 If you're disjoining, welcome to COVID year three, a form examining how COVID-19 could shape our future over the next year and beyond. A special thank you to McKinsey and Company for their support and to our many media partner, STAT. My name is Conor Goodwin and I'm an events associate with ProPublica. For those new to us, ProPublica is a nonprofit newsroom dedicated to investigative journalism. Today, we'll hear from a group of leading health experts about what we could expect from the next phase of the COVID-19 crisis. We will discuss different scenarios for how the virus might evolve and what this means for us as individuals and for society at large. Our panelists will also answer your questions. To ask a question at any point, click on the Q&A icon at the bottom of your screen and type it there. Also, if you would like to enable subtitles, click on the closed captioning icon at the bottom of your screen. Now, allow me to introduce our speakers. Mark Lipsitch is a professor of epidemiology at Harvard T.H. Chan School of Public Health. Dr. Nicole Baumgart is a professor of immunology at University of California Davis. And Dr. Umair Shah was appointed secretary of health for the state of Washington in December, 2020. Lastly, our moderator today is ProPublica reporter Caroline Chen. I'll let Caroline take it from here. Awesome, thank you Conor and thank you to everybody who's joining us today. I'm really looking forward to this conversation with this group of experts. I would like to start by defining a term or trying to define a term that has been used a lot and also misused a lot that we're all throwing around these days, which is what does endemic actually mean? Mark, maybe you could take a stab at that. Thanks, Caroline, and thanks for the chance to be here. I've been thinking about this a lot because it's really a term that has very many different meanings to different people. I think in some people's minds, it means the time when people like us don't get invited to webinars anymore because people have lost interest in the disease. The technical meanings are actually several different ones and I think the part that many of these definitions have in common is a sense of predictability, a sense that there might be seasonal fluctuations as there are with flu and many other diseases before we had vaccines for them. But we can sort of guess with reasonable accuracy how many people are gonna get it one in a given year and how many people are gonna have severe or fatal cases in a given year. And it might fluctuate a little, but not dramatically. And the timing is also somewhat predictable. It's either always there or seasonal or something kind of in between. I think we will talk a lot more later about COVID and what it means, but I think that's the best way to think of the term endemic. Yeah, well, one thing I did not hear you say was the word mild. So I just wanna clarify, I see you're nodding your head here, Nicole. What does the endemic have to do with, I feel like some people complete that with, it's going to be mild. What are your thoughts on that? Yeah, and then thank you also for having me. Yeah, I think that's really important that it's sort of currently used as once we don't longer have to worry about it than it's endemic, but that's really not what it is, as Mark already said, that it can be actually predictably cause a high level of mortality or people getting infected, that is not what we want. So that's the kind of endemic that we are not looking for, but that's also endemic, right? That can be predictable to be very bad. So I think it is not a great term to use currently. We also really don't know yet where all of this is going as we would discuss. So what are potential scenarios, Mark, for where we could go? Like what would post-pandemic look like? What are potential scenarios, best case scenario or most likely scenario? Yeah, there are a number and I would point people to the recent article by Don Burke in Stat News that lays out some scenarios. He was one of the first people to point to coronavirus as long ago as a potential pandemic threat and he's worth reading again at this time. But I think some of the possible scenarios are first the more mild scenario, which involves people having most, the large majority of the population having a certain degree of immunity, at least to severe disease due to their past infection and or vaccination. And a situation where that immunity lasts long enough so that in between times that people get infected with SARS-CoV-2 they don't lose that immunity to severe disease. Less happy scenarios involve probably mostly changes in the virus such that long-lasting immunity to severe disease is no longer as effective and maybe also immunity to transmission is less than it was. The first scenario is really what the seasonal coronaviruses do. They probably were once worse for us, we don't know that, but they probably were. And as immunity built up in the population they became milder in effect. But so the real question is how often and how greatly does the virus change in ways that make our existing levels of immunity not so effective. And we just don't know what that will be. So even when we reach a stage as I hope we are beginning to reach of mostly mild disease and mostly smaller waves of disease, public health officials and those who worry about these things will need to continue to worry about the evolution of more severe strains or more immunoscaping strains, particularly given the large number of people in the world in places like China, but not only China that have not had infection or vaccination. Yeah, I'd like to bring Umerin here at this point. What do you see as actions that we can be doing now or actions that people could be taking now that would shape the eventual trajectory of this virus? Because I think sometimes people also talk about this like it's going to do its own thing, but we are a factor in what happens. Well, first of all, Caroline, thanks for having me. And Mark and Nicole did a great job of defining where we are when we look ahead. And I did want to make the other quick comment about endemic is that as you're