And welcome to, Washington National cathedral. I am the dean of the cathedral. On behalf of the bishop of the diocese of washington and all of us who serve in his cathedral, welcome. We are so glad you have decided to join us for this important conversation this evening. Convening conversations and bringing people together to discuss some of the most important issues of the day is one of [indiscernible] priorities. And paul8 the Nancy Ignatius program has given his to focus on many important issues, issues that sit at the intersection of faith and public life. The nancy and Paul Ignatius program fund was established by children, their friends, and other relatives, as srecognition of nan and paul service and commitment to Washington National cathedral. While we said goodbye to nan last year, her legacy lives on here at the cathedral, and we are so pleased to have paul as the mainstay of our cathedral community. Not to mention that this years ignatius program is especially important because yesterday, Paul Ignatius celebrated his 100th birthday. Happy birthday, paul, and god bless and thank you for all that you have done. [applause] our topic for tonight could not theore relevant or timely, impact of this pandemic on our nation has been immense. Every week this cathedral holds a service specifically to pray r many of by name fo those who have lost their lives to covid19. Who among us this time last year could have imagined that we would see 230,000 americans who have lost their lives, and the number only growing . Months, past 10 we have experienced a lot of loss and heartbreak. Yet at the same time we have witnessed the selfsacrifice and heroic efforts of First Responders and medical personnel and frontline workers. Moreover, we are beginning to see the fruits of the incredible efforts made by scientists around the world to find a vaccine for this virus and to do before. Never seen the truth is there has been much suffering and loss, but there is also much to be thankful for. So, where do we go from here . And dr. S to dr. Borio Francis Collins and dr. Anthony fauci for being our guests tonight to tackle that question and so many others. If you will permit me, i would like to begin this evening with a prayer. If prayer is meaningful in your life, please join me. Let us pray. O god, our refuge and strength, our help in trouble, we pray for all those affected by covid19 around the world. Remove the presence of a and anxiety from our hearts and heal all of those who are sick with the virus. Give skill, sympathy, and resilience to all those who are caring for the sick, and your wisdom to those searching for a cure. Strengthen them all with your spirit that through their work, many will be restored to health. All of these things we pray in your holy name, amen. Pleasure tos my turn this over to the oldest of the ignatius children, david ignatius. David i am david ignatius, a columnist for the washington post. On behalf of all of the ignatius family, my thanks to this wonderful cathedral, i would like to welcome you to a special discussion of the topic that our nation and the world are thinking about more than any other, covid19, where do we go from here. We have had some hopeful news in the past week with the announcement of the vaccine, whose phase 3 test results our givene speaker, not a man to hyperbole, it is really quite good i mean, extraordinary. And we have had chilling news from what appears to be a winter surge of the virus come with everyion totals rising day and hospitals around the country straining to treat patients. We are blessed tonight to have three of the wisest doctors in america and indeed in the world help us think about where we are going and how to protect our families, and the world from this scourge of the pandemic. A word about our foreman tonight. We will open with a conversation between my brother, the editorinchief of Harvard Business review, and dr. Anthony fauci. Many of you may not have heard of dr. Fauci, so i will explain that he is director of the National Institute of allergy and Infectious Disease and for decades he has been our nations leading expert on Infectious Disease and a person who gives us faith that science and reason will prevail in the end. Following the discussion, my sister amy ignatius, a superior court judge in metric and will moderate a discussion with dr. Francis collins and dr. Luciana borio, who served in the Obama Administration as acting chief scientist at the fda, then directed medical and bio defense preparedness for the Trump Administration from 2017 to 2019 and is now a member of president elect joe bidens Coronavirus Task force. Finally, a word about the ignatius program. As the dean said, my siblings and i helped establish this event 12 years ago to honor our parents, paul and Nancy Ignatius, who have cherished their relationship with this cathedral. Over these dozen years, we have had many important speakers, including spigner brzezinski, brent schoolcraft, john kerry, susan rice, and many others. But we have never had a more important topic or more compelling panelists than tonight. Paulou know from the dean, celebratedur father, his 100th birthday last night. If you want to think about how to stay healthy in these isvid times, he your man. It is fitting that his birthday is veterans day, because he spent a lifetime serving his country, as a combat veteran in world war ii, later as a secretary in the navysecretary of the navy, and truly in everything he does for the adi, myamy brother sarah,amy, and my sister the only ignatius you will not see on stage tonight, we would like to dedicate this program to our father and the memory of his wife of 71 years, our late mother, Nancy Ignatius. Brother,auci and my adi. Adi all right, thank you very much, david, for getting us started. David has introduced a dr. Fauci. Two key things he has a top card and a bobblehead topps Baseball Card and a bobblehead doll. Somehow in 2020 americas leading rockstar is an epidemiologist. President trump suggested he might fire you, president elect biden says he might promote you. You are a 79yearold medford which sounds like the better deal79yearold man. Which sounds like a better deal . Dr. Fauci [laughter] my job as the director of the nah institute and is a Public Health official is to focus entirely on what my mission and goal is, to use science and health to preserve the health, safety, and welfare of the American People regardless of what the administration is. You know and many people know that i have had the privilege of serving six president s since i became director of the niad in 1984. That is what we focus on as scientists. I know we are living in a charge political environment, but that is not primary for us. We continue to do our job to foster Public Health, but also to do the science that leads to the things like the vaccine that you mentioned in the introduction that was just mentioned by the dean in the introduction. That is what i focus on. When you hear those things in the newspapers, many people think i get shook back and forth by that. To be honest with you, i dont. Adi let me followup a little bit on that. If people thought that the programsaw that the program we were going to be future, they