 Good afternoon everybody. I'm honored to welcome you to the 27th lecture of this year's annual lecture series on ethics and the COVID-19 pandemic, medical, social and political issues. This series was organized by by Laney Ross and Brian calendar, Marshall Chin, and I was part of that also. And today, as you know in the final lecture, 27th lecture of the year, our speaker will be Brian calendar MD. Brian is an academic hospitalist and medical educator with academic interests in global health, the inpatient hospital experience, clinical education, and medical humanities. Brian is the University of Chicago, half lifer, having attended the college as an undergrad, completing the master's in social science program before matriculating at the Pritzker School of Medicine. Brian also completed his internal medicine residency training here at the university, after which he joined the section of hospital medicine. Brian calendar is a graduate of the medical education research, innovation teaching and scholarship, the so called merits fellowship, and also of the McLean Center, clinical medical ethics fellowship. Brian is a core faculty member of the university's Stefano bitch Institute on the formation of knowledge. And the Brian also serves as co director of the global health track of the scholarship and discovery curriculum here at the Pritzker School of Medicine, and teaches a course entitled global public health. Burgeoning interest in clinical experience and in the health humanities has led him to develop a number of courses that explore ethics in the humanities that that those courses include, and I'll just read you some of them. Body in medicine and the performing arts. Second, graphic medicine concepts and practice. Third, death panels, exploring dying and death through comics. Fourth, the art of healing medical aesthetics in Russia and the US and fifth narratives and aesthetics of contagion knowledge formation and covered 19 formation. Currently Brian is teaching the course on graphic medicine. He's interested in how the health humanities can improve the patient experience, the provider patient relationship, and also how it can improve our understanding of the practice of medicine. The interest in the visual culture of medicine has resulted in the co curation of two exhibits at the university's library special collections research center. One of the exhibits is called the imaging and imagining the human body in anatomical representation, and the second one is called the fetus and utero for mystery to social media as a medical director for the advanced practice Brian supervises advanced practice nurses in the care delivery of general medicine, cardiology and post procedure patients. In this role. He's interested in clinical education, professional development and inter professional education. The talk today. As I said the 27th talk in the series is entitled quote, the carpet 19 pandemic past present and future. It's a great honor to welcome and to introduce you to Dr Brian calendar, Brian. Okay, thank you Mark. I'm going to do my screen share. So hopefully everyone can see that. Yes, so thank you very much Mark for that introduction. It's quite an honor and a pleasure to be here to present. What is the final lecture of this 2020 2021 McLean Center ethics series on the COVID-19 pandemic. And so to get things started I have no financial disclosure is related to this talk. Right. So if we think back about sort of how our minds were, we're thinking, you know, a bit over a year ago, like, our minds are probably sort of modeled like this right, but there's so much going on at the beginning of this pandemic right. And if we sort of look at this meme from early on in the in the pandemic. Right, I think this is sort of what our lives felt like right that on this y axis you could put angst frustration time spent consuming pandemic news time spent wasting time or just our life drama in those are in that early period of the pandemic right. And I became really interested I think probably like many of you with how did, how do, and how will we make sense of the COVID-19 pandemic. Right. So this has been a sort of driving question on my mind. When I came to be thinking about how I would teach this right that during the spring of 2020. And as Mark mentioned, I was teaching a course with a colleague of mine MK Sirwick on death on death and dying through comics and we had to sort of reconfigure and think the course within the context of a pandemic. And then I subsequently taught a course with Bill nickel called the narratives and aesthetics of contagion that dealt with knowledge formation in the COVID-19 pandemic, and additionally did some some sort of scholarly writing on the as well, all of the sort of idea of trying to think about a framework in which to think about the pandemic. Right and think about some of the stories that that we may tell. And this to sort of played out in organizing and the lecture series in which this is the last lecture of right that there are so many topics that could have been part of this lecture series. But we wanted it to make sure that it had some driving themes that at the time that we were, we were putting this together, we thought would be important. And these included resource allocation health disparities. We wanted there also to be a historical thread as well. And then touch upon topics that that that we're going to be relevant to our everyday lives, like surveillance, like school school reopenings or school school closings. And so those are some of the driving themes around this lecture series. But the idea that we wanted to hopefully capture and tell the story of what was going on during the pandemic. Again, not knowing where