything else too. And now increasingly, we care about other medications: dexamethasone, other forms of corticosteroids, etc. So whether institutions have all of that becomes really important. And then finally staff. And of course, staff was a paramount issue in the Northeast, in particular, in the pandemic. It's still an issue. If you read now, the stories coming out of some places, I read a piece today about Oklahoma. Now, Oklahoma in a different environment, say if there had been a tornado they could have that had devastated a vast area and hospitalized a lot of people, they could have called up staff from Texas. They can't do that now, right? And it's also going to be really hard to get the flow back across the country that occurred when COVID was really hitting the Northeast. Since a number of providers did come in,  for example, from California. California is not going to be in the business of exploiting healthcare providers anytime soon, right? So how systems are able to put together that constellation of stuff, space, and staff is really, really critical and is going to be highly variable, even within particular locations or localities. So that's number one. Then there is the operational aspect of it. As we know, in the first phase of the pandemic in the Northeast, lots of institutions cancelled elective surgeries. That same dynamic is now going on, of course, across much of the rest of the country. You have to do that for various reasons. You can't take up beds with elective surgical patients. You can't take up staff with that, you can't take up PPE with that. This is a hugely devastating financial impact on hospitals, as many of you will know. Elective surgery accounts for about 50% of overall hospital revenues, and the lion's share of the margin, because very frequently, elective surgeries are compensated relatively well by, especially by private payers relative to public payers like Medicare. So what's going on is the institution pulls back from doing a lot of elective surgery. And frankly, sometimes we call elective surgery, it's not clear it's so elective. Sometimes it's urgent surgery that in a perfect world we'd be doing anyway, for example, for people with cancer. So understanding and getting your arms around all of that, in the here and now is really important. And as we know, going forward, this is having an enormous impact on the financial viability of many institutions. Not all, some of them have plenty of cash in the bank. But others don't and they're going to be very seriously stretched. That's why some of you are probably watching very closely, as am I, the efforts now to pull together the next fiscal relief package. This next package is probably going to have to have some additional assistance to hospitals and other healthcare providers, because of the devastating financial impact that many of them have suffered today. So let me stop there, Carla,that was a stab at taking on some of those really important questions you posed. ROBBINS:  So, in my town, I've got a public hospital, I’ve got a private hospital. How public? How much information is there out there about either of those hospitals? How hard is it going to be to get the information that you're talking about as a reporter? DENTZER: It will depend, right, because some hospitals are being very public about what is going on. They have to report a lot of information to public authorities. And now we know that information now has to go up the food chain to the new protect site for HHS. Most of that information is still being reported on that site in the aggregate, but it does dial back down to individual hospital numbers. So with some digging in, and you can certainly go to the hospital and say, what numbers are you reporting yet, right? About your occupancy, for example. So you you can get it, it's just it will require some digging. And that's true for all hospitals, they all have to report that at this point. ROBBINS:  And so of the numbers that are being reported, what are the most important ones? We hear so much back and forth on the other numbers, you know, mortality rates, pseudo percentage infection, you see all the numbers on the front of the Times every day. But if I want to look at the health and the capacity of a hospital itself, and you went through those very good things, which particular numbers are the ones that I should be paying the most attention to? DENTZER:  Well, I think overall, you really you do want to understand. And it's important to say in most parts of the country, not all, in most parts of the country, what is developing is some way for hospitals to get together and share resources, and if not share resources just work together to address this pandemic. So you will frequently read about patients being transferred from one facility to another. So it's important to understand what's going on in the individual hospital, but it's also important to understand what's going on collectively in the state or the region. Because there's going to be a lot of this going on, there's will be movement of people being transferred when certain institutions get to be overcapacity, or they're experienced shortages of ICU beds or what have you. So understanding what that  looks like in the region and what is the capacity overall of the system regionally to respond is probably the most important thing of all. Because it's highly unlikely that every institution is always going to be able to respond to every element of COVID business that comes to that door at a particular time. It's going to need the ability to transfer patients to other institutions. So understanding what regional capacity there is to do that is important, but also who's overseeing that process, right? Who in the state health department is keeping tabs on this? And have they figured out a way to triage amongst systems that way? ROBBINS: So you talked to a lot of hospital administrators and people from different parts of the country and you also are watching the wave right now. Are there particular parts of the country that you're most worried about in terms of capacity and ability to deal with this? Because it means the lagging indicators are here and things are just really ginned up in the last few weeks again. DENTZER: Yeah. Well, you can first of all look on some of the big sites that are tracking all of this on multiple levels. COVID tracking project, for example, to some degree COVID exit strategy is tracking that, the new protect Health and Human Services (HHS) site, etc. And you can put together a picture, but it's very clear that the worst off areas of the country now are, not necessarily in this order, but it's California, Texas, and Arizona. ROBBINS:  But is that also true about their capacity? I mean, that's certainly true about their infection rate, but isn't that also true about their capacity? DENTZER:  Yeah, if you look at the numbers, they are bumping way, way up against capacity. Now, it's going to be different within different areas of the state. Because the urban centers obviously are much more stressed, relative to most of the rural centers, but some of the rural centers are very highly stressed. And already in California, for at least a month there have been big transfers of patients several hundred miles from various parts of the state into, for example, Los Angeles. So, this is where I was getting at this notion of understanding the overall numbers and also what is what are the patterns of transfer and movement of patients around and who's essentially guiding that process, as various areas become way over capacity. ROBBINS:  So, why did they change this thing with the CDC and the reporting responsibilities transferring it to the HHS? I mean, a lot of people are looking at that very suspiciously, but it's a way, one more attempt to Jedi mind game us on something. DENTZER:  Well, I think there was probably less nefarious stuff going on there then then some have reported. It is true that the CDC had some existing lines of reporting that for various reasons already were confusing for a lot of hospitals. Essentially what is happening now is it's all being inputted into this protect site at HHS, I think that probably was an appropriate thing to do. Could we rule out that people aren't going to try to play games with the data? No. But, in whose interest is it right now to do that? Maybe there's one person whose interest there is to do that, but almost no one else. So I think it's probably not an issue we need to spend a lot of time on. The really important thing, obviously, is getting the data as quickly as possible. And to the degree, I know, there's a lot of confusion right now among hospitals as the shift has taken place, but that should sort itself out. And now there will be this one entry point for the data and that should help the process. ROBBINS:  So I want to throw it open, but some of the things that I'm thinking about. And just one that I want to throw in very quickly right now a big question, which of course, it's ridiculous to throw in at this moment is there are rescue packages, potentially things that people are going to know. I don't know what the reporting requirements of financial reporting requirements are for hospitals, I assume that public and private have different responsibilities. But if I wanted to take a look at the financial health of my local hospital, how would I do that? How often do they have to report it? And how could I figure out right now how close to the edge they are? DENTZER:  Well, there are a couple of ways you can do that. For the larger systems, almost every hospital finances itself by issuing bonds and all those bonds are rated by the major rating agency, Standard and Poor's, Moody's and Fitch. So the first thing to do is if you're talking about a reasonably good size system, call up the rating agencies and ask them are they rating? Not every rating agency rates every system, so they're going to be taking different pieces of the pie. But find out what what's happened to the credit rating. And there have been a lot of credit rating reductions, especially in recent weeks for a number of these facilities. So that's number one. For smaller hospitals, and particularly for safety net hospitals, municipal authorities can often issue bonds on their behalf municipal bonds, and those are those are reported into SEC. So you can go on the SEC website and see what's going on with that level of institution. The other really critical thing is just to call them up and ask, right? Because if you can get the CFO on the phone, you know, hospitals don't have an interest right now in downplaying the degree of their financial duress. They just don't, if anything quite the opposite. And as we know, in the first wave of provider relief that came through to the tune of 175 billion, not all of which has been dispensed, by the way at this point. Because of the formulas that were adopted, both for that part of the program and also for what essentially amounted to loans, some of you who follow this will know that CMS in particular, gave, essentially lent hospitals their future Medicare payment, to help them address any liquidity concerns, and those were structured as loans that are going to have to be paid back eventually. There's a lot of discussion now about the timing of those paybacks, how much of that will actually be required, how much loan forgiveness should there be, and if there's not loan forgiveness, what is the interest rate that hospitals will have to pay if they don't pay that money back on a timely basis? If you put all that together, hospitals right now have an interest in disclosing what their actual financial situation is because this will not only sort out what to do with the first wave of the hospital systems, but also what to do with the next wave of hospital systems, right? And there will be another way. The House passed, its so called Heroes Act back in May that had a big element of financial relief. Now we're going to see what the Senate puts forward, if anything, and then of course, the negotiating will begin. But hospitals really do have an interest right now in being public about what their degree of difficulty is, and so I would start by asking them and get as far down the road as you can with them that way and then you have these backup options as well. ROBBINS:  That's great. Thank you so much for that. So Irina questions from? FASKIANOS: Yes. So thank you both. Let's go now to all of you For your questions and answers, please click on the raise hand icon on your screen to indicate you would like to ask a question and please accept the unmute prompt and tell us who you are and what news outlet you work with, to give us context. So let's see we already have two hands up. So we'll go first to Tiffany Stecker. Q: Can you hear me? FASKIANOS: Yes. Q: Okay, great. Well, thanks so much. This is really interesting. So I'm with Bloomberg Law. I'm based in California and was on a call with the State Hospital Association yesterday. And they mentioned that one issue is that patients that are usually discharged from a hospital and go into a skilled nursing facility for rehab for a couple weeks, and that option isn't available anymore because of the problem that cities have had with containing COVID. So, Susan, I just wanted to see if that's something you've seen in other states or nationwide where there's a backlog of patients that can't go home yet, but can't really go to an acute care facility because of COVID. DENTZER:  Yes, indeed, that's been a problem almost every place. And I'll just point you all to a webinar series that I hosted for the patient center at Outcomes Research Institute. Back in the spring, if you go to pcori.org, go down to the bottom of the site, you'll see, you can click on and get all of those webinars and almost everything. What's interesting is that almost everything that is being experienced in the health system now was exact same stuff that was being experienced two months ago and three months ago in the Northeast in particular, but also Louisiana and some of the other epicenter areas early on. But this issue of patient flow at large has been a real issue. So if you think of it, you had patients getting sick in the community, some of whom were getting sick initially in nursing homes. And so they were having to be admitted from nursing homes into hospitals. So there was one element of flow that had to be taken into account. Then once patients were treated, if they were recovered and had to be discharged, you had to get them out of the hospital. Well, in the Northeast, New York in particular, where did they go? Some of them could be discharged to home unless people at home were sick and couldn't take care of them. So that couldn't happen. Nursing homes initially in New York were refusing to take patients back because of the uncertainty about how long, even after they had recovered, whether in fact they would remain infectious, right? So there was concern about taking them back. And a lot of hospitals in New York and elsewhere, were requiring two negative SARS-CoV-2 tests before they would take a patient back. Well, that could take two weeks to get the results back. So patients were stacking up in hospitals, not able to go back into nursing homes. So that was an issue. And then as I say, they couldn't necessarily go home. And guess what, there wasn't necessarily enough homecare staff because at one point, the visiting nurse service of New York, more than a third of the staff was out sick, right? And then for patients who couldn't have a place to go home, shelters weren't taking them back, so the city essentially had to turn around and read a lot of hotel rooms to house patients. So various versions of this have played out across the rest of the country. And it's been a real real issue and it's only compounded by the disaster of the testing situation in most places, the availability of tests, the time lag for getting tests back, etc. FASKIANOS: Okay, thank you. Let's go to Ann Thompson. Q:  Yes. Thank you. Thank you for doing this. I was wondering about contact tracing. Have we just given up on that? Are there areas of the country that are doing it well? DENTZER: Yeah, there are some. It's becoming less and less of an urgent issue in the high surge areas, frankly, because as you all know, despite the large number of positive tests, we think it's a major understatement, right? I mean, I think CDC director Redfield has said it's probably 10 times the reported rate at this point. Well, if that's the case, you take some of the areas that have had really major surges in infection in recent weeks, the states I mentioned earlier and also Florida. If the actual positivity rate is 10 times what we're showing now, contact tracing does isn't going to really help that much, right? Because almost everybody will have already come into contact with people who are positive. So you know, it doesn't mean that contact tracing is useless. It still should happen for scientific reasons. I mean, we still need to further our understanding of how people become infected. We pretty much know the basic parameters, you know, that you have to be in a more confined area for a certain amount of time and be exposed to either aerosolized virus or droplets. But we could probably refine our understanding further if we have more contact tracing going on for scientific purposes. For the purposes of having people essentially stopping community spread, it gets harder as I say when the prevalence is higher number one. The other thing is with the testing delays. It is probably the case that let's say you got alerted that somebody you had been in contact with somebody who had tested positive. You go out today to get a test, you could wait a week before you get your test results back. So in a perfect world, what would you do, you would quarantine for that week. How many people are actually doing that? Probably not very many while they await their results. And in the meantime, as we continue to refine our understanding, we think people are at their most infectious before they're symptomatic, right? So it means they don't know. They don't want to believe that they're sick. They don't have symptoms, they're probably moving around a lot, even if they've been notified that they've come into contact with somebody who tested positive. So that makes the contact tracing piece a real struggle. FASKIANOS: Thank you, Missy Miller. Q: Hey there, thanks so much for taking my question. I was wondering, do we know what is a normal hospital capacity pre-pandemic? Because Florida now has a dashboard that it shows patient beds and ICU beds per hospital. And at the beginning some of these ICU’s were showing at zero percent. So the hospitals changed how they report it, so now they're reporting all their beds, not only their staffed beds, so it's very hard to judge what the number that we see on this dashboard is, whether they're doing well or reach 90 or 100%, if they’re full. Do you have any benchmarks to compare this with or what questions we should ask? DENTZER:  It's a complicated question, as you suggest, and back to what I said earlier, first of all hospitals do have some surge capacity, right? So they can probably add more beds. As I say, in New York, they were required to do so they haven't been required to in other states, but they, a lot of them do have capacity. So there's a little bit of surge capacity, probably still in a fair number of hospitals. So that would be one question to ask. Okay, so how many beds are you saying you have now and how much of that has been surge capacity that you've added? What additional surge capacity do you have to add? How are you thinking that you would segment that as between ICU beds and step town beds and general floor beds, etc. So that's one piece of it. Historically, particularly in recent years, it has been the tendency of hospitals to try to operate as close to capacity as they possibly can. And going into the pandemic, if you looked at major urban centers, hospital occupancy rates were way, way up in the 80s, or even the low 90s in most places in good times. Okay. Now, admittedly a lot of that is pointed be things like elective surgery patients. So these are people are not there for a long time, but they're there for several days. And the cycle because hospitals were churning through so much like elective surgery, they were trying to keep those beds relatively full because they were trying to do a lot of elective surgeries. So essentially, what we're having to do is compare life before COVID, which was operating under a completely different set of dynamics to life during COVID, which is totally different dynamics with no elective surgeries and lots of COVID patients. And as we know, in some areas of the country, you know, 40% of the patients who are in hospitals or more are COVID patients, they pushed out a lot of the other, in effect pushed out a lot of the other patients. So I wouldn't spend a ton of time asking what the normal world is because it doesn't matter right now what normal was, what matters is what is what's going on now. FASKIANOS:Thank you, let's go to Anastassia Gliadkovskaya. Q: Hi, thanks so much. I'm a data fellow at The City, we’re a digital newsroom that cover the five boroughs in New York. I had a question about finances specifically. You know, hospital systems are all of different sizes and their finances vary widely. Are there certain red flags that we can say definitively across the board, you know, are concerning for all hospitals? So for example, you know, some hospitals may say they lost half a billion dollars, you know, lost revenue on elective surgeries that were postponed. But another hospital may have lost less or more.Does it make sense at all to compare those losses, given how, you know how different they are in size? And I guess the follow up is, apart from the ratings that you mentioned, are there other indicators of health or sort of red flags? Like, for instance, heavy borrowing is that you know, would heavy borrowing indicate health or on the other hand, sort of concerning red flag? DENTZER:  The number one question you want to ask the CFO is how many days cash do you have on hand, right? Because days cash on hand means, can you afford to pay your staff or are you gonna have to lay people off? Can you afford to buy PPE or are you going to have to go without it, right? So days cash on hand, how many days cash do you have on hand? So after that, hospitals are borrowing all the time. But they shouldn't be necessarily borrowing for operational purposes, they should be borrowing to expand capacity and things like that. So, but if you can get it, if they don't have much cash on hand, then they are going to have to work out short term financial arrangements. That's why they need it, these advanced payments from Medicare so badly and from private payers as well. So I would ask them, you know, once you find out what days cash on hand owes, and if it's below 30, they're in big trouble, right? Ask them, what emergency sources of financial support are you lining up? Are you going to have to furlough staff? You know, all of the consequences that would normally follow from a hospital essentially running out of cash. So I would start there and then of course, you could look at their overall credit rating and what happens in that vein. And then, you know, ask them to tell you how many people they've laid off right recently, because they will if they have been really stressed, they will have had to already start taking measures like that to start to conserve cash. FASKIANOS: Thank you. Let's go to Mary Katherine Wildman. Q:  I am a reporter with the Post and Courier newspaper in Charleston, South Carolina. Thank you. The question I have, hospitals are dealing with all kinds of financial stressors right now. But one thing that I'm just a little unclear on is that many hospitals in our state have kind of stepped in to offer or at least facilitate a lot of our state's testing. Is that a financial positive or negative for most hospitals, and if it's possible to say how much does that cost them to provide? DENTZER: It depends, right? Well, as with most things, a lot of hospitals in larger health systems are able to develop their own in house tests. These are known as laboratory tests. For those of you who have covered this in an earlier era, those are what we would think of as tests that are governed under the regulations known as CLIA, right? And hospitals have always had the ability to develop those tests. And many of them have in this environment in particular, they are able to bill insurers for those tests, as we know they cannot build individuals for those tests. That was part of the some of the earlier relief packages that were enacted. So there's no cost sharing now for individuals for COVID related tests that have to do with establishing whether you've got the virus or not. There's a little bit more ambiguity around tests that are done to figure out how to treat you. That's going to be sorted out in the next packages of legislation. But at least if you're in the hospital and you get a hospital device test, you're not going to pay anything and the hospital is essentially going to have to negotiate with insurance companies as to what that test is going to be. And like most things, hospitals will tend to pick a number that they want to bill the insurer for. And then there's an effect of negotiation about what the insurer will actually pay. Okay, so that's that situation. There are other situations where hospitals might be doing either on campus or off campus tests, where they've linked with some other provider of some sort, who is handling the test. It's either a public health authority that is doing it, in which case the public health authority is picking up the tab for that, or it could be partnering, say with a CVS or one of the other major commercial testing labs. And in that case, it's going to be a function of what arrangements were set about who's going to bear the cost of it. Typically, if it's done by a commercial lab that has set up, let's say you've got like a CVS or you've got a lab, Lab Core or Quest Diagnostics, orchestrating the testing facility, the hospital itself isn't going to be on the hook for that or necessarily getting the revenue from that. That's going to be a transaction that's negotiated between the commercial lab company and the health insurer. FASKIANOS: It looks like we have no questions. Oh, we do have another question, Mary Zatina, Q:  I’m with WDET public radio in Detroit, and my question pertains to nonprofit hospitals and their requirement for funding. What do you see happening with nonprofit hospitals reporting their losses from the coronavirus and what they would benefit? And also, what implication might that have overall on community benefit from nonprofit health systems and hospitals? DENTZER: Well in the short run, if I were running a nonprofit hospital and by the way, when we say nonprofit, of course, what we really mean is tax exempt, right? Because they essentially do not have to pay many forms of taxes at the federal or state level. They may have to make payments in lieu of taxes that have been structured in various areas. But you know, every hospital has to have a margin of some sort to stay in business. And whether you want to call that a surplus or a profit, whatever, they've got to have some margin to stay to stay in business and to continue to reinvest. And historically, nonprofit hospital margins have been all over the lot. It really depends on, you know, what is the size of your institution, what is the mix of pairs that you have, etc, etc. So when we say nonprofit, we mean everything from a Cedars Sinai or Northwell Health. I mean, Northwell Health is the biggest employer in New York State, right? And it's a nonprofit system. So we mean everything from that all the way down to a very, very small, much smaller community hospital, for example, or even a rural hospital. So there's huge, huge range there. On community benefit, if I were running a hospital, you bet your life I would declare to at least to some degree, what I'm doing now, as community benefit if it's legitimate to do that. Right now we have a lot of forms of assistance coming in to cover the costs of caring for patients with COVID-19. And there probably will be another wave of that. If we look at the Heroes Act, if that becomes anything close to law, that if any of those provisions are taken up in an overall bill that passes both the Senate and the House and is enacted into law, there's a lot of Medicaid changes in particular there. There are numbers of provisions for Cobra extension, etc, etc. So, a lot of care isn't going to be free care. It's going to be picked up by somebody in particular by Medicaid. To the degree that there are unreimbursed expenses out there, it really does behoove hospitals to capture that and legitimately claim that as community benefit. I think it's going to be difficult to do that because of all of these payment changes that are going on. I think more broadly, you know, when this is over, there will probably be a look back at how hospitals have handled this to understand the situation. And I guess I would not go out on a limb at this point and say that I know what we're going to find. But you know, it this is a complicated exercise and could you imagine that a lot of hospitals are going to try to report things as community benefits that in retrospect, they probably shouldn't have. Yeah, I can imagine that would happen. I can also imagine that hospitals will throw up their hands and say, it's just too complicated. Let's get on with this. And then we'll see what happens with community benefit provisions if they are altered going forward. I don't even begin to pretend I can see that far into the future. FASKIANOS: Thank you, let's go back to Naseem Miller and she's with the Orlando Sentinel. Q: Thanks again, I am curious, how you would view a midsize nonprofit health system that, you know it started laying people off in April/May but at the same time since then they have acquired another small hospital. And the two sort of don't jive with each other, but maybe it works for high level finance, but I don't quite know what to make of it. And of course, the employees are pretty outraged about it. So I don't know what do you think? DENTZER: Well, there has been a trend of hospital consolidation on for quite some time, for the fundamental reason that to some degree, depending on the part of the country before the pandemic, you could reasonably argue that there were too many hospitals, too many hospital beds. That's not an argument many people make today. But before the pandemic, that was true in certain areas of the country. And if you think about it, if you have two hospitals, you've got two CEOs, two boards, two sets of overhead, etc. If you combine them, you streamline all of that. And so your fixed costs relative to your volume fall. So economically, that is a rational move and it is a particularly rational move now, because I can bet you I don't know that situation that you're describing. But I bet you the hospital that acquired probably had 10 days of cash left on hand, right? They probably didn't have a choice. And you should ask what the purchase price was. Because I know for example, up here in Washington, DC several years ago, Johns Hopkins, but it what had been a prestigious hospital in northwest Washington called Sibley for $1. Because it essentially in buying the hospital saved a lot of its debt. Okay. So find out what the purchase price was. If I were the employees, I'd say, you know what, if I want to keep working here, or even possibly be called back to work someday, it's probably better off at these hospitals merged. I know the optics of it look really bad but from a reasonable financial standpoint, I would bet you it was a smart decision. FASKIANOS: Thank you. We don't have any questions right now. But in the chat, can you reiterate, and we will send it around but the website that you mentioned at the outset, Susan, so people can look it up after this call? DENTZER:  Sure. It's the website of the Patient Center Outcomes Research Institute, which goes by the acronym PCORI, pcori.org. PCORI is not a government entity, it was created under the Affordable Care Act. So it's considered a quasi governmental agency, which is why it has that org as opposed to Gov. But go to that page. And if you look down at the bottom of that page, you'll see on the left a tile that essentially directs you to a webinar series. And that's the webinar series that we did back in late March, April, and into May. We did a segment on this whole question of flow within hospitals that I mentioned, including the nursing home piece. We did a segment on how hospitals should set up incident command structures, which is another thing that you might want to look into, particularly for purposes of maybe developing an interesting feature story. We did a segment on telehealth and the very broad use of telehealth that occurred in the early stages of the pandemic in particular. And we did another segment on the emergency room and what was going on in emergency departments. Because of course, those were primarily the receiving areas for the first waves of patients. And in the early, early days of the pandemic, that's where a lot of the really difficult stories were occurring as patients were showing up breathing fine one minute and dead within several hours as their breathing capacity rapidly deteriorated. So there's some fairly gripping stories there. FASKIANOS: Thank you. And we'll circulate that again after this discussion, but I wanted to give it make sure everybody had it right now. So Carla, over to you for more probing questions. I always have questions. ROBBINS:  I always have questions. So Susan, you know a lot about the way Washington works. Let's pitch forward a little bit. Vaccine has developed one hopes sooner rather than later. How much preparation is being made on distribution and on rational distribution? And who's going to make that decision? DENTZER:  Well, really important questions. As we know, what is happening now is the government is signing contracts, there was just one announced yesterday with Pfizer, to commit to buying a large numbers of vaccines, even before we have a proven vaccine, and it is doing that with more than one company. So companies can already start producing the vaccine even before it is approved and makes it all the way through phase three clinical trials. It's because we don't have time, right? I mean, it's better at this point to create the capacity, just building the capacity to produce the vaccines is important. Getting the glass vials, we don't have enough glass vials in the world right now to produce the adequate numbers of vaccines. So, gearing up all of that production capacity becomes really, really important. Then we have results out of some of the phase three trials, which are already underway.  