And more. Welcome to and the professors here and the director of the instituted the World Health Organization center on Global Health law. I am really delighted to introduce two amazing people, we are old friends, we worked together for so many years. I will be brief because he has to be back at the white house and run the covid response. Sitting next to me is julie, the former director of the center for Disease Control and prevention and has worked at the cdc in many capacities. She is currently the chief executive officer of the foundation for the National Institute of health. Ashish jha also needs no introduction. He was there when covid exploded in west africa, the head of the Harvard Aids Institute and at the school of Public Health and is now the white house coordinator of the covid 19 response. When im going to do is begin with a very big question and in the middle we will go into things that are important. Subvariants, therapeutic vaccines, funding. Let me start with this question. Somewhere near the beginning of the pandemic, marine doubt maureen dowd the New York Times said how long is this going to go on for . The comment was, i would have day history and normally it is a two to three year horizon. And people were shocked. Two or three years. While here we are. Let me just start with you and then go to julie. Where are we going to be a year from now . Entering another respiratory virus season, will we be getting another five jabs . Tell us a little about where we might be if we came back here. Dr. Jha thank you for letting me spend some time with you. That part, especially about the future, heres what we know. Think about where we were two winters ago. We were at a point where 4000 americans were dying every day. Last winter, still a challenge, better than where we were two years ago. And we expect this winter to have its challenges, but better than the winter before. The two questions, why is it Getting Better and why is it getting a little better . We are building up population immunity. There are two ways, through vaccines. One is a lot safer than the other. The virus is going to continue. We will have another respiratory season like we usually do. This is not fully seasonal like influenza. But we can talk about why it is becoming a little more. At some point it becomes one of the respiratory viruses we deal with. Not there yet. If we think about where we are, three to 400 americans dying every day, we are in a bit of a lull, this is still an normas amount of deaths. I expect that to get better still an enormous number of deaths. If we are doing the things we need to do we can continue driving this virus more into the background. Lawrence i will come back to that in terms of funding and if we will have the capabilities. Julie, i could ask you to expand on that. Or of vaccines that are there preventing transmission, which is been one of our weaknesses. What do you think some of the big lessons are that we have so far . We are into the third year of this pandemic and what degree what have we learned . What it thinks we should have learned . Julie thank you for having me. Last time i spoke at the Oneill Institute i think we were talking about hiv. Thats right. Julie thats right. There is so much conversation and so many of the if you think so gone really well and we can learn from those, too. In many cases, we achieve good local control thanks to the efforts of health care workers, employers who knew how to engage with their employees and get them to purchase a paid and even the free vaccines and pharmacologic interventions and so forth. That is Important Information because we do know how to bend the curve on hospitalization if we have to. That is Important Information for this, but it is Important Information that supports. The second has to be the countermeasure in diagnostic develop at. By the end of 20 20, there were more than 800 antivirals, antibodies and vaccines and stages of Clinical Development on a global basis. An unprecedented in the history. The whole pandemic would have been different if we have this for hiv. And team science which im learning more about, the ability for me, coming into a room where we have the Institute Directors of the nih sitting with the heads of the most important files Biopharmaceutical Company with the most productive academic researchers in the world, sitting around the table and thinking about how to accelerate, get regulatory pathways. It is just an amazing thing that has gone on behind the scenes. Other people dont really know the story of Antiviral Development but it is amazing. The third thing that is in my view gone really well is that in most parts of the world, to my surprise actually, we have been able to sustain essential services while there was chaos, terrible consequences to Small Businesses and families and the economic hardships that were experienced, our police, fire workers, groceries, most things in Society Still operated. That says something about our ability to be resilient. But the failures, i am not ever going to say that learning is not important. But i feel like im personally and professionally aborted with Lessons Learned from the pandemic. I will try to condense them in three big kids. One is a failure of information. Whether it is detection, disclosure, the ability to aggregate Population Health information, describe mortality or hospitalization, or to deliver credible information to citizens so they can make decisions. We have had a massive disconnect in our ability to get data, use it and trust in it. A second dimension of our failure really is of course equitable access. It is not just vaccines and antivirals. It is access to economic support, educational engagement, the community. Finally, it is what im probably most worried about is our