the pandemic would lead us up until this moment, right. And so, right to just think a little bit about where we've been and what we've experienced. Starting in June was one of your really think we sort of organizing this, this, this lecture series. And we think about the numbers back then we had passed surpassed in the US over 100,000 deaths and 1.82 million cases. Right. The first lecture by Emily Landon in October, at that point, we were at 212,000 deaths and 7.56 million cases. And if you think about what happened since that time with a very contentious election. If we go to January 6 the sort of insurrection at the Capitol. Where were we at on March 11, when it was the one year declaration from the WHO that this was was indeed a pandemic. And then where are we currently recognizing to that over the course of this period there were there were sort of significant social and racial protest during during the course of the pandemic. Right. And where we're currently sit now globally. Right. We're 3.3 million deaths, which is probably an undercount, as well as 159 million cases. Right. And we've all lived through this and we've all experienced this in one way or another. And if we think about this and look at this graph. And what that may recall in our own as you know personal as well as professional pandemic stories. Okay. So the objectives of this talk are to present the COVID-19 pandemic within a framework of a multi scalar narrative. Like I said, one of the things about teaching the pandemic and thinking about putting together this lecture series was how do you tell the story of what we're experiencing. And the other objective for this talk is to broadly understand the role of ethics as a constitutive part of the COVID-19 pandemic narrative. Okay, so the outline to do that is I'm going to talk about the outbreak and pandemic narrative sort of asking the question of why do we tell stories and what are what are those stories tell us about ourselves. When we think about the pandemic as a narrative. But then I also want us to think about the pandemic as a multi scalar phenomenon and just define the concept of scale, because that becomes important how we might think about the ethics at a broad scale during the pandemic. In which case then I want to move on to think about ethics in the COVID-19 pandemic and situate and articulate ethics within the multi scalar narrative of the pandemic, and hopefully then leaving some time for for reflection. So, I really like to think about the question of what have been what are and what will be the stories of the COVID-19 pandemic. And the reason I ask myself this is, is then to ask the question of why do we tell stories that stories help us make sense of and understand our existence. They are both a form of meaning making as well as a form of memory making. Now, this then raises the question of why do we choose the stories that we tell about ourselves right that we tell stories and we choose the stories that we tell. Narrative, in many ways becomes a form of identity, that the stories that we tell about ourselves, both reflect and shape who we are stories may be a form of self identity. In particular the sort of individual stories we tell about ourselves or our experiences. But they also to reflect and shape a social identity. When we think about how social, political and cultural context determines and shapes the stories that we tell. And then additionally, they represent a historical identity, right, that the story that we tell now, how are they connected to our past, but then what do they project into the future. Okay. And so, in thinking about a narrative framework related to the pandemic I've drawn from two to primary sources one is is Charles Rosenberg sort of now, you know, notable article. What is a pandemic aids an historical perspective, and then the work of Priscilla walled in her book contagious cultures carriers and the outbreak narrative. So first to turn my attention to sort of Rosenberg's work that he notes sort of famously that the epidemic has a dramaturgic form in which it starts at a moment in time. It proceeds on a stage limited in space and duration, then follows a plot line of increasing and revelatory tension that moves to a crisis of individual and collective character character that then drift towards closure. Right. So this is kind of the broad sweep of the pandemic narrative. Right. And in terms of just sort of definitions what he means by drama tragic is it's the art or technique of dramatic composition and theatrical representation. Right. The idea that historically the events of a pandemic follow a predictable narrative sequence. And it's a particularly dramatic narrative sequence. And he goes on to divide us up into sort of three acts with the first act being that of progressive revelation. And this is the idea that there's the initial appearance and gradual recognition of the intruding disease that in in some extent is a failure of imagination. Right. This is where if we go back to sort of January February of last year. Right. So we recognize that something was happening. You know, in China. But did we fully prepare for it and were we fully prepared for it may be an argument that we failed to sort of imagine what this could become. But then admission of the of the pandemic comes when the presence becomes unavoidable. Because to admit the presence of an epidemic disease was to risk social dissolution. Right. I think for many of us that we can go back to sometime in March of last year. When we were went to remote schooling, or we went to remote work that that now are sort of that our regular social routines were now breaking apart when we had to fully and truly recognize the risks and