If we have those by early fall, it is theoretically possible that you could get some initial so called emergency authorizations out of the FDA that would essentially say we're tentatively approving these vaccines, and then you will already have a lot of them produced and then able to be distributed. On the question of distribution, there's been a newly appointed panel under the National Academy of Sciences to look at this issue. CDC basically came to the national academies and said, tell us how to figure this out, right? Because it's an extremely important set of issues to figure out, you know, because we're not going to get all the vaccine doses that we need available right away, it's going to just be a drop in the bucket at the outset relative to the need. So figuring out how to roll the vaccines out who gets them first, is it high risk elderly people in nursing homes? Are we going to prioritize those people over, for example, schoolchildren, right, so that we can reopen schools again or universities so we can get universities open again or restaurants so they can open up again? I mean some really, really difficult issues. They will be made less difficult if we have huge volumes of vaccines, or if we have more than one vaccine. And it's theoretically possible that we'll have a couple or a few vaccines, but then even figuring that out on the basis of clinical trials, which, in the in the best of all worlds, we will have tested these vaccines on maybe 30,000 individuals, maybe 50, maybe 60. Deciding on that basis, what vaccines we think are going to work for which parts of the population is also going to be very complicated. So all of this has to be somehow figured out over the next say six months, so that we can come up with some kind of a rational plan. And it will be one of the hardest things I think from a public health standpoint that this country has ever had to do. ROBBINS: But it's not just a public health issue. It's also a political issue. And it's also a question of who's in charge. When you look at sort of the political struggle that's gone on, you know, even who gets to brief at the White House and we trust the CDC. Ultimately, who owns the vaccine and who gets to decide who benefits here? DENTZER:  Well, for these agreements that have been struck by the federal government, in essence, the federal government owns that vaccine, right? And some of  the manufacturers have said, when that price when that transaction takes place, they're not expecting a red cent more. Some have said no, we're going to take a lot of the government money to develop this we're going to see some advanced purchase commitments and we're going to strike those regions, but we're going to reserve the right to continue to sell the vaccine on the outside. So we'll see some variation I'm pretty sure in those arrangements as well. For the as best as I can tell, from reading the detail that Pfizer and MIH have put out and HHS to put out, the government is going to own every dose of the Pfizer vaccine that has it has committed to produce in this certain timeframe. So that means if there is a government decision about how to allocate that, that will be followed. But that's a big if, right? If there's going to be a plan. Now, as we have seen, there hasn't been a top down government plan on anything in this whole arrangement. So what emerges as a top down government plan? I honestly don't know. It could be that what will happen is the government will just say, we're just going to divide this on a population basis. We're going to ship it out to the states, certain doses, for whatever your population is. We're going to send you enough to vaccinate 3% of your population and you figure it out, states. I think if I had to bet, I'd say that is probably, you know, it depends on who of course, is making that decision. What administration and what is the timeline, but if it were today, I would say, I would bet that's how they will do it. They'll just allocate them to the states on a percentage population basis and let the states figure it out. But who knows, this is truly uncharted territory. ROBBINS:  This is the Council on Foreign Relations. Does anybody have a better idea internationally about how to distribute this vaccine? DENTZER:  No. It's a huge issue because obviously the rich countries are the countries that are in a position to put up the money for these kinds of arrangements, these major advance purchasing commitments. There is a movement now to try to structure that on behalf of poor countries. But it's not particularly far along. And it's not clear what how big the pool is ultimately going to be that is set aside to buy these vaccines on behalf of poorer countries. That's another for people who are interested in the global health aspects of that, that is a huge issue that we're just all gonna have to keep watching. ROBBINS:  I see we have one final question, Irina, from Frank Zufall. Less dependency on ventilators, what have hospitals, medical personnel learned about addressing COVID-19 over the last 13 months, have we become more effective in treating patients? DENTZER:  Yes is the word. And that's, you know, if you want to look at any silver linings in this, there is just incredibly rapid learning that went on at the clinical level and very rapid dissemination of the learning that went on at the clinical level. So, again, back to ventilators. As many of you will know, what was clearly showing up in a lot of patients is that their lung function deteriorated very, very, very rapidly. And there's a measure known as oxygen saturation and people would come in with a slightly below normal level of oxygen saturation in the blood and it would deteriorate by 50%, within an hour, just extremely suddenly. And early on people said, holy god, what do we do about this? And so the impulse was get somebody on a ventilator as quickly as possible. In retrospect, it looks like, as people understood that this deterioration that could occur, patients were first of all watched a little bit even more closely, you didn't just assume that if somebody was doing well in one hour that you'd come back an hour later, and they still be in that same situation. And then they were also put on alternative forms of oxygen support, CPAP machines, another kind of machine known as a BiPAP machine. Even things like proning, which is basically, you take a patient and you turn the patient over on his or her stomach, because that just enabled better oxygen exchange in the lungs. And even just doing that it was learned would support the breathing capabilities of a lot of patients. So for those of you who know much about this, what we know is if you put patients on ventilators very frequently they don't come off them, right? They die, right? Because it's a pretty extreme measure to undertake. So if you can basically keep from doing that and do other things to support the breathing of patients in the interim, that really helps. And then of course, we've been able to add things like remdesivir, dexamethasone, etc, other treatments that have helped. So there's been a lot of progress. And in the end, it happened very quickly. It could have happened even faster and we would have saved more lives but thank god at least it finally occurred and it's not over. We're just continuing to learn more and more and use more and more tools to help preserve people's lives. ROBBINS:  Well, a little bit of good news there. We've so appreciate your doing this was really fabulous. Lots of really good stories. Irina, I will turn it back to you. Thank you so much. FASKIANOS:  Fantastic. Thank you both Carla and Susan Dentzer, and that you can follow Carla on Twitter @Robbinscarla and Susan at @Susandentzer. And again, we will circulate these resources along with the video and transcript of this webinar. So again, please come to us CFR.org., ThinkGlobalHealth.org, and ForeignAffairs.com, for the latest developments and analysis on the COVID-19 pandemic, and share your suggestions and feedback for future CFR Local Journalist webinars by sending us an email to [email protected]. And I hope you all stay safe and well. So thank you again. Thank you. ROBBINS:  Thanks. STAFF: This concludes

David Scheffer: Thank you very much. Hello, everyone. I'm David Scheffer, visiting senior fellow on international law at the Council on Foreign Relations. And I've been a longtime student of Scottish devolution and aspirations for independence from the United Kingdom. We have the privilege today of being joined by Michael Russell, who is cabinet secretary for the Constitution, Europe and External Affairs of the Scottish Government, and he is a constituency member of the Scottish Parliament, representing Argyll and Bute. He was raised in Troon in Ayrshire and educated at Edinburgh University and has lived in Argyll for over 20 years. Mr. Russell was previously Minister for Environment from 2007 until 2009 and then served as Minister for Culture, External Affairs and the Constitution before moving to the role of Cabinet Secretary for Education, which he held until 2014. He was appointed Minister for UK negotiations on Scotland's place in Europe in September 2016. I can attest confidently that Mr. Russell is a close confidante of Scottish First Minister Nicola Sturgeon. And, after her, he is the most informed and articulate spokesman on issues of devolution and independence in the Scottish Government. He has spoken often of the hazards of Brexit, of Scotland's determination to remain in the European Union, and of the inevitability of Scottish independence if Westminster continues down a destructive path of its own separation from Europe. A significant majority of Scots have repeatedly expressed their desire to remain in the European Union. While the independence referendum of September 2014 failed to achieve a majority vote, in part because of the UK government's position at the time to remain in the European Union, there is a majority of Scots for independence in all of the polls reporting in recent months. Thus, the aspirations for independence remain very much alive, while the Scottish Government prioritizes management of the COVID-19 pandemic. So it's a bit complicated. Mr. Russell and I will engage in discussion for 30 minutes, and then I will open up the floor for questions. Please feel free at any time to raise your hand, and I’ll see those hands stack up, and I'll begin calling on individuals at the 30-minute mark. So let's begin. Mr. Russell, it's a tremendous pleasure to have you today at the Council on Foreign Relations. I want to start with this sort of cosmic question. The Scots have a long history of division and union with the rest of the United Kingdom, which includes England, Wales, and Northern Ireland. For those in our audience who may not be familiar in detail with Scottish history and politics, can you briefly tell us what it means to be Scottish, particularly being a Scot living and working in Scotland, or the European Union during the turbulent politics of the United Kingdom and of the world today? How committed is Scotland to remaining in the European Union? And why? Michael Russell: I think I could probably speak for the next hour on that topic and not complete it. But let me just quote somebody who may be surprising to quote, Cecil Rhodes, who said that to be English was to win the first prize in the lottery of life. Scots don't feel that way. I think that the Scottish view of the world is much more modest, much more inclusive. And the reason we regard membership of the EU as absolutely central is because we share European values and those values of cooperation. We share the view of the world as held throughout Europe. And we find it increasingly difficult to reconcile that with not the plain people of England, as Chesterton called them, but the English government and the way in which it operates. In order to be a normal nation, and in that simple normality, in order to be a normal nation, it will be necessary for Scotland to be independent within the EU. It is not normal to be in the type of constitutional setting where we are presently where a substantial number of the powers that we need to exercise are not available to us. And it is, I think, we have to see all this through two prisms now. The world has changed enormously in the last three or four months. And those two prisms are Brexit and the vote of the UK, but not Scotland, to leave the EU. Scotland did not vote to leave the EU and yet is being forced to do so. And the COVID pandemic, particularly, as I think it continues to change views. Every individual death is a tragedy, and I offer my condolences to those people in the United States who have gone through such terrible times, as we've all gone through those times. But we have to come to some conclusions about those and where we want to go next, what the future will look like. There's a tremendous book that actually originates in America, John Barry's 2005 book on The Great Influenza, which celebrates the success of American medicine and the coming of age of American science. But Barry writes about pandemics in general in that book, and he comes to a conclusion, though, what makes the difference in terms of coping with a pandemic in governmental and governance terms is quality of leadership. It is governance itself. The conclusion he comes to and let me quote it because it's really important, “The biggest problem in coping with a pandemic lies in the relationship between governments and truth. Part of that relationship requires political leaders to understand the truth and to be able to handle the truth. Those in authority must retain the public's trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one.” And I think what you may have seen in the handling of the pandemic is that in Scotland, the pandemic and the difficulties of the pandemic have added to the views that have certainly grown after Brexit, that we need to have a more honest, a more truthful, and a more values-driven politics that we are able to have, and a governance that is better for people. So we have to do a lot together, and we're not able to do that. There is a barrier between us and the world. And it is removing that barrier that is really important. And I have argued repeatedly, that devolution, the devolution settlement, the settlement under which Scotland, Wales, and Northern Ireland presently live, which is only 20 years old, has not been able to bear the weight of either Brexit or COVID, because of the demands upon the governments to serve their people. We've not been able to answer them as fully as we should, because we do not have the full powers to do so. So it's a question of where power lies, how power is exercised, and where it would better lie and be better exercised in the future. And it is not in any sense ethnic, or racial, or to do with disliking people. I was born in England. My mother was English. Her father's proudest boast was that he had bowled out the great W. G. Grace, the cricketer. If you look at the chronology, W. G. Grace must have been a bit arthritic by then, but even so, you know, this is not about being against people. It is about a modern reaction to the world in which we live. And the better way we could run things in Scotland, if we were not at arm's length from it and removed from it. So that is a long way of saying it's normal to do it. We need to become normal because it will lead to a better governance, a better equality, a better deal for our citizens, and a better relationship north and south of the border. There's a very old saying that says independence for Scotland will get rid of the surly lodger and gain a good neighbor. And we need to go to being good neighbors with the others on this island, but not to be controlled by them. Scheffer: Michael if, as the US or the UK government claims, COVID has proven that the idea of independence is not viable for Scotland, why hasn't the United Kingdom provided resources for Scotland to weather the pandemic? I just don't see much news of stuff flowing from the south to the north during the COVID pandemic. Russell: None of us are capable of making the cost of the pandemic without an extraordinary loosening of borrowing and the loosening of the public finances. I mean that's clearly true. I mean, the UK has borrowed an enormous amount, going north of £300 billion at the present moment. We do not have full borrowing powers in the Scottish Parliament. It is one of the areas of restriction upon our powers. So we have not been able to borrow the amount we feel we need to deal with it. If you look at the scale of the German response, we're not able to match that in terms of the way in which we should to spend in Scotland. Now, the way in which Scotland is financed, as you well know, is very complex, but it relies upon essentially a thing called the Barnett formula. And for every pound that is spent in London, for certain parts of government expenditure, a proportion of that comes to Scotland, but it did, according to the proportion of the population, which is about 8.6-8.7 percent at the present moment. There is a complicated balancing formula to do with public finances and taxation, because we do not have full taxation powers. Now we have spent more than we have received in that formula on Brexit. There's no doubt upon that. Equally, Brexit has cost us far more than any compensatory payments. But remember, part of the issue of the union is sleight of hand. If you keep reassuring people that everything is fine, and that you are looking after people, then they tend to believe it for a long period of time. And they tend to avoid the confrontation that inevitably will come. We have spent more than has been provided for. We are not able to borrow the money we need to tackle the job properly or the way in which we want to do so. And therefore we believe that the financing of this is far from proving that we rely on and would continue to rely on the UK. It actually proves the opposite. This gives a justification for saying we could do this better ourselves. Scheffer: Why don't you just go ahead and hold the referendum for independence if you think the people of Scotland want independence? What is the obstacle right now? Russell: Oh, this is where this is where it becomes very strange for people to believe. We can't do that. In 1997, when the Labour government was elected in London and was committed to devolution, devolution had been attempted twenty years earlier. It had failed on a referendum not because the people of Scotland voted against it, but because a stipulation was put in that referendum that 40 percent of those who were on the electoral roll would have to vote in favor of it, and it just failed. So there was a majority for Devolution 79, but it was not carried through. When the Labour government was elected 1997 with a commitment to devolution, then the sticking point for support for that from my own party, the Scottish National Party, which was very much a smaller party at that stage, was there to be no glass ceiling on the arrangement. In other words, if the people of Scotland at some future date from that, decided that they wanted to move on to independence, they couldn't be forbidden to do so. And the compromise position that was reached with the Labour government, I was there when it was reached. I was with Alex Salmond in negotiations with Donald Dewar, who was then the Secretary of State of Scotland. The agreement that was reached was if the Scottish Parliament sought a referendum, then both Parliaments would have to vote for that. But there was no question that if the Scottish Parliament asked for that it would get it. And that is the mechanism that operated in 2014, that the Scottish Parliament asked to hold a referendum. It was granted. The UK Parliament voted with it. We have asked to hold another referendum, and we have been refused on two occasions. The first time contemptuously by Prime Minister Theresa May. The second time in a complicated but equally peremptory way by Boris Johnson. So we are not presently empowered to hold that referendum. Now that is in itself a subject of debate in Scotland. Some people say that the constitution would permit you to do so. I have never believed that that is the case, because I negotiated the agreement that said something different, but we believe that if the Scottish Parliament asked for it, then it should be granted. That is not the present situation. Were that the situation, then we would be holding that referendum. The argument against it from Boris Johnson is we had one in 2014, which, you know, is equivalent to saying you had an election six years ago, you're not getting another one. Johnson has indeed said it should be a matter for a lifetime. So in other words, you had an election when you were 21. You're not getting another one until you were 60. This is democratic nonsense. But it is impossible presently for us to do so without a concomitant vote by the Westminster Parliament, which when you think about it is very strange, because the UK was able to hold a vote to leave the EU. And the EU never said, “No, you can't do this.” And if that had been done, I suspect that would have been a matter of outrage. Scheffer: Well, so far, we've talked about both the pandemic and independence and I want to bring the two issues together. What is the highest priority of the Scottish Government during this year of the pandemic? Is it to deal with the pandemic, ensure the health of the Scottish people, try to get more funding for the National Health Service, restore the economy, or is it to pursue the political agenda of independence in the event Brexit and how London handles the economic withdrawal from the European Union this year, compels Scotland to break perhaps as early as next year? Are these coterminous priorities? Russell: No, no, the priority has been an absolute priority has been COVID from the very first day. We went into lockdown on the 23rd of March. And we said the week before, as I wrote to my counterpart in the UK government that we were suspending the work we were doing on the independence referendum and that there would not be a referendum this coming year, because clearly we wouldn’t be able to prepare for one. There was no reciprocal gesture from the UK. There was an election in the UK last December. We recognize the mandate that the Johnson government had to leave the EU. We, however, won the election out the park in Scotland, 48 to 59 seats. We believe that they should recognize our mandate to hold that referendum. They have not done so. Even so, COVID was a priority and remains a priority. We've taken out a very cautious approach. There has been a four-country approach, and I think it's fair to say it did work to start with. The lockdown was a four-country approach—Wales, Scotland, Northern Ireland and the UK—the rest of UK, England, follow the same approach. That has diverged somewhat in the last two months. And certainly, we have taken a very much more cautious position particularly on easing the lockdown. Our first minister has been much criticized for it outside Scotland. Inside Scotland, she enjoys very substantial support for what she has done. And that means, for example, today is the day where pubs and restaurants can open, and that's for the first time since the 23rd of March. Hairdressers are able to operate today. I probably look as if I need one, but hairdressers allowed to operate from today. Most of these things have happened earlier in England. Health is a fully devolved matter. So we are able to operate that policy ourselves. And we have done so we have even made slightly different decisions on the closing of the borders. The UK’s list of border closures we did not accept in its entirety. We looked at it again. And there was one country that we took a different view, which regrettably was Spain. And we've not allowed visitors from Spain to come to Scotland without quarantine, although England has. And we base that on the science. We've been very driven by the science. We've set up our own scientific advisory structure, and we would continue to be that way, so we'd be very cautious, very careful, and it's not over. I would really stress this very, very strongly. The pandemic has not come to an end. You know, we've just had seven days with no deaths. That's the first seven-day period with no deaths since I think the end of February, beginning of March. But we know this can come back very quickly. If you look at the figures today in Israel, for example, where you see that at one stage they were down to 10 new infections a day. Yesterday, I think there were 1400, you have to be very cautious. So we will continue to go on being quite cautious. And the First Minister has said it is not her priority presently to move on the issue of independence. But I do think that there are things happening which will force our hand, and I've said this, to react to them. For example, tomorrow the UK Government will issue a white paper on a number of topics, which is taking powers away from the Scottish Parliament. That will produce a reaction without a doubt. Scheffer: Next year you will have elections for the Scottish Parliament. The Scottish National Party has the majority of the seats in the Scottish Parliament. Is the First Minister waiting to see what the results could be from those elections with a stronger majority, perhaps in the Scottish Parliament, before she would take a rather definitive step towards trying to seek an independence move after those elections? Russell: No, I don't think so. I mean, we have a very strong mandate. In any case, I mean, you know, we have one the last I can't remember how many elections in Scotland. But you know, we won the December election. We've won every election, I think, since 2014. You know, I don't think that is the case. I think the case is that COVID is the number one priority both to suppress and eliminate the virus and to rebuild the economy. I took part in a webinar in Brussels office this morning with a banker called Benny Higgins, who is chairing our recovery group. And you know, we are very focused on the issues of economic recovery and a green recovery. I mean, Scotland, you know, has world-leading climate change legislation. We are very focused on the green recovery. So all those things are priorities, and we need to do those. But the election is very significant next year. Because if the UK government continues in a way it's going, then the anti-devolution, the anti-constitutional change agenda will be very, very visible. And you know, that will be a place in which a decision has to be reached. The other thing we need to do is conclude this debate. I mean, I think the problem with constitutional debates is that they cause uncertainty, and it is very important that we conclude this debate. So I would want to see next year's election taking steps to say we have to conclude this, and the issue is to give the people Scotland a choice. The people of Scotland voted for a choice. We've said, for example, in the election last December, this is about choosing not to have Brexit and choosing to be independent in the EU. We won 48 of the 59 seats. It can't be really more definitive than that. Scheffer: Does the rise of the Alliance for Independence Party recently, which is more focused on trying to achieve independence, rather than the Scottish National party's current priority in governing on the pandemic and then ultimately, the independence issue. Is the Alliance for Independence a realistic threat to the SNP? Russell: I'm scratching my head to think I've ever met anybody from the Alliance for Independence. So to that extent, I have to say, probably not. I understand the frustration that people have. I have that frustration. I would like to conclude this matter. I think there's work for us to do. But you know, if you're in government, you've got other obligations as well, and you've got to fulfill those obligations. There is a sense in which the, the debate has been about whether you can game the Scottish electoral system. If you can, because we have a two-vote system, where you vote for a constituency representative and you vote for a list representative. They think if you could, if you only stood on the list in a separate party, you would get more members. Wherever that type of gaming of electoral systems has been tried, it hasn't worked. If you look at Germany, you know that they have a very similar electoral system to ours. It hasn't worked there. So I'm not convinced that this is something that we should entertain too much. Equally, I welcome everybody in the cause of independence. It’s a very broad church. You know, the SNP may be the cornerstone of it. But it's a very, very wide “yes” movement, which embraces people in all parts of the legal spectrum, so I'm not going to lose sleep over it. But equally, you know, I've been a member of the SNP for forty years. I think I'm getting too old to change. So I’ll stick with what I've got. Scheffer: Michael, is there any way for you to describe for our audience two legal strategies: one is, is there a general description of what your legal strategy would be for independence if Boris Johnson continues to balk on a Section 30 opportunity for you to have a referendum? And then secondly, is there an emerging legal strategy, under I suppose almost any scenario, for Scotland to try to maintain its ties with the European Union, single market or otherwise? Russell: It shouldn't be thought that we have been unwilling to compromise or to be imaginative in this. In December 2016, we published the first of a series of papers called Scotland's Place in Europe, which we put forward in compromise, which would have seen a closer relationship with a single market and the customs union. And of course, one has to be aware in politics, as in history, not to have false memories. At that stage, there was no declaration from Theresa May or the UK government that they wanted out of the single market. That was only really ruled out in the Lancaster House speech in January of 2017. So we thought it was a suitable compromise. And one of the great tragedies of Brexit is if Theresa May, having become Prime Minister, had sat down and brought the leader of the Labour Party, Nicola Sturgeon, and you know, Karen Jones, who was a leader of Wales, and at that stage, Martin McGuinness and Eileen Paisley from Northern Ireland and said, “Look, how do we all get something out of this? How do we all get a compromise here? That the UK can leave the EU, if that's the will of the people in England, but that we don't suffer greatly, and those who didn't want this get something too?” That never happened. Theresa May’s style was not to listen, but to talk. So you would just go to have a discussion with her in Downing Street, and she would talk at you for an hour about how you really just weren't able to understand how good the deal was that she was talking about. And that just didn't happen. So as a result of which we're left in a situation where there is no compromise for the UK. They want to leave, and that is quite clear where they are now, on the poorest possible terms, because the word sovereignty has become this enormously important word, and you can only exercise sovereignty, according to the Brexit extremists who are now in charge, by cutting all the links, by not having any substantial links at all, and similarly, by not accepting any of the rules that that organization has. Now, you know, our position is