ability to sustain a balanced response. Weve gone from total lockdown to laissezfaire and we need to make sure we can manage this as it waxes and wanes with a balanced and sensible, common sense approach. Lawrence so we need to be able to sustain our behaviors and we also need to build. I was at oxford recently talking about being trustworthy. But we do face challenges. I know you have been talking a lot about this ashish in terms of where this virus is going. Compared to ebola and other things we have been working on i have seen this. In terms of the development, the mutations, variant and subvariants, tell us where we are, what worries you and what we are doing about what worries you. Dr. Jha im trying to think of another time in history where you at this massive of an outbreak around the world and we were vaccinating billions of people at the same time. It has never happened. It creates all sorts of interesting dynamics. But most importantly it puts a tone of Evolutionary Pressure on the virus to evolve away from the immunity wall around the world. You get enough virus out there, you get the mutations and that is what we are seeing. We are seeing rapid evolution. A lot of virologists have described it as breathtaking how quickly the virus is evolving. I started my job about 6. 5 to seven months ago and at that point we were seeing the rise of ba. 2. We sought that falloff, that ba. 5, now we are seeing subvariants. I could bore you with alphabet soup all day. But it is amazing how much variation we are seeing. A couple of key things to understand. Our immunity is very robust and our ability, our t cell ability to identify and deal with these, especially if you have multiple vaccine doses or you have been vaccinated, it is quite robust. We are not heading to a period of time again where we are going to see three or 4000 deaths a day. Something extra ordinary would need to happen. That said, because of the rapid viral evolution, if we do not keep up, if we take it laissezfaire like i got vaccinated last year, i got infected in january, im good, we will see a significant wave of infection. Our job is keep up with the virus, updated vaccines. Keep up with the virus, updated treatments. And as julie said, one of the challenges of the pandemic has been information and good communication. Munich a clearly to the American People what they need to do to protect themselves. The virus is widely so is the community. It is not to be underestimated. Lawrence you have just started a campaign for the bivalent vaccine. Theyve got a different violent a different bivalent vaccine, which we have two address the original car. But now we are doing with something vaccine strategy, nursing if it is enough for nih and others to keep up with these. Where are we in relation to the virus, the vaccine, their ability to outmaneuver. Dr. Jha when people look back at what went wrong in the response, we talked about how federal agencies were not nimble enough or forwardlooking enough. Let me give an example of a federal agency that i think was incredibly forwardlooking and nimble. That is the fda at the turn of this year. Were lots of reasons to go with a bivalent vaccine. It is where the data was and there was a lot of pressure. The u. K. Did it. European countries did it. And the fda said nope, we are not going to look in the rearview mirror. Youre going to make sense of what is coming and we are going to make this one. It was bold. A lot of people were critical. It was the best decision i have seen in a long time. Because ba. 5 represents still 75 of infections out there. The one i am probably most worried about in terms of taking over the u. S. , but if you got a ba. 5 bivalent, the data shows a high degree of production. Even the one in singapore that is a problem, a little technical here, but the bottom line is these can be forwardlooking, can lean in and use scientific reasoning to pick a vaccine. It needs to have good durability for the fall and winter. The virus can throw a curveball. For bar lot for the majority of americans, this will be a shot you get now and you have to come back next fall. Lawrence that would be great. Maybe a nasal vaccine, Something Better in terms of transmission. Julie, you are a director and you arent close contact with the most amazing, the shining star of all federal agencies. It has had criticism. Tell us a little about where the cdc is going. Tell us a little bit about trust and trustworthiness, information. All of us know people that work at the cdc are just spectacular and get up every day to meet the needs of the American People. But the next director, what do you think . Dr. Gerberding the director of the cdc has a hard job. That is first. I guess i am not inside it. I have been very cautious about assuming i know something im not really part of seeing from the inside out. I can also give you a strong list of sisi and accomplish during the pandemic. But i do worry have to go back to the basics of what does an effective Public Health system and an effective cdc need to be accountable for. And we need to modernize for that approach. First and foremost we need to be focused on the frontlines. That is the local Public Health domain. It is not in atlanta or washington. Where Public Health is created happens in the communities with the people on the ground, the Health System on the ground, the trusted leaders locally. And across america that is a nice. It is a mess for a lot of reasons but we dont have the infrastructure, abilities, modernization, the data system, the workforce or leadership to have that part of our system be effective. Job one for the cdc is to focus on how do we strengthen that. What can we pay for, teach, what can we do to supply our people to the front line and shorted up . The second sure shore