hearing different definitions of it, I'm shying away from even using the word. It doesn't mean that we can, it's not a forbidden word to use, but it is a word that has so many different meanings to so many different people. And that is really usually when we get into trouble when we can't commonly define something. So as far as actions go, we are absolutely at least in this country. Now, there is something to be said about what's happening in international settings, but at least in this country, we are moving in a place where we are going to need to coexist with this virus for a long time coming. This is not going to magically, as states are removing all sorts of requirements or mandates and magically the virus will disappear, the pandemic won't be ongoing. So it's really living with the virus. And when we live with the virus, there are two things that happen. One is that we take actions that protect ourselves or the people around us. And the other is that we contribute to the ecosystem of the global community. And what I mean by that is that as we know that when we have such a large proportion of the world that is not vaccinated, then we have a more propensity for variants and other variants of concerns to be in the mix. At the same time, if we take our own actions to wear a mask or to get vaccinated or do our part, even as we coexist, which includes having those tools like tests and other modalities at our disposal so that when we are out and about and all of a sudden have symptoms, we don't just continue to go out and about. We actually cocoon ourselves, whether it's isolated quarantine or what have you and we get tested and we decide what is the action we need to take. So there are individual aspects of what we're doing that also have global consequences. And then there are global consequences that really have meaning to those individual actions. And the impact of this global individual or global local, global domestic interface is so critical as we look at this path forward where we're gonna have to really coexist but also recognizing that parts of the world are further along than others when it comes to vaccinations and other kinds of activities and tools. Yeah, we'll talk about the sort of global picture in a little bit, but first let's maybe zoom down to the immune system. And I wanna ask Nicole here, we can also think about this as individuals and sort of as a collective here. So, I've heard people say, well, we know that even if you're vaccinated you could still have a breakthrough infection. So how does our collective action here in our collective immunity, if I can say it that way, how does that affect the trajectory of the virus? Yeah, I think that's such an important question because another way of phrasing the question is if I'm healthy and unlikely to suffer severe consequences why should I bother getting vaccinated or it is another way of asking this? And the answer is that every time for the virus it's all about replicating, right? It's all about making more of itself. And every time it finds a host in which it can replicate every time it replicates it will build in some mutations some tiny changes in the genome. And most of the time that doesn't make a difference but every now and again it will make the virus a little more potent a little more activated. So the more people they are that can be infected and that not only can be infected but can harbor the virus for a long period of time. So these would be the completely unvaccinated and also the immunocompromised. The virus has a chance to mutate and make itself better and then cause the next outbreak. And I think we have seen that was Omicron which we don't know where it came from but it has so many mutations over 30 changes to its genome. And the best guess we have that it likely came from a patient who was immunocompromised and how would this virus for a very long period of time to accumulate all these mutations? So the better our immune system is the less we have a chance for that next Omicron to come along. Yeah. So you mentioned earlier living with the virus. So I wanted to ask a question to Mark about this. So I feel like everybody at this point is very tired of the constant mental calculations they're making of risk benefit particularly for parents of young kids or people who have immunocompromised loved ones. What does that look like as we sort of move into a more post pandemic world where the coronavirus is still out there? Are we gonna have to continue to constantly be making these risk calculations or what might that look like? It's really hard to say for sure but what I imagine is likely is that there will be periods when we forget and where our attention is elsewhere as seems to be happening now. I'm in London right now and with the Ukraine events and other things COVID is really and the announcement of living with COVID as a official government policy it's really you can see a change. So I think there will be periods where people go about their business some more cautious people mask and some take other precautions. And then I think we have to assume a significant chance that there will be waves of future variants that make us have to go back to some of the more careful calculations and behaviors that people have been used to during the big surges in this pandemic. We all hope that doesn't happen but I think until we see a very long period of several years with no events and even then we might be still nervous. I think the public health world has to be on alert for looking for signs of upsurges but I think most people will have periods where we're not thinking about COVID all the time. Yeah, Mayor, initially obviously when we were still learning about the coronavirus and the pandemic had just started there were a lot of changes to the way we lived that were supposed to be temporary and some of that definitely were like lockdowns or things like that. But are there any changes that you can see becoming more ingrained in our society and lifestyles going forward from your position as you think about sort of a population level? Yeah, Caroline, the way I look at it is that we whomever all of us