we are willingly members of the EU. We agree with the pooling of sovereignty. We think the pooling of sovereignty is how people should go forward. It does not make you any the less sovereign. That is quite clear. I've asked the French, are the French any less sovereign for being in the EU? Are the Germans? The answer is no. So the question is, we want to join that. The EU will never say to any candidate member, “You're in. Fine.” But you know, we do observe the acquis. For over 40 years, we’ve observed all the rules. Members who come to join come very often from a long way back, and they have to change a lot of their systems to meet what are the 35 chapters of accession. We don't. We qualify. We've been doing it for 40 years. So the legal strategy there is we need to understand the chapters of accession very clearly and to be able to prove to the EU that we meet them all. The issue of accession has also been a live issue with the French in recent months. The issue of membership. Montenegro was part of this. But there is no intention to exclude. We are essentially functioning as an EU member. So of course, the legal strategy there is simply to go into that position, but connected with that is the EU’s quite proper position that they would not accept a candidate member unless they were independent, because it's an organization of independent states. So you have to get yourself past first base. And that first base is independence. How do you get to independence? Well, the barrier is holding a referendum at the present moment. I don't believe the barrier is getting the majority in that referendum. I think that would happen. Now, I think things have changed substantially from 2014. The barrier is holding a referendum. And I think there are only two ways you can go about that. The first way is to challenge that in court. And I think that is the most likely outcome. COVID has interfered with that. I think if you look at the way in which the Scotland Act was passed in 1999, there was no intention that the power to hold a referendum would be withheld for political reasons. And there are also mechanisms by which you can take a bill to the Supreme Court and have it judged there. So you will have to follow a legal route, I think, to get to a referendum, or a purely political route, you know, and you might want to, you know, think of Parnell, no one has the right hold the march of a nation. If the people of Scotland say they want a referendum, if the people of Scotland say we wish to vote for this, you’re democratic, I'm democratic, anybody who is democratic has to accept that that is a right that they have to do so. And the longer you refuse to allow that to happen, the less democratic that person is. Scheffer: Let me ask one more question and then we'll open it up. What is Scotland's place in the world today and under a prospective independent status? I asked that in the context, as well, of your relationship with NATO, which would be of interest to our American audience. Russell: We plan to have membership with NATO. Who wouldn't? That has been an issue in the party over the years. I have always been strongly on the wing that says this would be utter madness, given both where we are geographically, and also where our politics are. So that would be our intention to be part of that Alliance. I suppose you could describe us as a small, moderate, moderately left of center, European nation. [INAUDIBLE]. In Scotland, we're a fairly ordinary, small, quite talented, European nation. Resource rich. We have a very, very rich set of natural resources, very well educated. We are, according to the OECD, the best-educated country in Europe. We have assets to bring to the table, but we are a small European nation. That's what we are. And that's how we would operate in the world. More than half the members, actually just under half the members, eleven of the members of the EU 27, are the same size or smaller than we are. And in a rather neat thing, we're almost exactly halfway in the table of independent nations in terms of size. So there's nothing exceptional about Scotland in that regard. You know, we don't claim to be exceptional. But we do want to be normal, to go back to that point. Scheffer: Well, thanks so much, Michael. That has been so helpful. I want to open it up to questions now. And I see some hands popping up and I'd like to start. I think the first one that popped up was Ambassador Peter Galbraith. Peter. Moderator: Ladies and gentlemen, as a reminder to ask question, please click on the raise hand icon on your zoom window. When you are called on please accept the unmute now prompt then proceed with your name and affiliation followed by your question. Ambassador Peter Galbraith Hello, can you hear me? Can you hear me? Scheffer: Yes. Russell Yes. Ambassador Peter Galbraith: First, I want to express my appreciation for this program since my ancestors left Crinan in the Highland clearances, and my grandfather, who was in Canada, was all things Scotch as the Scottish community were called there, and he would be amazed and thrilled at the thought that Scotland might be independent. As David knows, I've spent much of my career in countries, in fact, that were breaking up or aspiring for independence. In Croatia, I was the first Ambassador there, but also East Timor, as it separated. And more recently, I've spent a lot of time in Kurdistan. And one thing that strikes me is that the power for independence is where you have a separate identity, often ethnic, where they feel unfairly treated by the majority, by the dominant group. I wonder, in the case of Scotland, whether this sense of unfairness at this stage overpowers the economic argument that Scotland really needs to be part of the United Kingdom, that it receives large amounts of funds. And the second question I have, very briefly, is that when you look at how other countries have become independent, when the Croatians or the Slovenes held their referendum, they didn't ask Belgrade for permission, they went ahead and did it. Would you consider holding a referendum if, in fact, Westminster turns you down? Or you lose the court case? Russell: Interesting questions. First of all, Crinan is in my constituencies, so I am the representative for Crinan. So you can you can come and see me at the constituency office, and I'd be bound to give you an explanation then. Thank you for your question. They are very good questions. Can I just challenge you in your view that in some way we are dependent upon money coming from south of the border? That is not the case. This is an area of some contention, I have to say, between economists, and when economists contend, and you will know what I mean, I tend to stand to one side until the dust is settled. But the reality of the situation is that you can certainly take an analysis of Scottish fiscal flows and see that there is substantial resource that goes the other way. And indeed, one can ask oneself, an interesting question, “Cui Bono,” who benefits? And if it was no fiscal benefit to the UK to have Scotland as part of it, why are they trying so hard to avoid independence? So I just I think that the premise needs to be examined, as all these premises do in terms of the history of, I won't say one's economy because it's not, but if you look at the history, for example, of the British Raj, and you look at the work that's been done on that in recent years, about the position of India prior to the Empire, then you begin to see some very interesting things. So I wouldn't accept that. And therefore I don't accept that, you know, in a sense, a feeling of grievances is overcoming the finance. I don't feel a substantial feeling of grievance. I think the system doesn't work. But, in that sense, I certainly blame the politicians who are operating it, but I don't feel oppressed in that way. I'm the biographer of Winnie Ewing, who was a great SNP figure in Parliament, one of the first MPs and a long standing MEP, and she tells a story of when she was on the lobby convention in the EU. And she tells the story of meeting Robert Mugabe, who said to her that the problem with Scotland and independence is that you are not oppressed enough. I don't think that is the case. I think we have a modern case for independence. And one in which, as Alex Salmond has often said, none of us have suffered so much as a nosebleed in the course of independence. It's a peaceful and democratic movement. In terms of permission, the big issue here is not permission, but recognition. I've talked about the way in which the EU would find an application for membership, I think, to be final. It would take some time as these things do, but it would be there. But recognition requires a constitutional route to independence. And you can see with the issue of Catalonia, that the lack of a constitutional route is a barrier to recognition. So I am cautious about taking any route that does not have constitutionality at its heart. And this is a longer process, but it is one I think it has to be gone through. And, therefore, I do not envisage circumstances in which we would say, you know, we are now going to break what is the Constitution. What we need to do is to make sure the Constitution does not attempt to break the people and to make sure that it is not a barrier to the normal process of a nation saying “we want to follow a different path.” Scheffer: And Michael, can I just follow up on that and ask is one of the strongest legal points that you might contemplate the one that you made earlier, namely that where the Scottish Parliament itself is requesting the referendum, that somehow has a significant weight with respect to the UK Parliament agreeing to that? Russell: Well, it should have. I mean, if you have a structure in which you'd have four Parliament's operating, and one of those Parliament's regards itself as sovereign, that is the UK Parliament regards itself as sovereign, which is a very medieval concept, but it still does. That system isn't one that we believe is stable, and neither actually do the Welsh, and Wales is an interesting example. Wales has a Labour government, not a Nationalist government, and yet their present First Minister, Mark Drakeford, who was my counterpart in dealing with Brexit and the UK before he became First Minister, has argued that the concept of sovereignty needs to be revisited. And in the UK, the concept of sovereignty should be shared sovereignty, and it should be willingly shared sovereignty. And therefore it can be withdrawn. Just as in the EU, you can choose not to share sovereignty. In those circumstances, Scotland would say we wish to withdraw that and take our sovereignty to put in somebody else's bank. And that's the modernization of the Constitution, which the UK needs to have. Wales, Scotland and Northern Ireland, for example, all voted against the withdrawal agreement, but it didn't matter because it can be overruled. And that is a difficulty. Scheffer: Let me ask now, Paul Sheard of the Kennedy School at Harvard. Paul Sheard: Thanks very much. I'd like to ask about the currency that Scotland would have or aspire to have, if it gained independence from the UK and tried to rejoin the EU, and what kind of monetary arrangements Scotland would aspire to have with the UK in the interim? And of course, in asking this question, I'm mindful that the euro is the currency of the EU. And the UK had a derogation from ever adopting the euro. But a rejoining Scotland presumably would not have that derogation, automatically at least. Russell: There is no obligation. I mean, this is an interesting issue, as you clearly know, because it's been a controversial issue in the first referendum and will be in a subsequent referendum. There is no obligation upon a member state joining to take on the euro. There's an expectation, but there is a process to go through, and for example, Sweden did not go through it and did not take the euro and is not a member of the euro area. I'm not going to give you a definitive answer on this. Because the moment I do, somebody will jump on it somewhere else and say this is why you can't do it. Rather strangely, the issue of whether or not Scotland could have its own currency, could continue to use a sterling in a sort of sterling area, or should go to the euro, is a matter of huge debate within Scotland by the anti-independence forces. All of which seem to end up with the view that Scotland cannot make any choices about its own currency uniquely in the world, that Scotland would have to end up with cowry shells or something, because it just couldn't have a currency. And what we've said very cautiously, and we are cautious about this, is as we approach a second referendum, we'll lay out the options that we have. We have talked about whether those options should include the continuation temporarily of a sterling area, with a number of tests that were applied before we move to our own currency. Some people have argued that the euro would be a suitable currency. I think, you know, there's been such a tabloid press attack upon the euro for years. I mean, one of the problems with Brexit, there’s been something got up substantially by this tabloid press. There's been such an attack on the euro for years, it's very difficult to have a rational conversation about whether the euro would be the right option as well. So, Paul, I'm going to disappoint you by not giving you a definitive answer. I am going to say there is, and will have to be, a definitive answer. But it's one which I think is as an aspirant country, we should only go to when we are ready with the Scottish people to have that debate. And at the present moment, that debate would be nightmarish, because it would be seen as a lightning conductor for everything else. Scheffer: Thanks. I think the next person on my list is Hani Findakly. Hani Findakly: Thank you very much. This is quite an interesting discussion. I'm not familiar with the politics of Scotland and the UK, but I have looked at the economics of countries that have broken up, starting with the India-Pakistan breakup and looked at about 30 countries. And while there have been a few exceptions, maybe about 10-20 percent, the majority of countries that break up tend to do worse than they would have done under a union and some of that, I think, is for obvious reasons. But another part is because of what economists call externalities. Things that we don't account for, and they interact with other things. So, you know, this is history. What's more important is looking forward, and it's fully understandable the emotional and other forces that drive that. But with COVID-19 and the expectations of some kind of a new normal with changes in the world economy, trade, the value of natural resources, and other things that countries depend on for their economic performance, I wonder if you have been through that kind of analysis and whether or not you have expectation that changes in the new world after COVID-19 will continue to be a benefit a breakup of Scotland from the union? Russell: Well, I'd refer you to a paper we published last month on the expectations we have of both a COVID recession and a Brexit recession. Whereas the rest of Europe will be suffering severely from a Brexit recession, they will have the advantage of what appears to be, and this week's EU summit will confirm it, you know, a pretty exceptional response from the EU 27 in terms of the MFF agreements that they're going to reach, and they're likely to reach with the leadership of Germany actually making sure that they do. They will not have a Brexit recession. So the UK will be double dipping in its approach. And that's one of the reasons why we believe Brexit should at the very least have been postponed. There was an opportunity to postpone the negotiations by up to two years, which the UK refused to do. And that would have been helpful. So our view is, as part of the UK, the economic prospects are very poor and will continue to be poor for longer and will be worse than we would otherwise have it from the COVID recession. I think it was the Financial Times that estimated that the recession would be the worst for the UK since 1709. I have no personal experience most of that period. But if that is the case, then I think we've got problems there. The second issue to consider here is the nature of Scotland, and as it is just now, Scotland is actually a rich country. I mean, you have to step back a little, and look at it. It has a small population, which is well educated. It has a very substantial amount of natural resources both of the 20th century and of the 21st century. It has a pretty considerable reputation and ability in exports. The number one food export of the UK, which is whiskey, of course, is a Scottish export, but actually, Scotland's export offering is very wide-ranging. So there is no reason why Scotland should not flourish. The fact that it isn't flourishing now might say something about how its economy is managed, and its economy is managed by the UK. And you know, when you look at that in the light of other experiences of economies being managed at a distance, and say that actually also may be a considerable issue to factor in. So my expectation is that choosing independence now, I don't think any of us can avoid the COVID recession. But I think it will mean that we would avoid the Brexit recession. It would also mean that the potential of the Scottish economy and the Scottish people were fulfilled. Our recovery plan leans heavily on the issue of natural capital. And I think if you look at the issue of natural capital, and the work we're doing as a well-being economy, I think you can see considerable advantages. So I'm not pessimistic about this. And I think there are occasions in which countries that go their own way suffer from it. As in personal relationships, if these things change, then people can flourish, and I would expect us to flourish. Scheffer: Thank you. The next individual is Julia Moore. We can't hear you quite yet. Julia Moore: Okay. I apologize if this question has already been asked or was the issue was addressed earlier. Because as you can see, I'm technologically challenged by this zoom technology. But let's assume that your Scottish exit happens constitutionally as you hope, and as you describe, what makes you believe that Scotland could overcome the tremendous obstacles to getting, forget the euro, getting membership into the EU and into NATO? Russell: Well, my personal conversations have convinced me that that is a case, to be honest. I spend a lot of time talking to people. It seems to me that the enthusiasm for having a small, new, highly educated, wealthy, and sharing European values country as a member of the European Union is likely, to be blunt, to be virtually irresistible. You know, there is no work to be done. There’s no queue. Nobody stands before or after anybody else. You have to qualify. But you know, I think it would require quite a lot of imagination to say that Scotland, being as it is, does not qualify. And certainly, the people I talk to regularly and all of the countries believe that Scotland will be a suitable candidate member for the EU, and will be accepted as such. And indeed, it would be very strange if it wasn't. This was, of course, an argument that the UK put during the 2014 referendum as David referred to earlier. And that argument was that an independent Scotland would not be a member of the EU. Now, David Cameron as the UK Prime Minister called in a lot of favors to get a few people in the EU to say that, and Scotland was affected by it. Because for many Scots, being in the EU is extremely important. But I have absolutely no doubt from my experience, from who I talk to, and from what they are saying because, you know, many European figures are saying this entirely clearly, Scotland would be a good fit for the EU. In NATO, I think that's also the case. I can't imagine that NATO would want to say no, that's not suitable to have. If you look at NATO membership, and if you look at our geographic position, I think that would be a strange decision to reach and a quixotic decision to reach. Whatever else you might call NATO, I don't think I’d call it quixotic. So I think in all those circumstances it is fairly obvious that will take place. It will take the procedure of admission. It will take, before that, the procedure of application. But what is different about Scotland? I would fail to understand that. Scheffer: You know, I might add, Michael, an answer to Ms. Moore’s question. I certainly recognized when I was in the quarters in 2014 in Brussels, skepticism because of exactly that point that you raised, that they wanted to simply maintain the United Kingdom as a full coherent nation, a powerful one, within the European Union. However, of course, because of Brexit, I had to witness with great interest that last summer, when the First Minister Nicola Sturgeon visited Brussels and gave some speeches there, she was feted almost by the European Commission and the European Union officials. It was a very, very different reception for Scotland. One that was very supportive and understanding that Scotland has a tremendous amount to contribute to the European Union. So, the tide, as far as I could see, had completely turned by last summer. Russell: I attest to that. I mean, I was around in 2014, of course, and you know, in recent years I have been talking to lots of people. But, Van Rompuy, the former president of the Commission and a former Belgian Prime Minister, so not a man fond of separatism in any description, has been on the record saying if Scotland applies and Scotland qualifies, which it does, Scotland will be a member. And I'm not asking people to be wildly enthusiastic about it. But that's the fact. You know, if we qualify, and we do qualify, and if we observe the acquis, which we have done, then we will be a member, and that's what we would want to do. Scheffer: Let me turn now to Frank Klotz, who is retired from the US Air Force. Frank Klotz: Thank you very much for an excellent presentation. I'd like to follow up with one of David's questions and your answers related to NATO. For many years now, NATO leaders have endorsed the importance of the UK’s independent nuclear deterrent force to NATO defense strategy. The UK independent nuclear deterrent depends, of course, on its space in Faslane. The SMP’s position in 2014, prior to the referendum, as I recall, was that continued presence of nuclear weapons in Scotland was not to happen. Has that position changed since? And if not, how would you see the UK’s concern, and ultimately NATO’s concern, about the future of UK nuclear forces being resolved? Russell: Let's start with the obvious, which is, you know, a small country of five million people is not going to possess nuclear weapons and shouldn’t. Scotland has no interest in so doing and would, therefore, not be a nuclear nation. Our position has not changed on Faslane. I think there's a substantial majority in Scotland who do not wish to see nuclear weapons on Scottish soil, and you know, I am one of those people. We may take a different view on these matters, but I am sitting as the crow flies about fifteen miles from Faslane across this lovely lock outside, and I therefore think I would feel perhaps a bit better if that was not happening. We said during the 2014 referendum that we recognize that doesn't happen overnight. And that therefore there would have to be a period in which that was negotiated and took place. But we would expect to negotiate having those nuclear weapons not in Scotland. Now, that is a matter, of course, which would have to be discussed with the UK and with NATO. But that would be our position. Now, it could be a different government in Scotland than the one that I would favor, but I think, broadly in Scotland's there is a pretty wide agreement upon that. In the UK, the Labour Party has always espoused the continuance of a nuclear deterrent. That is not true of the Labour Party in Scotland, by and large. So I think that would be likely almost under any dispensation. We believe in strong conventional forces. We talked about how those might be arranged in an independent Scotland and you know, we would follow that and we would wish to be part of NATO, but on that one, we do not wish to see nuclear weapons in Scotland. Scheffer: Michael, is there any particular opposition in Scotland to out-of-theatre operations by NATO? In other words, if you become an independent nation and join NATO, would we see Scottish soldiers in a future type of Afghanistan situation with other NATO soldiers? Is there any point of view on that? Russell: Yeah, I think the two areas in which we've expressed our interest and concern. One is we regard NATO sanctions as being extremely important and the NATO umbrella being extremely important. So as a member, we would meet members’ obligations. If we felt those obligations fit with our own view of the world, and we also believe in the European defense model, then we'd go along with that. We're also very interested in the way in which Ireland, for example, has carved out a place for it in terms of UN peacekeeping. And we do think there's a role for Scotland in that. We have a day efficient and effective contribution from our armed forces, Scottish regiments and Scottish soldiers. We would have thought we would want to see that within that context. But you know, we are committed to NATO membership. We're committed to working with Europe on defense issues, and we're committed in terms of UN action too. So we wouldn't be standing back, but equally, we'd be doing it from our standpoint. Scheffer: I want to entertain more questions. So I'll keep my eye on the roster here. But I actually have two I can pitch at to you in the meantime. One is, did you just have a special session of the Scottish Parliament? If so, why? Was it all virtual, and what was the big deal? Why did everyone have to get called back in July? Russell: Well, you know, we have a work ethic. Unfortunately, and necessarily, during the COVID epidemic, nobody believes that we should be away for a substantial period of time. We are technically on recess, but we're meeting in three weekly cycles. Because the First Minister, and the review of our regulations under COVID takes place every three weeks, so she addresses the Parliament, and we deal with that. And we do virtual questions sessions because we believe that that we should still be answerable to the country through its representatives. We are able to do quite a lot virtually. Where I'm sitting in my outdoor study in Argyll looking over Loch Riddon, I've done a parliamentary statement from here. I've answered parliamentary questions from here. I've appeared in front of parliamentary committees from here. Edinburgh is about three hours by car, so I've driven through on four or five occasions to do things there. But it is not a normal year. So our normal pattern would be we would end in the end of June. We would start again at the beginning of September. We finished at the end of June. We will start again on the 11th of August when schools go back. Schools have been off since the 20th of March. Schools go back on the 11th of August, and we will go back then. But I will be in parliament on the 29th and 30th of this month, and I will be doing a statement of some sort before then. So, we keep ourselves busy. We believe in serving the people. Scheffer: But there's no particular crisis this month regarding London's negotiations on Brexit or anything? Russell: Well, I think the reason I may have to give a statement before the 30th will be, you know, we're certain there will be a white paper from the UK Government tomorrow, as I said, on issues which we believe, substantially undermine the devolution settlement. So that will be part of it. But you know, the main issue is COVID. And the main issue is making sure that we keep the Parliament and the people informed of that. The first minister undertakes daily press conferences on COVID. Up until now, they've been five days a week. I think that will change shortly. But we still do them. They are televised. She is open to press questions for a lengthy period of time. And the quote I gave you earlier about truth and being honest with people is what we try to follow. So we've tried to make sure that people have all the information they need. Scheffer: I believe Peter Galbraith has another question, Peter. Ambassador Peter Galbraith: Thank you. And I wanted to just say I was not being critical of Scottish independence when I was asking about the economic issue. It was the sense that often in these circumstances, where people feel they're, in the case of Scotland, dragged out by what England did, that can overcome economic issues. And I also think I've pointed out that countries often do very well after independence. Obviously, the Baltic countries case in point. In fact, Croatia and Slovenia, clearly better without Yugoslavia. My question is how do events in Northern Ireland affect the Scottish situation? I think the polls show that there is a majority now for a united Ireland or at least very close. There's a process perhaps you might explain for having a referendum there. Do you see that process going forward with Boris Johnson's government? And I guess it would raise the question of if they are willing to do it in Ireland, how could they say no to doing it in Scotland? Russell: We've always accepted the special situation in Ireland. Ireland is recovering from, you know, a generation of civil war essentially. It is not like Scotland, and therefore, we've always accepted special arrangements for Northern Ireland have to be made and for Ireland. And we've never drawn equivalences with that and wouldn't do so. And it's quite dangerous to try equivalences, as you well know, between national movements in various places. You know, everything is different. But there are some interesting issues in Northern Ireland, and a special settlement within Brexit is a particularly important one. There is a special protocol in the withdrawal agreement that means that Northern Ireland will sit somewhere between the EU and the UK. It will have regulatory alignment with the EU and the border will therefore not be a border, per se, in terms of goods, and it will be treated in a special way. Now our view is if that is possible for Northern Ireland, it should have been possible for Scotland, and there should have been some special arrangements with Scotland, and that was not reached. The question of Irish reunification is a very, very different one. You know, there are a number of players in there. I think the new Taoiseach in Ireland, Micheál Martin, has made it clear that he doesn't think the time is right for a border poll. And the border pool can be called with the consent of both sides, but I don't think that's likely to happen immediately. I think it's likely to happen at some stage. But a lot of this is the same issue. And the issue is, Brexit has precipitated change that was underway, In any case. Northern Ireland voted against Brexit too. The only part of the of the island, so to speak, that didn't get anything it voted for was Scotland. Wales voted for Brexit narrowly, but voted for Brexit. England voted for Brexit, Northern Ireland voted against it and is getting special status. Scotland voted against it, and it's getting nothing. And the tensions created by Brexit have exacerbated what was an ongoing process. You've got to look at the issue of Scottish independence not as some modern phenomenon. This has been going on for well over 100 years. The establishment of the committee for the Vindication of Scottish Rights in the 1850s and 1860s, they campaigned for restoration of the position of Lord Advocate. The growing administrative devolution that took place in the late 19th, early 20th century, and there's a school that would argue that what has held us back were a number of events, which renewed UK solidarity or British solidarity: the two World Wars, the creation of the of the National Health Service, and so on. But the process has been going on. I mean, you know, I mentioned earlier my grandfather. My grandfather was a publisher. He was an Englishman, but he was a publisher in Edinburgh. I think he would be astonished that there was a Scottish Parliament, because he died in the 1960s, and it was a long, long way then. I mean, there was certainly no majority for it. I think he’d be astonished that his grandson was in a Scottish Parliament, a minister in the Scottish Parliament, perhaps even more so, discussing this with a distinguished American audience on a night like this. There has been a process underway, and that process continues to be underway. And that is true in Ireland as it is true in Wales and elsewhere. It is a question of how those that process comes to a conclusion that I think we're now talking about. Scheffer: Thank you so much, Michael. This has been a tremendous conversation about the past, present, and future of Scotland. And I deeply appreciate it and the Council on Foreign Relations and all of our participants do as well. You take good care of yourself, stay healthy next to the Loch there. And we'll see you. Russell: Thank you very much.  