threat of the pandemic. And so then follows as managing randomness. And this is where we sort of try to find agreement on an explanatory framework. Now the historical trend of this explanatory framework tended towards spiritual and religious explanations to now are sort of contemporary biomedical explanations. The medical explanation suggested that physical and risk enhancing effects of behavior style of life and environment exist around the pandemic. And this is important because it allows for a number of things. What it allows for sort of social criticism, especially when we think about those that may be responsible for spreading spreading the pathogen. It also serves as a rationale for social control. Right when we think about sort of modern epidemiology and our understanding of our understanding and explanations of communicable disease allows us for social control of that condition. Right. But then what it also did was provided promise of control of the pandemic that if we know how a pathogen spreads and isn't transmitted. We can take that spread to certain certain measures of control. So that's act to act three then is negotiating public response right that once we sort of recognized in the recognition of the pandemic, it generates decisive and visible community elements that are acted out through rituals, collective rights, integrating cognitive and emotional elements that all serve as a visible acting out of community solidarity. Okay. And this sort of appeals to sources of authority, in terms of who who might be telling us what our rituals or collective right should be. Now the content of public rituals provides insight into social values at particular times, while conflicts over priorities among them provided insight into structures of authority and belief. Right and I think this is important to think about, because these sort of conflicts are or contest stations are sources of political populist and in the sort of context of this series, ethical conflict for us to think about. So, those are the three acts that Rosenberg sort of describes, and then he goes on to say, sort of somewhat famously that epidemics ordinarily end with a whimper, not a bang. And this is sort of interesting to think about in that will this hold true for coven 19 that that are we living the whimpering end of the pandemic, at least in the United States when we look at some of those graphs. Right, he also notes though that epidemics have always provided occasion for retrospective moral judgment, which raises the questions then, how will we judge our actions and responses to the coven 19 pandemic. And what judgment will future generations cast upon this pandemic. Well, it's important to note that that when Rosenberg wrote wrote this article that it was written in the context of the HIV AIDS pandemic, in which the epidemiology and the temporal aspects in terms of both duration and pace are quite different than the current pandemic, right, that the pace of this pandemic has been pretty remarkable in terms of the extent to it, the extent of it and the degree to which it's sort of affected our everyday lives. He also notes within the context of the HIV AIDS pandemic that the great majority of Americans have been spectators in, but not of the pandemic. He notes that the HIV AIDS pandemic was a media reality for most people, which to me sort of raises the question of how does the fact that we are all directly impacted by the coven 19 pandemic change our perception, right, that in many ways we are both spectators of and participants in the pandemic. And so, the other thing he says to is that epi or pandemics remind us of our mortality. And he brings up the issue of, of the narrative feedback loops that we may have watched and continue to watch about death counts and case counts and what sort of narrative feedback that that create that was a constant reminder of our mortality. And note, he states, he notes the parallel between the biologically determined chronology of an epidemic and its social chronology so so the sort of the dramatic narrative that he lays out he notes is a social phenomena, in which that you have an increasing steep curve of case incidents. And the exhaustion of susceptible individuals and the gradual decline in mortality and morbidity that on the other hand just parallels the social pattern of gradual recognition, negotiated response and gradual decline. And so how does this relate to the various graphs and data visualizations that we have seen during the course of the pandemic. Mark mentioned one of my interest is in sort of the visual culture of medicine, right, and that when we look at these graphs while they're telling us something epidemiologically. They're also telling us something about our lived experience, both individually, but also collectively about the pandemic. As we live through surge one and surge to, and then surge three, and then search for right that there's a certain drama that unfolds there's a certain certain certain story that gets told in these graphs that we have all lived. Right, and we can think about that sort of emotionally that if you sort of take the flip side of those graphs those epidemiologic graphs we might have to something emotional graph like this. And it's interesting for me to think about where are we currently at emotional, either as individuals, but also collectively on an emotional graph like this, as we're now more than a year into the pandemic. Hopefully, at least again in the United States that we're at the whimpering end. Okay. So Rosenberg lays out the sort of broad idea of the pandemic narrative as as a drama as a dramatic narrative. The work by Priscilla walled further provides detail to that narrative. Okay, that