 Hi everyone, I think, I think we'll start now and then there's people who join in, they'll be fine as well. So, hi everyone. Welcome to the state of global vaccine distribution, which is an event she's co-hosted by the Institute for Global Leadership Student Groups, including Tufts Latin American Committee, Tufts European Horizons, the South Asian Regional Committee and the Middle East Research Group. So the Institute for Global Leadership at Tufts supports 28 programs, such as coursework, student groups, internship experiences to develop future generations of effective and ethical leaders. And we would like to thank the IGL for their support in putting together this webinar. So we're extremely thrilled to bring you to a conversation with Gavin Yamey, the director of the Center for Policy Impact and Global Health and a professor at Duke University. This discussion will be about the tailwinds and headwinds facing global inoculation against COVID-19. So I'll start by giving a very brief introduction of our speaker before we start. So Gavin Yamey is trained in clinical medicine at Oxford University and University College London, as well as medical journalism at the BMJ and public health at the London School of Hygiene and Tropical Medicine. He was deputy editor of the Western Journal of Medicine, assistant editor at the BMJ, founding senior editor of PLOS Medicine and the principal investigator on a $1.1 million grant from the Bill and Melinda Gates Foundation to support the launch of the PLOS neglected tropical disease program. In 2009, he was awarded a Kaiser family, many media fellowship in global health reporting to examine the barriers to scaling up low cost low tech health tools in Sudan, Uganda and Kenya. Dr. Yamey serves on two international health commissions, the Lancet Commission on Investing in Health and the Lancet Commission on Global Surgery. He has been an external advisor to the WHO and to TDR, the special program for research and training in tropical diseases. Dr. Yamey has published extensive on global health, neglected diseases, health policy and disparities in health, and has been a frequent commentator on NPR. Before joining due, Dr. Yamey led the evidence to evidence to policy initiative in the global health group at the University of California San Francisco and was an associate professor of epidemiology and biostatistics at the University of California San Francisco School of Medicine. So I'll now pass it on to you, Dr. Professor Yamey, and we very much look forward to your thoughts today and so having a great discussion. Thanks for the nice introduction. Thank you, Gavin. I guess I'll take it from here. First of all, let's just reiterate how excited we are to have you here. We know that our audience have a couple of questions. So I'll go ahead and plug in that if anyone has any questions, be they regional or global to ask, please feel free to use the Q&A function, as we will have a designated portion at the end of the event to kind of ask Gavin directly. So, Gavin, one of the things that you kind of focus on pertaining to global distribution, something that we saw specifically in your Twitter, is your interest in vaccine or pandemic preparedness. So, and that's kind of where we want to start the conversation. Yeah. Now, two years before the COVID-19 pandemic, you warned that we must be prepared for such a catastrophe. What were the main factors that led to your prediction and which countries were the most prepared and unprepared. Additionally, what does preparedness entail, be it writing a manufacturer of vaccines, fund research and development, increased hospital beds, PPE storage, et cetera. Yes, Patrick, it's a great question. So maybe I'll start with what it means to be prepared and the way to the way that I would look at it is to say that there's kind of two major planks of preparedness. There is the national plank, which of course includes subnational regions, you know, some countries are quite devolved to provinces or states, but there's a national plank, and then there's a global plank. And the national plank includes functions such as surveillance, the ability to communicate with the public, workers who understand and already testing capacity, all of those pieces. And then at the global plank, by which I mean going beyond the boundaries of individual nation states. So at the sort of regional and global level, there's a whole host of activities that are needed for preparedness, regional surveillance, global surveillance, research and development for pandemic and epidemic vaccines, vaccine stockpiles, surge manufacturing capacity. Now, after Ebola, West Africa Ebola 2014 to 2016, there was a realization that we had done quite poorly at being prepared, and there was actually quite a flurry of activity and the launch of all sorts of very valuable initiatives. For example, the Africa CDC, the WHO's contingency fund for health emergencies, the launch of CEPI coalition for epidemic preparedness innovations, the public private partnership Norway that finances pandemic vaccines. So there were a whole host of these and many other things. There are a whole host of these activities. So what it is that was, there was a little surge, a kind of a sugar rush if you like, of financing external developmental financing aid whatever you want to call it for pandemic preparedness after Ebola. So that financing was not maintained. We have what are called the cycles of panic, and then neglect during the panic phase of Ebola, you know the international community rallies and spends more money. And then when the, when the panic is over when the epidemic subsides and the, and the sort of diseases out of sight out of mind, and the spending falls and actually our center. So in fact, in global health we did some research showing this that when there's an emergency, you see greater financing for global public goods for health, in other words for activities that have these transnational benefits like pandemic feathers. So then you see that you know the contingency fund for emergencies at the WHO was just struggling to raise enough money, even after Ebola. So much money was actually forthcoming for global pandemic fairness. And then on the national side, it's very interesting