great, i love fauci, those people would be democrats. Independent said you are the only person serving under president from whose Approval Ratings have gone up and not down. On a serious note, you and your family have at threats against her life because you defended signs of defending the white house. How did science become so politicized . Dr. Fauci that is an important question, but also sad that you have to ask that question, because that is what we have seen a lot in the United States, but not just restricted to the United States, because we are also seeing it with my colleagues in the u. K. And in europe and in other regions of the world. I dont think there is a simple explanation for it, but i think there has been an antiauthority component to this. People dontax, like to be told to be vaccinated. Scientists are often perceived as authoritarian. They made that perception themselves by the way they act also i think we can improve on that. But right now it has been just lumped into the politics of what is going on. We live in a divisive society, and even if we didnt have a pandemic, it would be a divisive society, and the fact that we do have a pandemic and a pandemic is a Public Health issue and Public Health is intimately related to science, that all of a sudden science gets caught in a lot of this divisiveness. That is unfortunate. What we as the scientists hope i know my colleague francis colleague feels the same way this,hen we get past science will resume its rightful place in being something that is for everyone without divisions. Adi when we get past this, meaning covid19 . Dr. Fauci covid19. When we get out of the charged nature of the stress and strain put upon us by an outbreak, people will realize the importance of science. Adi lets talk about where we are now. It has been a terrifying spike in a new cases, hospitalizations, deaths. As you look at this and the spread of this thing, where are we in the cycle . Dr. Fauci data speaks for itself. We are in a very difficult situation. It is quite problematic. I have said that many times not to scare people, but to bring a reality check to where we are. If you look at it, we have 10 million infections in the United States, almost 250,000 deaths. We have had 60,000 hospitalizations. 100 for count we had the 3000 infections in a single day. 00en i tested 143,0 infections in a single day. When i testified before when gas,i saidbefore congress, people thought i was being hyperbolic. Now look what is happening. That is the bad news. I think think urging news people need to understandthe encouraging news that people need to understand, Public Health measures not knocked out of the country, but Public Health measures that are simple and easy to understand, the universal wearing, physical distancing, avoiding crowded places, outdoors better than indoors, washing hands, it sounds simple in the context of this ominous outbreak, but it can turn it around, and that is what we need to do. Adi to be at this level of this new spike, is that just a lethal pandemic working its way through the country, through the world, or are we doing something historically wrong to be at that place again . Dr. Fauci i wouldnt say it is horribly wrong. I think what we have not done, and it is not just the United States if you look at what is going on in europe and the u. K. Now, they are in many respect in the same boat as we are with major surges. But when you look at what happened in our own country, we did not act in a unified way. I always say one of the wonderful things about our country that i love so much is that we are the United States of america, and we are a federalist country and we have states that are independent and they have in some respects important that they are that way. However, when you are dealing with an Infectious Disease, the Infectious Disease does not know the difference of the border between mississippi and louisiana, or between florida and georgia and south carolina. An Infectious Disease means the entire country. We did not approach it that way. We had too much individual approaches towards how we are going to handle the outbreak. Our baseline never came down to the local level that we wanted it to be, so when Community Spread came in as we try to to open the country, it just soared right out. It is a selfpropagating issue because the more Community Spread we get, the more difficult it is to contain it by identification, isolation, and contact tracing, because there is so much of it going on that it becomes very difficult. That is the problem we are in right now. We have an enormous amount of Community Spread. Adi so if your model was telling you a while back that it would be 100,000 cases a day, what is it telling you now . Do you look forward to the winter, cold weather . Dr. Fauci models are as good as the assumption we put into the model. I have been one to challenge models not challenge the validity of the modeling process, but to challenge the assumptions that are put into it. If we all literally pushed together as a group and did it in a uniform way, we do not necessarily need to see the 1000 day. 00 desperate we dont need to see the 140,000 infections per day. We can turn it around. If we stay the way we are, you do the civil math. 1000 deaths a day can 140,000 cases a day. You multiply it by 31 days in december, two weeks left in november. By the time you get to january 1, we have a really bad situation. So what i am saying as a Public Health official, and as my colleagues say, we dont need to accept that. I want to make one point that is important. I know you will get to it in the questions. But one of the things about a vaccine which is really important not only in and of itself as being a tool that is essential to end this outbreak. When people know that help is on the way and what i mean by help is on the way is we will start giving vaccines in december, and then as we get into january, february, march, we get the privatization of the people who need prioritization of the people who need it the most that there is light at the end of the tunnel, i hope we can get over what we call covid fatigue, where people are so exhausted with the Public Health measures that they really feel like they want to either give up and say lets do what you want to do, which is not the time to do that now. Now we need to double down on the Public Health measures as we are waiting for the vaccine to come and help us out. Adi there is covid fatigue and there is covid resistance, or resistance to taking the measures you are talking about. In your mind, is there hearted data, hard evidence that these behaviors you call reckless big political rallies where people are not wearing masks, motorcycle rallies, whatever is there clear data that those have led to outbreaks . Dr. Fauci i think it is pretty clear when you see congregate settings where people are gathered indoors without a mask, there is no doubt that we have seen that with the sturgis rally, number of other situations. We have seen it in clearcut examples of people getting together in a congregate away, particularly indoor, where you trace after that, there is clear outbreaks. Adi you talk about vaccines. Lets talk about vaccines. Dr. Fauci talk about