Thomas J. Bollyky, senior fellow for global health, economics, and development, and director of the Global Health Program at CFR, discusses the resurgence of COVID-19 cases and the effects of reopening economies around the world.  FASKIANOS: Good afternoon to all of you. Welcome to the Council on Foreign Relations State and Local Officials webinar. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR. We’re delighted to have participants from forty-three states with us today. So thank you for taking the time to join us for this discussion, which is on the record. As you know, CFR is an independent and nonpartisan and membership organization, think tank, and publisher focusing on U.S. foreign policy. Through our State and Local Officials Initiative we serve as a resource on international issues affecting the priorities and agendas of state and local governments by combining analysis on a wide range of policy topics. And we also are the publisher of Foreign Affairs magazine. We are pleased to have with us today Tom Bollyky. We previously shared his bio with you, so I’ll just give you a few highlights. Tom Bollyky is CFR’s senior fellow for global health, economics, and development, and director of the global health program at CFR. He is also an adjunct professor of law at Georgetown University. He is the author of the book, Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways. His book was included on Bill Gates’ booklist, so I commend it to you all. And he is also the founder and managing editor of Think Global Health, an online magazine that examines the ways health shapes economies, societies, and everyday lives around the world. The site offers useful resources on COVID-19 and other topics, so I again encourage you all to go there. Visit ThinkGlobalHealth.org. All right. So let’s get to it. Tom, thank you for being with us. We are seeing an increase of COVID-19 cases in many parts of the United States. Can you talk about this trend that we’re seeing and any lessons we can draw from how other countries have handled and are handling the pandemic? BOLLYKY: Great. Thank you so much, Irina. This is one of my favorite calls to participate in at CFR in this program. I really do enjoy the opportunity to speak with state and local officials who are at the front line of all public health issues really, but this one in particular. So I look forward to this conversation. And thanks to Irina and her wonderful team for organizing it. So the eyes of the nation are rightly focused on what’s happening domestically with regard to the coronavirus pandemic. This is understandable, of course. It’s what we all experience in our home lives, in our—in our communities. And as state and local officials, it’s where your responsibilities lie as well. But we are not alone, of course, in experiencing this pandemic. There are now over 180 countries in the world with reported cases of coronavirus, thirteen million have been reported infected globally, nearly—or, more now than 570,000 have died worldwide. There’s no sugarcoating it. The U.S. is anomalous, particularly among high-income countries, in how we are experiencing this pandemic. The U.S. represents 25 percent of all cases—reported cases of the coronavirus globally, and nearly a similar percentage of the number of deaths. New cases of COVID-19, the disease, are expanding at a rate of 1-2 percent daily in the United States. On Sunday, Florida reported fifteen thousand new cases. That’s three thousand more cases than all of Europe combined. So we are anomalous, unfortunately, in that regard. The U.S. is one of ten countries that represent 80 percent of the increase of reported cases that have occurred in the last several weeks, globally in a number of cases, after plateauing in April have started to increase in May. Most of—we are the only high-income country for which that is responsible for the bulk of this increase. Most of the remainder in countries like Brazil, India, South Africa, and Peru. That said, again, we are not alone in this. We’re all in the same epidemic curve together. And it’s important as policymakers and members of the interested public that we, in our attempts to surmount this terrible outbreak—or, pandemic, rather—together, that we look to learn lessons from the countries that are ahead of us in this experience. I’m going to focus my initial remarks on schools, in particular what we’re seeing abroad on schools. Obviously, it’s a topic of interest. We are not alone in having—most communities having shut down schools. Worldwide 1.5 billion school-aged children have been kept home at one point or another by this—by this pandemic. That has, of course, had dramatic educational consequences for the students that have missed the opportunity for in-person learning. It’s, of course, disproportionally affecting the poorest students with the least ability to obtain those services remotely. It also has dramatic economic and social consequences. In the United States, one-third of our workforce has school-aged children. I have school-aged children. You may hear them on this call. So we all feel this from that perspective. But it’s also been associated with higher rates of abuse and mental illness. So this is having a significant consequence that extends beyond just the educational environments. We all have an interest in addressing this. What can we learn from abroad with how other countries have addressed it? And the good news in terms of thinking for future is that since June, by early June, rather, more than twenty countries that had shut down their schools have reopened them worldwide. There are several countries that never shut down their schools—Taiwan, Sweden, and Nicaragua. I’m going to draw three broad lessons from those experiences, things to keep in mind in this context. I am going to focus on the lessons that emerge internationally. I will not be exhaustive, although we can talk about some of the research coming out domestically about what to do about schools. But I’m not going to focus on elements of that that extend beyond what we’ve seen internationally. So in my initial remarks I’m going to focus on the international lessons. Not exhaustive. After this call I am going to send to Irina and her team, and we will post it, and maybe there’s some way to circulate it to the participants, several documents that are going to be important. One is the CDC guidelines that have emerged on children, and infants, and adolescents. I’m also going to circulate a good overview article from Science that focuses on the international experience. And last, from the—from the American Academy of Pediatrics has also put out a set of guidelines. And those are the three documents we’re going to include. And you should definitely reference those. All right. So let’s get to the three broad lessons. What are we learning from abroad? We are certainly learning that the risk of this virus is lower for children, but it’s not nothing. The experience also differs somewhat for underage children and adolescents. So we have seen uniformly fewer cases in children, but again not none. There have been some. Children under the age of twelve are—appear to be, our latest estimates, one-third or one-half as likely as adults to contract this virus. The risk appears lowest for the youngest children. In the United States, Spain, China, Italy between 0.5 and 2 percent of the confirmed cases in those countries have been in children. That said, a number of those—a number of countries, including elementary schools in Israel, daycare centers in Toronto, have suffered outbreaks among children. So it’s certainly possible, even if it is a lot less frequent. There is no question the risk of spread is higher for adolescents—thirteen-year-old children and older. A recent study in France found in a high school that antibody testing showed that 38 percent of the students, 43 percent of the teachers, and 59 percent of the non-teaching staff had become infected. Among the worst school-wide outbreaks we have seen have been in a middle school and a high school in Jerusalem, where 153 students were infected and twenty-five staff in May and June. The studies involving nasal swabs of older children have shown a very similar viral load as to what you see in adults. So that suggests a similar level of contagiousness. In general we have seen less severe outcomes, but again they do occur infrequently. The largest study of pediatric patients remains in China, a study involving roughly two thousand, a little bit under. There, you saw the rate of children developing severe disease with low blood oxygen being around 5 percent. Critical cases involving respiratory distress or multiorgan dysfunction represented—or, occurred at a rate of 0.6 percent. U.S. data is broadly similar. There have been fewer children requiring hospitalization among overall patients. And ICU, intensive care unit, admissions have represented between 0.6 and 2 percent. That said, there have been severe complications that have occurred in children as young as four, or nine, or twelve. They do appear to be infrequent. Many of you have no doubt read about this multi-inflammatory syndrome that presents with a persistent fever and has been shown to cause damage to hearts and other organs. This is something we’re still studying. It still remains quite infrequent, but it’s real. And that is—that is something to watch moving forward. So, again, lesson number one is risk for school-age children is lower, particularly for children under twelve, but not nothing. All right. Let’s move onto lesson number two from what we’re seeing abroad. There has been a variety of approaches used on social distancing, masks, and testing that we’ve seen so far, with some success in all cases. Netherlands has cut class sizes, but otherwise did not enforce social distancing in children under the age of twelve when they’ve reopened. They have now extended that policy to children seventeen and under. Denmark and the province of Quebec have assigned children to smaller groups. That’s been the strategy, where they can congregate and interact but it’s smaller groups. You have probably—may have seen, Germany, Canada, and England have all announced a similar bubble model as a way of reducing transmission, where you have smaller groups that don’t interact with other classes as a strategy, so you can potentially isolate effects. Societies that are more comfortable with masks—China, South Korea, Japan, Vietnam—have adopted them, even for young children. Many countries in Europe at first required masks, but most of them have dropped them for younger-age children, under the age of twelve, and moved to a more optional model. The U.K. and Berlin has been exploring doing regular surveillance testing as a way of identifying cases as they arrive. I am very sorry to report, despite looking I have not found very good studies internationally on special education. If we do find any, we will let you know. But it is, unfortunately, an area where little research has been conducted to date. All right. Lesson number three, and this is, of course, the hardest—has proved the hardest one for, I’m sad to say, our country—is reducing community spread. All other countries, with the exception of one which I will get to, have suppressed the spread of the virus ahead of reopening their schools. Most that have done so were successful in doing so. There were a few exceptions, the largest one being Israel, where infections have increased steadily after schools reopened. But this also paralleled a similar increase nationwide and it is not clear, as of yet, whether the schools were drivers of that overall national increase or just yet another symptom of that overall national increase. That said, Israel by mid-June had closed down 350 schools. Other countries have adopted a policy where, you know, they’ve been closer to really crushing the curve, that you’ve heard about, in terms of new daily cases. So when there have been resurgences, they’ve responded quite aggressively in shutting down schools. South Korea closed down two hundred schools when they had a resurgence—or, a spike of cases in Seoul. Hong Kong has also intermittently closed down schools when they had increases in cases. Now, keep in mind their number of cases are quite low relative to the United States, but they have really focused on trying to drive down that number to zero. All right. So now to the exception. The only exception out there really is Sweden which, again, never closed down schools and has a high rate of transmission and spread throughout. Unfortunately, Sweden didn’t do any testing serological testing to show the different effects of different policies, school policies, for keeping them open. They have had some episodes. In one school, a teacher unfortunately perished, and fifteen—eighteen out of the seventeen staff tested positive in a school about of roughly five hundred students. The one serological test they have done of a couple of thousand did suggest that the virus had been spreading in schools, though it’s not clear how much. Unfortunately, they did not design policies to study this, and that’s their loss but ours as well. Some caveats about Sweden that I do want to point out, though, is that by and large Swedish—the children in Sweden have much lower rates of asthma, diabetes, and other comorbidities—other illnesses that have been associated with worse outcomes than we do in the United States. So that’s a significant difference. Also unfortunately the U.S. daily rate of cases now is between—this is population adjusted, so per one million people—is 130 to 180. That is higher than it’s ever been in Sweden, let alone any of the other countries we’ve talked about so far today. Israel is climbing now to closer to levels of new cases that we’re seeing in the U.S. but, again, they’ve had to shut down their schools. The numbers look a little bit better on deaths, where Sweden had much higher population-adjusted death numbers than we’ve seen. But it’s now lower than what we have in the United States. And we’re increasing on that metric as well. I won’t spend a lot of time on policies or other activities in these initial comments for what has happened around resurgences, but I’m happy to do that in the question and answers. I’m really looking forward to hearing what you all are doing with schools. Again, in addition to looking at this through this cross-country comparison and our work at CFR, you know, we all—many of us have children or relatives that are impacted by this in one way or another, and we’re all in this together. It really—it’s a fundamental issue moving forward for our country and our community. So I look forward to learning from you about this as well. FASKIANOS: Wonderful. Thank you very much, Tom. That was a terrific overview. And let’s go to the group now for questions. (Gives queuing instructions.) The first question is from Jeffrey Dahlen (sp). And I you could identify yourself and what state you’re—where you are, to give Mr. Bollyky some context. Q: Sorry. I accidentally hit the button. FASKIANOS: OK. Let’s go to Martha Robertson. Q: Hello. Thank you so much. Martha Robertson. I’m a county legislator in Tompkins County, which Ithaca, New York is the home—the county seat. So Tompkins County, New York in upstate, the Finger Lakes. My question about schools—and there’s no question of the huge disadvantages of keeping kids out of school and trying to do remote learning. We had the last third of the year with a grandson, a high schooler, doing remote learning with us, and so I can tell you how hard it is. But my concerns is that what about the teachers and the staff? If kid went to school by themselves, that’d be one thing. But it feels to me that people are only talking about health impacts of the children, which are obviously critical, but how do we—how do we, you know, consider this equation without really looking at what happens to teachers and staff? In particular, I’m concerned about asymptomatic or pre-symptomatic children. So what do we know about the prevalence of that in kids, and what happens to their adults? Thanks so much. BOLLYKY: Great. So a couple of things to point to. I mean, the main answer is we don’t know a lot about asymptomatic spread in children. Again, by what the—all the research that we do have suggests that they spread less frequently than adults. But again, it does happen. They are also, of course, and anybody who spends time with children, or has, can tell you they engage in activities that maximize their chances of spreading, even if they themselves are less likely to be prone to spreading. So that is a real risk. In terms of—there isn’t a lot of experience. I mean, again, we’ve seen—as you mention, we may have seen, when I mentioned some studies—observational studies—identifying the numbers of teachers and staff who get infected. It happens—or, it has happened in other countries. Particularly given the high prevalence in the United States and depending on your community it’s going to be really important to have personal protective equipment—whether the children wear masks, the teachers may want to do so, or should do so. And this is going to be an important factor moving forward. Again, we had seen infections of teachers and staff. It’s not entirely—it’s difficult to know for certain, without serological tests, whether that’s come at school or come independently. But we’ve certainly seen this, particularly in Sweden. And we did have that one unfortunate example that I mentioned in Sweden of a teacher perishing at that school amid an outbreak. So these risks are real, and we have to account for them and protect them because, as you rightly suggested, you know, children are only one part of a functioning school. And it will be critical to protect staff and teachers as well. FASKIANOS: Pamela Pugh, please. Q: Hi. This is Pamela and I am in Michigan. And I’m a member of the State Board of Education here in Michigan. My concern is returning to school, obviously, as everyone here. We are concerned with the social, emotional, physical wellbeing of children. My background is public health and environmental health. I’ve studied the indoor environment for most of my research career. My concern, we just had children that returned to Detroit. Eighty-three percent or more African American. The balance is probably—is Latino children. And so, as you all know, Detroit is one of the hardest-hit communities in this country. My concern is we’ve just acknowledged that airborne—or, transmission through airborne—the virus being airborne is real. And so, thank God, we’ve had over two hundred researchers that have come out and said that. We were just fighting in Detroit around not having adequate ventilation. I guess my question is, what are we doing to address that? Air conditioning may not be the answer, it may actually be a problem. Who is looking at and who is pushing for adequate ventilation plans and that fix, looking at the air quality, looking at the air movement, and the air turnover in these schools, before we force our kids to go into these closed areas, as well as the educators and the people that they will be contacting—parents, grandparents? BOLLYKY: Really great question, and an important one. The short answer is I’ve seen nothing on that. Domestically, it may be that the CDC has taken it on without reporting it, but I—but I haven’t seen a particular study of ventilation in school systems. Perhaps there’s somebody on this call who has seen it. But we did not, in the review that we did ahead of this call. I will say, with the data, it is still the—people are much, much more likely to become infected through direct exposure of respiratory droplets. As you very rightly said, that doesn’t mean you don’t see airborne spread. But in terms of priorities ahead of reopening in the short period of time, certainly minimizing to every extent possible the possibility of direct exposure infection through respiratory droplets has got to be the priority. But there really needs to be a greater study of ventilation, particularly in settings or communities where outdoor instruction is not going to be possible, because that is something else that we’ve seen some of internationally, where schools have really looked at the opportunity to educate children outdoors. That’s not something a lot of places can do, and certainly not something they can do indefinitely. So this is going to be important to study moving forward. I’m sad to report I haven’t seen one that’s happened. FASKIANOS: Sorry. So, Tom, there’s a follow-up from Pamala. Should our children be forced to go to school if we aren’t sure of the indoor air quality and ventilation systems? BOLLYKY: So, I mean, this is—these decisions really—and this is another point that less emerges internationally but is part of the—should be part of at least our conversation domestically. There is—I have not heard very much support from anyone on the public health side for the idea of a strictly national approach to these issues. Obviously, this should be tied—decided individually by states and communities, depending on what their local situation is with the virus is, what their schools look like, what the environment looks like in terms of the different mitigation strategies that can be employed. It’s going to be a balance of risk no matter what, reopening schools. And that’s something each community is going to have to decide. And there’s going to be a lot of unknowns. We don’t really know why children aren’t spreading, for instance. We still don’t know, as I mentioned, exactly what is driving this multi-inflammation syndrome. There’s going to be a lot of uncertainties heading into the school year that we will not be able to resolve. And, you know, this is—this is something that will have to be decided by state and local governments. It’s inappropriate to assume that there should be a nationwide approach to these. It’s going to have to be something considered. The balance of the benefits of reopening versus some of the risks. But there are going to be many unknowns under any circumstances as to what this will look like. FASKIANOS: Great. I’m going to go to the next question, but before I do, Ron Mann (sp) in the chat talk about is comparing case rates might be problematic because—have you balanced that with the amount of testing that’s being done? Because obviously I think here in the United States we’re not doing as much testing as other countries. So have you adjusted for that in your numbers, Tom? And then the other—just a note about UV light and what you know about UV light helping to reduce the spread of virus, especially in enclosed spaces. BOLLYKY: So on the first question, on comparing numbers of cases, it is true, particularly internationally, that there have been a great variety in the degree of testing being done. That is a little less true on the population-adjusted level, when we’re talking about other high-income countries, like the ones that we have. The U.S. had conducted a great many tests, of course, at this point. We did conduct them, by and large, relatively late in this pandemic. So the bulk of those tests came a bit late. So we’re not comparing quite apples to apples in terms of when the tests occurred. But I think at this point what most would say in terms of the case numbers for—when comparing to other high-income countries, we’re not expecting to see a great difference in terms of underreporting in those settings. When we’re looking at some low- and middle-income countries, absolutely, there’s a great deal of underreporting. But when we’re talking about many of the East Asian nations that we’ve been talking about, or the European nations we’ve been talking about in this comparison, I wouldn’t expect a great difference in reporting rates. FASKIANOS: Great. OK, Meredith Childs (sp). Q: Hi. Thank you for taking my question. Again, I’m Meredith Childs (sp). I am in St. Louis, Missouri. And I’m with one of the health plans, Anthem, working on social determinants of health. What I’d like to know, or what I’m curious, is anyone collecting data surrounding those supportive services that our children and families are needing in order to deal with all of the ramifications of COVID-19? I recognize and realize just in my area and with the work that myself and my team are performing that definitely housing instability is one of the issues when you are moving from home to home, or couch surfing, or you don’t have housing, or adequate housing, or safe housing at all, then it’s very difficult to do things like practice social distancing. So I’m wondering, is there any information that’s being collected and what type of resources may you be—might you be aware of that is connected to maybe federal funding or assistance to address those issues for our children and families? Thank you. BOLLYKY: Great. Really great question. So on the federal level there—I mean, in general there’s been an increasing amount of research into the role that social disparities have played in this pandemic, because we’ve certainly seen it in the outcomes. So it’s—there is more research. Some of that is on CDC’s website in terms of moving forward. They’ve been a little bit slow in issuing guidelines, but they are—they are doing it. It is clearly one of the lessons of this pandemic moving forward that in addressing these social disparities or mitigation strategies to address them should be part of any pandemic response and part of pandemic preparedness. I have not seen as much in terms of resources that really has been to some degree at the state and local level, how different governments have responded to support people in that environment. I will say, more broadly, to tie back to our conversation around schools, as you know for many disadvantaged communities a lot of the social services children access are really through the educational system. So that’s one of the things people have looked at in terms of engaging some of those community—some of individuals that are under less advantaged circumstances and providing these services through those—through those contexts. And that’s going to be important. I did see someone mentioned, and I did forget to respond to the UV light question, so forgive me for that. It is—one of the thoughts as to why we’ve seen less spread outdoors is UV light. As a general matter UV light is inhospitable to viruses and other microbes. Obviously, you have a lot of air circulation as well. I haven’t seen beyond—haven’t seen many studies indoors. The only thing is, of course, you can’t irradiate a room with UV light with people in it. And in terms of cleaning products by and large people have—there are other options that can be effective in cleaning surfaces. So I’m not sure it’ll play too much of a role in the conversation we’re having. But it certainly is one of the factors that people expect to account for the fact that the virus spreads far less frequently outdoors. FASKIANOS: Thank you. Let’s go to Heather Hillard next. Q: Hi. Thank you for taking my question. I am here in the greater New Orleans area, where we are right now competing to be number two or number three with the number of cases we have. And my question is, the antibody results that are coming back, that if you’ve been exposed, and positive, and recover, that now the antibodies are not as prevalent in people. And even Tom Hanks is saying, because he’s part of the original, you know, study, since he got sick so early on. Do you see an antibody factor in this, that if teachers had been exposed and recover that they could have gone back to teach in classroom, in situ, or is there some aspect of this that it’s not just the nasal testing but there’s another aspect of this with antibodies that we might be able to capture, to provide a safe environment for children and teachers? BOLLYKY: So the primary—great question and thank you for it. The primary question—or primary use that people have made of serological right now is to get a sense overall of the spread of the virus and the extent of the population being exposed. There are a number of reasons why people have been hesitant to use it as a form of kind of immunity passport for people operating in settings. One is a lot of the serological tests haven’t been particularly accurate. That’s improving over time but has been an issue. The tests of infection are a lot more accurate, particularly the PCR tests of infections are a lot more accurate than the serological tests. So that’s one. The second reason is you don’t want to give people a perverse incentive to get infected, so they can work. So there have been a lot of reluctance in that setting. The third reason is there is still some open debate—and this ties to your Tom Hanks comment—about the degree to which people clear the virus. We do—you know, for most coronaviruses you would expect to see some acquired immunity. It is—we’re still not one—you still see some anomalous reports of people who had been previously infected testing as not infected and then later testing as infected again. And it’s not entirely clear what’s going on in those cases. They’re not common. But you know, again, this is a novel virus and—a novel virus. And to that extent, we don’t know. And I saw your comment. And please don’t—I’m saying more for the group, not because I think your question in particular was suggesting that teachers go out and get sick so that they can work. But giving the broader notion why people are hesitant to use serological tests as a condition of employment. But I don’t mean to suggest that you were implying that they should do so in this case. Please. FASKIANOS: Sorry about that. I’m trying to unmute myself. Let’s go next to Susan Hairston is up next. Q: Thank you for reengaging these calls, Irina. I have missed you all. You have really—I’m a councilwoman in Summit, New Jersey. And I have found these calls to be ahead of the curve in information on what’s been happening in the New York-New Jersey-Connecticut area. So glad you’re back. Thank you. FASKIANOS: Thank you. Q: And thank you to Thomas for this information. I want to follow up on two questions. We know that there is the racial disparity. And I haven’t heard talk about it with children. And so if you can share specifically if you’re finding that to be the case. And I relate that to the studies that you’ve done overseas. And so I don’t hear anything highlighting what you’ve learned overseas about racial disparities, especially in the countries that you’ve chosen. And I happen to have a call with a client in South Africa who was really speaking about the low incidence that they’re having. However, they are taking it very, very seriously, and in lockdown. And so I wondered if that was how you were relating when you said there’s underreporting happening in other countries. So I don’t want to mucky up my question too much, but I hope I’ve given you enough to go on. Thank you. BOLLYKY: Great. Well, first, let me start by saying thank you for the kind comments of the great work that Irina and her team are—we are CFR—are doing with these calls, and the other programs they run. We certainly—everyone at CFR certainly agrees they’re doing a really great job, but it’s kind of you to acknowledge it. In terms of racial disparity among school-age children, I mean, as you probably know domestically there’s been an enormous underreporting by states of this information. So we’ve been really hamstrung in term of making these—having—we’ve been hamstrung in general in terms of having good data broken down by race in many U.S. states. We’ve been even more hamstrung by data breakdown both by race, and age, and gender in many states. So this is really something that I’m hopeful is one of the broader