i p up . The second diagnostic testing was a mistake. That is in a much improved state but there are lots of opportunities to build the kind of Information Networks that we need. It is going to be expensive and it is going to take a long time to link Public Health with the Health System. Make it interoperable, timely, accurate and complete. At the same time, retain peoples privacy. It is going to be a heavy load but it is an important piece of the action. The last thing, you will be supposed to hear former cdc directors say this. There needs to be structural change in the way cdc is funded. We cannot have the famine feast or famine approach. People need to understand maybe there is a billion dollars coming in for outbreak x, but as soon as it is over the money goes away. We cannot hire people on onetime money. It is a systemic issue that congress is going to need to fix. Lawrence a segway. I want to add, we have talked in a while ago about congressional funding and you have been so checked in. This is no time to be complacent. Tell us, are we going to get the funding, both white house response, vaccine, therapeutic, cdc data systems . How optimistic are you . Dr. Jha it is an absolutely essential thing. You cant have Health Response against covid, monkeypox and all the things the cdc does without money. There is very good reason. There is data that investment in these things has massive payoffs from a social welfare and economic benefit point of view. If you think about vaccines and getting elderly people vaccinated, the number of hospitalizations it will prevent, it will save a ton of money for medicare and medicaid. We do it to save lives. But the point is, we continue to make that case to congress, this is not the time to walk away from this response and say we are all done. Weve got a lot more work to do. It has been a challenge and it has been interesting to me. Obviously for six months we have been making the case if we do not get more funding we would have a more difficult fall and winter. Our Vaccine Campaign funds are very limited. But has made it hard to get people vaccinated and run a real campaign. There are two key treatments we use. The monoclonal and the one for me to compromise, both are likely to go away depending on which subvariants that dominates, they potentially no longer work. Our medicine cabinet, which should be getting bigger as we go further along, is actually getting smaller. We can make that case to congress. I think over the longer run, congress will realize that not only is it really harmful to people, and is financially not very smart to underfund the Public Health response. But it is a challenge. And has been a challenge in a highly polarized time period where Public Health has gotten politicized anyway that is disturbing and alternately harmful for the American People. Lawrence and is an important point. I want to pivot to international. Julie mentioned equity. If you think about in the United States, equity drivers and the white house has a great team looking at equity and race, things like that. Globally, there are a few exciting things happening. The Sustainable Finance was dead in the water after the executive committee in january. The usga that bailed us out. So the u. S. Has really become a leader in this. The other things are the reforms that the International Health regulations, which the u. S. Has been the team driver on that on u. S. Representative on the ihr you Committee Meeting that is meeting in geneva. So reflect on that and the end of the pandemic. Opinions are pushing for it very hard. Maybe just i will ask the first one and you can ask each other questions. Where are we internationally with equity, Global Governance and to try to build up Global Response. At the end of the day, we are only as strong as our weakest link. Dr. Gerberding i will let you start because you have been purchasing and there. Dr. Jha let me make a few highlights of the way we have been thinking about this. First, the president during the campaign, and carried out as president. The idea if you remember our last president , we walked out of w. H. O. That does not make any sense. You cant have a Global Response to a Global Pandemic and have the u. S. Not participate in it. It is bad for the world. It is bad for america. So the idea of u. S. Engagement and u. S. Leadership is deeply baked into everything. The u. S. Is obviously very involved in trying to get vaccines out in the world. We have done about 50 million doses. And we have really pushed hard, mostly through covax but some through our lateral so it is not like we are going into the country and releasing these mechanisms. Covax is very important. We have been a funder. It is not meant to be a celebration of look at the cool stuff we got. It is supposed to be an investment that we believe in multilateral, we believe in engaging. We are working on developing a program now to make sure as treatments have come online, they are now widely available and we want to make sure pieces treatments are available in other parts of the world. That work continues. Obviously the work of thinking about super future pandemic, the financing for the world bank, the fit is important. Lawrence intermediary. Dr. Jha financial intermediary, yes. There is one area where we excel. There is the intermediary fund, making sure that we are building up Global Manufacturing capacity. One thing we saw with much of the manufacturing capacity with vaccines was in south asia, europe, north america. But very little on the african continent. Many of us feel it is really important for future outbreaks, even managing Health Care Issues and responding, we have a capacity to distributed including because thursday brought agenda but if you what you have for the precedent of this