because clearly some countries have done very well at getting ready for pandemics. Some of those countries had experienced other epidemics in the past SARS for example some of these countries had SARS memory I like to think of it as even the South Korea's and Singapore's and so on. And others didn't do so well but you will have seen that prior to this is very interesting prior to COVID-19. There are a number of scorecards given to countries, one scorecard the global health security index ranked countries going to how well that they were prepared on paper. And of course the US came number one and UK came number two on paper, they had systems in place in practice of course those are two of the countries that perform the worst amount of the most ineffective responses. And that is in part because you know we had Trump and Johnson, and we're also seeing the same with Bolsonaro and Modi populist men who turned inwards, embraced nationalism, rejected multilateralism, rejected science have been very bad for pandemic and these indices didn't capture the sort of the political side. So the last thing I'll say in relation to your question is the piece that I wrote a couple of years before COVID-19 was in response to the Trump administration's plan to cut funding for pandemic preparedness, particularly at CDC, and particularly downgrading activities, CDC support activities in countries with the highest spark risk. In other words, you know epidemics, pandemics, zoonoses, they jump from species to species. And that's called a spark that's the epidemic or pandemic spark. And so the CDC was planning to cut funding for a whole host of countries including of course China. And that's why I was raising the alarm you know I wrote this piece saying this is not the time to be cutting back on pandemic preparedness is the time to be stepping up the gas. And here we are. So it would have cost probably somewhere between $3 and $4 billion a year to properly fund pandemic fairness. And now instead it's going to cost us the IMF says last year alone $28 trillion in economic loss so an ounce of prevention would have been tiny compared to the cost of the cure. Thank you so much for that I mean it's definitely interesting how despite all the public health challenges that we've seen only in the 21st century. There still seems to be at the international level kind of a reactionary political culture when it comes to global health so it's definitely definitely something very interesting, which which I guess you know segues into into looking towards the future, given that this kind of seems to be a cycle of reaction and then, I guess, failure of preparedness. What do you think this means for future pandemic preparedness do you think people post pandemic with a clear understanding of the importance of anticipating such events or do you think it'll just keep on being a vicious. That obviously is is the, well it's the trillion dollar question it's the multi trillion dollar question we are in a pandemic era now we will have more epidemics and pandemics they've been getting more frequent. You know that is empirically has been shown, you know, SARS, MERS, Zika, they are becoming more frequent. And on average, we've had one serious pandemic every 100 years. And so you know people thought after Ebola we'd learned the lesson and we clearly didn't this has been obviously far more severe. Many of the hardest hit countries were rich countries this time around and that is almost certainly the reason why we were able to mobilize billions of dollars of funding for vaccine and therapeutic and diagnostic development in ways that we weren't able to make as the rich nations were affected. The question of what it means for for the future. Again, I again, I think it has a two part answer it's country preparedness and it's global preparedness. And you know at the country level systems need to be stronger surveillance needs to be stronger early warning systems need to be stronger health workers need to be ready, etc. But then at the global level I mean we do have this paradox and I've got strong feelings about this paradox and they're not very popular. But, you know, you know, you don't, you don't come to these conclusions just to be popular. The reality is that if we take this pandemic. We actually did put in place a solidarity mechanism, which we had never done before in an outbreak. You know and if you look at H1N1 2009. We developed a vaccine rich nations hold of the vaccine, right they went into these direct purchase agreements with vaccine manufacturers, and they bought more doses, and they bought them quicker and less wealthy nations were left behind for the first time around. For the first time we put a pool solidarity mechanism in place called COVAX and full disclosure I was in the working group that gave advice on the design of COVAX. It wasn't perfect, but we absolutely thought that the world would come together around this pooled mechanism, and basically rich countries bypassed COVAX in the end they did exactly what happened in 2000. There was no very pooled mechanism there was no compulsion for rich nations to get involved, and they didn't. And so my unpopular view is that we're going to need a compulsory mechanism for the future and people tell me I'm crazy. No one's going to do that, but the old I don't see any other I don't see an alternative. And I think there has to be some kind of compulsory pooled mechanism that every nation is going to have to fund according to its means whether it's percentage of GDP, whatever, it's on users, and whether it's paid for out of a carbon tax or tax on international financing transactions or whatever it is. I see no future for pandemic payments or indeed for any other of these global public goods and services, other than the pooled mechanism, and the mechanism in which the rules of the road are decided now. Right, we've seen horrific vaccine nationalism. We have the most unjust, unethical dystopian world, in which only about 0.3% of all vaccine doses have gone to low income countries, where rich nations with as a, you know, looking forward to a lovely summer, UK, Israel, probably the US, everyone's planning you know their trips, trips away, and the rest of the world is on fire. I see, I don't