lessons to emerge from this pandemic is to dramatically increase the quality, the timeliness of our public health reporting. It is true that many of those, as you probably have seen from news reports, still come from faxes. I’m appalled to hear that. I worked at the New York City Department of Health in the mid-’90s, and of course that’s how we were getting these kinds of information then. It is sadly still largely the case. I have not seen enough—I have not really seen anything, I should say, internationally that looks across within country racial disparities. I will say, as you point to South Africa or other countries, South Africa’s testing rates have been a lot lower. I am sad to report, as someone who lived in South Africa for a year and a half, that South Africa is one of the ten countries that is growing fastest currently in number of cases. So they had been really broadly seen, and many of us were cheered by this, as a success story. And I’m sad to say that is becoming less the case. There have in general in sub-Saharan Africa, the number of—the reporting, testing rates have been a lot of lower. So it makes it a little more difficult. There are countries that people believe may be being successful, but it’s difficult to have a really good handle on it with the low rates of testing that we’ve seen. Overall the continent last week reported a 25 percent increase. And you know, we’ve had a resurgence in this country, so it’s taken some degree of the global attention away from what had been seen as now the epicenter of the pandemic, which is South and Central America, and India to some extent, South Asia. But everyone really expects sub-Saharan Africa, unfortunately, to be after that. And many countries will not have the ability to impose the kinds of social distancing that they did early, from an economic perspective. They just can’t afford it. So this is a—this is going to be a challenge moving ahead. FASKIANOS: Thank you. Let’s go next to Denise Garner. And thank you very much for that wonderful comment, I should say that. I appreciate it, Susan. Q: Thank you very much. I am a state rep from Arkansas. My background is in public health and I’m on the education committee, so I’ve been kind of overwhelmed with all of the information coming in. I really appreciate the information that you’ve given on schools. That will be extremely helpful. We’re in a state that has some out of control spread. We never shut down. We don’t have a mask mandate. We have problems in—with testing supplies, the supply chain. So we’re under-testing. I’m also in a community where undertesting is extremely low. We’ve got percent positivity rates between 30 and 50, very high. And we are also the home of the University of Arkansas, which is getting ready to start. So not only are we starting our public schools, K-12 schools, we’re going to have an influx of twenty-five thousand people into our community of eighty thousand coming from all over, but particularly, 50 percent, from Texas, which is even higher than we are. So what can we do even locally. I’m trying to help locally because our state had not been—I think we’ve—in my opinion, we have been a little bit—our risk-balance has been toward the economy and not toward health. So in that situation we’re really trying to work locally. So what can we do locally as the university gets ready to start, as our public schools get ready to start? And we have been told that schools will start as usual, and with the blended learning. So there is an option for virtual, and that the university will start as usual. So given that, what do we do? (Laughs.) BOLLYKY: So it’s a difficult problem. I mean, as we’re starting to see from many states, the decision between the economy and public health is a false one. If people are becoming infected at high rates, if health systems are becoming overwhelmed, you see deaths going up, people aren’t going to be going to restaurants, and bars, and movie theaters under those circumstances. And you’ve started to see some of the states that had reopened—California obviously most notably this week—have pulled back on that in response to resurgences. So just to make that broader point, which you may be appreciative of already, but I think is important to remind everyone. In terms of moving forward, you know, the most important thing that can be done both for the school setting and the community setting, of course, is to suppress the spread of the virus to every extent possible. It is not rocket science in terms of what the strategies are. And there are all the ones that you know well. They’re where—I mean, my colleague Tom Frieden likes to refer to them as the three Ws, but wear a mask, wash your hands, and watch your distance is a big component of it. And it needs to be combined with strategic testing, isolation and contact tracing, and supportive quarantine, where we can. All these are going to be important moving forward. But on the broader level, it really is the wearing of a mask, washing your hands, and watching your distance. All these are cheap, for the most part. Distance can be a little bit complicated, depending on housing situations, but for the most part quite cheap. It’s matter of getting people to adopt them. And obviously that has been a bit of the challenge with the degree to which these issues in some communities have unfortunately been politicized. But there really is—there’s no other solution to suppressing the spread in this environment. I don’t think we’re going to see broader shutdowns. As you suggested, these things are moving forward. So it’s really at a local and community level trying to approve—improve their adoption. You’re right to be worried about university settings. They really have emerged—bars, and fraternities, and sororities in particular—have emerged as great sources of spread. And it’s something that we’re all concerned about. In the school setting, particularly in an environment that’s high burden, I would really advise you look at the American Pediatrics—the Academy of American Pediatric guidelines, which do have a lot of a more tiered structure of the degree to which some of these social protections, nonpharmaceutical interventions for reducing spread, should be adopted in schools. Obviously in an environment which is really high spread, and if you can’t move to remote learning it’s important to adopt as many of them as possible. One worry I have, in addition to ones you’ve mentioned about testing shortages, is trying to secure protective equipment for teachers, particularly in high-burden settings, in advance. So this is something that really people should be moving towards because particularly in high-burden settings, as another official mentioned earlier, it’s the teachers that are at greater risk. And it will be important, particularly in a setting like that, to do everything we can to protect them. FASKIANOS: Great. Tom, we’re going to go next to—oh, let me open the list—DeAnne Malterer. And I’ll just draw your attention, there were two comments in the chat section, so maybe you can weave those in, about contact tracing. So let’s go next to DeAnne Malterer. We have several more in queue, so I’m going to try to get to you all. Q: Thank you so much. DeAnne Malterer from Minnesota. And I come from a rural part of the state. Is there anything that we can learn internationally to help us deal with what are typical rural disparities in dealing with this disease? Obviously, Minnesota, by the time it gets to be October and November, we’re going to be inside most of the time. And that’s going to be so until we get to April. It’s just the way it is here. Broadband access in rural Minnesota is not good. So we’ve found online instruction, particularly for the kids who need it the most, their access was very limited. And then just lack of daycare in rural Minnesota is a big issue too. Is there anything internationally that we can learn to help us address some of these things? BOLLYKY: Really great and well-delivered question. So thank you for that, identifying the challenges that you’re facing. So I have not seen great breakdowns between rural—whether it’s in the educational environment or urban environments. There’s been a lot on the spread in terms of mitigation strategies. There’s been less, but we’ll look into it. One thing I will say that is going to be important, you know, much of the U.S. is going to have a rough ride the next four to six weeks. Where you see a rapid increase in cases, an increase in deaths will follow. And people—virus spreads among young people won’t stay there. I am hopeful, of course, and remain—I am cognitively optimistic. So I will remain hopeful that we are able to suppress this somewhat, because when we do move to the fall we will see resurgences, for all the reasons you’ve suggested. It will also be flu season. So one thing I do want to identify is, boy, is this an important year to make sure as much of the population gets their flu shot as possible, because if, particularly rural health systems that are confronting both a surge in influenza, as well as surge in coronavirus cases—you know, we’re not likely to have a vaccine prior to the beginning of next year. And who knows exactly how long it’ll take to distribute to many Americans. We will have flu shots. And it’s important that people get them. But you know, this is something where we really need to press state and federal officials for is more on the housing and the isolation capabilities, even in rural environments, to enable people to do distancing, where you do have people in houses that become infected and there’s not an ability to shelter, and for other members of that household, to shelter in place. So this—these are the kinds of things we need to be preparing for now. So I’m glad you’re raising them. I wish—I don’t know what’s happening on the Minnesota state government level. Perhaps somebody else on this call does. But I would love to see more from the federal government in terms of supporting communities that need to make this kind of particularized adjustment to their circumstances. FASKIANOS: Thank you. Let’s go next to Lee Gilbert. Q: Lee Gilbert, county commissioner in Rockwall County, Texas. Are you aware of any studies of perception of the American public, or are we doing anything—and I’ll give you the personal experience here in my county and my precinct. At best, coronavirus is viewed as a 50/50 deal, half the population taking this seriously, following the governor’s orders, local orders. The other half are reluctantly following or not following at all. And how can you stop a pandemic if only half your population participates? Thank you. BOLLYKY: So this is a—there have been polls and surveys in general to the degree to which people across different states, across party lines, across age ranges view the coronavirus as a threat. So those polls do exist. The main challenge, of course, is you need to see consistent messaging at every level of government around the fact that people should take this seriously. One of the challenges we have with this virus is it is, and I’ll say something that seems odd at first but stick with me, mainly is it’s not deadly enough. It is not deadly enough to inspire the behavior change that we need to see in people, but it is seriously enough and causes serious health consequences enough and it’s deadly to vulnerable and older populations. So it’s not deadly enough to get younger populations to do the behavior changes that we need to see, but just serious and deadly enough to overwhelm health systems and have a disparate effect on the vulnerable and older populations. And in that sense, you know, much of our pandemic preparedness assumes really high rates of case fatality. And as, you know, the more bad case, worse-case scenarios of what we can see from a pandemic, and what has been revealing about this particular pandemic, is, again, the rate at which it spreads asymptomatically, overwhelms health systems, but isn’t quite deadly enough to get young people to take it seriously has really been a disastrous combination, particularly for this country. FASKIANOS: Thank you. Let’s go next to Arianna Calderon. Q: Hello. This is Arianna. I’m District 16’s aide in Florida—Tampa, Florida. So it is commonly known that the degree of danger from COVID is seen as a bigger threat to people with compromised immune systems. We are all here discussing and debating opening schools for this fall when we don’t have a lot of studies or research to help guide us in how to do that safely. And it is also known that in fall and winter everybody’s immune systems are lower, viruses spread quicker because the temperature is lower. Parents are constantly complaining that when one kid catches the flu everybody in the household gets the flu. So I just want to hear more on, like, your opinion and the studies that you have witnessed and everything on how you think it’s going to, like, affect the fall, because we’ve been dealing with COIVD since, like, February here in the United States. And that was coming out of that season. BOLLYKY: Yeah. So I will first conceded I was not one of the people who thought this would be seasonal. A lot of coronaviruses aren’t. So I’m a little less surprised to see, but the main reason—we will see resurgences in the fall. And we’ll see them mostly because people are crowded together indoors. And again, the primary way—the overwhelming way this virus spreads is through respiratory droplets through direct exposure. And people being indoors and close to one another is the most likely way that is going to happen. Everybody expected to see resurgence, a second wave, in the fall in the United States. What we hadn’t really expected is the fact that we’ve had this continued churn in between. That’s important, because what you’d really like to do ahead of the fall is to drive down the community transmission to levels that give your health system a bit of headroom so that if you do see resurgences you can adjust and move personnel around, move equipment around, try to address those hotspots and control them to the extent possible. We’re—you know, last week there was a day when we had nearly seventy thousand cases. We are not in that circumstances in some states, and unfortunately Florida in particular. So this is—we should expect resurgences in the fall. And to the degree that we can’t protect people from influenza, we should expect the consequence of both conditions to hit the health system like a hammer. And it is incumbent on us to do everything we can ahead of that to reduce—to reduce community transmission as low as we can go because there will be undoubtably some amount of spread. Whatever anyone thinks about the school, to tie this to our topic of conversation, lower risk, high risk, it is not—there will be some risks. There will be some increase of spread that happens with schools. It’s a risk-benefit analysis for communities to identify whether to reopen them. But as we reopen them. But as we reopen schools, as we move to winter, it’s important to get the background rate as low as possible and make as many of the preparations that we’ve talked about here today as possible. I see we’re out of time. I’m happy to field questions through email or other things. Again, we’ll post those sources for this group. And, you know, thank you for all that you’re doing to combat this pandemic. I’m very grateful to state and local officials for that hard work. FASKIANOS: All right. I second that. Thank you all for all that you’re doing, and thank you, Tom Bollyky. As Tom said, we will send an email out with the links to the resources that Tom mentioned. I also encourage you to follow him on Twitter at @TomBollyky, and also visit ThinkGlobalHealth.org for more resources, as well as CFR.org. We’ll also include a link to the transcript of this discussion, as well as the webinar. And please let us know how we can continue to support the important work you’re doing. You can email us at [email protected]. So thank you all, again. Stay safe. Stay well. And we’ll just have to continue thinking through these issues and figuring out the best way to move ahead. (END)

Vin Gupta, public health physician, professor, and health policy expert, discusses the recent surge of COVID-19 cases in many parts of the United States. Carla Anne Robbins, CFR adjunct senior fellow and former deputy editorial page editor at the New York Times, hosts the webinar. FASKIANOS: Good afternoon to all of you. Welcome to the Council on Foreign Relations Local Journalist Webinar. I am Irina Faskianos, vice president for the National Program and Outreach here at CFR. As you know, CFR is an independent and nonpartisan organization and think tank focusing on U.S. foreign policy. This webinar is part of CFR’s local journalist initiative created to help you connect the local issues you cover in your communities to global dynamics. And our programming connects you with CFR resources and expertise on international issues and provides a forum for sharing best practices. It’s great to see you all. We’re shaking up the format a little by showing video, so we’ll look forward to your feedback. I want to remind everybody this webinar is on the record. And the video and transcript will be posted on our website after the fact at CFR.org/localjournalists. I’m delighted to have returning with us today Vin Gupta. He was with us several weeks ago, or months, I’ve lost track as we’re all in lockdown. Vin Gupta is an affiliate assistant professor of Health Metrics Sciences at the Institute for Health Metrics and Evaluation at the University of Washington. His research interests include pulmonary and critical care medicine. Dr. Gupta holds an active commission as major in the United States Air Force Reserve Medical Corps, as you can see. And he recently served as the primary public health consultant on pandemic emergency financing for the World Bank. He’s an NBC News and MSNBC medical contributor and is also a term member of the Council on Foreign Relations. Carla Anne Robbins is an adjunct senior fellow at CFR. She is faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously she was deputy editorial page editor at the New York Times, and chief diplomatic correspondent at the Wall Street Journal. So, Vin and Carla, thank you very much for being with us today to talk about the resurgence of COVID-19, and if we’re still in the first wave or second wave. We’ll discuss that. I’m going to turn it now to Carla to have a discussion with Vin, and then we’ll open up to all of you for your questions and comments. So, Carla, take it away. ROBBINS: Thank you so much, Irina. And thank you to all the journalists who have joined us. I know it’s an incredibly challenging time to be a journalist, and we really appreciate all the work that you’re doing on the ground. And, Dr. Gupta, welcome back. Thank you so much for what you’re doing. I said I wasn’t going to say thank you for your service, but I’m going to say it. It’s great to have you back with us. So this week, and this is the only arcane moment I’m going to have today, but this week as I was listening to Vice President Pence’s brief on the pandemic and talking about early indications of positive tests flattening in Arizona, Florida, and Texas, I remembered one of my favorite quotes from graduate school. And Thucydides wrote that during the Peloponnesian War words had to change their ordinary meaning and to take that which was now given them. And so I suspect that for many Americans coronavirus numbers are losing their meaning. We’re bombarded with data, we’re constantly being spun—being told this one matters, the other one matters, don’t pay attention to this, pay attention to that. So can we start with a quick overview on where we stand today nationally, regionally, and what numbers we really need to be watching the most closely and why? Is it new infections? Is it emergency room visits? Is it hospitalizations? Is it deaths? Is the age of those infected? Is it the percentage of people with antigens? I mean, I have a PhD and I’m utterly and completely confused.  GUPTA: You’re not alone, Carla. And I want to say thank you, again, for everyone coming to this event, for Irina for inviting me back, and Carla for moderating. It’s a privilege. I did have to just do a disclaimer. I’m in uniform. We’re actually—I’m an ICU doc with the Air Force Reserves. And we’re getting alerted occasionally that we may get sent out, just given everything that’s happening. So I’m not speaking on behalf of the Air Force even though I’m in my fatigues. And so I apologize for being in the car in fatigues. So with that all aside, my opinion is the following. You know, there are so many metrics out there. And the metrics themselves have gotten politicized. And it’s sad, frankly. And I’m going to speak candidly here. I think what I saw yesterday at the White House press briefing was diminishing urgency, flattening of curves, that if you go to COVIDActNow.org, for all the journalists in the room—I’m going to try to give you as many directed pieces of advice from my own biases as I can. They’re all going to be evidence-based in my opinion. COVIDActNow.org is a great repository of information on metrics that matter. One of which is the positive testing rate. If you go to—if you’re in front of a computer I’d urge you to go there right now. Go to Florida. And you’re not going to see anything that’s flattening, at least the way I think about flattening. I don’t think of a sharp curve up as flattening. The vice president was messaging as such. And I think that’s dangerous. And I’m going to get into Carla’s question in just a bit. But saying things that are not true in real time is dangerous because it puts our guard down. It makes the vice president, and the president, and the secretary of defense potentially say, well, we don’t need to active the critical care transport team in the U.S. Air Force—I happen to be in that team—where we could rapidly deploy portable ICU capability in Houston, in Tucson, in Florida, places that need it. You can’t just flip a switch tomorrow and say, hey, we need dialysis nurses. We’ll get them tomorrow. I can’t do that if I’m here in Seattle in an ICU. If I need dialysis on a patient with COVID, which is a frequent need, I can’t sometimes get that in my own hospital when there’s open beds, because there’s staffing issues. There’s all types of things. So we need a proactive approach and how we talk about data really matters, because it keeps your guard up or puts your guard down, which is concerning. Positive infection rates. What’s the test positivity rate? You hear a lot about that. That is critical. And that’s really—I’m going to give you a few metrics that I think matter. That’s an important one because no matter how much we’re testing, if the outbreak is not getting out of control it’s not like that number should be dramatically spiking, and you shouldn’t be seeing such dramatic growth rates in that specific test positivity number, the percent of tests that are positive. You know, they should remain—if the outbreak is not out of control that should not be an exponential curve, as you’re seeing on COVIDActNow.org. And it is. It is an exponential curve. It was flat and then it just immediately peaked up. That is concerning. So I would pay attention to that. And the threshold that you really want to focus in on is 3 percent or less. With below 3 percent, and then we think—and the WHO has sanctioned this, the CDC to some degree has sanctioned this although I don’t know—the CDC has become so politicized that it’s hard to honestly trust what comes out of the CDC anymore. Yesterday was a prime example. I don’t want to rabbit hole there. But anyhow, WHO has said 3 percent or less on that positive testing rate is key. And why is that important? It’s important because then if you are below that level you can feel reasonably confident to move from a mitigation, we’re going to—everybody needs to shelter in place, we need to minimize what we’re doing in public, there’s such disruption to normal life—to containment and contact tracing. One thing that has gotten lost in all the hullabaloo and all the mixed messaging is contact tracing right now is utterly useless because, one, the positive testing rates—or, the test positivity rate in Florida is 18 percent. It’s way too high for contact tracing to be effective. Because at that point we think the outbreak is out of control. You’d be contact tracing everybody. And we think you need five tracers for every confirmed case to do it well. How can you do it if an outbreak’s out of control? So you want that test positivity rate, the number of tests that turn out positive out of all tests done, to be less than 3 percent, because then you feel like maybe you can manage the number of positive cases that are being detected by isolating those individuals and then tracing their contacts. Anything higher than that, and tracing becomes impractical and cost ineffective. So that’s one. Hospitalization rates, to me, is self-evident. What’s your ICU bed capacity? Those are key. And I think for self-evident reasons. Because who cares what’s happening with cases and how we’re debating whether cases are rising because we’re just testing more, which is just a nonsensical argument, it doesn’t really—all those things are very proximal indicators—how many tests are happening, what’s the test positivity rate. Those things matter but they’re proximal indicators of the outbreak, meaning those are early—that gives you an early sense of what’s actually happening. The later indicators of, oh my gosh, Americans may die, are hospitalization rates and ICU bed availability—also available, to some degree, on COVIDActNow.org. You want to look on websites that aggregate data like that. You also want to look at the state health department’s website, especially in places like Florida, Arizona, that are in the midst of the worst of it, to see they sometimes will break down at the county level how many ICU beds are available. I should note that in Florida they’ve done some pretty astonishing things. They are now not even reporting accurately, supposedly, the number of ICU beds that are now available. They’re just defining—they’re listing beds by acuity, either it’s high acuity or low acuity. They’re not even talking about intensive care beds anymore in certain counties, which is problematic because it’s an effort to, in my opinion, manipulate the data so we don’t actually know what’s happening, which is extremely dangerous to planners and hospital administrators when they need it figure out workflow. When the governor needs to figure out if he needs to call the National Guard or beg the president to deploy somebody like me and our team members to come out and help. Data manipulation and trying to massage the data to make it seem like there’s not an emergency is a problem. And just I wanted to flag that for all of you. Some states, namely Florida, are trying to fudge definitions and trying to mask reporting availability of ICU beds. And it’s bad. But that matters. That’s a late-stage indicator. So just like hospitalizations, hospitalization rate, ICU bed availability, and then of course death rates, which I can get into in a bit. So one’s positive testing rate, which matters. We talked about the threshold. The other thing that matters on the proximal end, to get a sense of where are we headed, is the number of tests per confirmed case. So I’m not going to throw twenty different metrics at you. I’m just going to try to give you a few. The number of—so, test positivity rate, and the second one I would urge you to pay attention to is not how many tests are we doing in the country every day. That’s meaningless. But it’s the number of tests done per confirmed case. And why does that matter? We do about twelve tests per confirmed case. That’s pretty bad. Countries that have gotten it right, Australia does about eighty tests per confirmed case. New Zealand does 370 tests per confirmed case. Taiwan, South Korea, about ninety to a hundred tests per confirmed case. We do twelve. That means we don’t have to look too hard. We don’t have to test too broadly to get a confirmed hit. Said another way, we have a ton of cases and we’re still limiting who we test. I’ve been in the ICU to some degree since March. Because I’ve never had symptoms I don’t qualify for a test. My Air Force colleagues, some of them are anesthesiologists on the outside, none of them have gotten a test. And we’re actively caring for these patients. It’s absurd. Other countries don’t do that. You have to have symptoms. Really and you’re seeing in Houston and in other geos and even in Los Angeles, we’re back to where we were in March. Very narrow criteria on who can get tested. You have to be high risk, over sixty-five, living in a communal facility. You have to have symptoms, et cetera. We’re not testing broad enough. So that’s why look past the headlines on aggregate number of tests being done. It’s meaningless. We’re not testing broadly enough. And confirm—the number of tests per confirmed case. Our World in Data, if you Google that, I don’t believe that’s the actual URL. But Our World in Data, if you Google that, that will actually get you to a website that shows you the number of tests done by confirmed case. It’s a bar graph. It’s beautiful. And will compare it against other countries. That number needs to be quadruple what it is now for us to feel like we have adequate testing. So in summary, I would say on the proximal end the number of positive tests, and using 3 percent as a threshold, the number of positive tests done over all tests, number of tests per confirmed case. And then on the later end, so called non-lagging indicators—so gives you a sense of what’s actually—you know, how are people being affected. Look at hospitalization rates, ICU bed capabilities, and then of course death rates. And one last thing on death rates. We still think we’re underestimating the number of deaths nationwide. One, because COVID—you know, sometimes—first of all, there’s a huge epidemic of people just dying at home because of deferred care in places like New York City that were hard hit. And it wasn’t clear what they died from, but in many cases COVID-19 was either suspected or confirmed. But that was not lodged as the primary cause of death in an autopsy report in all cases. So there was a sense that there was some misreporting, not intentional necessarily, of deaths, especially amongst those that died at home in hard-hit areas back in March and April, and to some extent even now—especially in hard-hit areas down in Texas and Florida—because either a diagnosis was never rendered or was highly suspected but never confirmed. So there’s a sense that we’re still underestimating the number of deaths that are occurring because of COVID-19 in the United States. I’ll stop there. ROBBINS: Thank you so much. I have many more questions to ask you, but it’s not all about me. So let’s—why don’t we turn it over to the group, and I will follow up with my own questions. Irina, do you want to? FASKIANOS: OK, so Ray Stern, you go first. Q: Hi, there. Thanks for your time today. I appreciate it. It’s very helpful. I’m from Arizona. And as you know, there’s been a lot of attention given to my state because of what’s happening with the surge. I have a couple of questions for Dr. Gupta. Basically, I’m wondering how much blame, you know, should we fairly put on our leaders for this? You know, there seems to be mistakes just made all over the place. And the right decision, you know, often has consequences for the economy. At the same time, you know, our governor has seemed to follow the Trump plan. And there’s been already some accusations of covering up the data, just like you talked about in Florida. So I’m wondering if you look at Arizona, just how serious do you think the leadership problem is here? And then of course, the surge is the other extreme problem. I just looked at the COVIDActNow site. They’re putting us at 99 percent for ICU beds. You know, I guess I’m wonder how worried should I be about that? You know, is there a surge capacity that will come in, hopefully? And also we’ve got a governor who isn’t placing a mask enforcement requirement on the state. Should that be done? And what else can Arizona do to try to flatten this new curve? Sorry for the long question, but we’ve got a lot going on here.  