that her work sort of comes out a lot of the nonfiction and fiction works that came out of the sort of the late 80s 90s into the early 2000s that were concerned with emerging infections and emerging infectious diseases. That she notes that the outbreak or pandemic narrative is an evolving story of disease emergence, whose repetition of particular phrases, images and story lines produced a formula that was amplified by various media. Right, so if you just look back at the last 2530 years, every time there was sort of an epidemic. What were some of the images some of the phrases some of the stories that were produced. During those epidemics can whether it was Ebola, SARS, MERS, you know a whole host of them in which various phrases images and story lines produced a formula that we are now in many ways living out as well. And this narrative highlights our fascination with dangerous pathogens and the changing social formations that that result from an epidemic or pandemic. Contagion not only sort of as an epidemic is an epidemiologic phenomenon, but also in the context of the pandemic, how it's concerned with how beliefs circulate and social interactions. And I think this is particularly germane to where we are currently in this pandemic when we think about the infodemic and the circulation of misinformation or disinformation, right, that there are two forms of contagion going on here during this this pandemic. So she defines the outbreak narrative as sort of in its scientific journalistic and fictional incarnations. It follows a formulaic plot that begins with the identification of an emerging infection includes discussion of the global networks through which it travels as sort of a commentary on our on our global modernity. And then it chronicles the epidemiologic work that ends with its containment. Now this is a compelling story of the perils of human interdependence and the triumph of human connection and cooperation. Scientific authority and the evolutionary advantages of the micro ecological balance and impending disaster. Right. So this is how she sort of defines the outbreak narrative. Epidemiology is really important to this narrative. Right, because the epidemiologic work of the narrative registers the particular spaces and interactions of global modernity. Right, that that our current pandemic, in terms of thinking about the pace of it will not have been as as as fast, unless it was for sort of our global modernity and our global networks and the speed at which goods and individuals travel around the world. Okay, so our response to the pandemic reflects our attitudes towards social interactions, as well as political and scientific authority, and then individual and collective identity. That the epidemiology again depending on how it's used and deployed and interpreted can promote and mitigate the stigmatizing of individuals, groups, populations, locales again whether those are regional or global, as well as behaviors and lifestyles, and they certainly can change economies as we've experienced during this pandemic right and this becomes important to the narrative in the sense of the, the idea of other that that happened during the course of this pandemic with our politics as well. Right, the idea of stigmatizing a country or individuals for their practices that has led to the pandemic. Okay. And so that's some of the work that epidemiology can do, but you when used in ways that can be othering have potential damaging effects. What the epidemiology further does is provide a methodology, a language and a framework for the narrative, a framework narrative for the broader pandemic narrative. Right, if we think about just some of the aesthetics that we've seen during the course of the pandemic right the epidemiologic aesthetics that partly tell the story of what is going on. Whether it's describing and depicting are not right that how an infection spreads through a community, or whether it's you know this this sort of now iconic graph of flattening the curve, right that that with or without protective measures, where does that leave us in the in sense of the epidemiology and the peak of the of the pandemic. So, importantly, the pathogen traces our interactions within our communities globally and ecologically as concepts and actual spaces, and in doing so it articulates two important things right when we think about tracing using epidemiology to trace the pathogen through our communities that it does two important things. One is it articulates our responsibilities in those relationships. And these these this could be our human animal relationships, when we think about the pandemic starting as sort of a zoo, not a zoonotic transmission. When we think about human environment relationship that often plays a part in emerging infections. And then certainly we've all been living sort of our human to human relationships and how we go about our day to day interactions with one another, and what responsibilities do we owe to one another. Right. Now the other thing that tracing the pathogen articulates is our beliefs and behaviors that reflect our values and ethics. Okay, and this certainly has been part of the discussion over the course of the lecture series right that what are beliefs and what are our behaviors and how do those reflect our our ethics. Now, the other thing to think about in this pandemic is sort of the idea of belonging, you know, that the idea that a common susceptibility of all people attested to the common bonds of humanity. And this is sort of one of the things about sort of a novel pathogen that if nobody's been exposed to it before, we are all susceptible. And the idea that it's a great equalizer often often is sort of a term