see any other way forward in the future, other than some kind of compulsory mechanism that we all agree to now, we all agree on the rules of the road when it comes to vaccine distribution that is based on principles of equity. And of course on public health need. And that was the theory that we had behind COVAX, the idea was that through COVAX, the whole world, every single country would get enough doses to vaccinate health workers and high risk people first. Then as supply ramped up, doses would go to the general population. That was the idea with the recognition that that form of equity has to be coupled with public health needs. So there was supposed to be a reserve supply, 5 to 10% of all doses that could then be directed to where the hotspots are. And that never happened because, you know, to a roughly two dozen rich countries bypass COVAX, and just went straight to the manufacturer clear the shells, you've got Canada that bought enough doses to vaccinate, you know, every citizen six or six or seven times over the US four or five, and here we are. I mean, there's definitely a lot. A lot of very relevant points being made there just because you know that global cooperation sort of what you were discussing at the beginning is extremely important, especially when it comes to preparedness given that individual preparedness can only do so much if you don't have that collective kind of framework established to deal with global health crises which are really irrespective of borders as we found out. Some countries did well. Don't forget one fifth of the world's population lives in nations that have essentially to all intents and purposes eliminated. And those nations, they have very few cases or no cases each day, you know, Vietnam, South Korea, Thailand, Singapore, Australia, New Zealand, etc. Those nations. So first of all, listened to the science adopted public health science acted fast after aggressively. And secondly, as we said earlier they had previously experienced an epidemic. And so they in some ways, they had that memory and they were ready to act fast. Some places had had had run kind of simulations, and we're ready for the next one or they have reserve capacity reserve clinics ready for pandemics, etc, etc. There was a, you know, there was less and less of the politicization of public health measures you've seen that here in the United States this horrific politicization if you wear a mask. You know that's somehow political. We saw a lot less politicization of public health measures which I think helped a lot. Leaders were often women. It is scientifically proven that women leaders have done better in this pandemic communication was better. They had, they had, you know, you had New Zealand's Prime Minister Jacinda Arden on television many nights just at home sitting on her sofa talking to her citizen to army of 5 million and bring them into the fold. There were a lot there's a lot that we have to learn from. One thing that I find very frustrating is that there's these endless Twitter wars from people saying well, these countries all just got lucky. And there's nothing that America could have done. That's just a historical and not science based. It wasn't luck. It was not luck at all. It was preparedness and it was very aggressive action. Right. Yeah, and thank you for bringing that gender dimension in because it is very important it was something that we wanted to touch upon in the agenda. I do. I want to return to something you mentioned on vaccine nationalism we actually saw that you tweeted the back and I quote the vaccine will have no nationality it will be a global public good enough with the nationalistic claims which is something you just reiterated. We wanted to ask, you know, not only the consequences of vaccine nationalism globally, but many scholars have indicated that vaccines could potentially be used as a new form of public health diplomacy, we're going to countries with ulterior motives extend vaccine distribution to developing countries in exchange for other unrelated favor, especially when it's outside of the covax framework. So I guess the question is, you know, how is vaccine diplomacy or how could it be used as a tool and could dispose a serious problem for developing countries and make an entrenchment of persons with systems. So I'm going to do it, I'm going to do a two foot because Oliver Martinez Lopez, and bienvenidos, it has asked a question and I'm going to answer that about covax and yours at the same time because they are linked. Excellent. I would argue to Oliver's point that, look, I'm a bit biased. I have no financial stake. I wasn't paid as an advisor. It was just a voluntary group. But I do have a stake in wanting to see multilateralism work. It's, it's had a huge number of problems obviously. The idea was that it was supposed to be a multilateral mechanism that avoids some of the problems of bilateralism. And, you know, there's now a fairly substantial empirical literature of the value of multilateral approaches of bilateral, you know, less politicized, less, less tied aid. And so the, the idea behind covax was that you could participate in two ways. It's true it was voluntary and Oliver asked a very, a very pertinent question on why didn't rich countries come on board in the end. The idea was that if you were a wealthy nation, a high income country or an upper middle income country, you would, you would be a so-called self-funded member of covax. So you would come on board and you would buy your doses through that mechanism, enough to initially vaccinate 20% of your population, the high risk and medical workers but potentially more. And through buying through covax, you would support R&D would support so-called manufacturing at risk, and you would help to bring prices down for everybody through pooled mass purchasing, and therefore help subsidize doses to low middle income countries. So those were the rich self-funded nations. And then all low income and low middle income countries are automatically members of covax. And they are, they get their doses bought for them through aid, through official development assistance. So the idea there was and is still the plan. I mean, the India crisis is one of the many threats to this plan