vaccines. Adi pfizer caught our attention with its announcement recently of 90 efficacy for its trial. There are a lot of tests. You said you thought there would be a vaccine rolled out in december. Talk to me about what you are excited about and specifically what you are seeing. Dr. Fauci if you look at Infectious Diseases in general, what you need to get society projected, you need a certain number of people who are protected because they are immune to the virus. There are a couple of ways to do that. One way is very painful, that everybody gets infected. That leads to a lot of deaths. That is an unacceptable way to get this fire is under control. The other way is to have a highly effective vaccine that the vast majority of the population takes. Have ather words, if you 50 , 60 effective vaccine, even if the majority take it, there is a large segment of the population that is not immune. But we are fortunate, because the first one out of the gate is more than 90 , probably close to 95 effective. What we are hoping is that those who have vaccine hesitancy, who are skeptical about a vaccine, will see that the efficacy of this is so high that they may change their mind about wanting to get vaccinated. The other part of the good news is that there are other vaccines, some that are almost identical, such as the moderna product, which will be evaluated in the next week to a few days, that we anticipate, though you never want to get ahead of yourself, that it will be as good or close to that. That is the case, we have two of them. Whatthe capability science has done in an unprecedented way if this were 15 or 20 years ago, it would have taken a few years to get to where we are now. The idea that you went from a recognition of the virus on july 9 with the sequence to a phase 60someoddterally days later to a phase three trial a few months later to a vaccine that will be getting to peoples month is extraordinarygetting to peoples month is extraordinary. I have been doing this for 40 years, and this is really extraordinary. Is,as extraordinary as it what we dont want people to do is to say, oh, we have a vaccine out, we are done. We are not done. We still need to implement Public Health measures in a very intense way. Adi but when you say the vaccine will be rolled out in december, that means frontline workers, people at risk . Dr. Fauci the standard thing that happens when you have a vaccine that is not readily available to everyone at once is you privatization. Oft is the responsibility the centers for Disease Control and prevention, the cdc. They rely heavily on an Advisory Committee on immunization practices, acip. The cdc makes the ultimate this year we complemented that by asking the National Academy of medicine to also weigh in. Im not going to get ahead of their decision, but likely it will be frontline workers like healthcare workers who are taking care of individuals, people who have underlying conditions that make them susceptible to a severe outcome were they to get infected, people in nursing homes, people with underlying conditions for in schools,ldren adults, teachers and schools, fundamental people who are responsible for making society run in an orderly way. That is the kind of prioritize asian you get. We hope by the time we get into the Second Quarter of 2021, we will have enough vaccine that we will progressively vaccinate people so that when we get to april, may, june, we will get people in the general population is starting to get vaccines. Adi so i guide like me who is not a particularly highrisk level . Dr. Fauci probably by the end of the First Quarter or end of the Second Quarter. Adi so the people who said they probably will not take the vaccine that number has increased rather than decrease in the past six months or so for the people who are resistant because they dont trust what anybody saying, you talked about that, showing the early efficacy but the people who just say, i dont want to take a vaccine, i dont want anybody to tell me to take a vaccine, how do we move the needle on that . Dr. Fauci you have to continually outreach them and do what we Call Community engagement. There will be a core of people who will not take a vaccine matter what you do. I dont think you should give up on them, but i dont think you should necessarily expect. But there was a larger group of people who probably just have misinformation and dont understand the process. And what we have been trying to and myself, dr. Collins, others we have been trying to explain clearly what the process is of making a decision that a vaccine is safe and effective. It is an orderly process, it is done by independent groups that have no allegiance to an administration or a company or to anyone. They make that decision. They look at the data and determine, is it safe and effective. Then there are letters of Advisory Committees, the career scientists at the fda that i trust, the scientist like myself and dr. Collins who will be looking at the data. There will be a very transparent process. I dont think people who are vax fully appreciate how transparent the processes. They think there is something hidden and people are trying to put something over on them. We need to reach out to them and make them realize that is not the case, and it is to their benefit and the benefit of society to get vaccinated. Adi so if 50 of the publishing maybe not that many, but a large chunk of people do not take the vaccination how does that play out . What does that mean for me if dr. Fauci i think that would be quite problematic, and it would not be good for the country in general, because if you really want to essentially crush, that word they use, an outbreak, to get the level of transmission so low that it is no longer a Public Health problem, if you have 50 of the people who dont get vaccinated, there is a lot of infection that is going to be going around the community. If you get a 90, 90 5 effective vaccine, and 80 of the population get vaccinated, you have an umbrella of protection already that the virus has no place to go. It would be looking for Vulnerable People and not finding it. That is when it goes way down and it is no longer a threat. If 50 of the people dont want to get vaccinated, it is going to take quite a while to get to that point. Adi so, covid19 seems to be mutating in concerning ways. Is there anything that we do not know yet about covid19, a mystery that, i dont know, either continues to surprise you or we need to unlock . Dr. Fauci yeah, let me count the ways. [laughter] dr. Fauci there is a lot we dont know, and we have to be humble that we have learned an extraordinary amount in the last 10 months, but there is a lot we do not know. That is the reason why the study, the cohorts, the research we are doing is going to be going on for quite a while even after we have the outbreak under control. Adi we solicited questions from viewers, and a lot of them more i have had covid, am i safe, for myself and anybody else. I have the antibodies, am i safe . Dr. Fauci at this point in time we dont know the durability of infection. If you get infected any recovery, it is likely that for a finite period of time you are protected. You have seen that is the case for that we have seen