GUPTA: No, no. That’s a really important question. Thank you for that. And first of all, I hope you and your family are safe. In Arizona, I know from colleagues, that’s a really difficult situation. I won’t mince words here. We’ve had failed leadership. And it’s been, in some cases, catastrophic. And I think if I did—if I willingly—here’s the analogy I like to think about. There’s a lot that’s not being done that we know could save lives. And if I withheld lifesaving treatment intentionally as a physician in the ICU, my license would get pulled. I probably would get sued. Other bad things would probably happen to me. So where’s the accountability? So let me start there with Governor Ducey in Arizona, not to pick on him but since you asked the question. Basic things are not being done. And you can only reason to think that maybe it’s political, that he doesn’t want to fear upsetting the president. The mask issue to me is mystifying at this point. Why are we even debating this? There’s plenty of data at this point that suggests masks cannot be recommended because, unfortunately, a citizenry like ours—which is diverse, which is opinionated, is not used to wearing masks—we can’t reliably expect us to comply with that at scale. We need 90 percent mask adoption, otherwise it’s not going to work. That’s what we know is effective. That’s what we’ve learned from our peer countries in the Asia-Pacific, where this is not a problem, cooperation with masks. They readily do it. But how can we encourage that? There’s no—we can’t just encourage it. The time for encouragement is done. That’s why mandating—a national mandate on masks is important. But when I even hear leaders that I think have gotten this largely right talk about it they say, well, we need to mandate masks. Well, where’s the enforcement mechanism? To your point, there needs to be an enforcement mechanism. What I’ve seen here in Seattle and elsewhere—I’m from Ohio originally—is essentially there’s a sign at the door: You must wear a mask. But what happens if you don’t wear a mask? And I’ve seen a lot of people just skirt the rules and not wear the mask. It falls to either me, with my toddler son, saying something to somebody, which I may or may not do and risk who knows what could happen afterwards. So I think it relies on our fellow Americans to enforce it, which is dangerous, or security guards to enforce it. That’s just not right. It makes no sense. So mandating masks at the state level, since the president’s not going to do it, makes a lot of sense. Governor Ducey should do it. But he should fine—there should be a fine. Just like we do with indoor smoking. And that, the threat of a fine, compels people to do the right thing largely. We need that. It’s very basic. And we should make it happen. Yes, people are going to be upset, but tough luck. That’s just how it needs to be. We’ve had success with indoor smoking. We should do it there. That’s one. Indoor dining needs to stop. I don’t know how much more evidence now we need out of Wuhan or other places that have studied indoor dining or other indoor gatherings in poorly ventilated air-conditioned facilities, but the transmission rates are twenty times higher, in some cases, than outdoor dining, outdoor gatherings where there’s distancing, at the very lease. If I was the governor I would stop indoor dining now. And Governor Murphy and Mayor DeBlasio have done it. To some degree you’re seeing some counties adopt that approach. But again, this county-by-county, municipality-by-municipality approach is not going to do anything for us as a country. It’s why we have a surge and Spain, and all these other countries, have continued flattening. We have fifty different approaches, multiple different approaches even within a state. It’s not going to work. So that’s number two. And to your other—to your last question about surge capacity, I’m deeply worried about all of you in Arizona, because 99 percent capacity in an ICU in the setting of COVID is a really terrible signal because it’s not like you have throughput of these patients through an ICU. These patients can take up to upwards of forty-five to fifty days to come off a ventilator. I just got off the ICU last week. I was caring individuals from Yakima who were in their early thirties who were there for forty days, intensive care. I mean, the definition of intensive care. I was in there for hours. My nurses were in there literally nonstop. Turning patients over from their back to their belly, continuous dialysis, twenty different drips, changing IVs out, big IVs in your neck almost—you know, every few days. This is serious stuff. And so it’s not like that number’s going to change anytime soon. Unless you deploy the military, unless you get the National Guard to do its job. I mean, one thing I think the military does do a good job of—again, I’m saying this—I know I’m saying this in uniform and so I want to be clear this is my opinion this is not the opinion of the Department of Defense—we know what we’re doing when it comes to portable ICU capabilities. That’s what we get trained to do. That’s what the taxpayer expects us to do. There’s a lot of money that goes to the training and keeping this mobile capability ready. Why aren’t we deploying it? It doesn’t make any sense. We deployed it readily for Ebola. Why are we not deploying it now to Florida, and Texas, and Arizona, and California? It does not make any sense. And yet, we continue to sustain the capability. Again, I think deploying active duty and reservist branches of the military—Air Force, Army, Navy—would give us some relief. Oh, sorry about that. It would give us some relief. But it would also mean that it would be some degree of admission of failure on the part of the president, that now we have to bring in the calvary, which, you know, if this—if the right thing was being done, again, to answer your question, that would be the right thing. And if I was Governor Ducey I would beg the president to do that. ROBBINS: Thanks. FASKIANOS: Thank you. Let’s go to Rosemary Westwood. Q: Thank you so much for doing this. I have two quick questions, I hope. The first, on ICU bed capacity, what is your understanding of, you know, the percentage of beds that are being used after that point at which it’s a big problem. Like, we’re seeing some regions in Louisiana have, say, eighteen beds, one of the most worrying regions right now. And as a percentage, I think that’s at about maybe 60-70 percent of the ICU capacity. So how can I measure, as a journalist, when I’m looking at this data, what threshold should cause us to think that we might overwhelm that system? And then the other question I have for you is can you just delineate between percent positive and what you call the number of tests to get a positive test? I think I’m sure not the difference between those two. GUPTA: Sure. No, no, I’m happy to elaborate on that. So on the first, anecdotally this is what I’ve seen, and working now in a few different ICUs in the COVID era and then before COVID. What I’ve seen is we never fill up—we never fill up every single bed because the rate limiting step often—is never the bed. It’s the number of beds you can staff. And staffing, especially nurse staffing, is always a bottleneck, especially now. So what I would urge you to do, and it’s probably different in your zip code than it is in my zip code. But what I’ve seen, to your point, about two-third to maybe 75 percent of so-called surge capacity is the most I’ve seen us actually operate in. It’s the rare time when you can call in reinforcements and everybody on a second call, third call, to come into the hospital. Its happens, but it’s in the rare circumstance when it’s all hands on deck. In my—what you really want to key in on, and the question you would want to ask your administrators at major health systems in your zip code, is what’s staffing look like? What’s ICU nurse, and respiratory therapist, and dialysis staffing look like? Double click on it, because it’s so easy to just talk about ICU beds. But I can say as a practitioner, it’s never the bed that’s the rate limiting step. We can always find a bed. We can—we can find a bed. What we can’t find necessarily is—can you find the twenty-four-hour nursing coverage, the highly skilled nursing coverage to take care of that individuals? And maybe—and in most cases a dialysis machine? Those are the rate limiters up front. So I would say typically speaking 75 percent bed capacity usually—if you’re going on the bed side, once you hit about 75 percent bed capacity from what I’ve seen, again, anecdotally, that usually correlates to 100 percent max capacity when it comes to your human health care workforce. And so that’s where I would really key in on when you ask probing questions to the CMO or the leader of the hospital administrators in the major health systems in your geo, because that’s the critical piece. To your second question, let me know if I didn’t answer your question, to the second question, so percentage positive tests. So just at a basic level, if you do 100 tests how many of those are positive? That—so the percentage of tests done in the prior twenty-four hours that are positive, and trend that out. That’s basically what COVID Act Now is reporting in Florida I think on a daily basis, if not a forty-eight-hour basis. So the number of tests done in a state or in a specific geo, and of those tests how many turned out positive. That positive infection—that positive test rate is key. And again, above 3 percent, you know, basically you worry that the outbreak is on an exponential growth pattern and it’s potentially going to get out of control. And it also means that contact tracing is effectively useless because there’s just too many positive tests that are out there. And in the absence of a technological innovation or broad adoption of technology to inform tracing—which we as a country are just not willing to engage in for a variety of reasons, unlike the U.K. and Germany—there’s no way we can do a manual contact tracing effort right now in the United States at scale. It just doesn’t make sense. The number of confirmed—the number of tests per confirmed case, so basically it’s—the way you would want to think about it is take the number of total tests done in you name the state and divide it by—or in the country—and divide it by the number of confirmed cases identified in that way. So it’s almost the inverse of what the positive infection testing rate—positive infection rate is. That inverse ratio, so number of cases per confirmed test, almost—again, it’s almost the opposite. It’s the reciprocal—is one way to think about how broadly or how narrowly we are testing, because if that number is small you basically means you don’t have to search too far and wide before you get a positive hit. So in our case, it’s twelve tests before you get a positive hit. In Australia, you have to test 370 individuals before you get a positive hit. There’s two applications for that. Again, just to make sure we’re—just to make sure I’m being clear. Maybe this point’s already come across, but if it takes 370 tests before you get a confirmed case, that basically means either you are testing everybody—symptomatic, asymptomatic, and people you don’t think likely have the disease. And that means anybody who wants a test can get a test, in other words. Or it just means you don’t have an outbreak. In our case, we’re only—twelve tests done before you get a confirmed hit, that either means we’re narrowly defining who can get a test, which is the case. You really can only be symptomatic. Don’t believe what they’re saying. You can—only if you’re symptomatic are you a high priority for tests still, all these many months later. There’s some exceptions, but that’s generally the case. Or it means your outbreak’s out of control. We have a combination of both. We have narrow testing and our outbreak’s out of control. In Australia they have broad-based testing. If you want a test you can get it. And they just don’t have that many cases. So that’s why that rate—you have to test many more people before you get a positive hit. I don’t know, is that clear? Was that—on either part of that question? Q: Yes. Yeah, they’re connected though, so that’s I think why I was confused. But that makes sense. Thank you. GUPTA: No problem. ROBBINS: Thank you. OK, so— Q: Can I get that website again, where that information shows up, Dr. Gupta? GUPTA: So COVID Act Now will do the positive test rate, I believe. And then Our World in Data I believe is the name of the website. Or if you just Google “confirmed COVID”—or, “tests per confirmed COVID cases” it should pop right up. And then you’ll see actually a really nice histogram that compares this against other countries. FASKIANOS: Thank you. Let’s go to Marie Albiges. I hope I’m pronouncing that correct. If not, please. (Laughs.) Q: It’s Albiges. I’m a reporter in Virginia at a daily paper. And so every day, you know, we put together the story of all the data, the confirmed cases, confirmed, you know, number of tests, et cetera. But I’m wondering just how much we really should be writing about the data on a regular basis when, A, the state has made mistakes in reporting in the past when it comes to coronavirus data and sometimes they’re unreliable. And, B, like you said, people have become kind of desensitized to what the numbers mean. So I’m wondering, you know, how much we should really be reporting on that data every day, or if there’s a better approach to how we’re writing about the data. GUPTA: So thank you for the question. And I think you’re appropriately concerned about the data, and how to best report on it. I would love—you know, I still think it’s important to present some of the data that we talked about, for the reasons mentioned . You know, there’s still value, even though there’s some concerns about how Florida is reporting ICU bed capability, if you—if that’s part of the story, it’s still a critical part of the story to tell because trends matter here. A snapshot in time is less useful, but trends do matter. So I would—I guess I would push you to, say, report on trends. And that’s key. And report on them—don’t report on absolute anything. Report on relative data metrics. So everything I’ve just mentioned here what you want to report on is trends in the positive infection rate, trends—by definition the number of tests per confirmed case is a relative metric. ICU bed availability, all these things. Trends over time, longitudinal data is what we really care about. I think that’s what you want to really focus in on. So whether it’s week over week or every three-day averages, that is very helpful.  What I think is really useful, and I think this gets back to a prior question here, is just double clicking on what are the major health systems in your—you know, in—wherever, in your region of Florida. And then speaking to the hospital administrators there directly, and not relying on the data the government’s reported out on the state of Florida’s Department of Health website, because I think you’re going to—it’s important to hear directly from the COs, the CMOs about their pain points. And it’s usually going to be, again, as I mentioned, on staffing, on the need for PPE, or what have you. To me, that’s the type of data, especially at the local and the municipal level, is really key to surface, because then national attention gets brought to it, and then potentially enough pressure gets made on state officials that they’re forced to act. But if you can balance—I think the best reporting at the local level is a combination of trends, quantitative—you know, looking at trends on these aggregate numbers, but then also seeing to the extent that you can get real data, actionable data from hospital officials and other leaders of major health systems. I think that’s going to be the most useful. So I don’t know if that’s helpful, but that would be my—what I’m—what I found to be really helpful when I try to message on some of these issues, you know, for certain elements. Q: Thank you. FASKIANOS: John D’Anna. And you need to—yes, thank you. Q: Sorry about that. I wonder, Dr. Gupta, if you could comment on the importance of timeliness in receiving test results. We’re talking to people here in Arizona who are waiting a week to ten days to receive their results. And as a follow up to that, are there any tracking systems that you’re aware of, or resources that you could point us to, that give us an average length of time to receive test results? GUPTA: Such an important question, especially as we think about this broader debate on returning to school. And so right now the delay—the most commonly available test is from Quest and LabCorp, and major lab-based companies that do lab-based tests. And these are the classic nasal swabs that you stick into your nose, and then somebody—some technician will then send it back to a Quest or LabCorp type facility to get run. On average, the best-case scenario is a seventy-two-hour turnaround on that test. What I’ve seen typically is five to seven days on average, just in the health systems I’ve work in, anecdotal reports. I’ve seen as bad as almost a month, just because things got messed up in transit. And it’s totally unacceptable and it makes testing virtually useless if we’re thinking that testing is a bridge to something. It’s all fine and well to know that you’re positive or negative, right, but we think it’s a bridge to then determine who needs to be quarantined, but then importantly who needs to get their contacts traced. And if we’re saying there’s a seven-day potential lag between finalization of the positive result and then notifying your exposures, then that doesn’t make any sense. We need point of care testing. And so I think this is where this synchs in with the larger debate on the CDC guidelines on school re-openings nationwide, and then the president’s pushback on that. One thing you’ll notice, a common thread, is that neither the CDC nor the president stipulated testing for children or adolescents going back to school as a requirement. And it’s—myself and colleagues were sitting here wondering, haven’t we been messaging on testing every single day since early March? And now suddenly it doesn’t matter, and we’re going to have fifty-six million school-age children go back to school, and they don’t need to get tested? This is the type of inconsistent messaging that ruins the trust—that trust compact between the American people and then I think people like myself, that have been trying to—and my colleagues—who are trying to message on the importance of masking, testing, et cetera. If we’re now saying we’re going to just restart a huge part of our economy and we’re not going to do anything with testing, if I was—if I was listening to that not living and breathing this reality every day I would say: What is happening here? Why are we doing that? And so the reason why they’re not messaging on it, it cuts to the heart of your question. Oh, sorry about that. Which is, we don’t have the right testing. They don’t want to message on it because you can’t have a seventy-two-hour lag between—or, a week lag—between testing and then saying you can go to school. We will, though. Importantly, we will have that testing capability, we think, by late fall/early winter. Becton Dickinson, Quidel, these are two companies that have a direct—a certain type of test that’s point of care, that’s going commercial in the next few months, and to the tune of multiple millions of units of supply in circulation, you know, we think September/October, and then tens of millions thereafter. These are the types of tests that you stick something in your nose, with a clinician watching over you, and then within fifteen minutes you get a result. Within fifteen minutes. And there’s other innovations that are in the pipeline, we think by late fall/early winter, will allow for not just same day but same hour, or even within the same half-hour finalization of the result. That’s the type of innovation that the government should subsidize for every school district in the country. That’s the responsibility. They should make sure they—every school has the proper clinician to administer the test or supervise it. And that’s the infrastructure unfortunately we need until we get a vaccine or there’s herd immunity. That’s what we need. And it’s going to cost money. That’s what the taxpayer dollars—federal taxpayer dollars should be funding, or at least partly subsidizing so it’s not on schools. But that’s what we need to reopen schools. And until we get that, this notion that we’re going to just stagger schedules, we’re going to thermal scan folks, we’re going to make sure there’s adequate ventilation, it’s all just nonsense. And it’s—us not messaging consistently is going to ruin—further erode trust between public health officials, people who are on the front lines, and the American people. They’re not going to trust us. So sorry I rabbit holed there and went a little bit in a bit of distraction, but I don’t know if that was helpful. FASKIANOS: Vin, what about saliva testing? Are those—is that an effective means? Are those tests being developed? GUPTA: They are, Irina. Right now what we understand internally is that saliva testing captures the right—the cases you want—i.e., the cases that are—there’s enough of a concordance between saliva and sticking something up your nose that—it depends on the organization, but Major League Baseball, other major organizations are adopting it. There is a chance that saliva—what we’re seeing is there’s about one in ten cases where saliva misses a positive hit that you would otherwise detect on a nasal test. But those tests we—that one case usually is a case of an individual that had the infection but is no longer infectious. So in other words, saliva captures the cases that matter. And you know, I’ve gotten some push back. Well, you know, how can you expect a six-year-old to assent to a nasal test, because they’re not going to like that. It’s going to be super traumatic. And I agree. Some of these point of care tests will allow you to spit into a tube instead of sticking something up your nose, but they’re not going to go online, Irina, until we think November/December, at scale in Q1 2021. But it makes this notion of a fall reopening of schools broadly I think terribly unsafe. And it’s creating an expectation that’s wrong for parents. I think parents need to be prepared, unfortunately, to hunker down yet again through the fall semester, with relief starting hopefully in the spring semester. But that’s the messaging that we need, not oh we’re going to start things up to September. Because now it’s going to create all types of disagreements, it’s going to create false expectations, and then people are going to get upset. FASKIANOS: Thank you. Let’s go to John Wotowicz next. Q: Yes. Thank you so much. And this is a terrific conversation. And, Dr. Gupta, thanks for all of your observations and answers here. I’m going to take it just—down a different path here, which is it would be great to get your thoughts on the extent to which this whole global pandemic is revealing some real structural flaws in the United States kind of devolved system of state-level health policy, health regulation, health reporting of data. Because when you look at, you know, larger places—you know, such as Germany—where, you know, it’s a substantial population, but where obviously all of these issues are being ultimately decided and directed at the center and at a national level. It’s hard not to at least raise that question. And just to identify, I’m with The City, New York’s local nonprofit—local news platform. GUPTA: Thank you for that question, which is a really important one. You’re right, the lack of a unified—all fifty states are sort of—you go at it alone approach to our health care system and financing of our health care system has been a huge problem for decades. And I think COVID-19 has really unearthed inequities in access to care. Until May, to give you an example, if you wanted to get a test—until May you had to—and all you could do was access a physician or an ARNP through a tele-environment, you had to—you actually had to own a smartphone, because they did not allow—CMMS did not allow you just to call your doc and say: Doc, I need a test. Or if you were working with a nurse practitioner, same thing. They didn’t allow that. They didn’t allow someone to get reimbursed on the provider end to communicate over phone with somebody to then, you know, prescribe a test. So basic things like that, where the essentially the common motif here is you have to be affluent, and you have to access to broadband technology. Otherwise, you’re going to get a prescription. It was a huge problem in the initial months where this epidemic, now this pandemic, took root. So I think there’s been progress. So what I will say is, and I hope there’s continued permanence of some of the changes I’ve seen, at least in a temporary fashion, when it comes to, for example, telehealth. There has been ninety pieces of legislation in the last three months to telehealth to broaden access to make cross-border licensing—to strengthen cross-border licensing arrangements, so I can be a doc here in Seattle and care for you in New York, who needed it. I didn’t have to be licensed in New York. I can how physically go to New York City, if needed, and practice medicine and get a license within twenty-four hours. Previously it would take months. Those changes—let’s hope they become permanent because that’s going to rapidly increase the ability to deliver access to health care in a tele-environment, regardless of if you’re sitting in an urban, densely-populated area or if you’re in a rural/exurban area. So that’s one. And I think that’s important. What I fundamentally think is a problem in our health care system that has not been addressed is we just have the wrong types of health care workers at scale. We have a—yes, we don’t have enough doctors. Yes, we don’t have enough nurses. But we don’t actually have enough medical assistants. And those are the types of individuals that do the type of work that allow me to practice at my top of license. So I’m not doing care coordination. I’m not calling in meds. I can focus in on the patient in my fifteen minutes I may have with him or her in clinic, try to deliver the best quality care so they can come in less often to see me, and it’s less of a charge to the system, but then they can interact more with the medical assistant, who can focus in on coordinating the care with social services, getting your medications refilled on a timely basis, making up those phone calls. Do you know what happened in the months right after COVID-19? Most MAs got furloughed, and then fired. So now we don’t have the connective tissue in our health care system that we need. We have nurses. We have docs. But they’re all being overstretched. There is a lot of unhappiness in our health care workforce right now—either because a lot of them have been laid off, and they have untenable bills, student debt, et cetera. Or, because we’re doing work that’s quote/unquote, “beneath” our license, that’s stressing—we’re expected to do top of license work, because we’re in charge of a patient’s care, ultimately, we’re guiding their overall care trajectory. But then we also have to make sure we’re care coordination. We also have to make sure that they have a safe discharge. All these things where we need more people that can strengthen the connective tissue of the health care system. I don’t know if that directly answers your question, but to me that is the dire lack—the key need for American health care moving forward. We need greater access to care. And broadening telehealth is going to be a key piece of that, making permanent some of these legislative changes. But then we also need a rethink on how we can incentivize roles like medical assistants, and more broadly. How do we make that a career that’s worth saving, and worth investing in, and that people feel like they want to actually continue in on? Without that, we’re just going to have a bunch of expensive clinicians, whether they’re nurses, ARNPs, or MDs, who are going to be doing nurse that they shouldn’t be doing. It’s going to create a bunch of waste with the health-care system. And it’s going to have these trickle-down effects, where you’re going to have Republican administrations come in every four to eight years and want to block grant Medicaid and create haves and have nots among states. And it’s just not right. But the proximal causes of that are waste, inefficiency. And part of—and a big drive of that, I don’t think we talk enough about, is who are—who are the people delivering our health care in and what proportion? We just don’t have that right. Q: Thank you so much. FASKIANOS: So we’re waiting for more questions, so Carla I know you’ve got questions. ROBBINS: I have a question. So if you look around the country, are any leaders getting it right? Are there any models for how to do a measured reopening? Or are we all just going to have to hunker down and wait for a vaccine or herd immunity to set in? GUPTA: So I—it’s a great question. I love what Governor Murphy has done. I think what Governor Cuomo and Mayor DeBlasio are doing now in terms of messaging in the setting of a very complicated situation is laudable. They’re taking action on indoor dining. They’ve been as strong as I think I’ve seen on masks. And they went through the worst of it and had the humility to call in reinforcements. And so they had humility. They’re operating with evidence. And so I think they should be praised accordingly. Truth is, I don’t think this is a state-level approach. So you know, this notion—and this is where I worry about their false sense of creating these regional approaches here. It’s not going to matter what Connecticut, New Jersey, or New York do if Arizona and Governor DeSantis in Florida decide, hey, we’re going to go our own way, because we’re all one country with one set of contiguous borders. The state-level approach has limitations. Just like if you’re a mayor, or if you’re the mayor of Miami, and I understand the president’s about to go to south Florida tomorrow. And the Mayor has said: You have to wear a mask. Turns out, the mayor doesn’t have any discretion or jurisdiction if the governor says, well, you know, what? You don’t have to wear a mask. We’re not going to mandate—especially if—and if the president comes in and says there’s not going to be a federal penalty even if state law says—if there’s one way or the other on masks. If there’s not a federal penalty for not wearing a mask, then it’s even further weakening messaging on the city level. And so I think it just goes to say there’s only so much that can be done at the city, municipal, or state level. We need federal leadership. We certainly need governors to be aligned with that federal leadership. But I feel for governors like Governor Murphy, Governor Cuomo, I thought