because, you know, India was going to be the vaccine maker to the world in many ways. The serum Institute was one of the sources of doses for covax. And the idea was that there would be enough doses, two billion doses by the end of the year, enough to vaccinate a billion people, assuming a two-dose regimen, which would be enough still to cover about 20% of the population of low income and low middle countries, high risk people, medical workers. What happened, as I said, is that instead of rich nations doing that, they bypassed covax. They went it alone. They cleared the shelf. There wasn't enough doses for covax. It actually meant there weren't enough doses for some of the richer middle-income countries to do large bilateral deals. There are some countries that have managed some bilateral deals, Uruguay, Mexico, Chile. I think those are the three with some of the highest vaccination rates in Latin America. Since the rich world got there first, they used their market power. But it is absolutely the case that with covax pushed to the back of the queue with the US essentially deciding to go it alone. And to be honest, even with the Biden administration, full disclosure, I voted for Biden, still really going it alone. I mean, you're not seeing an enormous change in, you know, in COVID-19 vaccination policy. They're not sharing doses. I mean, they reluctantly now, after a lot of moral suasion, agreed to share some doses. Wow, that was like pulling teeth. There hasn't been a dramatic change in policy on sharing of IP, on sharing of patents, on sharing of know-how. We hear the administration is divided on this topic and there's clearly an internal flaming that there's a real war going on. And maybe things will change. I don't know. But so with the US having gone it alone, clearly not interested in any big way. Again, we keep hearing through the grapevine that there may be some big sea change and Biden might be announcing something soon and all of that we have to continue to push for and hope for. And that has left China, for example, Russia, for example, that are making their own vaccines, you know, entering into the space, you know, and completely understandably if there's no multilateral mechanism that has the doses. If the US isn't playing its usual PEPFAR like role, or President's Malaria initiative like role, which is what a lot of people want, totally understandable. That's quite a long answer to your question. Sorry. And so Gavin, so I have a question very linked to what you're just talking about. So we wanted to ask you about vaccine intellectual property rights. I know that there's been a lot of countries like like South Africa and India, which have asked to waive. Yeah, patterns and to increase mass production. Yeah, what is what is your view on these calls. Do you think that would be successful in mobilizing the manufacturing power needed to produce more vaccines globally, particularly in developing countries. Yeah, also help address disparities and vaccine access internationally. I think it will and I think that I am somebody who believes in an all of the above approach. I'm someone who believes that this is a pandemic. This is the worst pandemic in 100 years, it is getting worse cases have been rising consistently over the last seven to eight weeks. Some countries have had their worst week ever. And the, the there is an urgency to, to try everything to open up all the barriers to share patents to share intellectual property to share know how to do tech transfer and to urgently globalize the manufacturing of vaccines and therapeutics but particularly vaccines, you know, vaccines are clearly our way out of this pandemic. You know it's a cliche that science is our way out but in this case, reaching close to vaccine herd immunity or achieving vaccine herd immunity is what we are aiming for to, you know, to end these devastating ways. And so, you know that that there is as you have seen in the last few weeks this debate about, you know, if you if you take away patents you somehow remove the incentive for innovation. I don't buy that. I mean first of all, of course, huge amounts of public money were used to de risk what farmer was doing. So these are, these are largely not entirely but he's a largely publicly invest public investments that should result in public access to the vaccines. Secondly, if there's any barriers right now why wouldn't we remove them. I mean how can you watch what is happening in India or what is happening in Brazil or Iran or Turkey. You know, or as we can, as you see now rising cases in Pakistan and Nepal and what could become a regional crisis how can you look at that and not think, whatever the barriers, we need to remove them. Some things matter now. I mean, you know, the most breaking the cycles of transmission in India need to happen now. So that's there's an urgent set of things that have to happen to, you know, now obviously, from high filtration tasks to, you know, targeted circuit breakers stay at home orders with food and financial assistance, avoidance of crowds, you know people working for all of those things are going to break the cycle of transmission now whilst ramping up vaccination which is still very slow. At the same time and the urgent vaccination has to include donation. I mean, it can't be a long term donation model, India and every other low and middle income country needs to have a sustainable route to making its own vaccines but that is not going to happen overnight. There are facilities that are ready, and that could start making vaccines if given the know how the technology transfer. There are others that would need to be stood up that would need to be set up to know though from the beginning, those things are sort of weeks and months. If we are to be in a better place, say by next year, globally, across not just the rich world, which I said, as I said before is that, you know, people are high fiving in places like Israel and the UK and the US, and I don't blame them. I'm not, I'm not taking, I don't want to take away from people's wonderful joy vaccine ecstasy in these nations and I've, I've been vaccinated. I'm a beneficiary of that. So is my family in Britain. I'm a health workers in my family, I don't deny. I mean, I don't