are the billions across the globe will never be the same after this pandemic and the post pandemic world which we're not there yet but there is no doubt that we have gone through an incredible collective and individual set of experiences that means a lot for how we go about our daily lives. And so even if it's as simple as having a mask that we put on that many of us never thought we would be putting on in public settings or people are coming to your home and you're asking questions about their health I mean, how often do we do that at dinner parties where somebody would say, hey, gosh, I'm gonna make sure you get tested before you come into my home. I mean, these are things that have really transformed but even broadly and more collectively how we go about our business, telecommuting, teleworking, schools with and although it did not go so well with teleeducation but we do now at least have capabilities of being able to do those things. And obviously there's a big equity gap that we have to be mindful of. So I think we have absolutely transformed the other piece of this and Mark has brought this up as well a couple of times is in public health. And I do think about this very much every day as being a public health official and all these years of being healthcare and public health as an ED physician, it was always about quick decisions in public health, it was always about these long deliberative processes to get to a decision point. This pandemic changed that. We have not had that time to be able to liberate for the long term because the pandemic, the virus, something changed the very next day. So the reason I bring that up is that I do wonder what our field will be like in the future. I know there are going to be opportunities to be deliberative and methodical but I also think that our pace is going to be markedly different based on this collective experience of making decisions very quickly and even sometimes when you don't have all the information and you still have to make a decision. Yeah. So one group of people I'd really like to address and maybe Nicole, you could take this question is people who are immunocompromised and this was a frequent theme in the questions we got from the audience ahead of this panel. So there are a lot of people who are immunocompromised who feel like they're basically being left behind. That everybody is saying, oh, we're returning to normal but they may know that they may not have produced as strong a response to the vaccines or know that if they have a breakthrough infection that they're at much higher risk. So what is your advice for people who are immunocompromised and feel like they're being left behind here and what do you think is the trajectory for people who are in that position? Yeah, it is most unfortunate because at the end of the day, they are definitely more vulnerable and they will have to and they were more vulnerable before COVID and they remain so now but now there's a threat of COVID on top of everything. So I mean, obviously in close contact with their primary care physician and getting tested and not just vaccinated but if they can get tested or whether their vaccine actually produced a measurable result because it may take a number of vaccines more than the healthy person needs to develop this immune response. So if we make these recommendations about boosters about the particular in this group of immunocompromised about their actual response which would be very different from person to person this sort of more personalized medicine I think would be very important. And then talking to their friends and family about the importance of them basically being vaccinated and protected for that individual and provide this buffer around them so that their likelihood of getting infected is smaller. So there's really unfortunately no magic bullet of how they can be protected but those are some things that I think are really important. Yeah, thank you. I wanted to turn to the global picture a little bit. So Mark, earlier you mentioned large countries that may have populations that are still where there isn't a high proportion of vaccination. So how do global vaccine disparities affect the trajectory of this pandemic and sort of how different countries might experience the next year? Well, I think there are a few things that are clear and a few things that are harder to figure out. I think one of the things that's clear is that China in particular as the largest not very vaccinated and not very infected country is gonna have to come up with an exit strategy to reopen itself. I mean, just personally I know a number of Chinese expats who have had a hard time getting home to see family and that's not to speak of all the trade and other things. They can't maintain no COVID introductions policy but yet their vaccine uptake is low. So I think that that's just gonna be potentially, depending on how it's done, at least a big transition for countries like that and also potentially a source of new high levels of exposure for the rest of the world. I'll be at the rest of the, much of the rest of the world already being vaccinated. A different situation has occurred in places that have had little vaccination but have not closed their borders and much of Sub-Saharan Africa and some parts of Asia and elsewhere are in that category. And for those, I think the question is how much the immunity from prior infection is going to act like a vaccine, probably not as good as a vaccine and certainly not as good as the combination of prior infection and a vaccine but to what degree that will protect those individuals. Again, not from transmission and from seasonal epidemics and not all from severe disease but will lower this into a more normal kind of disease process that we're used to from other diseases that have been around for longer. Yeah, Ymer, how do you think about that? Do you think that you will potentially see a different level of threat from COVID in different countries going forward? Like I think about how, there's some diseases like malaria is endemic in some countries but not in others. How could this play out in different countries across the