administration, you have a president who cares about it and want somebody acting. Lawrence julie, you can talk about the equity side but another thing is these in these global governing issues of preventing, preparing a response and recovery, deep prevention, the one health approach, zoo not big spillovers, that is going to be really hard. And the microbial resistance. Talk a little about that i was just thinking about the role of the needed seats mode was also thinking about have really the w. H. O. It has the only mechanism that can bring the world together and yet it is weak, underfunded, political. It is a very challenging construct. Lawrence the overall budget is less than that of a large u. S. Teaching hospital. Dr. Gerberding yeah that is a long separate conversation. Five there is something magnificent when he calls for accountable treaty or similar instrument to improve pandemic preparedness. Something coherent with International Health regulations. These kinds of multilateral engagements are extremely rare and often not successful, but the commitment to building what we say euphemistically, i pandemic treaty, it is something we need to get serious about and thank you for your contributions and with kevin and larry, they have all been behind the scenes trying to understand how we can be helpful. But why would we need a treaty . One reason to make a treaty or convention of some sort is to make it invincible and built some accountability. But if you have a commitment and a set of expectations you can tell if somebody is not living up to their committed commitment or tradition. The committee needs to grapple with equity. It needs to go much deeper and a multisector way so we are not counting on the government to do this heavy lifting but we are bringing in the private sector and some of society because it is all of us involved in this and we learned how important this was. Everywhere in the world, this will coordinate with the pandemic response. This does create a platform for true collaboration and that needs to go beyond the w. H. O. And the Health Ministry of the countries involved because we just said one health. Other times we have talked about animal health. It is legal and and the legal and humanitarian connections. But coronaviruses are present in basically every animal at this one is now present in some dutch a number of animals. Muskrats, minks, it has spilled over into many species. It may be doing the same thing of those animals that it is doing in us, it is evolving. So then you get this phenomenon of spill back. That needs to be part of what is included in the pandemic agreement. We need to understand spillover or spill back at the white house connection. Right now there is minuscule investment and looking at the ultimate prevention and preemption of these problems. Lawrence it is a political uphill battle. Dr. Gerberding it is hard. Lawrence it is really hard. I will ask another question. We have talked a lot about this. You are a big thinker on these things. But it is not just covid. Right now we have got the monkeypox pandemic officially declared. Weve got ongoing covid19. Youve got ebola in uganda, a strain that is not acceptable susceptible to the vaccine. Polio in new york city and london and another declared. And it seems like these things are happening more and more. Maybe it is that way. Talk about disease x, the w. H. O. Would say, and what are we facing as a Global Community and the United States . What do you do about it . Dr. Jha the first part is about is it happening more often or are we paying attention. It is actually happening more often. If you look at the diseases, is not humans in the last 30 or 40 years, it includes the accelerated. The one Health Conversation most pathogens come from animals. They hang out in animals and spillover into humans, often because of greater context between humans and animals. So what is happening across the world . We are seeing a lot more environmental change. Deforestation, Economic Development which is generally a good thing, it lifts people out of poverty, and has a lot of Environmental Impact because you do it sustainably. Climate change and globalization. China in 2003 when sars one broke out, if you can. Two 2019 when sarscov2 broke out, Global Travel was about 25 or 30x. Once the disease breaks out in a highly globalized world, the ability to complete best to contain it is gone. It is way harder than it was. We are going to see more of these. The question is what we do about it . Obviously you want to build up surveillance capabilities globally. Want to build a Public Health capacities globally. And you want to build it on the global scale. Where this what is lucky about this, which is not lookee because the virus killed a lot of people, but we knew about sarscov2. We realized we had a close cousin and we had done scientific work on it. I dont want to understate the amazing accomplishments of building the vaccine when we did, but we got a head start with all the work that had gone on. What if we get a truly novel virus we dont know much about . That is a reality we have to plan for. We think there are a set of virus families likely to cause future large outbreaks. What should we be doing . We should be building platforms will restart understanding Vaccine Technology for each of those virus families, where we start developing therapeutic potential potentially for those so that when we get one of those we can get the head start again. But in general, we have to work on people talk about platforms. Building the capability so that whatever it is that Mother Nature throws at us, we are not starting from scratch. We can move more quickly. That does mean better surveillance. The rna platform ended up being a powerful part of that tool. And the ability to