want to, I don't want to say, you know, that I'm ecstatic about that but isn't that the same kind of protection that we should be providing everybody on the planet. Why is it only the rich that are getting that protection so we've, we've got to be able to think. What are the urgent things that need to happen now. And then over the next few weeks and over the next few months and we could be by 2022, you know, we could have the world, pretty much self sufficient in manufacturing vaccines including mRNA vaccines if everybody would play ball. So this bizarre business in which the rich nations are hoarding the most vaccines and are also blocking lower middling countries from making their own vaccines. This notion of rich nations being both hoarders and blockers it is grotesque. It is one of the most grotesque things imaginable. This is a global crisis. It's sort of the defining crisis of our era right now. And if we can't, if multilateralism fails us now, I mean, how can we, how can we begin to even think about the future at all or other future, you know, multilateral challenges from climate change to antimicrobial resistance to all of these other challenges is that we're multilateral is being tested right now and it's clearly failing. Q&As and a chat question. That's fine with you Gavin I think we will ask you one or two more questions and then then we'll go into the Q&A. Yeah sure it's not years by the way that I do one of the questions is oh it'll take years it won't take years that's not true it didn't take years for factories here for plants here to be stood up, it won't take years for those same plants to be stood up elsewhere. But it's true that it's not going to happen overnight but we need to start building these plants now so that by the end of this year beginning of next year, we're in a much better place if we don't start that now. It's really hard to see how we manufacture enough doses for the world. If we want we can also kind of go back on that question in about 10 minutes but so so the next question I wanted to ask you. We've already talked a lot about about some of these but I want to address them perhaps a bit more directly. There's been tons of hurdles to vaccinating a majority of the country's population. There's been a mystery in capabilities there's been the politicization of vaccine distribution, stigmas fake news. So we still wanted to understand if there's been some countries that have been much better at addressing these concerns with you talked a little bit about some countries like South Korea like Vietnam. Do you think there's enough communication between countries on what the best practices are to address these difficulties. Yeah, it's a good question I mean they have been has been obviously the big challenge in this pandemic. The amount of misinformation out there, and that there's a whole range of misinformation obviously there's the sort of snake oil remedies that are being sold online. And then you've got world leaders obviously Bolsonaro and Trump and others just saying bizarre things you know the Trump saying that it's just going to disappear that you should that the ingesting bleach could help all of these things. There are people to break social distancing, very unhelpful. I think there's been a profoundly unhelpful movement around, or a sort of a cult of people thinking that the way forward is through natural herd immunity not vaccine herd immunity and I, you know I try and correct that misinformation online all the time but it's a very personal view. So yes there's a lot of misinformation out there. Some countries have tried to get on top of it. There has been in the UK for example there's a sort of a kind of a rapid, a rapid science fact checking center there's one in Taiwan. You will have seen at the University of Washington, Karl Bergstrom and colleagues set up a center information of science during this pandemic. There have been these initiatives trying to sort of counter the misinformation misinformation. And I know and again I think some of the countries that have that did very well in this pandemic were really good at countering misinformation at communicating, you know, proven science on distancing on you know, avoiding crowds on wearing etc. And so I think that, look, we absolutely have to learn from this pandemic lessons from what countries did well and what they didn't. And there was a very wide range in performance. We will be studying for years to come. You know why it is that in some parts of the US one in 200 people died in New Zealand one in a million died, it is not down to luck entirely. Yes, it's an island. There are all those advantages, but it's not entirely down to luck. And we are going to need to learn the lessons of success and failure and be very honest about those because every country is going to need to have a core set of capacities that is going to have to include the communication of science. There is a lot of information tackling anti-vax misinformation and, you know, anti-mask misinformation, all of those things. And absolutely we're going to need a sort of an international way of learning, you know, across, across boundaries. And so, absolutely, yeah. There's a little bit more on some of these infrastructure and administrative hurdles. So we did see that that Gavi, the Global Vaccine Alliance announced last weekend that it had secured vaccine doses from Moderna to distribute around 500 million mRNA vaccines to countries in need. However, there's definitely concerns that because of the need for mRNA to be stored and transported at very low temperatures that that could be difficult to basically combine with countries that don't have this easy access to this kind of infrastructure. How do you think this could impact the viability of these vaccines? Well, of course, I mean, obviously, we, you know, there are logistical issues in rolling out vaccines. No one can pretend that there aren't. I think sometimes those get somewhat overplayed. You know, we, the international community has and countries themselves have distributed vaccines in challenging environments before Ebola vaccines, for example, in places that are very resource, resource poor. Those challenges have been overcome, you know, trials of vaccines requiring