Governor Whitmer withstood a lot of angst, a lot of conflict, but stood firm with a very strong shelter in place order, which I thought was right. I thought Governor DeWine actually initially—my native Ohio—was great, with Dr. Amy Acton, in terms of messaging, shutting everything down early. But unfortunately I think Governor DeWine’s a cautionary tale of somebody who has let that initial strength essentially completely dissolve, and you’re noticing a very clear uneven response now to the second wave or this extended surge, where now he’s saying, hey, we’re going to do masks in a few counties, but not statewide. Again, it does not make any sense. So I think governors— ROBBINS: But I understand what you’re saying about it can’t be piecemeal and all of that, and you know shutting down borders obviously is not possible. We’re not East Germany during the Cold War. (Laughs.) I suppose the question that I’m asking is: What do you think is a reasonable series of steps for reopening that when the numbers become—like, New York, in which the numbers are flattened after the horrors that we went through earlier. I mean, Cuomo’s talking about reopening malls, you know, there’s all of these things that are going on. What are reasonable re-openings that can take place once the numbers are, and at what level? I mean, what’s the pacing that you’re comfortable with that the government—that the government—a government that has good public policy should be doing? GUPTA: So, no, I appreciate that. What I would say at a high level is that to enter any phase of reopening moving forward a jurisdiction, however you define it—but I think we have to do this at the city level or at the county level—has to have an infection—a positive infection rate—that’s the most important metric in my opinion. That’s an early indicator of where things are at with the outbreak—has to be less than 3 percent, for re-opening. And the only reason I say that is because that’s when, it hit on the theme mentioned earlier, that’s when we can actually do something about it prospectively. If you have new cases, you have some hope of maybe containment because you can scale contact tracing. So I think, number one—one criteria here—and this is, again, my opinion. The infection rate, positive infection rate, has to be less than 3 percent. You have to have—you have to speak with local health system leaders about what’s the true ICU bed capability, not just what’s—not absolute number of beds, but how many can you staff? If that’s 100 percent of all beds, great. In most cases, it’s not. But assuming that you feel like there’s enough elasticity in your health system capability to handle a surge, and that—in my opinion that means only a third of beds are filled at any period of time—if ICU beds—3 percent less—or, percent or less on your infection positivity rate, one-third of less ICU beds filled. Then you can enter a phase where you’re opening up outdoor dining, where you can reengage in public in groups of less than ten, if there’s social distancing and, you know, universal masking precautions in public areas. That’s where that makes sense. And then I think the critical piece here that we just need to—if we really want to normalize life and get back to normal, until before a vaccine hits, we have to accept that we need app-based technology to guide contact tracing. That’s what the U.K. has done or is about to do. That’s what Germany’s about to do. There’s ways to do it that can protect data privacy issues. There’s ways to do it that could be, I think, sensitive to communities of color and other underserved areas, where there’s going to be even greater sensitivities to the adoption of technology to facilitate tracing. But let’s be real, we’re not going to be able to do a manual contact tracing effort at scale quickly. But we can do it with the assist of technology. So I think if we have a community that hits those metrics, less than 3 percent on the infection rate, we have adequate ICU capabilities—as defined by what administrators are telling you not what numbers are saying just in some database—and if there’s an appetite and an acceptance of broad downloading of an app, or what have you, or another non-app based technologies that could facilitate tracing, then I think we can think about outdoor dining and outdoor activities upfront. Of course, you’re assuming that you have mandatory mask enforcement as a part of that legislative approach. But that would be how I would think about a reopening process that may actually have some hope of curtailing any new infections from becoming niduses for new outbreaks. ROBBINS: And of course, those things are—many of the things you’re talking about are already happening in New York City, without contact tracing and without mandatory masks. I mean, certainly not with enforcement of masks. GUPTA: Well, I think those are two—those are two critical gaps that need to be rectified because—but New York is, again, far ahead of the curve. I think you had—and New York is—that’s why I highlighted it, because I think if you’re thinking about indoor dining and stopping that, the messaging on masks has been excellent, at least from elected leaders in New York state and City. So those are two things that most of the country doesn’t have. MR. RUBENSTEIN: Let’s try to sneak in Ray Stern before we close. Q: Thanks so much. Just wondering if you can talk about death rates just a little bit more. On one of the conservative sites that I was looking at they talk about how the CDC says this this is barely an epidemic at this point, according to the CDC. And I looked that up and it’s true, basically, though, they say that that could change. How do we explain this in full context to people? And the last question is, New York, of course, had this big first wave surge. A lot of doctors and nurses got sick. Are these people getting sick again or have they achieved immunity as far as we know, at this point? GUPTA: I think the death rate debate is—it’s so easy to mis-message on death rates as it’s 0.6 percent, why—or, the true death rate we think is 0.6 percent, even though we think the case fatality rate—how many people are actually dying right now in the United States out of those confirmed cases is about 5-6 percent. The question, and you’re seeing that sort of death rate curve level off and it’s decreasing consistently. So it’s causing people to wonder, what’s all the fuss about? And there’s a few reason why we’re all fussing. Number one is, this outbreak—if we continue to open up the way we’re opening up, if it continues that, you know, young people continue to be vectors for transmission, the median age of—that the majority of newly infected individuals in Florida is thirty-five, versus sixty-five in March. Similar findings in Arizona, in your home state, where younger people are now the predominant focus of the infections. You know, these are individuals that are—as long as COVID-19 is still circulating in an environment, it poses a threat to us as we enter the fall with flu. That’s the concern, because you can still end up in the ICU if you’re young, number one. But then you can still transmit it to older individuals, number two. As older individuals resurface and are now, you know, potentially going out, because we can’t have them shelter in place forever. So there’s going to be a tendency to want to normalize life. And as long as we have this circulating, it’s going to still pose a threat to those that are the most vulnerable. So that death rate, one, is a lagging indicator, deaths now probably are largely occurring from infections that occurred four weeks ago. And so there’s nothing to say that we’re not going to see an uptick in deaths as we continue to let our guard down. And I worry that our guard is being let down, based on scenes from July 4, based on core messaging from the White House. And if schools do reopen because the president’s blackmailing school districts nationwide with funding, which is, I mean, just completely dangerous to do, you’re going to see—there’re all the ingredients for a repeat surge and more potential risk to those that are the most vulnerable. That’s one reason. Number two, and I know I’m going over time. I’ll say this quickly. My colleagues and I have gotten better at saving lives at ICUs. We know things that we didn’t know in March. It doesn’t mean then that we should be playing Russian Roulette with ICU bed capacity. Yes, we can save more lives now because we know steroids work. We know that you should put everybody on blood thinners. We know that you should probably put somebody on their belly instead of keeping them on their back on a ventilator. These things we didn’t know in March. And so is that helping with the death rate and we’re saving more lives? Yes, potentially. But is that a pop-off valve we can rely on at scale? No, because as we’ve talked about ICU bed capacity staffing is such a limited—it’s still in such a limited supply there isn’t a lot of room there. And I wouldn’t bank on it. So that’s a key piece here. And then, number three, we’re testing more. And so we’re seeing that most of these new cases are happening among young people. Again, not a cause for celebration. Young people are transmitters of the disease. They can still end up in the ICU. There’s still a lot of risks. So that’s how I would—I guess I’ll close there, just in the interest of time. FASKIANOS: So, Vin, I just—one question came over chat. Natalie Megas. She can’t ask her question out loud, so I’m just going to read it. But going back to the school systems reopening safely: Is testing, in your opinion, the only indicator to reopen safely? Many states are leaving it up to parents to decide between virtual and in-person instruction. How can I report on this to help parents make an informed decision? And she’s a freelance reporter in Virginia. And that will have to be the last question. GUPTA: And sorry, just to paraphrase, it cut out a bit, the question is safety of going back to schools and balancing needs in terms of virtual versus brick and mortar. FASKIANOS: Yes. If testing’s the only indicator—if schools are not doing testing, are there any other indicators that would help parents make the decision of whether it’s safe to send their kids back to school or do virtual. So is testing—if we’re not doing testing, would you say then don’t send you kids? GUPTA: My opinion is: don’t send your kids. Because it just doesn’t make—I don’t understand the argument for why we’re saying testing doesn’t matter. It just doesn’t make sense. I know the American Academy of Pediatrics, the CDC, and the president are all aligned that we need to restart schools. We all want schools to restart, but it’s just what are we then basing a return to school strategy on? That’s where I would really ask your school district. Here in Seattle they’re talking about thermal scanning, which makes no sense. And I love our elected officials here in Seattle. They’ve been leaders on this issue. But looking for something, fever, amongst individuals that we know that if they were positive adolescents they would not have a fever—we’re looking for something we know is not going to be there. It doesn’t make any sense. So we have to—testing has to be the backbone. If it’s not, I would encourage parents to wait and not take the risk. Because even if your child may not be at risk, you would be at risk, or your grandparent—or, your parents might be at risk, if you’re a parent. So I would be very cautious. FASKIANOS: Well, with that, Carla, any final words? ROBBINS: Just actually one quick list here. The Times did this extraordinary things, they asked 511 epidemiologists what they would and wouldn’t do, what normal activities they would return to, and in what timeframe. What are they—are you doing any normal activities, or are you going to wait for the vaccine? Getting your hair cut? Going out to dinner outside?  GUPTA: Outdoor dining, absolutely. And I think that is something that we call still can enjoy. And I’ve seen a lot of restaurants innovate with community spaces, and I think there’s going to be more of that. So outdoor dining, I’d highly encourage it. And I think that’s fine. And that’s the only thing I would say that I’ve done that’s been true normalization. ROBBINS: It looks like you got your hair cut too. FASKIANOS: It does look like you got your hair cut. Or was that a home cut?  GUPTA: It’s my wife’s incredible cut. But, no, so I guess yeah. Sort of semi-normal. ROBBINS: Thank you so much. GUPTA: Thank you for having me. FASKIANOS: Thank you, Carla Anne Robbins and Dr. Vin Gupta. This is fantastic. We really appreciate it. We will be sharing out the recording and transcript of the webinar. We’ll also include links to the URLs that Dr. Gupta mentioned. You can follow Carla on Twitter at @RobbinsCarla. And you can follow Dr. Vin Gupta at @VinGuptaMD. So go there for more information on what he’s thinking about. Also his commentary on the news outlets. We encourage you to come to CFR.org for the latest and greatest on COVID-19 and other situations around the world, because the world keeps moving even though we’re in this pandemic. And please feel free to send us your ideas and suggestions for other issues and people you want to hear from as we continue this series over the summer. You can email [email protected]. So thank you all.

The Trump administration has expanded immigration restrictions to suspend until the end of 2020 the issuance of most visas for foreign workers, including those for high-skilled employees and for intra-company transfers. Our panelists discuss the ramifications for business and U.S. competitiveness.

Drs. Lisa Cooper and Leana Wen discuss the racial inequities that exist in the health care field today and how that impacts the course of the COVID-19 pandemic. 

Panelists discuss the rise of cyber attacks during the race for a COVID-19 vaccine, the role of various actors in carrying out these attacks, and their geopolitical consequences.   ANDERSON: Good afternoon, everyone. Welcome to the Council on Foreign Relations Virtual Roundtable. Our topic today is “Cyber Attacks in the Age of COVID-19.” My name is Trisha Anderson and I’m a partner at Covington & Burling, practicing primarily in the area of cybersecurity and national security. We have a terrific set of speakers today. I will introduce them briefly and then engage them in discussion for about thirty minutes, and at 3:00 p.m. I will ask the operator to open it up to Q&A from the participants. So let me start with Theresa Payton, who is the CEO of Fortalice Solutions, a cybersecurity consulting company, and co-founder of Dark Cubed, a cybersecurity product company. She started her career in financial services, serving in executive roles at Bank of America and Wachovia, and she was the first female chief information officer at the White House under George W. Bush. She speaks and writes frequently on cybersecurity and data privacy and is the author of several books, including Manipulated: Inside the Cyber War to Hijack Elections and Privacy in the Age of Big Data. Next, we have David Sanger, who is a national security correspondent and senior writer at the New York Times. He’s been on three Pulitzer Prize-winning teams, and his newest book is The Perfect Weapon, which examines the emergence of cyber conflict as changing the nature of global power among states. He’s also the author of two New York Times bestsellers on foreign policy and national security, The Inheritance and Confront and Conceal, and for the New York Times, Sanger has served as White House correspondent during the Bill Clinton and George W. Bush administrations, among other roles. And, finally, we have Adam Segal, who is the Ira A. Lipman Chair in Emerging Technologies and National Security, and director of the Digital and Cyberspace Policy Program at CFR. An expert on security issues, technology development, and Chinese domestic and foreign policy, Segal is the project director for the CFR-sponsored Independent Task Force reports Innovation and National Security: Keeping Our Edge and Defending an Open, Global, Secure, and Resilient Internet. His book, The Hacked World Order, describes the increasingly contentious geopolitics of cyberspace. And before coming to CFR, Segal was an arms control analyst for the China Project at the Union of Concerned Scientists. He’s been a visiting scholar at numerous universities and writes for numerous publications, and his writing can be found now on the CFR blog Net Politics. So given that we only have thirty minutes, we’ll dive right in, and I think all of us that have lived through the last several months have seen, most notably, the increasing dependence of businesses, individuals, and governments on information technology to maintain our work, our social relationships, our governmental operations. So I’ll start by asking Theresa but, of course, welcome others to jump in, how this increased dependency on IT infrastructure has changed the cyberthreat landscape and, in particular, whether we should be thinking about new areas of vulnerability or new threat actors, or whether it’s really an intensified version of the existing threat landscape. PAYTON: Thanks, Trisha. Really, it’s great to be here with all of you and I’m excited to hear the dialogue that unfolds today. And I would say, to answer your question in a real simple way, it’s an all-of-the-above scenario. So it’s definitely accelerated existing forms of cybercrime but we’re also seeing new and different types of approaches leveraged by cyber operatives with nefarious intent, cyber-criminal syndicates and nation-states. I mean, really, the pandemic created that goldmine of opportunity for cyber crimes. So as businesses and organizations were sending employees to try to attempt to work from home and figure out this sort of interim new normal and were reimagining their operations, cyber criminals were reimagining as well, and at my firm our incident response line just started buzzing with calls. So what have we been seeing and, like, where do I think they’re going? Just real quickly, unauthorized logins, especially attacking any organization in the health care ecosystem. They were definitely being hit with sort of these unauthorized access points: remote desk protocols, remote logins, VPN access, as well as account access. We also saw business email account frauds resulting in wire transfer, monies going to the wrong place, really accelerate like a hockey stick. Ransomware attacks against all different types of industry verticals also went off like a hockey stick, and for the first time in a long time not only did ransomware increase, but my team and I have seen new deviants and new strains of ransomware that have not been previously identified either by law enforcement or by some of the larger security and product companies. And so that’s been really a little frustrating, really, for businesses. I think the other thing that was interesting about this is that the State Department noted, and we also track misinformation campaigns, that sort of this weird, almost like a collusion marketing effort by Russia, North Korea, Iran, and China to actually promote to their own citizens they were handling the pandemic very well, that the EU was not, that America was not, and promoting these misinformation campaigns including state-run media promoting the idea that maybe the U.S. military actually created COVID-19, and we needed to sort of explain that. The other thing I do want to mention is, you know, just in case people are thinking, well, maybe since you’re on the front end, you know, Trisha, and I know you deal with incident response as well in your role, that maybe we were just sort of seeing an anomaly. Towards the end of May, the U.N. disarmament chief actually said that they had seen a global increase in malicious emails of 600 percent just since the pandemic had hit. So if you think of that January through May time frame, and those are the ones that have been reported and identified. This is going to translate into not just short-term impacts for the pandemic, but as we start to reimagine business operations coming out of the pandemic there will be long-term impacts because businesses will be moving to contactless everything wherever possible, and as they implement these technologies in sort of a rapid innovative approach, that contactless, whether it’s Internet of Things, Bluetooth technologies, has inherent design flaws, which makes it hard to secure. And cyber criminals, nation-states, and cyber operatives with nefarious intentions will be ready to pounce. But other than that, everything is great. (Laughter.) ANDERSON: Adam or David, did you want to add anything there? SANGER: The only thing I’d add is this. You know, crises like this don’t tend to create new schisms but they tend to open up existing ones, and so we have seen new opportunities that are being exploited by the same old actors. One of the oddities is I think that the infrastructure has held up in the United States as well as it has, given the number of people who are working from home, though any of us who are out in rural areas, as I am right now, are seeing the strain on the cable networks and all that. What that does tell you, though, is that we have opened up new attack surfaces, because with everybody coming in from home, they’re coming in from systems that weren’t designed to handle this kind of traffic and weren’t designed necessarily for this level of security. Some of that’s going to be overcome by VPN and other technologies, but much of it won’t. And so you’re seeing some strange things happening. Intelligence officials tell me that they’re kind of stuck because they would have to go into the office in order to work on their classified systems. That’s a pain these days. So the reality is, of course, that a lot more information that ordinarily might be flowing over a classified system is probably flowing over an unclassified system, with people praying that there are not interceptions of it. I think it’s all made us more aware of what the vulnerabilities would be when we move to 5G systems if we’re reliant on Chinese or other supply chains. I think the last thing that’s really interesting about this particular moment is that we are beginning to see companies and the government recognize that we’re not going to get back to something that looks exactly like what we had before. So we have to think about internet security in a very different way if you’ve got to spread it out in such a broad way to everybody’s houses. You know, it’s the problem it had for a long time in my neighborhood in Washington, where only very senior officials would get secure systems, you know, run into their basements. Well, now a lot of people are going to have to have pretty secure systems as standard equipment into their basements. SEGAL: I’ll just add that I think, as David and Theresa have both said, it’s accelerating a number of discussions. And so, on the response to the nation-state attackers, I think we’re seeing many of the issues we’ve been talking about before come back up. So what type of attacks under COVID are beyond the pale and sort of international norms—are there certain discussions about attacks on health-care networks? Are those outside of international law, or how should states respond? We saw the Australian signals-intelligence organization basically threatening that they would respond with cyberattacks if they were going to disrupt. And we saw, you know, the FBI and CISA warning U.S. actors about attacks from nation-states. So I think the debate is happening—kind of replicating, reduplicating itself on what the norms of behavior should be in this space. And we clearly have—you know, we don’t have a lot of answers and we don’t have a lot of tools to try to shape that behavior. ANDERSON: So that brings us, I think, to a good topic to pick up on. And Theresa obviously mentioned the increased impact on the health-care industry with attempts to gain unauthorized access, but also efforts by nation-states to engage in misinformation campaigns. And it does implicate interesting questions about cyber norms and the extent to which that behavior is acceptable for states or other actors to engage in. It might be useful to talk about what some of the geopolitical implications are or are likely to be with respect to those types of activities, efforts—as we’ve seen, you mentioned, Adam, the FBI and CISA announcement about the Chinese efforts to hack into vaccine-related data. What does that mean? Are we entering into a competitive environment among states for a race to the vaccine or treatments? And how do you see that playing out? Adam or others, if you want to take that question. SEGAL: Yeah. I mean, I think, as you said, we’re clearly seeing a race for the vaccine and we’re seeing nation-states trying to, if not steal what their competitors are doing, at least have a better sense of where they might be in the vaccine production schedule. We’re seeing attacks on international organizations, so Russian and Iranian and North Korean attacks on WHO and other public-health agencies also for information-gathering. And then, as Theresa mentioned, we’re seeing the disinformation around the narrative of COVID and who is responding more effectively and less effectively and using it to bash geopolitical competitors. SANGER: The only thing I’d add to that is in our own reporting we have, of course, you know, recorded what you’ve seen from the U.S. government about increased attacks on those working on the vaccine. It’s not clear that that is necessarily for the vaccine itself. It may simply be, as Adam suggests, to understand where they are in the race. And remember, this is sort of a three-way race right now. It’s got a number of American competitors, a few Chinese competitors, including some backed by the PLA. So there’s very little doubt that the PLA would use units that it’s long used for these kind of purposes to make sure that they are where they want to be; and then the Europeans as well—Oxford, Sanofi, others—who are in this; and I think a really hard question for the offensive side of U.S. Cyber Command to go deal with and the NSA, because this is essentially industrial spying, but it’s also a national-security issue because it deals with the health of the entire country. And it may be a while before we’re able to sort of suss out what it is that is being done to defend many of these companies, but whether persistent engagement, active defense, as Cyber Command likes to call its offensive operations, are being used in what is also at least partly a commercial context here. PAYTON: Yeah, Trisha, the only other thing I’d add—I agree with what Adam and David both just laid out here. The other thing that I would add is don’t forget about the insider threat and the potential for insider threats. We have kind of the nation-states and cyber operatives, as well as cybercriminal syndicates want to be able to monetize anything they can get their hands on and certainly anything around supply-chain orders, you know, how things are going to unfold in, you know, kind of that intellectual property of the vaccines. That’s all information that could be monetized if they can get their hands on it. But the other piece is the insider threat. And although insider threat is more rare, when it does happen, because they’re on the inside, have authorized access, it can often be sometimes the most damaging type of attack that happens. We actually worked a case where the individual is in jail. This is in the clean-energy industry, where the engineer was actually taking information and selling the secrets to China, and they were an American citizen. So the insider threat is also just one other thing that I would add that’s a little harder to detect than traffic coming from, you know, different parts of the world and looking for tactics, techniques, and protocols. ANDERSON: So I’ll pick up on one thing that David said, which was—David, you alluded to, you know, there being some uncertainty about what the governmental response, in fact, is, in light of, you know, classified information, the fact that our military typically does not, you know, publicize its cyber—offensive cyber operations or its active defense. You know, what is your prediction, either David or others, for how the government is going to respond to some of these trends? You know, we’ve seen a little bit more public activity in the very—relatively quick announcement by FBI and CISA about attributing the attempted vaccine data hacks to nation-states. Is that sort of more of what we’re likely to see? What predictions do you have for the kind of governmental response that will unfold in response to all of this? SANGER: Well, we certainly have seen—and I think you have to give the Trump administration credit for this—more attribution of bad actors more quickly than we’ve seen in past administrations. It happened a little bit in the Sony case and so forth in the Obama administration. But early in the Trump administration North Korea was identified as the bad actor in one major hack, Russia in another. And you’ve seen as recently as recent—just the past few weeks, Russia named again for other attacks, mostly on email systems. The problem is that there’s no particular evidence right now that these name-and-shame efforts actually act as much of a deterrent. You know, we’ve been naming Russia since the 2016 election and it does not necessarily seem to have cut the level of their activity. So then the question comes: Could you see the United States intervene in the COVID case and in the vaccine case as the way it intervened in 2018 to send a shot across the bow of Russian actors who were beginning to look at the midterm elections? And you’ll remember at that time that Cyber Command, with NSA help, shut down the Internet Research Agency for a few days, sent some warning shots to members of elite hacking teams in some of the Russian intelligence services, and so forth. Easy to do for an election because in that case you’re protecting a clearly all-government function. A little more complicated in the American system when you’re stepping in on behalf of manufacturers. Who do you step in on behalf of? Do you protect Johnson & Johnson because it’s an American firm? Or one of the other American competitors? Do you do the same for other Western firms that are working perhaps outside the United States? This is pretty tricky territory. And usually we’ve not seen the U.S. use its cyber capability on behalf of American firms other than to block attacks. But the interesting question here is are they willing to go further. And we simply don’t know yet. ANDERSON: Adam, do you have any thoughts about it? SEGAL: I agree with David. I would—I would add that the—I think the other component on the Trump side which is also praiseworthy, although we’re not really sure what the effect is, is that the attribution is not happening alone. It’s happening, you know, with—usually with the Five Eye partners, but also the Dutch and others who I think are becoming more of leaders in this space. I think David’s right, though. We haven’t really seen a significant drop in activity, but it certainly helps create a sense of shared norms among the likeminded about what we might respond to. You know, on the defense side we clearly see, as you said, attribution happen faster with the FBI. CISA I think is doing a fairly good job of sharing information. But other than that I don’t—I don’t think we’re going to see a lot of dramatic change. We have a playbook, right? The Solarium Commission released its findings, you know, a very strong set of recommendations that have been, you know, floating in the air