manufacture at scale. In 2021, such huge inequities in vaccine distribution, because some places could manufacture vaccines that others could not. The reason why right now anyone in the world can get access, we have plenty of vaccine, is because vaccine supply caught up with vaccine demand. We have got to work on building capabilities so we can take billions of doses in very short order for the next disease so we dont have a timeline. We can move quickly once we identify it. I was the president of merck vaccines for little bit of time so noah little bit about manufacturing. It is great to think about being able to turn on a dime and make liens of doses, but what are you going to do when you dont need that manufacturing capacity and youre sitting on idle capacity and nobody can afford that . We have to get real about how we think about, innovation in terms of how we approach the manufacturing of the vaccines or we have got to think about paying for the idle capacity so that we have it ready when we need it. Because it isnt possible to have that capability sitting around unused during the off years. It just does not work from an Economic Perspective for anyone, even a nonprofit could not do that. That is exactly right. Their plea of things we pay out of capacity for. Like military, we pay to make sure we have a ready military in case we need it. That is important. There are things we do. Fire fighters sitting around and we pay for that because it is absolutely essential service that if theres a fire, there is an emergency want them to go at full speed. This is not a new idea, we just have to think about how to apply it. The other part i often worry about in our conversations about Global Manufacturing and distribution come is this idea we dont want to build a bunch of plants planes and have them sitting around waiting. It is not just the money, it is the expertise, the capability. You have to be using those plans for building vaccines and therapeutics during peacetime and then know how to turn on a dime and shift to a wartime mode. Our military doesnt sit around. Theyre constantly training and doing things. When theyre called to action i am glad you brought in the military perspective because i think the middle model mental model is security is not about Public Health and softening the community level, security is National Security and we need to be approaching it with the same scale in mind, the same capability investment in mind, the same surge in idle capacity, if you will. But we just not approaching it that way yet. It sounds to me from what youre both saying, Public Private partnerships are really the future and also mrna Technology May make us a little more nimble in terms of these kinds of things. Let me just ask, from your merck background that Civil Society is asking, if we get that investment to the private sector, what do we get in return . What we do about calls from really broad calls from Doctors Without Borders and other really good organizations that are saying, what about ip waivers . The u. S. Has been a leader in that but not successful because our European Partners dont always buy into it. What about Technology Transfer . How do we think about this tripartite government, private sector, and people in Civil Society . What is the right balance . What is the future of how we govern these kinds of activities in making vaccines, everyday vaccines but also pandemicready vaccines . There are different domains of preparedness and countermeasures where this is going to make a lot of sense. For example, i can imagine ubiquitous access capacity developed diagnostics. We saw the global Funds Investment in hiv, tb, malaria labs to be converted into covid testing labs in a pretty fast period of time. That investment paid off. I think it is realistic we can make molecules in multiple places and probably monoclonals, although it is a bit tricky. The vaccines are a bit different. Even mrna vaccines. This is not something you can cook up in your bathtub. I know this because when i started working as a leader of merck vaccines come half of our products were not in the markets because of challenges in manufacturing and we saw that with the emergent plant could not produce the j j vaccine because it had its own manufacturing challenges. It is not for the fainthearted. The other thing i hesitate to bring up but i think it is important to remember, the major supplier of vaccines for covax in india, nationalize the vaccine supply from Serum Institute of india to india and they were not available like controls in europe and other places. We have to be realistic even if youre localizing, nationalization impetus may compel people to not respect those agreements. So we need pandemic treaty and other enforceable mechanisms to make sure we can do that. And we need a whole lot of scientists sharing. We really do. Sharing information. We only have a few minutes left. We have had the richest conversation, everything from funding and Lessons Learned, where we are going to be in the future, how the virus is evolving through to the International Equity covax, accelerator and other parts of that and the pandemic treaty. If there were just one or two things you would like everyone to take home to kind of understand about the challenges our, what the hopes, the opportunities are for humankind. Another big question, how would you some up . I go back to some of the things julie said. It is easy to look at this and think of the failures and plenty of things that have not gone well but there has been an extraordinary amount of things that have gone well. The ones i often begin with is the scientific endeavor. What science has produced in 2. 