world? Well, Carolyn, I think we don't even need to look at the future path forward. I mean, it's already happened. I mean, we've already seen that play out and policy decisions that have been made that have led to a difference in outcomes. I do think we need to be very careful though when we do a cross country analysis because it is not an apple to apple comparison. And so I remember even when I was in Texas and people were trying to equate the population of Texas and the geography with other countries and it was very different. And now I'm in Washington and it's a very different geography here, obviously. And I do think to Mark's point, there are two things that are really critical. One is access to vaccines and the other is this really ongoing investment in access to healthcare. And I'm the public health guy. I'm also a healthcare person. And I know it's not all about healthcare. Obviously, I'm very much mindful of prevention and health and wellness and the overall collective piece that population help brings you. However, I do think in many settings that access to vaccinations and the access to healthcare, especially at a place where those factors are really driving outcomes, whether good or bad, are really critical. And so when you have countries like Haiti that has a markedly lower vaccination rate compared to a Canada, it really does lead to a number of different challenges. Not that they cannot be overcome, that they're insurmountable. But I do think what that leads to is all of a sudden this differential investment in health overall, then really leads to how do people then access healthcare and even those health services when you're in the midst of a pandemic or trying to come out of it. Yeah. A question I get a lot, Nicole, is what did booster requirements look like going forward? Is this gonna be something like the flu shot where we're gonna have annual shots to take? And what are sort of the inputs that go into that decision and how that's gonna look in future years? Yeah, I mean, currently what we do is we look very much at the antibody levels and everybody has been hearing that a lot about the dropping antibody levels and the need for a boost. And it's very clear when we give these boosts that we increase these antibody levels, although that also differs on patient to patient. And the question is at some point, they are diminishing returns of how often we can boost and expect to see an outcome. So that is a question that's said. This currently the recommendation for that third boost were very important and has led to really increased immunity. And that just last week were a couple of really promising studies coming out to show that that third vaccination for those that had Pfizer Moderna has really led to not only an increase in antibodies which do seem to bane over time but really the long lasting immunity, the changes in the immune response, the cells that can rapidly get activated if we get infected again. So may not prevent us from getting infected or prevent us from severe outcomes. And those are really helped by the boost. And then somewhat surprisingly, maybe the recent studies have suggested that adjusting the vaccine to make it Omicron specific actually didn't have the sort of expected beneficial outcome. So in contrast to flu where we adjust every year to the virus, it's not clear right now whether that also needs to happen for the coronavirus. Got it. Well, we'll be really interested to see what the data says as more of these studies go underway and also I know people, some people working on pan-coronavirus vaccine. So I think that's all. Yes, other countries such as Israel for example have gone to do a fourth shot for some and so we're awaiting to see whether this is actually long-term beneficial or not. Yeah, I have a question for everybody on the panel which is what have we learned in this pandemic that should help us prepare better for the next public health crisis, whatever it is? What are concrete steps towards a more robust public health system in the US? But, you know, Carolyn, I would just start with the investment in public health. You know, a lot of what we have seen that has played out during this pandemic been a lot of finger points that have gone towards the sector of public health and, you know, why couldn't you have done this faster? Why weren't those systems available? Why weren't the staffing to these levels? Or why didn't you have the right technologies? And that all goes to ongoing, you know, honestly this just value system where we have continued to value health care and to the detriment of investment in public health and investment in these very systems that are needed. And it is not a one time. So I'm very appreciative, for example, of the federal government that has said, okay, look, we're going to go ahead and get dollars into the public health system, but it has to be scalable. It has to be sustainable. It has to be strategic. It has to be smart. We have to really look at public health investment as an investment in community and investment in health and protection. And until we do that, we're going to continue to have this situation where no matter what the next pandemic or emergency or even the everyday chronic disease or what have you, we're going to continue to really not do right by our communities because we've just not invested and the value system is just not in the right place. Yeah. I'm curious in the conversations you've had so far, do you think people are getting that message? Because we've done this many times. I mean, there's the whole term of the panic and neglect cycle in public health. And, you know, after Ebola, money came in and then money went away. Do you think it's going to be different this time? You know, that's funny. I think you're asking me to install, you know, H1N1 Ebola, Zika, you know, multiple hurricanes, all sorts of emergencies, global earthquakes. I'll tell you, it is absolutely true that we react and we try to throw those dollars back in and say now we have solved the problem rather than being proactive about the capacity and capabilities that are necessary to have a robust system. I, at