specific instances of reinfection, people who got infected, recovered, and got infected with another sars cov 2. We dont know how extensive that is going to be. In athough antibodies are lot of people who recover come we dont know what is related to production and how long that lasts. We dont want to scare people to think, oh my god, i got infected and i will get infected again. Unlikely. But what we have a lot to learn is what the durability of protection is. The one thing i can say as an Infectious Disease person is it is very unlikely it will be like measles. I got infected by measles as a child. Im sure you did also. The fact is you are protected essentially for life. It likely is not of that magnitude, because what we know about the common cold coronavirus is that keep reinfection people. We feel lik that it is measuredn several months to a year or more, but it doesnt look like it is going to be 20, 30 years. Which means people need to get vaccinated even if they have been infected before, which we think is going to happen, and it is conceivable but not absolute that you may need to boost people every once in a while after the vaccine, which is fine. We, so, more generally, are and by that i mean the planet, more susceptible this seems like a onceinalifetime occurrence, but is it . Should we be braced for more . Dr. Fauci no, they will continue as ive said, pandemic outbreaks over history have occurred before even recorded history, before understanding what a pathogen is. They have occurred in our own lifetime. Within the memory of some people, 1918 was a disaster for the world with the flu pandemic. You have seen outbreaks, some of which have been trivial, some of which have had a major impact. Right now this is the most serious outbreak that we have had in this planet in 102 years. Will it happen again . Yes. Will it happen 10, 15, 20 years from now . We dont know. The thing about outbreaks are they are unpredictable. As scientists come we cite you likely cannot prevent the emergence of a new microbe, but you can prevent that emergence from becoming a catastrophic pandemic. That is what we mean by pandemic preparedness, to prevent the inevitable emergence of microbes. As long as we have an interface 75 ofe animal world, all the new pathogens that emerged have jumped from an animal species to a human they were zoonotic and they jumped to a human. That will continue to happen. The question and the challenge for us is are we prepared enough so it doesnt become a catastrophic outbreak. Adi so we didnt do very well this time. Dr. Fauci no, we didnt. Adi how do we avoid or mitigate the next want . Dr. Fauci there are a number of things we can do. We have got to think globally. Pandemics are global, so we have to pull together globally. There is a thing called the Global HealthSecurity Network or agenda that was established several years ago. We need to strengthen that. We need to strengthen our international collaborations. We need to have people speaking to each other. It has got to be open and transparent. When you do that, you can detect it early and respond early. Scientific approaches, technologies, are going to allow us to do what we did with this outbreak and rapidly make a vaccine. We can do even better than that, but you cant do science alone. It has got to be Public Health and classic science. Adi so, are there countries there are countries that seem to be doing well. Are there countries that hold up as models for a pretty good response to this . Dr. Fauci you know, the answer is yes, but right now it seems like every country is suffering. We are often compared with countries that are not comparable to us. We are not a Little Island of 5 Million People that we can shut off. We are not a country that would accept if a ruler tells us you must do this. I was talking with our u. K. Colleagues just today who were saying the u. K. Is similar to where we are now in outbreak because each of our countries have an independent spirit, we dont want to be told what to do. Well, i understand that, but now is the time to do what you are told. [laughter] dr. Fauci and i think it really is something we should be doing right now. Adi what you are talking about is walking a fine line between lockdown at one extreme and open activity on the other extreme. A professional medical person probably err on the side of caution and health. If you are the president elect, how would you balance those two priorities . Dr. Fauci i believe you have to be sensitive to distress and restraint of lockdowns. The economic and psychological consequences. I do not believe at this point that we do need to lock down. We have to leave that on the table. We are not going to just push it off the table. I dont think we need to do it, because my experience is that when you as a group, as a nation, implement the Public Health measures i mentioned to you, we can turn this around without locking the country down. Adi so you have answered the question im about to ask a million times, but it is useful for people tuning into here there are those who think that the herd immunity strategy is a good strategy. Dr. Fauci no, it is not. It just is not. I dont want to disrespect any of those who feel that way from that is their opinion, but it is just not the case. 25 will sayow, come of the people of this country combat got hit badly in new york are immune. 10 of the country as a whole. The cdc did a very good study and said 10 of the people in have gotten infected and are therefore protected. To 250,000,000 deaths and 10 million infections. You were not going to get to herd immunity until you get to 70 or so percent. Now, if you want to go from 10 to 70, multiply that by seven and look at the number of people who will have to have died to get to natural herd immunity. It is not feasible and it is not acceptable. Adi i read a lot about people who feel that they are suffering longterm effects, survivors of covid19 you are having secondary longterm effects, fogginess and other things. What is the medical view on that . A realci it is phenomenon. We are as we speak this afternoon it was about 3 30, callis, we had a phone about trying to investigate that. It is a phenomenon where people clear to the virus, but for variable periods of time. We dont know the percentage, whether it is 2225 of people, have symptoms that are bothersome to their functions shortness of breath, muscle aches, inability to control temperatures, what they call brain fog, which means a real difficulty in concentrating or focusing. It sometimes can be incapacitating to people. We need to figure out what that is and what we can to about it. So we are doing a very big look at what we can do, and it will likely be some very large studies. Adi another study that seems peful was a ho nasal spray that seems to block infections. I think it was tested on ferrets. Is that something you are taking seriously . Dr. Fauci oh, of course. Whenever you have a study that looks favorable in an animal, you are almost obliged in many respects to go ahead and carefully do a phase one study in the human anaphase two,and that and a phase two and a full efficacy study. We are going to be studying that, but we need to warn people that often we find that things