refrigeration have been conducted in low and middle income countries. So these are challenges that can be overcome. We will continue to innovate, right? We've got single dose vaccines. We, some of them are two doses. Now we have a single dose vaccine. That's already an innovation that helps to potentially make it easy. We will continue to, this is, if you like, the first generation of vaccines, there will be second generations and third generations. There are nasal vaccines under development. For example, that could be a game changer. There are more thermo heat stable vaccines under development. So I think we're going to continue to, you know, see those sorts of innovations. There is a huge debate right now, you've probably seen about, you know, what's the end game for this pandemic. And I think eradication is often is off the table. I mean, that would be the most enormous Herculean task. Imagine we've only ever eradicated one human disease smallpox. And so nobody is talking about eradication right now. But there is a very big question about whether it's feasible for countries to eliminate as some countries have already done. That is also a large undertaking. Vaccinations will clearly be a key if countries are going to do that. What it requires, if you take a look at Australia or New Zealand, it requires incredibly high functioning surveillance system, you need to be able to spot a single case and act fast to dampen down to basically quash any small outbreak. You have to have very good border measures. So everybody coming in, if you find a case, you have to go into managed isolation, you have to be able to manage quarantine. So it's a very intense process and there's a huge debate right now you will have seen the big story in the New York Times today on herd immunity and how that, you know, we may not even be able to achieve herd immunity here. The debate on elimination is very fraught in the US, you know, we don't have a fantastic national surveillance system that could instantly identify a single case, you know, and squash an outbreak we don't have border management. So it would be a very heavy lift here, but can we transform this into something with that that's, you know, low endemic levels with very few cases. And if you get it, it's not, you know, high fatality disease, yes, and that we can absolutely must go for, you know, even if we can't eliminate we should try because the root, what you're doing in getting there. And so elimination and other measures as necessary, you know, is to massively reduce mortality and turning it into a disease that even if you've got the illness it doesn't kill you. And for equity reasons, it's really important to keep striving for that. And one of the reasons that New Zealand, as you know, when it when when COVID-19 first hit in New Zealand, they didn't go for elimination. They used a flu playbook, a flu pandemic playbook, and then they realized that there would be a mass death event if they did that, and that there would be massive inequity in who died. And they were calling, for example, on, you know, income lines on racial equity lines, and they realized that it would be a catastrophe. So that's when that's when they went for elimination. And they, and the officials there have said that equity was a really important reason why we did it. It's a really important reason going forwards for why you should obviously try your hardest to reach the lowest levels possible going forward. And all of which is to say, we may need to be having boosters, you know, we may need to have future shots that are adapted for for variants of concern. You know that that I think a scenario that many think think is likely is that this becomes an endemic disease in many countries. It may be eliminated in some, but endemic in others, but maybe you have a regular shot. And maybe there are local flare ups that will require public the usual kinds of public health measures to, to, to, you know, to dampen down as we go forward. And I'll let Mira ask her final question and then we'll move on to the Q&A. So the world seems to be operating and do separate realities you spoke about this already countries like the US and Israel are celebrating entering a post vaccine world while people in Delhi and Gaza are basically begging from oxygen. As someone whose family is in India right now I, I can see the two realities very clearly where people at home are finding difficulties finding hospital beds. You read different articles every day about things like that. And everyone out here is living a different like actually living a different. People are describing this what is unfolding as a vaccine apartheid. I was hoping to get more of your opinion on that. Well, it is. I mean, first of all, I'm really sorry for, you know, what you're going through. And for the, for the crisis that is happening in India. A third of my own team are Indian and are in contact with their families all day every day. You know, we partner with researchers there, the public health foundation of India, you know, we're in daily contact and we are all of us trying to do what we can, which is kind of limited. I guess one of the things that I'm involved in is I'm in the information space and so getting help helping to get information out as much as possible. And there's been some fantastic efforts on that front. The reality is that clearly, we do have a massively inequitable distribution. I mean, the term vaccine apartheid, the director of you and a winning she came up with that it's not that that's her term. I mean, you know, I think that's the first time we've heard it. And some people don't like the use of the word apartheid, you know, I was all under in Cape Town under apartheid, and we left when I was a kid. And some people feel that that word shouldn't be used outside of that context but I think people get that what we're talking about is that the mirror you described it very well there's the sort of ecstasy of being vaccinated here in the US versus seeing what's happening, you know, in India with people literally dying on the streets and, you know, cremations on the streets and so on. Obviously, there's going to be a lot of analysis on what happened. I don't think now is the time now is this is a humanitarian