times during this pandemic was very hopeful that that an optimistic, yes, yes, yes, it's going to happen. This is the one. And the more that I really think about this, I think about it from the standpoint of there are two ways to end this pandemic. One is what I call transactional, that it's one and done and we sort of wipe our hands and we, you know, move to the next headline. We, as Americans, are very good at that. What's the next big shiny object? The other is to be transformational, is to say what are the collective experiences and what have we learned? What have we experienced? And put that back into the hopper for the future and really transform our systems. If I went to Congress today and said, I need more dollars for epidemiologists or contact tracers, I would be laughed out of the building yet a year ago, that was exactly what the dollars were coming for. So I am actually now not as optimistic as I was previously, but I do think we still have an opportunity to be transformational. And if we do that, then absolutely we can go there. But I'm just maybe beaten down a little bit from this two plus years of responding. So honest answer. Yeah. I think the building of trust is really important. One of the most frustrating things to me was that I thought it would take us a while to get the vaccine and we need to sort of tie ourselves over and maybe the vaccine we get is not really that great. And all of this didn't happen, right? We had this fantastic vaccine. We have these fantastic vaccines and there's a considerable doubt of whether that vaccine really is as good as people say it is and what it could do. And so, and I think it is because we need to have a constant voice that people trust that when they make heads for commendation that these are seen as not political, not coming for a particular reason, not to make money or really part of the normal message. And then when something like this happened that people will look to that entity. And I think the sort of CDC used to be that voice and it didn't play that voice this time. And we need to get that back, I think. And then I think we would have more people trusting that what is being recommended will actually be done and is for good reason. Yeah, Mark, what do you think about steps for the future changes we should make? Yeah, well, I think a lesson that's really in a way the same one as Nicole's mentioning but has another dimension is the importance of leadership. And especially in our country that lack of trust was a direct product in part of divisive leadership at the beginning. And I think once the diet was cast it's been very hard to undo that. I think the other piece that I'm very enthusiastic about in my other role as I'm on loan this year to the CDC to help set up a new center for forecasting and outbreak analytics. I think the role of data and the ability of data to move from the states to the federal government and back again, the ability of systems to talk to each other is really critical for making better decisions. And that doesn't just mean figuring out how to interrupt people's lives more. It really means figuring out when to stop interrupting people's lives just as much. I'm in the UK right now and I've come in order to learn what they did to set up really the world's best studies of the community transmission and other aspects of COVID and the degree to which they've linked their clinical, their census and their genomic data is just extraordinary. And I think that is the way that 21st century pandemics can be fought but we have a long way to go in the United States. Well, the bar is low. I think a lot of my readers were really surprised to hear how many health departments run on fax machines in the United States still. So you're right that there is a long way to go there. Great, I think Connor has joined us at this point to bring some of our audience questions. Yeah, now we're gonna pivot to the audience portion of the event. Before we do that, just quickly, I dropped in a link to an event survey. If you wouldn't mind just taking a few minutes to fill that out, we'd really appreciate your feedback. But now on to audience questions. So sort of sticking with what Mark was just saying about improving data and our use of it. Umair or Caroline, this question could be for you. As we do enter this new phase of COVID, how will public health metrics evolve in this next stage? And what will we continue to use case rates to determine mitigation measures? Nicole, you want me to go first? Yeah. Yeah, I would say that we do know that case rates are important. They are a number though of other metrics that are there. And the reason I say that is the more and more we work to decentralize or empower people to get tested at home or to have a way to do rapid tests to make individual decisions, we have less and less a picture of what's occurring. Now, over time, you can monitor the number of at-home tests that are ordered and maybe more like a syndromic surveillance to use that as we did previously with antipyretics and say, okay, acetaminophen or Tylenol or aspirin and try to follow that around. But really honestly, what happens is that we get less and less a picture of what's happening. And so really it's this transition to more of almost as we've done with influenza, a targeted focus surveillance system that really to Mark's point about analytics that it really is very much not as individual human dependent as it is the actual machine learning if you will, the AI aspects of it that really allow us to really determine what's happening. I think genomic sequencing, which is something that we in state of Washington are very much one of the leaders with our genomic program with our laboratory. I will tell you that that is also a sequencing aspect that for the future. So there's a lot that is very much about where we're going but I think as we see a lot of these metrics, these requirements and mandates come off, a lot of public health officials are really looking at hospital metrics and healthcare metrics rather than the case rates and Omicron obviously showed why that was not as important. So maybe that helps and maybe Nicole