for a long time. But they brought them together. They issued a white paper that speaks to the pandemic in particular. So I think there are lots of things that people have on the table to do. IoT security, reappointing the cyber director in the White House in the assistant level, and the secretary of state level. So there’s lots of ideas out there. I don’t suspect we’ll see a lot of traction on that, though, on the domestic legislative side right now. PAYTON: You know, Tricia, David and Adam, they brought up something I think that’s really important, which is, you know, not only do you have sort of the separation of, you have the Five Eyes, you have our three-letter agencies and the federal government, and then you have the private sector, who’s largely on private sector infrastructure solving problems for the nation, but really in a private sector way. So where do the lines blur to protect and defend that information both nationally, and then also internationally with our allies. And many of the companies who are working on this here are global companies, not just American headquartered companies. And so I think one of the challenges we also have to look at here is that every dollar that is spent on securing the infrastructure and doing threat hunting, and trying to look for tactics and protocols, and looking for digital evidence that maybe there is a problem—every dollar and every resource spent on that is a dollar and a resource diverted for the race for the cure, for the vaccine, for better identification tests, for treating people who actually catch it. And so we really do have this dilemma where, you know, a dollar on security is a dollar diverted from the actual effort that we’re trying to undertake. And so who should bear the cost, as well as who should bear the burden of prioritizing resources to focus on that? So not only do we have the challenge of that’s a real gray area of protecting private sector endeavors using the Five Eyes, and the three letters, and the federal government, but also having the best and the brightest trying to secure the digital elements of this ecosystem is very, very challenging. ANDERSON: Agreed. Before we get to the Q&A section I did want to touch upon the issue of election security, which David touched upon briefly, drawing that distinction—interesting distinction between the government’s defense of the private sector versus its approach to defending an election. How do you see the leadup to November—the November elections playing out? Are the threat actors the same? Are they different? Are there different playbooks that we should be thinking about that they are likely to be using? Theresa or others, if you want to jump in and handle that question. PAYTON: Yeah. Just a couple of thoughts on that. You know, for starters, I think our dry run during sort of the caucus and what happened in Georgia and, you know, just sort of the primary elections, who needs hackers when you implement technology and people aren’t trained and they’re not sure what the process is, and we kind of trip on our own feet? So that’s unfortunate. Hopefully, lots of lessons learned there. I am very encouraged with all the work that DHS, CISA, and the states have done, and vendors, and the ethical hacking community have done. I’m very encouraged that a lot of work has been done to secure the elections. But the misinformation and manipulation campaigns are still a real challenge. I am seeing as far as tracking on COVID-19 on the antiracism movement, as well as all other kind of big social issues that are very important to the presidential election. The misinformation, manipulation campaigns attempting voter disenfranchisement. And the playbook has changed. I mean, I think the Muller report did a great job laying out the parts of the Russian operation that were known. I talk about in my book—I believe that some of that was designed to be found, and that was the part that, you know, they didn’t want to be found out, but if it had to be found out, you know, this was one operation. There’s others. But the other piece is there—we can’t legislate our way out of this issue with misinformation, manipulation campaigns. We can’t just count on the user and we can’t just count on big tech and social media to solve it. It’s going to be an international everybody’s got to be all in spotting and detecting and reporting misinformation and manipulation campaigns. They’re doing burner accounts. They’re taking true organic American citizens who are posting something and then amplifying it. They’re leveraging artificial intelligence chatbots that look like organic human-controlled behavior of accounts. And then once real humans start arguing with each other, they kind of move onto the next issue. So they’ve definitely changed their tactics. I believe the social media companies have done a really good job trying to combat this, but it’s going to take individual citizens, the international community, big tech. And I don’t think legislation alone is going to solve this issue. SANGER: I’ll throw in a few thoughts as we’ve began to work on this. I would agree with everything that you just heard about how they’ve got to go change the playbook. And they do have to change the playbook because the Russians understand that the same playbook is not going to work a second time. The U.S. is going to see them coming this time. Facebook will. Google will. Twitter will. So what have we seen happen? As Theresa suggested, we’ve seen more of a move to trying to convince individual Facebook users to pick up a meme so that it’s not coming out of the Internet Research Agency. It’s coming out of your neighbor’s house, right? And at that point, it’s protected First Amendment speech, right? It’s within an American citizen’s right, even if they are being duped by the Russians. They’re doing a very good job of just amplifying things that come up out of our own natural divisions. And then again, you know, I’m not sure that you can necessarily say that that is foreign interference. It’s foreign amplification of issues we have underway at home. It’s the infrastructure of the election system, though, that I think is changing to some degree. Obviously, the coronavirus issues are leading many states in a very patchwork way to move to more vote at home, vote by some kind of paper ballot that you would mail in. On the one hand, that’s good, because it leaves a paper trail. On the other hand, it puts a much bigger vulnerability aura around the registration systems, because this only works if the registration database and the pollbooks are all coordinated so that you’re mailing out the ballots to everybody who needs to have one mailed out. And if they mail one back in, they then can’t show up at the polling place and vote a second time. And the Russians understand, and others understand, that you don’t need to hack into that registration system all over the country. You just need to hack into the most vulnerable small parts of it and create the aura that you have done a much bigger hack. And that’s all it would take for President Trump or others to say: See, I told you the system was rigged. And you’ve already heard those words come out of his mouth more than once. So I think our focus ought to change at this point to making sure that those registration systems are really locked down. My biggest fear is that you could have a ransomware set of attacks, similar to those attacks you saw across Texas and elsewhere last summer, because most small towns and cities don’t have the money to put into this kind of security. They certainly don’t now that they’re dealing with reduced revenues because of COVID-19 and other issues. And again, all we have to do is lock up a couple of big cities—think about Baltimore and Atlanta and what they already suffered from—in order to create the impression that somebody has gone into the entire network of voting systems. SEGAL: I think everything’s been said. I’ll just add that I think David’s point about aura and impression is really the main one because in some ways it doesn’t matter what we do. We know there’s going to be some glitches that are going to be, as Theresa said, self-inflicted. And already the debate is about foreign interference. So no matter who loses they will be able to point to those events and say: We think those were, you know, foreign interferences and the process was rigged. And so in many ways it strikes me that it doesn’t matter that much what the outside actors do, the foreign actors do, to change their playbook. We’re already existing in an environment where it will be contested and contested in politically divisive ways.  ANDERSON: All right. Thank you, Adam. At this point we’re just past the 3:00 mark. So I will invite participants to join our conversation with any questions they may have. Just as a reminder, the roundtable is on the record. So, operator, if there are any questions could you please let us know? STAFF: (Gives queuing instructions.) Our first question will come from Kate Moore. Q: Hi, everyone. I’m Kate Moore from BlackRock. Thanks very much for your really interesting comments and insight today. One question I wanted to dig a little bit further into was the coordination between companies and the government. There were some comments made that there’s going to have to be better coordination going forward. But, you know, one complaint we’ve heard from a lot of companies has been that there are lots of independent operations, that the network is not necessarily connected, and that a global, or at least a national, infrastructure doesn’t exist for fighting cybercrimes. So if you guys could comment a little bit more on that, that would be helpful. Thank you. ANDERSON: Theresa, would you like to take this one? PAYTON: Yeah, I’ll start off, and I’m sure David and Adam probably have some insights here as well to help. But I don’t disagree with you. I think that is an incredible challenge that we face, because I work on incident response. And we have a really great relationship with FBI, which has their InfraGard, which can be sort of a local chapter where offices are and where headquarters are, as well as with DHS with CISA, they also have a team who will get involved in incident response. Both teams will brief companies proactively, put out indicators. They are putting out more joint bulletins, which is really helpful. And during an incident response, I oftentimes will ask the client, either we could do it for them anonymously or not anonymously, if we would have permission to get those entities involved during a ransomware event, or incident response. So I agree with you. I think it’s real challenging for a business to know, how do I get information proactively? Once I get it, how do I consume it and turn it into something actionable that I can actually, you know, just have it work and actually help protect and defend the organization. And when I have an issue, do I call my lawyer first? Do I call an incident response team first? Do I call DHS or FBI? And I think that is an ongoing challenge. I do see in my time in working in the cybersecurity space that the collaboration and coordination is better. But it is still confusing. ANDERSON: Unless there are other comments that David or Adam wanted to share, operator is there another question? STAFF: Yes. We will take our next question from Maurice Tempelsman. Maurice, please accept the unmute now prompt. OK, maybe the hand raise was a mistake. At this time we don’t have any other questions. ANDERSON: All right. Excellent. Well, that gives us a chance to get into supply chain issues, which I think is a really interesting topic, and it intersects in ways that—with the COVID-19 that we wouldn’t have anticipated, you know, when we were talking about supply chain more generally back even a few months ago. Obviously here in the U.S. there’s been a great deal of concern about supply chain reliability and vulnerability that’s led to efforts to relocate or regulate supply chains. And so my question for the panelists is whether you all see this trend as one that’s likely to continue, and relatedly whether we might see a parallel with data. In other words, a trend toward data localization increasing as well. SANGER: You know, I think we saw this already underway before COVID happened, but it’s really accelerated. Think about the 5G debate. So a year ago Secretary Pompeo was traveling around Europe trying to convince countries not to account Huawei as a supplier and saying that if they did they’d be cut off from U.S. intelligence. The Europeans basically called his bluff and began to sign up with Huawei, usually not on the core of the system but on the radio networks and so forth. And that’s where I think we’re headed until we saw COVID spread. And suddenly countries began to ask the question: Do I really want to be dependent on a Chinese network any more than I want to be dependent on Chinese suppliers for respirators, for ventilators, N95 masks? And you know, if you don’t want to be dependent on a Chinese supplier for your N95 mask, then it doesn’t make much sense to be dependent on a Chinese supplier for your power grid or for your 5G network. And so you’ve seen, particularly in Britain but not just in Britain, some rethinking of this. I don’t think it’s as much going to affect the localization of data. That was happening with Chinese regulation making companies localize the databases in China, and some by the Europeans and others. But now I think you’re going to see it much more with domestic supply. And here in the United States President Trump has certainly accelerated it with an effort to try to make sure microelectronics and so forth are being supplied domestically. I don’t think they’re going to manage to go revive a 5G manufacturing capability here. I think that may have to wait for the next generation. But certainly there is an effort underway. SEGAL: So, I mean, I think it’s also important to distinguish between what we think is going to happen to the supply chains. And I think there’s a greater focus now on the resilience of the supply chains. A lot of those are not going to be reshored, right. When you look at the surveys that the European Chamber and the Shanghai-American Chamber did, in most of those companies they’re still saying that they’re going to invest in China for the China market, and if they do relocate supply chains, it’s going to be to Southeast Asia, not back to the United States. So I think they are going to be able to do some resilience in the supply chains, but not necessarily move them back to the United States. The one thing I’d add to David’s narrative about what I think has shifted the debate on 5G is the most recent round of commerce sanctions, the May 2020 sanctions that are going to really focus on TSMC, the Taiwanese chip manufacturer, which allowed the British and the intelligence agencies to kind of reopen the debate and say, well, we’re no longer sure where Huawei is going to be able to supply its chips from. And so that adds a whole new level of insecurity, which allowed them to kind of open the door and reopen the debate, which then, I think, lets things fall into place with other—perhaps the Germans and the French as well. So I think, on that level, the tightening of the Commerce Department’s restrictions really was an important kind of move that shifts that debate. PAYTON: The only thing I would add there, Trisha—because I think David and Adam covered some really fabulous points there—is that this is absolutely the right time to take a look at your business continuity and resilience and incidence-response playbooks and update them and ask yourself the tough questions. How much redundancy do you actually have in both sort of the materials of the supply chain that you need? Because we had clients who were waiting on things that they had paid for sitting on planes. And when China decided that they needed it for themselves, they canceled the order, refunded the money, and kept the supplies. And this wasn’t just health-care supplies. So there’s sort of that physical element of the supply chain for whatever the core business is that you are in and whether or not you have redundancy in that. I would say the second piece is if you do find yourself leveraging different technologies that suddenly end up on sort of the kind of the bad list or this-could-be-bad list or the sanction list, what’s your go-to backup plan, again, from not just a cybersecurity perspective but a business-continuity and resiliency perspective? And so that would be the only other thing I’d add is just make sure you take a moment to take those lessons learned while we were in sort of the—I call every week a new normal. (Laughs.) So as we’re in sort of each pandemic week’s unfolding of the new normal, take those lessons learned and update those playbooks. ANDERSON: I’ll just remind participants that they should feel free to raise their hands to ask a question, if anyone is interested in asking a question. And we’ll keep going if not. STAFF: There are no questions at this time. ANDERSON: Excellent. So, Adam, I will turn to you maybe to speak a little bit more about the overall trajectory of, you know, how some of these phenomena that we’ve been talking about today will impact the broader U.S.-China tech war. A number of you have alluded to the kind of increased actions designed to tighten—by the U.S. government to tighten restrictions on Huawei or other Chinese entities. You know, where do you think all of this is headed, and what has been the impact of some of these impacts of the coronavirus on the U.S.-China relationship? SEGAL: Yeah, I don’t think we’ve seen the bottom yet. I think we’re waiting to see how the sanctions on Huawei play out. Is the Commerce Department going to allow some workarounds like it did for the first year and how the sales are going to work? We’ve seen some expansion of the sanctions to companies that are involved in surveillance and AI technologies. We see a lot of bills that are focused on Chinese students, and in particular some students that might have some connections to the PLA or the military-industrial base in somehow—in some shape or measure. So I think there’s still a lot of discussion going on among China hawks in particular about how you can cause more pain to Huawei specifically, and then to slow Chinese technology development more broadly. And then we have the question about, you know, how the Chinese are going to respond. You know, on the domestic side, we saw coming out of the two sessions a focus on technology infrastructure, so about 1.3 trillion (dollars) in investment on technology infrastructure. But it may be very hard for the Chinese not to retaliate if there’s real damage to Huawei, given how much in the Chinese press and coming from Chinese spokespeople about—talking about Huawei and the unfairness of U.S. actions. So, you know, we haven’t seen very much specific retaliation. You know, some outlets, like the Global Times, have, of course, suggested it. But that is still, I think, waiting in the wings for the Chinese to really consider. SANGER: Let me just add in one thought here. Let’s say that the Washington strategy is successful beyond its wildest dreams and that the United States, its NATO allies, and a handful of allies in Asia don’t go with Huawei. Huawei will still have probably 40 percent of the world’s communications, just because with China alone, and then states that are willing to go sign up, states that are developing nations, states that are taking this as part of Belt and Road, a fairly large number of nations will be on a Chinese Huawei-dominated network. And that won’t just be Huawei. And those that aren’t will still be using newly laid Chinese undersea cable, because while we’re laying some new cable, mostly by Facebook and Google and Microsoft and others, the Chinese are laying out new cable along the way, partly through a subsidiary of Huawei or what was a subsidiary of Huawei. So we’re going to have to, as Sue Gordon, the former deputy director of national intelligence put it, learn how to live in a dirty network. We’re going to have to learn how it is that we manage our communications knowing that they’re going to flow through Huawei networks even if the Huawei hardware is not present here. And I think that too much of the discussion that I hear, particularly on Capitol Hill, seems to suggest that if we can just ban Huawei from our networks and our allies’, we’ve solved the problem. And we haven’t. And this is where it rolls right into the encryption debate, because if you don’t have truly solid encryption, you’re not going to solve the problem you were intending to solve by keeping Huawei out. PAYTON: David, that’s such a great point. And Trisha, just to add a little bit more to what Adam and David said on this, this is where, from a development standpoint, whether it’s the mobile apps, the Web apps, whether it’s the communications themselves, focusing purely on the network is not enough. There’s multiple layers here that are being, you know, potentially overlooked that need to be secured. And so we need to be taking more advantage—this is where, if we can containerize our development and think about transactions as their own independent element, regardless of what the transaction is transported on, what it’s transported to, that actually helps us with mitigating the risks in this global supply chain we find ourselves in. So, you know, everything is not made in the same country anymore, whether it’s an Internet of Things device like Google Home or Alexa or your Ring doorbell. Everything is not all created in one country or even in one factory, right. It’s all distributed across different organizations, different companies. So the supply chain is very complex. The way you reduce your attack surface when you have a very complex supply chain is you actually look at the transactions themselves. So it’s encryption. It’s tokenization of each transaction, and when I’m done and I have what I need, I don’t ask for it the same way again. It’s all the different types of elements for the data and the apps themselves. And if we can start focusing on containerizing those and actually making each and—each one of those components more secure in and of itself, then we’re able to help whether it’s 5G and Huawei or any other part of the supply chain to actually have a more secure experience where we’re not relying on the human, the user, to, oh, make sure you have multifactor authentication; don’t forget, don’t click on links and open attachments even though it’s a core part of doing your job; you know, all those things that we put the burden on the user. You’re right, David and Adam. Just deciding who provides the 5G network doesn’t mean our job is done. There’s so much more to it. ANDERSON: I really like the phrase that David used, learning how to—learning how to live in a dirty network I think is really apt here. We’ve touched a little bit upon the governmental response to some of the cyber threats that we’ve been talking about, and I think—with Adam, who I think expressed some gloom or pessimism about the likelihood that we would see legislation. To the extent we have seen legislative efforts, they have really focused on the hardening of the network and exclusion of Chinese entities from 5G and the network generally. Is there—do you see any efforts, or do you have any thoughts about the role of government in terms of moving to that different strategy of learning to live in a dirty network? Or is that something that it’s just still lagging behind and we don’t really see the government yet taking action in that regard? SANGER: Well, I think governments are conflicted a little bit because of the encryption debate. So what’s the—what’s the fear of letting Huawei in? There are two fears. One is that they could shut a network down in time of conflict. And you can pretty well solve that by keeping their parts out of the network, although you’re, obviously, always going to have some Chinese components in it. The second fear is the one of interception of data. Now, I would argue the Chinese did a pretty good job intercepting data in the old, boring 3G and 4G worlds, right? I mean, Unit 61398 did a nifty job stealing industrial secrets when we weren’t even thinking about 5G yet. So we’re not going to solve that problem entirely. But the more that governments step out and say we can’t live with complete and total encryption because our law enforcement capability needs a way in, the more they are tripping on their own message about network security from China and others. And what I think I’ve seen in my reporting is that government officials do not like to see this correlation made. They want to think as if they can have their encryption debate purely in terms of law enforcement and being able to get into your iPhone or your network to find out where a missing child is, which is certainly a very reasonable argument about why they may want to do that. But they want to do that thinking that they’re not along the way compromising the rest of their network security, and of course, they are. SEGAL: I mean, I think we’re probably seeing some thinking in the Defense Department about operating in dirty networks. I think probably most of the thinking now on the—on the tactical or operational side is based on an assumption that, you know, the networks are not going to be as reliant, no matter who supplies them, as we think they’re going to, and you have to have redundancies and backups and analog and all these others things that are—that are going there. I think, as David said, at the policymaking or the kind of U.S.-official point of view, no, I mean, U.S. officials always think they’re going to have their cake and eat it too—that we’re somehow going to achieve both, you know, perfect transparency into our opponents and complete security for us, and that somehow the other actors are not going to do things to prevent that. And so, you know, I think there is a kind of inability to see that others are just not going to passively accept how we shape those networks and they’re going to kind of operate in ways that are, you know, going to force us to be more strategic and make some difficult decisions, make some compromises about which things we’re willing to give up in return for what we think are either national security interests or law enforcement interests or widespread commercial encryption usage that defends, you know, more people. ANDERSON: So I’ll just invite participants, if there are any questions, to please raise your hands. I’ll pause for a moment. (Pause.) If not, then I will ask each of our panelists to wrap up by— STAFF: Trisha, we do have a question. ANDERSON: Great, OK. STAFF: If you don’t mind me interrupting. ANDERSON: Of course. Absolutely. STAFF: Take our next question from Josh Green. Q: Hi. This is Josh Green from S&P Global. I appreciate the comments today, though it does seem to paint a pretty bleak picture for the future. And I’m curious if there’s anything that’s giving you optimism about the path forward specifically around our ability to operate in a—in a secure environment. ANDERSON: That’s an excellent question on which we can end. So I’ll ask each of the panelists to give their thoughts on this question. Theresa, do you want to start? PAYTON: Yeah, sure. So what’s interesting is—thank you for asking that so we can end on a high note. Some of the things that I’m incredibly encouraged around is actually removing the friction of security for the user by leveraging technologies such as machine learning, artificial intelligence to actually do the behavioral-based analytics in real time and to be able to say: Does this transaction make sense, or is this transaction an anomaly where I need to actually layer back in more friction just to actually validate and authorize the user? So I think we’re finally at sort of the place where we have enough information about you, about how you do business; we have enough computer processing power and technology to actually start to make your interactions with technology more secure. So I see a lot of hope and promise there. We’re not quite there yet, but I do see a lot of hope and promise there, where things like implementing encryption for a transaction and the tokenization of that information in the moment that you need it being something that’s easy for a business to implement and easy for you to consume, and those are the key elements. And then to be able to use that behavioral-based analytics and machine learning to analyze a transaction in real time, and if something doesn’t look right about it ask more questions about it, and if it seems like the transaction is not legitimate to be able to actually stop it in its tracks. So there’s a lot of promise there. Also, some of the frameworks that have been rolled out, both the international frameworks but some of the ones rolled out such as NIST, some of the things coming out of Department of Defense, the FedRAMP certification for cloud, those frameworks are starting to pay off. I don’t want to see them used as checklists because checklists don’t stop bad things from happening, but they are starting to create a level of rigor and discipline that’s sort of like a basic pay-to-play that I think is incredibly helpful. So you put the two together, if we can always make sort of security be a warm hug around the user instead of an add-on, that’s a good day in my book. And we’re approaching that. SANGER: Oh, I’d add in that we’ve come a long way since 2016. The Russians may have done us an enormous favor, because while they created a fair bit of paranoia and so forth, I’m not sure at the end of the day they actually affected the outcome of the 2016 election. And I think it’s going to be hard for them to get away with things unseen except at the very last moment in the coming election. Every upside has got a downside to it, and the downside is that we have learned that the psychological benefits of interrupting a process, a network—as Adam and I were discussing earlier, just creating a perception hack can do a lot of damage. But we have a much more cyber-savvy electorate today than we had four years ago, and I think that’s going to be—make it easier for people to recognize that, in fact, they are hearing from a bot; that, in fact, the registration system may be messed around with by a foreign power or it may be a case where simply the state has made an error, the way Georgia made a series of errors in training the other day for the primary. So I think we’re a lot more savvy. That doesn’t mean we’re safe. SEGAL: I don’t think I’ve ever ended a cyber talk on a positive note, but I will—I will try. I think there’s lots of interesting things happening in the—on the public-private side, that we’re seeing a lot of groups like the Cyber Threat Alliance and others that are, I think, doing a very good job of popularizing, reaching out, benchmarking, providing guidelines, reaching new audiences internationally and domestically, and providing some of the solutions. I think also the efforts on the international level of the private sector to shape the norms discussion has been interesting. I don’t know long term how effect it has been, since states still say this is still a state realm. But they’re certainly, I think, affecting the debate and putting new ideas in the discussion. ANDERSON: Thank you so much, Adam. Well, we covered a lot of territory today, and I just want to thank all the participants for joining the Virtual Roundtable. And thank you so—(inaudible, technical difficulties)—to our speakers. (Audio break, technical difficulties)—and posted on the CFR website. So thanks again, everyone. SEGAL: Thank you. SANGER: Thanks. (END)