look really promising in an animal, but it doesnt hold out in a human. Adi again, the questions we received from viewers before we started this, some of them were very personal. Everyones experience either with covid or fear of contracting it is very personal. People have moving and personal stories. I know you talk about this a lot, but people would love to know what do they do at thanksgiving . You talked about what you will do and wont do. Any general advice you can give . Dr. Fauci yeah, i think every family unit needs to do a Risk Assessment and a riskbenefit ratio. If you have people in your family who are elderly or have underlying conditions that make them susceptible to severe outcomes, you have got to make a decision. Do you want people to travel and spend time in a crowded airport and get on a plane and maybe not have time for quarantining after they get here, or not have the ability or understanding how they can get a test quickly enough . You may want to make a decision that you are just going to whenever i say that, i am the grinch that stole thanksgiving. Im not saying that. I am saying that Everyone Needs to seriously think about the riskbenefit. You might say that i had a wonderful thanksgiving last year and im looking forward to a wonderful thanksgiving next year. Maybe right now is not the time to have 25 people in a house when you take your mask off as you are eating. Adi we have time for a couple more questions. You mentioned it is the most serious pandemic we have faced in over 100 years, and we go back to 1918. Looking back at that, im sure you have looked a lot at that, is there something to learn from that and how it plays out and whether we go path a, path b, and there is a good path and bad path . Looking at 1918, what do we need to do . Dr. Fauci we know from historical little anecdotes that became studies that when people took seriously the kinds of things that im talking about, wearing masks, physical preparations, they did much better in cities that did that then in those that just set the heck with it come we will do what we want to do for the history is kind of repeating itself 102 years later. Youst question started to talk about this in the beginning, but you have worked for many president s and many years. What keeps you in this game . It is not like you just get adulation. You get a lot of grief. Again, you have bodyguards. Choose theeach of us path we want to take in our lives. I have chosen Public Service in the context of medicine and science. There is nothing more exciting to me than that, or more challenging. It totally energizes me. So when people talk about my age and how long ive been doing it, it almost seems like ive only been doing it a short time and i have a long way to go. Adi i want to thank you very much for your work and being here tonight. Dr. Fauci thank you. Thank you for having me. [applause] amy good evening. I am amy ignatius, and happy to be able to continue the extremelyon with two explaini g knowledgeable people. These are long days for you, and we appreciate your willingness to keep on working a few extra hours and share with us and continue the conversation that adi and dr. Fauci began. I also want to say, thinking about somebody who is dear to all of us who has recently left, our treasure to Justice Ginsburg once said, i am a very strong believer in listening and learning from others. The ignatius program was created for that very purpose, to listen and to learn. It is a great pleasure to be able to work with the two of you to continue that conversation. You have such expertise, each of you come in such difficult times. Lets get right to it. There is so much to talk about, we could spend all night. I wont make you do that, dont worry. President elect biden has created a new task force, and he , to beed you, dr. Borio on the task force. I dont know if you are allowed to say much about what your mission is going to be and what your role is going to be and whether it has started its work or not, but what can you tell us about the task force . Dr. Borio sure. The president elect made very clear that he wants to be ready on the first day to begin to establish programs to counter this horrific pandemic come that he is going to work very closely with state and local officials, the American Public, to turn around the explosive numbers we are seeing, because we need to be able to reopen schools and businesses in a safe and sustainable way. We do want to go back to our way of life, and that is the work ahead. The task force has met, and it is going to meet regularly to advise the president elect, the Vice President elect, and his transition teams that are working very hard to get the Administration Ready to govern in january. Judge ignatius dr. Collins, you as head of all of the institutes of health, are you able to quit and aid your efforts with the task force . Coordinate your efforts with the task force . How does that work with you in the next couple months . Dr. Collins the good news is the quota nation, the ability to Work Together on this Public Health crisis, is truly amazing. Nih, i have ar of lot of opportunities to steer people and coordinated functions, and it has been phenomenal to see the way people have decided to drop everything and Work Together. Back in march, we had a few initial discussions, and ingest weekseks in just two put together the largest Publicprivate Partnership on Infectious Disease ever assembled. Active accelerating covid19 therapeutic interventions and vaccines. It is half industry people and have nih and academic it is fda, cdc, the veterans administration, the department of defense, managed by the foundation for nih with extremely high levels of skill. That has done something in just a few months that i didnt think was possible. We have been partnerships like this before. Usually they take about two years and at least 39 lawyers to sign off on everything. This just got done. People actually were willing to drop everything and put the rest of whatever they were doing aside and work 247, designed master protocols where we could test therapeutic agents, prioritized therapeutic agents and pick the ones most likely to have some promise, figure out how to do these Clinical Trials networks outd the there had never really been organized, and all of that in the space of just a few months. Where we are now with vaccines and therapeutics and antibodies causing a lot of excitement as treatment for people who are infected and might be able to be kept at the hospital with this in event kept out of the hospital with this intervention, that is exhilarating. I get to work with people like dr. Fauci, the leader of this effort, but other people joining from nih in making this their passion. It is remarkable. The science has been breathtaking. Judge ignatius it is interesting that you described this tremendous coordination, because from the publics perspective, all we know is what we are seeing on the news and reading the paper it felt disjointed with multiple different speakers and people in charge and different committees and policy groups. It has not felt like a coordinated effort. I dont want to put you on the spot for any of that, but it is gratifying to hear that on the