has some additional thoughts on that. Yeah, I think the testing is, I think the sequencing is really what is so important and the collection of data point throughout even when we think there's nothing going on as we saw, unfortunately South Africa was sort of punished for actually coming up with these sequences of the Omicron early on. But we need to maintain a grip on the circulating viruses and the variants that are coming so that we know why this comes. Unfortunately, right now that we sort of after the fact, we know it's there and then it's already too late because it has already spread. So if we could get ahead of it rather than running behind and just confirming that what we are already seeing us and that would be very useful and taking a chapter out of the flu, what we're doing with influenza where we have set up these surveillance systems so that we can see what is happening in the different parts of the world. And then maybe develop a new vaccine or have other strategies or alert people ahead of time that it's time to maybe change behavior again. That will be our idea. Yeah, and I would just like to add, I think case rates were the best we had in most parts of the United States. They're not the best indicator either because of all the things that go into who can get tested, how long it takes, whether the test is sensitive, et cetera. And really the gold standard is again what the UK did which is to have random samples of the population tested at intervals. And that's what they used for surveillance. Their case rates were a secondary consideration by far. And that's not that hard to set up. It costs money, but it's not that hard to set up but it has to be done carefully and with some design in the process. Thank you guys. And just as a reminder, if you have a question, if you just click the Q and A kind of at the bottom of the screen, you can type it there. Sticking with you, Mark, someone asked in the chat, given the Omicron spike we saw in December, do you think we've reached the herd immunity needed to make this an endemic virus? Yeah, that's a question that I get a lot in different forms. And I think one thing that's really important to, well, let me first answer it. I think possibly so for the moment, but for the moment is possibly on the order of months, not on the order of someone's lifetime. And the reason I say that is that we're used to thinking about herd immunity in the infectious disease world as something where immunity from a prior infection or a vaccination is almost complete and lasts for many decades. And that's immunity to transmitting. Herd immunity depends on immunity to transmitting the virus, not just immunity to getting sick. And we've seen with COVID that as time passes and as variants emerge, and especially with the combination of say people whose vaccination or probably to some extent prior infection, although it's less clear is old and they get Omicron, they're not as protected. So herd immunity is not like a place you get to and stay. It's a place that we're constantly moving up and down on. And so we may be at a very high level of herd immunity now, but that doesn't mean we'll stay there. And so that model which makes sense for measles and mumps and rubella and a lot of other things really doesn't make sense for a disease that's where the vaccine, where the immunity is less long lived. And that's why people get coronaviruses every couple of years or every several years with the normal endemic ones that herd immunity does not ever get reached permanently. Nicole, do you wanna weigh in on how this latest surge? Yeah, and I think in part it has to do also with the vaccines that we have are fantastic. I didn't do saying for what we call systemic immunity. So that's immunity that sort of protects your body from harboring the virus for a long time, but it doesn't provide the immunity in your nose and the upper respiratory tract that is required for preventing this infection. And once you get infected, you replicate the virus, right? And so maybe, and so there are some attempts right now to maybe have booster vaccines that actually will induce that immunity. The problem with that is we don't know how long lasting this local immunity and the respiratory tract in your nose is. And so whether this idea of herd immunity that you can really prevent this virus from coming in, whether we can reach that, whether we have this long lasting immunity the system in the respiratory tract to actually make that possible. And sticking with you, Nicole. So flu has been an endemic virus that kills unvaccinated people every year. Could you compare and contrast what a COVID-19 endemic environment would look like compared to the annual flu? Yeah, I think what, I mean, coronaviruses can infect, of course, and we know that our pets and other animals, but the kind of nature of flu is that it lives in these foul populations and which is generating new influenza viruses every year. And so we are, for that reason, testing always what is coming out and often we get it right, but sometimes we get it wrong, right? And so, but we know about when it's coming, right? It's coming in the winter months. Right now the coronaviruses we see come every three months. I mean, that's about what it is. And so we don't know, we don't know why there is this interval. We don't know whether there are animals that are actually harboring it. And so I think that we are not at a point yet where we could really know whether it becomes like flu. And then the final point I would like to make is that when we think about flu, we are thinking about, you know, mild respiratory infections and so on. But for everybody who lived in 2009, we had the scare of the last influenza re-assortment. So that flu virus looked quite different from the one we had the years before and we didn't have pre-existing immunity. And so we would have these scares where we don't have the vaccine that doesn't really work. So of course, and that could happen with coronaviruses, of course, as well that we get relatively mild infections and then we get these mutants appearing. But right now it happens so frequently that we are far away