that is used and we know that's not true that some people are able to weather a pandemic better than others due to having more more resources, but there's this idea that if we are commonly everyone is susceptible. What does that mean. Okay, that if we are all susceptible susceptible. How do we go about then defining at risk populations. The potential workers. Right, the pandemic because we are all susceptible will forced us to sort of define our tartly circumscribed circumscribed social circles right who was in our pod who are we interacting with over the last year. You know, when would we let somebody else into our tight social circle, and what were the conditions under which we would let people into our tight social circles. But we also had to sort of define who are the carriers and who are the vectors. And in the case where we're all susceptible we're all at risk at being in danger from from these various vectors and carriers. And this also becomes important because susceptibility becomes a label as immunity within the community develops right if you think about the SIR model and going from susceptible to infected to recovered as we try to get us all into that recovered box we create populations that are susceptible and those that that are immune. And this has important epidemiologic and societal implications, as well as ethical implications when we think about the discussion around vaccination and immune response force, right, that we create categories of people we label categories of people based on their immune status. And it goes without saying though that the threat and routes of the pathogen reconfigure communities in the social order right we've all experienced this over over over the last 1415 months right that the pandemic has reconfigured our communities, reconfigured communities, think about communities, as well as the social order with within those communities. Okay, and just to sort of outline very briefly just sort of thinking about the pandemic narrative and who are some of those characters in it. Right, we have the animal or animals from which the pathogen emerges. That's part of the sort of early story. We have the pathogen itself. Then there's that index case or patient zero and it's important location of origin. Then there's the pathogen and disease carrier, and this could be a healthy carrier or a sick carrier. There are innocent susceptibles. Then there are heroes and villains and those heroes may be epidemiologists and scientists, healthcare and essential workers public officials, and the villains in this in this narrative maybe quack pseudo conspiracy theorists and media figures, public officials as well, and rogue scientists right. We've seen all of these characters play out over over over the over the last couple, you know last year year year and a few months right. And so, I want to focus a little bit attention on the disease carrier though, right, with the idea that the disease carrier as a threat. What happens when the threat is ourselves, right, that that one of the challenging things about this pandemic was the asymptomatic carrier, right, that we could all potentially be threats to those in which we socially interact with. And so this raised very important issues and questions about our obligations to others. And raised the issue about sort of the everyday ethics of our routine interactions, which really did reflect our responsibilities to one another, but it also may have reflected our sort of values, and what we believe about individualism versus community. Okay. And so the other thing that this brought up to us, how do we label these threats, and how did the media label these threats. So, so, you know, when we think about those who hold or those who attend super spreader events. When we think about anti maskers what do we think about them individually but how are they portrayed in the media, depending on what information ecosystems, you were you were obtaining your information from. And similarly, we're having a lot of discussion now about sort of anti vaxxers or a vaccine, you know those who are vaccine hesitant. What do these labels mean within the context of the sort of broader narrative that we're thinking about. The other important thing about the pandemic narrative is regulation, because epidemics dramatize the need for regulation that control and containment of the pandemic. Requires policies and practices that regulate individuals and communities in such a way that the role of the authoritative scientific, political and governmental figures take responsibility for enacting implementing and regulating behaviors. And some of the, you know, these figures they may be the villain or they may be the hero. Right. And we've seen globally, both the populist approaches to the pandemic, as well as technocratic approaches and, you know, I don't have time in this discussion to sort of talk about the differences between those but it's really something to sort of think about within this pandemic and how this pen the story of the pandemic will be told in the future. This also raises the issue of sort of bio ethics is bio power. And I don't have sort of the intellectual capacity to really get into this at this point, but it's just something to think about in the context of how ethics played out during this pandemic. So, just to sort of sum up the key points of the outbreak or pandemic narrative right the key points being, there's the emergence of a pathogen in which we race to identify it, and it's epidemiology. And thinking about the impending and spreading threat, our scientific and medical treatment and cure as part of that narrative, our efforts to contain it, and then how do we come to some result resolution. Right. So