5 years is unbelievable stop the variety of vaccines, the variety of therapeutics, the variety of diagnostics, the knowledge about how this virus spreads. Incredible amounts of scientific progress. I actually think there have been some challenges with our Industry International institutions but i think, yes, covax has not been perfect but has done a lot of good stuff and think how quickly they came together, how hard what they tried to do was come to actually pull off come how many hundreds of millions not billions of doses they got out. Most of the doses in low in middle Income Countries came from covax. That is extraordinary. Covax did not exist three years ago and they have gotten billions of doses out to the low in middle Income Countries. One of the key things is to make sure we learn how that happened and how we make sure we can repeat those. One of the bigger challenges has been we have realized we live in a world where there are vastly different information landscapes , a lot of people everybody is in an information bubble where the information they get is different than what other people get. There is a ton of misinformation and disinformation. Those kinds of challenges really make social cohesion harder, response harder. We have got to do a lot more work to learn how information flows, how to communicate more effectively, how to connect with people who dont necessarily agree with us. Theres a lot of important work to be done. One of the things ive come to realize and appreciate is the scientific endeavor has been a phenomenal success, but the social science of how you pull people together and get a country or world through a pandemic, that has struggled and that is an area where we need to do more. Amen to that. Julie, finally, you started the trust and trustworthiness. In berlin at the world health summit, they were lighting up with some new data about trust deficits in the world and it was shocking to see how low the United States was compared to everywhere else. We have seen that with the differential death rates, republicans and democrats. That should not happen with the virus. Just walk us off the stage with a little bit of building of trust. Trust is earned. I used to think it was about telling the truth, which is essential, but it is more than that. It is about walking your talk. It is about how you act. Your transactional capabilities. And it is about transparency. Really owning up to what youre doing and why youre doing it. We have some problems in all three of those areas, truth telling, transparency, and transaction. And yet as if science is on our side, we know what to do to solve our problems, argued lee, and the not distant future, we could take pandemic threats off the table because of what we can do with our science. But society is lagging. We really have to think about how do we inform but not frighten our society so that we can get what needs to get done paid for and accomplished without resorting to these Political Warfare that has been going on for so long. And i think, again, i hate to make the argument over and over get about the importance of local, but when i was the cdc director axa, before i was the cdc director, there was a poll conducted about trust. They trusted the cdc director then much more than they did the Surgeon General or the secretary where the fbi leader. The person they trusted most was her local doctor. That really tells you we have to be able to engage in create a network of credible trustworthy communication at every piece of the action and that it does not come from the white house no offense. That is not the most trusted place for those in our country, nor is atlanta. We really have to appreciate we are in a world of peertopeer communication and the more we can support an credential that communication, but also everyone in this room, in this audience can push back when you hear something that is not true or not defensible or not evidencebased, stand up to it and participate in the conversation. Because what really look at who is perpetrating misinformation, which i think is often the source of mistrust, it is not really very many people. So we can collectively counter that if we really work with truth on our side. The best way to counter that information is with good information. As julie said, we like to think it is you craft the perfect tweet or go out on cnn and give the perfect no. The best information flow happens oneonone in the grocery store, in the Bowling Alley come at whatever, the place for people who know each other meet with each other. And that means all of us have a role in creating and promoting more good information and our society. And that means talking to people, particularly people you may not was agree with and sharing good information. We really have to think as all of us as people trying to fill the void that often is out there, especially in a pandemic where people dont know what is going on. And that information void becomes a hotbed for misinformation. If you can feel that with good information, you can counter a lot of what we see. I want to build on julies point that this is a collective responsibility, not the responsibility of the cdc director alone or the white house response coordinator. If we could only recapture this notion of a common good and commonwealth, great progressive era. I think perhaps you will see why these two people sitting next to me are my two heroes. They always have been, always will be. Thank you so much, julie. Thank you ashish for all you do for our nation and our communities. Keep on all of the things, all of the wonderful things you are doing. Thank you to all of our students, our community, and we will pick up after the break. Thank you. [applause] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] which is responsible for its captio Georgetown Institute of politics and Public Service in washington dc. [applause]