site you see of scientists working with both Public Private and government providers, that there has been a tremendous coordinated effort. Dr. Collins you heard some of the same words from tony, that the science has been zeroed in with great affected misand moving at a pace you have never seen before. There is a lot of noise under all of this, and what comes across on the evening news has more noise than science, and we would love to see that ratio change a little bit. Maybe now that we are starting to see these kinds of results with vaccines that have 90 plus efficacy, that will start to be more of the news that people are anxious to hear. Lets be clear, this is be clear, this is a very polarized time in our country and other countries is welcome and that tends to make the news, that people dont agree with each other. The fact that you have an advanced scientifically, welcome thats nice, but not what people are fretting about. We have her own issues in terms of the way information gets shared. Scientists could do a better job of portraying what we do to make it more digestible and less offputting and jargonladen. We need to work on that as well. Judge ignatius dr. Borio, a moment ago you said one of the things the task force will be looking at is not a full lockdown, but the right kinds of controls to get us back on track. Can you tell us more about what you are thinking, almost a strategic decisionmaking about what to restrict and want to keep open . Dr. Borio well, i cant speak for the task force can we have just started to do our work, but dr. Fauci delineated issues on the Health Measures that are and we are able to contain the outbreak come in the absence of having to do lockdowns. In a lockdown, a lot of measures are curtailed because they dont offer an advantage to contain the epidemic. The American Public is tired and they are confused about what really needs to be done. Communications has not been science has been very consistent, but we have not seen our price the government consistent, clear recommendations. It is natural for people to be tired and fatigued and confused about the best course of action for them. The measures again, it is about clear, consistent communication, people understand what measures they can follow to help themselves, their families, their communities. We need to develop a much stronger strategy for how we use diagnostic tests and augment the use of diagnostic tests to think about how we amplified the Public Health workforce and do contact tracing. We need to increase the delivery of medical care and capacity and access to care. We have seen Health Disparities has been a significant, very sad story for us, to see the increased number of cases and morbidity associated with people of color and low socioeconomic status. That is a very disturbing number, and we need to turn this around for the American Public for the the work ahead there was a lot of work ahead, but im confident that working together we can work with the science response and the other domains of a comprehensive response. Judge ignatius there is so much to follow up on they are, i dont know where to begin. Seems like one of the most critical questions is to deal with the disproportionate impact we have seen on people of color and people of low income in this country. And im sure there is other globally, other targeted communities that are harder hit than others. As we think about treatment and vaccines, how do we target people in a way that makes them want to embrace early used a vaccines use of because it is out of caring and not to assume they are being experimented on . People say i will take the vaccine after we have had plenty of time to see how it works, but i will not be the one early on. To be targeted with a vaccine may be the last thing certain people want. Dr. Collins . Dr. Collins it is a really important question and something that is occupied a lot of us the last few months. Now that these trials for vaccines are underway, do you just want to put them in Young Healthy white people . No, you want to find out if they work in vulnerable groups, people over 65, african americans, latinx, native americans who have shouldered an undue amount of the burden. This happens at the moment that you are pointing out in your question where there is distrust about whether medical researchers really have the best interest of those minority communities at heart. The first thing that often comes up in the conversation is tuskegee. We have this long and really unfortunate history of how medical research has not always behaved ethically when it came to underrepresented groups. We have to get out there and explain that an up lodge ice for that. Presentapologize for that command try to make the case that this is not like that. This is one of those things where we are not targeting. We want to be inclusive. We want to be able to offer the opportunity to be in these trials so we can find out, does this work for all the people who might need it the most. I can tell you, having me as the head of the nih say that, doesnt help that much. What helps is engaging the communities, finding out who are the spokespersons in those communities who are trusted and who can look at the evidence and say we should be part of this. We are doing a lot of that right now. The madrona vaccine that dr. Fauci mentioned, which you will be hearing news about in the next few days it seems like they are getting to the same point of finding out what the efficacy is we worked really hard with the leaders of that company to take what was going to be a pretty unimpressive diversity of enrollment, and by pushing hard and bringing on called whole Group Community engagement alliance, we were able, more than 10 were africanamericans, more than 20 were latinx, a total of 37 of people in that group were people of color. It could be better, but that is so much better than what it was. We learned a lot of lessons from that. Tony was a big part of that with me. We can apply that more broadly in other examples like this to turn the corner so that we are not talking tests key is the only exampletuskegee as the only example, so people can point to that and say that time they did it right. Dr. Borio these trials that are being done are the gold standard. Veryoffer really highquality data about the vaccine safety and effectiveness. But it is Still Limited information. It is going to be really important after these trials are completed and as these vaccines are rolled out to a larger segment of the population to continually monitor for their communications, trust can be built on strong data. And to continue to look for safety signals, how the backseat is performing all the vaccine is performing across different operations, is critical. The work doesnt end once the files are completed. Judge ignatius but if you have worked through ebola and the response to that. How transferable is the social signs aspects of that, how to prepare for people to be willing to be vaccinated, how to get into a community that might be skeptical worldwide, in order to make it as effective as possible . Is each one of these events so different from the other that it is hard to translate from one to another . Dr. Collins ebola never became