that's sort of the outline of the pandemic narrative for us to sort of think about what has happened over the last 1415 months. And then move on to scale and the coven 19 pandemic to further help us think about the sort of narrative, and how ethics get situated in it. So, right, we, you know at some point, during the course of this pandemic right we probably stared at screens like this. And it's interesting to me when we look at at at these screens what's happening in terms of scale, right. There's a global scale. That's talking about cases and deaths. There's a national scale that's talking about cases and deaths. Right, there's sort of an economic scale that's being being sort of looked at and monitored in the course of the pandemic, but then also the this sort of screenshot is that of an individual. So they are are are suffering from the pandemic, or in this case it's a mayor who's talking about his community. Right, so there's this collapse of multiple scales into this screenshot. We were all living in an experiencing the pandemic across these multiple scales, which, which in some ways created cognitive dissonance or made it difficult and challenging to fully understand the pandemic. Right. So, when I think about the coven 19 pandemic I think about it as a multi scalar event or phenomenon in the sense that it is pervasive effects across multiple scales. And this I think has been unparalleled in our lifetimes. Right. And when I talk about scale what I mean is that scale is a spatial temporal quantitative or analytical dimension used by scientists to measure and study objects and processes right. We often hear about sort of micro scale, meso scale or macro levels or scales, but it's important to note to that these are socially constructed right that we can construct whatever scales we want and think about how they relate to one another. But the important thing is is that the concept of scale offers a framework for identifying and analyzing connections relationships between different yet connected phenomena. Right, and if we're living in a sort of a multi scalar event that becomes and comes important right. So, we can start the pandemic and sort of a pathogenic right that the now sort of iconic image, you know, CDC image of the SARS cove to virus. Right, but we can go down a scale and think about its genome, which is also sort of a very important thing from a scientific and vaccine development standpoint. But then we can move up to sort of the scale in which we all inhabit and that's sort of the individual level scale, right. So we had to think about our own actions we had to think about sort of the, the provider patient interactions that were occurring. Okay, so that's that's one scale to think about. Then there's a scale of our community, and thinking about the communities we live in, and the social interactions we have with others, but you could scale this up then to think about what was happening nationally. Further to think about what was happening globally, and then scale that up even to think from a planetary perspective that then brings into sort of ecological and climate change effects. Right. And so this is sort of what's going on. When I talk about and think about and conceptualize the pandemic as a multi scalar event, right, that we are engaging with the pandemic simultaneously across all of all of these different scales. And this is just sort of another graphic that sort of illustrates that right that the virus and sort of our relationships with the ecology and animals. And what does that mean when when when when a virus spreads to an individual human in terms of its impact on the community at both national and global scales but also what's happening at that individual scale. When we think about providing care to sick and ill into individuals. Okay. So those are sort of spatial aspects of the pandemic to think about, but I also want us to think a bit about temporal scales of the pandemic. Right. That in one hand there's the long history. For us to think about sort of the long history of pandemics and where and how will the COVID pandemic be situated in that. But then there's just the sort of the temporal scale of the pandemic itself, if we just go back to January of last year. What has occurred over that time period, you know, brought up earlier, how many people have been sick and infected how many people have died. You know there are other ways to sort of look at the temporal scales of what's happened in the last in the last 1415 months right. And the scale of time is important in part because we are living in a historic moment. I think many of us sort of recognize that this is sort of a sort of once in a generation once in a every 100 years sort of event that we're living through, especially when we compare that to past pandemics. And what does that mean when we recognize the historical importance of our current era that these are unprecedented times you hear the time of COVID-19 heard or like, we are living in an era in and of itself. And that we compare ourselves historically to past events, and that will be projected into the future as well. But when we think about the scale of time I think it's also important for our narrative to think about the day to day medium of the pandemic. Right, which was written about a lot right that that there was the effect of the pandemic on our day to day But I think it's also important to think about the scale of time related to the pandemic when it comes to the epidemiologic chronology that Rosenberg sort of defined like over what timeframe did this epidemiology occur. And then I think there's a sort of scientific chronology as well that became important when we thought it when when we when