from what we have with flu. Thank you. And then, Umair, I wanted to bring you back in. Is there good transnational information sharing among public health professionals about outbreaks and variants? And if not, where is this still falling short? Yeah, Connor, thanks. You know, again, this is where the investment in systems and investment in public health come in. And Nicole mentioned earlier, you know, the role of the CDC is not just to be the public health leader in the United States or in the domestic realm, but it is to be our conduit of information on a bi-directional manner with our global partners. And then obviously the World Health Organization with WHO has traditionally been where we also look at the global umbrella organization, if you will, that then allows for transfer of knowledge back and forth. But I do also say that we have learned a lot during this pandemic, but even prior to this pandemic, we recognize the importance, again, of those technologies that would allow for transfer of information across borders. Look, if a virus or a bacteria or an infection does not know borders, neither should our public health response to the information sharing. And so we have to match the threats that are upon us. And if we are not going to be able to match that, if the virus goes faster than us or information travels faster than we're ready or capable to be able to process it, then shame on us because we're never gonna be at a point where we're gonna be able to respond to very quick in time emergencies and threats to our population. So yes, that system is in place, but I do think there are opportunities to improve on those systems. And I did wanna make one additional comment, Connor, which I did wanna nestle in somewhere, which is that we have also learned another aspect, which is the importance of communication. And I know that all of us believe in science, all of us believe in the importance of data, all of us the importance of, how do we share knowledge? But we, and I'll go back to my own training and from medical school, residency, fellowship, I can really count on maybe a very small finger, the amount of times that I had a formal discourse in communications, in debate, in dialogue, in how do you really speak to people who don't always agree with you? We get that in the patient setting, we don't always get that in the population health setting. And why that is so critical is that I do believe that we start with science, but we cannot end with science. We have to be very good at translating that information and the currency of trust with the communities because we are of those communities. And I think that's where we missed the boat. So when in Washington, a lot of folks were concerned about vaccinations for kids, I didn't start with I'm the Secretary of Health for the state of Washington or as an ER doctor or as a public health professional, I started with as a parent. And I think we missed that. And oftentimes we are told not to bring that into the mix. And I think that's what then further separates us from the very people that we're trying to connect with. And that also includes on social media, of course. Thank you. Just to get back on the international thing, I think it's worth calling out the very good example of South Africa providing to the world in a very rapid and comprehensive and sophisticated way, the information on Omicron followed very quickly by careful analyses of what its potential for spread was because they happened to get it first. That was a remarkable decision that was like many good decisions rapidly punished by closures of borders that probably long outlasted their usefulness in much of the rest of the world and caused harm to not just South Africa but much of Southern Africa. And fortunately that harm was temporary and the borders have largely been reopened. But I think, A, the fact that it was South Africa and not many other countries was fortunate in the sense that they had the infrastructure to do the work and share the work. And also that we need to change the incentives such that countries don't get punished for such valuable warnings that they provide to the world, yeah. And a lot of people wrote in concerned about long COVID. Nicole, I was hoping you could speak to what looms as a post pandemic COVID-19 generated health effects. Are there things you have your eye on? Well, I think what it demonstrated is that there's long-term effects after an acute infection are real and not in people's heads. And there are many diseases where we have observed that and it's more anecdotal because the numbers are just not there. So I just bring up Lyme disease which is one of those examples where people are often told it's all in their heads, right? Having so many people infected now. And with that, even if it's a small proportion of those that have these long COVID symptoms it is a large number of patients. And now we have a group of patients that we can study and that have been studied. And it is very clear that these are real effects. And so we are beginning to see a pattern of what underlying conditions are that are associated with this long COVID, comorbidities such as diabetes which have been long identified to make COVID worse. And some we can't do anything about but one of them is the how much virus is actually in the blood and that of course has to do with our vaccination status and our immune status that is also non-aligned. So that is one thing we can actually work against it so and can prevent by getting vaccinated. So that will be my recommendation that it clearly seems to have an effect on the number of people that are developing this long COVID. But I think this is going to stay with us for a long time. We have to figure out what we can do for these patients that is more than just symptomatic treatment. And I think there's a lot of research that needs to be done. And going back to Mark's research on the UK health system what are the main pain points blocking the US from centralizing health data across symptoms in your view? Across systems I think you meant. Well I think the main, there are a number. One is the one that's hardest to solve is