a major threat to the United States, despite the intense population anxiety about it. We didnt have the experience of seeing if people would be willing to roll up their sleeves for the vaccines. The vaccinations were done where the disease was happening in west africa. Im not sure we learned about the social science, but we did learn about other things. Monochrome will antibodies that are showing promise for covid19, similar approach for ebola, and a very challenging trial that was done essentially in a war zone showed that those antibodies could be lifesaving, and gave additional confidence to the idea that this could work for other Infectious Disease. When it comes to the socialscience part in our own country, you have to look at other examples, and there is nothing quite like what we are looking at now in terms of something that is so devastating, as tony said, the most horrible pandemic we have had in 102 years, and all the public attention that comes with it. It is harder to extrapolate. We can look at the fact that there has been growing, in some vaccine, a hesitancy. This has given an opportunity for those anxieties to expand, and social media has been great at promoting conspiracy theories that have added to that. I dont know if you have looked at conspiracy theories on social media, some of them are really creative. There are people i have talked to who said im not going to take the vaccine because bill gates put a chip in it and that has wired my brain. , people, lets look at what is really happening. I am hopeful, as tony articulated, that when people have the date in front of them, look at the data, tell me why would you not want to take advantage of something that might protect you and your family and other people you love from a terrible disease. If you have a good answer to that, thats good, lets hear the answer, but lets not have it be because bill gates has put a chip in it. Judge ignatius you brought a wonderful little show until peace. You want to tell us show andtell piece. You want to tell us we have been talking about the coronavirus for 10 months, and we dont know what were talking about, most of us. Dr. Collins this is what it looks like, this coronavirus. But it spherical virus, has the suspect proteins on the surface. They enable the virus to get inside your cell. They find a match in the protein in your cell. That led to jump into the cell and start copying itself like crazy. What you want to do in terms of developing a vaccine, you want to get a way for your immune system to make antibodies that attach to those spikes like chewing gum and keep them from getting into your cells. All of the vaccines are trying to make antibodies against the spikes. This is a fancy version where the spikes have two different colors because they have an open and closed configuration. But basically it is those spikes proteins that we are trying to immunize against, and it looks like it is working pretty well with the first one or two out of the gate. There are six that are in the works. Dachshund there are six in the works. Not only warp speed is helping trials, but manufacturing. Imagine if we did not do that, we ran the trial and had a big announcement, guess what . We have a great vaccine, but we have to work to build a factory to make enough doses. That is not happening. Warp speed is doing at risk manufacturing, making tens of millions of doses even before you know if that vaccine will work. If it does not, you throw them out. If it does, you are ready to go, which we hope to be in december. We have saved many lives by that investment. It is one of the things we have done in this country that has never been done before. I want to switch gears because you come to this with both experience in working in the obama and Trump Administration, but also your focus has been not so much on pandemics as Health Crises they are Health Crises, but coming at it from the perspective of bioterrorism threat to our country and to the world. A very different type of focus. Tell us a little bit about that. Assess a biological agent like this, and how does the response differ when you think of it from a Security Point of view as opposed to a Health Crisis . Fundamentally, it is a health issue. On a time i was working document, the effort was with the eye to the patient at the hospital. What would make a difference at the bedside and what can we do to prevent them from getting to that point . It is a health issue. The strategy published in 2018 made it clear. Biological threats, we are agnostic to the cause of the threat. Fundamentally Health Issues can have disruptive powers to our economy, the fabric of our society, confidence and political systems. A lot of other impacts, but fundamentally a health issue. Perhaps, one of the most , it createsactors other geopolitical risks because we are talking about somebody deliberately developing and using a weapon to cause harm to the health of a population. Were is that layer, but cannot let that distract from the fact that at the end of the day, it is about saving lives. Judge ignatius i think of the early stages, as we were grappling with what this was, involves conversation about whether this was an intentional release in order to harm other countries, was it an accidental itease, was it bad luck, jumped from animal to human, was it created in a lab . It has gotten in the way of the publics understanding of what was going on for many months. Maybe for some, having an inability to trust the information. Dr. Borio ultimately, we cannot let that distract us from the work that needs to be done to develop a response and work on Health Measures. At the end of the day, we have to focus on the patient and how to prevent them from getting there. How do we prevent that, minimize morbidity and mortality . Where theree a time will be looks to see if there was any possibility, something we never really know. Most scientist think this was accidental. It has been ruled out this was a deliberate issue, but you never know. It does not matter, at the end of the day. Shows say that it really how important it is for us to be ready to address these biological threats because this is not going to be the last epidemic. We hope it does not grow to be this significant in the future, but it wont. The way we behave and approach animal habitats, there is urbanization, population density. Easier for there to be crossover viruses from animals to humans and we need to be always vigilant. Forward weing continue to apply more technology and strengthen our just drug to end, not discovery and medical response, but the forecast, predict and do surveillance more effectively. President trump withdrew us from the World Health Organization and president elect biden says he wants to put us back into it again. What is the practical effect of that . Will that be useful on what you describe as being ready to go when something does become apparent . Is it coordination of data, research . To the public, i do not know what it means. It sounds like a good idea, but i do not know why. It is very important to all this response. Thingllins it is a good that Infectious Disease research has been international for many decades. Even with the tensions with the a fair it