catastrophe. I feel strongly that now is not the time, you know, to sort of criticize there's plenty of criticism to go around I mean I wrote a piece. God last summer I think with Greg Gonzalez at Yale about populist leaders who who had turned away from science and at that time, Modi had been sort of clamping down on journalists who were saying anything negative about his performance. And, you know, as you know, earlier this year, you know there's been the administration there was quite triumphant about how well they were doing and there are a lot of people nervous about that. Is it really, I mean, is it really the time to be letting up on public health measures and so on. There's going to be plenty of, there's going to be plenty of time to sort of figure out what went wrong and again I don't, I think it's extremely important. I cannot stress how important it's going to be for us as an international community to understand why some countries did well even without vaccines and why some some kind of support, we're going to have to learn those lessons. So how is the time to figure out, you know how can communities be empowered to enact public health measures from masking ideally better masks you know higher filtration masks to distancing, you know to ventilation to stay at home to staying at home if possible, you know, if I think about my own team, you know, their families have luckily been able to start working from home etc. Simple things like opening windows and making simple box fans that don't cost very much money with borders on all of those things to help to break the cycles of transmission, trying to support implementers as much as possible with oxygen, the basic drugs that are needed for all of those things, trying to support those who are running food banks and and supporting those staying at home. All of those measures, while surging vaccines, I mean that the vaccines themselves are going to, they will they are not instant they don't provide the break if you like, that those other measures that I mentioned did. Clearly, we have to surge vaccine as well that's how the pandemic is going to end there and that's how it ended in both the UK and Israel they had awful surges in the winter. You know, my family is in Britain and it was a winter was a dreadful horrific time. A surge driven in part by one of the variants be 117, which is probably more transmissible there's some debate about whether it's more deadly, some somewhat conflicting research on that but the surge was imparted by that very. They had a I mean it took Boris Johnson forever, and he was given I think very bad advice, you know, not to institute a so called circuit breaker lockdown and and didn't and that delay is estimated to have caused an additional 1.3 million infections. Clearly, he had to do it and that stay at home order drove started to drive cases down even before the mass vaccination campaign kicked in and the vaccinations accelerated the decline a sort of a one to kind of double whammy punch. You know, I'm not an expert on India clearly I mean that's just that's not my domain I am fully aware that a national lockdown is just I mean, I know that some many Indian doctors, Indian experts publicate first desperately crying out for one, but the logistics of that are really important to imagine if there was really strong financial support and really strong food support and all of those things, then sure but I suspect it's going to need to be more targeted and more localized to where the hotspots are. There's no reason why scaling up testing is helpful in identifying kind of where the hotspots are. And so it's going to have to be one of these sort of comprehensive all of the above approaches. There's a lot of, a lot of people who've been who've been, you know, Madhika pie, for example, and others have been writing information sheets in lots of different languages, distributed across India some for this some for the public some for doctors treatment some for the clinical protocol plans for doctors, basic public health measures for citizens and so on so there has been this kind of you know, activism and sort of a surge in people trying to help out. So yes, that inequity has to, you know, is one of the sort of defining how we how we meet the challenge of ending that inequity I think is one of the defining moments of our time really. Thank you, Professor. Quickly moving on to the Q&A section we have a question. Yeah, who asked, what is your take on vaccine passports. Yeah, it's a good question. I mean, first of all, I think the term itself can mean a lot of different things to a lot of different people, right. Some people it means the ability to travel between countries, you know, only if you're vaccinated. And I think that's quite problematic because it's going to it's going to lead to another kind of global inequity. I mean let me just give you one very specific example to just kind of bring that issue alive. I mean maybe it's not the most pressing example but I mean, it's, it's, I think it's just emblematic of where we could be heading if we only allow, you know, vaccinated people to move between nations. Let's just say that we don't do anything about the current rate of vaccination that the current rate of global vaccination. It's going to be years before there's widespread vaccination in many lower than years. Let's say the United States says well you can only come here if you're vaccinated. Then, what does that mean for our international partnerships international collaborations, our global health meetings, I mean for a for a long time global health meetings in the US were that's because we had a ban on people with HIV coming so you know HIV positive people couldn't couldn't come into the country which meant that a lot of the global health meetings. There are people who we wanted there that couldn't come. Then there was Trump's Muslim ban, which meant that my Muslim scholars and friends and collaborators couldn't come making these meetings totally meaningless again, excluding, you know, much of the world. Now we're saying people from most of the world, or at least from, you know, a huge number of countries not going to come here. What does that mean, and then you're going to have this situation where this