the fact that we have many healthcare systems and for some people we have no healthcare system rather than one. And so the payer and the provider are in most cases separate which means that there is nobody who has really comprehensive records on most people's health that are easy to, well the people have figured out ways to standardize and make sense of. There's a lot of good work going on in trying to make electronic medical records more useful but because there are so many different kinds that's a big challenge in so many different systems. So I think that's one. I think the second is that right now the state public health systems and the federal public health systems don't share as much data as they could. And the states are in many cases free to share or not share with the federal government and that makes it harder from the federal perspective to have a national picture. The final thing I would say is that a lot of what the UK has succeeded in is linking different kinds of data and we don't have a system for doing that yet although the CDC is working on trying to link certain kinds of data that are in the public health system and just haven't been properly linked yet. So I think there are some very bright spots but I think a combination of continuing these efforts and for pandemic preparedness planning to set up random samples of the population to understand what's going on in future pandemics is kind of the best way forward. Great. And then this will be our last question. So what is one thing you wish everyone knew and this is for everyone? Is there a common misconception that you like to clarify or a take home message for our audience? What would you say? I can start because we're throwing this at everybody without and I'll give you some time to think. I have two thoughts. One which is as we've heard from our experts today this pandemic has exposed a lot of existing flaws in our healthcare system that we knew were there the experts knew were there but maybe we hadn't paid attention to which range from underfunding of public health as you may have said inequities in our system in terms of health access and a lack of technology and communication as Mark has said. And my hope is that even though everybody is eager for this pandemic to end that we will not miss this opportunity to learn from this and be ready for the next healthcare crisis because another one will come for sure. And my other thought as a member of the media here which I think was touched on also when Nicole talked about trust is I think we have often underestimated the audience. This is both leaders and reporters like myself because we've oversimplified messages to say things like don't buy a mask. You know, when the concern was really like we might not have had enough supply and we presume that the public could not understand nuance. And so I think that is something that I've thought about a lot. You know, how reporters can help convey clearly nuance and I don't know being a fair answer and that's something I will definitely be taking forward with me. You may. Yeah. I mean, I think you, great. You're eloquent and now you throw it to me. You know, I would say all of the above, you know, and I agree with all of that. And I would also say that the, this pandemic is not over and we are continuing with the headlines that look things are better and then everybody just stops doing the things that are making it better. And now all of a sudden we get back into trouble but we also should take the lesson away that there's so much that we have to do to invest in the true long-term. And if we believe this is the last time we're going to have this kind of a situation shame on us it's happened like you said before Ebola, Zika and all sorts of other even H1N1 and way prior to that and we've had all sorts of opportunities. Let's not lose the fact and the site of the fact that this is going to continue on for our path forward is really requiring us to continue to invest for the long-term. Yeah, what I would say it's became very clear that you can't act alone and that you have to act as a collective. And I think we have failed acting as a collective. And I think it has come to our detriment to do so. We haven't vaccinated everybody. And so we have Omicron emerging from Africa a continent that has a very small number of vaccinated individuals. And even in this country we haven't really acted as a collective. And I think if we wanna be better prepared and look better and have better outcomes for the next pandemic we need to understand that we can only beat this as a collective. Well, I'll end on a slightly upbeat note which is not my usual note, but I think if we had had this pandemic in 2015 I think vaccines would be just coming around maybe around now. And it was investments made by the scientific community by pharmaceutical companies to some degree but especially by NGOs and by government research entities that decided that we needed to be prepared with vaccines for the next pandemic. And as it happens, they were lucky to be working on mRNA platforms and on coronaviruses. But that bit of foresight really paid dividends and as many bad things as we can say about this pandemic I think it probably bought us, I'm guessing but around a year of 2021 being a nice, partly nice year instead of another horrible year like 2020. So on that note, I think the things that everybody's been talking about about improving our communication, improving our preparedness on data, improving our preparedness on public health resources and improving, building up the public health workforce. All of that is really evident lessons of this pandemic just as the need for rapid vaccines were evident lessons from the Ebola crisis of 2014-15. So I hope that we can replicate that success rather than the cycle of neglect that you talked about earlier. Yeah. Thank you guys. Well, that's all our time for today. I wanna thank each of our panelists, Umair, Mark, Nicole and our moderator Caroline. Thanks to McKinsey and company for their support and to our media partner stat. And of course, a big thank you to everyone who joined us for this important conversation.