is fair to say amount of International Exchange has been going on. We interact with the staff at the w. H. O. Almost every day. There has been a severe downturn in attention to this, but this is a time when we need international attention. It will be interesting to see what happens next. Thatorio an epidemic happens overseas matters to us because we want to prevent it from coming here. And also, because sometimes they impact areas of interest to our National Security or economic security. It really does matter. The w. H. O. , what people do not appreciate, they are on the ground, boots on the ground, to contain an epidemic. Americansicult for because of conflict. Zones and war zones essential in being leaders and to help coordinate the Global Response to these types of crisis. Judge ignatius are we Getting Better in our preparedness . Do you see an upward trajectory of improved response capability, yeartoyear . Dr. Collins you should answer. I know you are on this council of foreign relations. Job, aio my fulltime nonfor profit in technologies. Our chief Technology Officer [indiscernible] we do more than technology. Our business is optimism. I thought that was good, because it is true. The future is brighter. It is remarkable what has happened the past few months with the diagnostic space, for example, thanks a lot to your efforts in bringing it to where it is. Where wecan talk with are today with diagnostics. Dr. Collins we all could agree if we could snap our fingers and have a homebased test you could take every morning and find out whether you have gotten infected, in which case you should not be going to work, that would be fantastic. My thought experiments, suppose it is on your toothbrush and you just find out as soon as you get your day started. We are not quite there yet. We had a focus until recently were testing is for people with symptoms, and we need that and are pretty good at that now, but what we really need is testing for people who do not have symptoms because that is where Community Spread is happening. That is what colleges need to keep their students and faculty safe and keep classrooms going. A wholere developing lot of new technologies that are like that, pointofcare. You do not have to do the swab and send it to a central lab and hope you get an answer in a day or two. You get the answer right there or in 30 minutes. At nih we have a program called rapid diagnostics. We set up a venturecapital system to look at epidemic, lab and Small Businesses that have really cool ideas about how to virus. D detection of the in that short time we have that are technologies about to get to the point of 3 million tests a day, more than half of which are pointofcare and we are starting soon with inhome testing because that is where we want to get. This is an example about how this has lit a fire under what would have been technologies that would have happened over a few years, but have happened over a few months. That will have spinoffs for other applications and that is my hope of what we can push hard the testing situation where it needs to be so as we are waiting for the vaccines become available to everybody and we are still dealing with this winter season, we have a better chance of capturing the pandemic before it gets even worse. Judge ignatius it is an amazing period of time. The anxiety people are demonstrating is so extreme. The press covers a lot of people who are resist resistant. We asked questions of people. Overs remarkable to me, 100 questions came in and many uncertaintygenuine about what to do, what to do for thanksgiving is one example. But much more than that. They have a child with a preexisting condition and should they send them back to school . They want to visit their aged aunt before they die and they are afraid to do it. They have been planning on a trip for the past two years. To read howof sad many people were really troubled and wondered, where do you go for good, reliable, unbiased information . Is there a place the government is collecting that information . Does nih do that . Is that something the task force is thinking about to help people be smart about decisionmaking . Dr. Collins that is really a job for the cdc. If you go to their website, there is lots of information people can sift through. They are not the only place offering this up. Dr. Fauci is probably the source of this kind of information that most people have heard and depended on, and has always said it exactly like it should be said because these are the facts. The facts are changing, lets be clear about that. We are getting new information all the time. If people feel like, hey, they said Something Different than last time, it is probably because we have new information and the recommendation needed to change. I would say, start with cdc. Those in the middle of this are getting barraged by questions many times a day. They do not have easy answers. People who desperately want to get together for a holiday, maybe because they think it might be the last thanksgiving for the grandmother, and you will say, that is just not safe, that is a hard thing to hear. I get that. I will not have thanksgiving with my family this year because of people in the family who are at risk. I will miss that. The first time in 27 years there has not been a gathering of 30 or so people around the table. When you put the evidence together, we can get by this year without that. We can get through a serious, worldwide crisis and it will have an end. If we can appreciate there is a light, maybe that will allow us to redouble our efforts to get through in the meantime and come out to the point where we can finally say, that is in the rearview mirror. We are stronger as a result. We have a lot of work to do to pull ourselves back together again. We can do that. Dr. Borio i would second that. Judge ignatius part of your work in optimism . [laughter] questioners, which i thought was so interesting, you are a man of faith and of written about your faith, the question is, is there any data that shows that peoples outcomes are better if they have an important faith, whatever it might be, in their lives . Are you aware of research that would support that . Dr. Collins i dont know about covid19. That is a Good Research question someone should be pursuing, if you have not already. That is a good tip. Peoples evidence that who have a spiritual part of their daily life seem to have more resilience when it comes to Health Issues and other things. It is not a huge effect, but it is in their. 6, god isith psalm 4 our refuge and strength and presence in trouble. To have the sense that we are ouralone, that god is refuge and strength and will help us. Though it is up to us, you cannot just let it happen how it will happen. We have a lot of strength and capabilities, lets use those. But also, having confidence there is something more than you can see, that is a great source of comfort. Judge ignatius a great way to invite the dean back on to wrap things up. We could go on forever, but our time is limited. Thank you so much for your time, your wisdom, for all the work you are doing to advance our response and for keeping us safe. Thank you. 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