is a whole other topic for a whole other meeting but the whole sort of way in which global health education is often set up with, you know, rich students from the United States and Europe, or rich researchers in the United States and Europe, going into into the field in low and middle income companies that's going to be fine right they're vaccinated off they go there's going to be this awful I worry kind of, you know, for a new form of sort of power imbalance and colonialism around it so I worry about that. And if you're taking it to mean that there are certain activities that you're not going to be able to do, say in the United States because you because you decline vaccination. I sort of understand that so Duke, for example, in order to register for class next semester, you have to be vaccinated and to be honest, I think that's going to happen across every pretty much every university I'll be, I'll be surprised if there aren't holdouts. And there, you know, I'm less concerned about that. And you could said anyone who has not had access to vaccination plan will vaccinate you day one so as long as there's no inequity in that in that that I do understand and I do get. I do understand that. I just want to ask before we move on to the next question do you have a couple minutes extra to go. Stop at seven to have dinner with my family and then you know get my five year old to bed. No extra minutes sorry. I'll quickly dive into the last question, which is from John share on the note of MRA vaccines which required to those setup. Is there a risk of significant loss to follow up in developing countries where adequate education regarding the functionality of vaccines is felt to be minimal. Is there an argument to be made to target a single dose vaccine for these developing countries. It's a very good question so look any time that you can reduce the barriers in health care in resource limited settings travel transportation, all of those things that whatever you can do to make things easier the better. So for example one of the biggest trends in international health and global health whatever you want to call it has been the integration of services right so HIV services being integrated with family planning services, for example. So you have this this kind of one stop shopping if you're going to if you're going to take time off from work and you're going to travel 20 miles or whatever it might be and pay for your transport and lose money from your job for that day be there. Just for this one moment where you get lots of integrated so so in that respect, of course, a single dose is going to be more, you know, may end up being more efficient, more practical, better for roll out than than two doses. On the other hand, I would say one thing that is really heartening is, there was always this worry that with two dose regimes people are not going to turn up for their second dose in the real world that hasn't happened. There's a huge adherence to the second dose. In the UK it's been I can't remember 98 or 99% or something. People are to, you know, it's not that surprising people want to be protected against illness and death. There's a real hunger for that amongst those who want to be vaccinated. The adherence to the second dose is very high. So from that point of view, I wouldn't worry too much. I also want to just recount the, the, the story of anti retro viral adherence which might there might be a lesson here for us. I don't know I don't want to pull push the analogy too far but there's always a worry in the early days of HIV there was this awful sort of neocolonialist racist attitude I think that when anti retrovirals came along it was very common to hear, well you know we can't roll out anti retrovirals in poor countries because people won't take their medicines and it was bullshit obviously. And it wasn't just bullshit it was proven to be bullshit. So the first studies on adherence we looked at Kylie sharing South Africa versus Boston adherence rate people taking the attendance on time were higher in some of the poorest places on it. And you know, so I think we, we should challenge our assumptions about you know where vaccine adherence is going to be higher and lower. So there may be some lessons there I don't know. That's it. Oh wait there's one more minute, but let's see if there's a short short questions. Very difficult one this mandate I don't know about that it's a very good question. You know, my, my hope in my senses that we're going to be able to have enough people vaccinated that even if we don't reach this technical thing called herd immunity, there will be very little of the disease around. There are some interestingly I mean there are some, I don't I'm not a lawyer and I don't know that I don't know enough about the law I'm not answering this in any legal way but there are. There are some health centers hospitals etc who are asking their health workers to get vaccinated to a mandating it unless you've got a religious and medical exemption. And I completely understand the rationale for that. But, but I think most people would say that we are that we are the great hope is that vaccination is going really, you know it's going really well in the US. It's gone very well in the UK Israel sort of shows where we're ultimately heading if you're a rich nation with plentiful doses life is almost back to normal now. There's a lot of positivity very few cases. Very few public health measures left I think I have a friend who just was a medical school there who's been tweeting out photos, no outdoor masking I think indoor masking still but pretty much restaurants at full capacity so that I think that's where life is heading. And so I think the hope is that with that higher level of vaccination I think once you get to their levels of vaccination. And, you know, much rarer, I think that mandates probably not going to be necessary. That's it. You know Patrick mirror thank you for the invitation thanks to everyone who joined. And I've got to go now and have dinner with my family. Thank you so much for keeping you a little bit over. Great pleasure. Great talking to you great questions and excellent Q&A. Thank you doctor. Thanks. Everyone in the audience will be putting up the recording very soon.