we contextualize vaccine development and vaccine just distribution. But I think it's important to think about the temporal aspects of ethics, that how might the ethics of decisions that were being made change as the pandemic extended in time. Okay. And so just thinking about each scale that each scale has specific participants principles and boundaries that guide actions and practices within that scale. And that there are aspects of a particular scale that these may include the politics of that scale science and medicine and how that's being developed and deployed. What's the effect of culture at a certain scale as well as ecology and economics, right like what market effects occur within that's in that scale. This raises questions about how do we think about what is occurring at each of these scales and the nature of one scales relationship with phenomena at other scales. And in doing that, the question arises of what differences or tensions exist between scales, and how do we reconcile these differences between scales. In such a way that we, we understand what is lost and gained, as we move from one scale to another. So how can we view the pandemic as a multi scalar event to understand the theories and practice of ethics. Okay, and when we think about ethics and scale. I think two issues are particularly relevant. One is the relationship between scales, right, that that the tensions and conflicts that exist that may exist between scales, what ethical dilemmas do they pose. And the second issue is hierarchy. So which principles and priorities take precedence. And how do actions and resources concentrated a particular scale. So in the sort of literature about scale you'll hear the term privilege scale, and that tends to be the scale that sort of drives what actions are taken. So if we think about with the pandemic and the multiple scales of the pandemic. And we might think about what have been some of the privilege scales of the pandemic. How do we reorient to a different scale if we feel that those principles should take priority. Right. And so just want to think a little bit about the question how does the application of the core principles of bioethics change across scale. So are there additional principles that need to be applied. And this sort of played out I think in both the lecture series, as well as some of the questions that that were asked right that on one hand at that sort of kind of individual level, where we may have clinical medical ethics, right, but then as we move up in scale and we think about the community and we think about our roles as individuals and our relationships to one another. And that ethics then comes into play when we think about public health ethics. And as we scale up to think about what's happening regionally and nationally, and then scale up even further again to think about what's happening globally. How do the different principles get deployed, and what principles are deployed at these different scales when we think about sort of ethical principles or bioethical principles right. And this came up in a question at the end of, of wills lecture. Last year about, maybe we were just sort of thinking about why are we focusing on clinical medical ethics that maybe we should be focusing on some of the higher scale, higher scale ethics, in order to prevent some of these sort of ethical dilemmas that are occurring at lower scales right when we think about clinical medical ethics, right, we think a lot about sort of the provider or doctor and patient relationship right and we focus on the individual. And often this is sort of secondary and tertiary prevention diagnosis and treat right that we have sort of biomedical interventions that can help diagnose and treat, you know a specific disease disease or condition. And this level of ethics often, you know involves the active engagement of participants. But if we do go up in a level right, and we talk about public health ethics and how that operates at the community or population level. And we think about primary prevention, rather than secondary or tertiary prevention, and we think about preventing disease and disability and promoting health. How do those actions and behaviors conflict potentially with what's happening at sort of the clinical medical ethics level. Public health ethics often operates are sort of in a more passive engagement, but what has been interesting and I think from particular from an ethical standpoint is that the pandemic has made engagement with public health ethics more active. When we think about issues around a mask wearing social distancing quarantine and isolation right, but then what happens when we go up further and think about global health ethics right we had Dr singer on sort of talking about what the pandemic is, and he often use the term solidarity sort of raises the question of what, how does, how does how at that scale, how should we think about ethics right that global health ethics operates at the multinational level, and that it recognizes global variation and complexity in biomedical interactions and approaches. So how do we reconcile these differences. And when it comes to thinking about other core principles that may drive operationalizing ethics that sort of a global scale. Should we be thinking more about justice and human rights and solidarity right like solidarity was one of those terms that Dr singer used quite a bit throughout his talk, but we also have to think about global health security and diplomacy considerations, when it comes to global health ethics right. We're hearing a lot now about what's happening in India is going to affect all of us right that if we don't stem the pandemic everywhere, it's going to come back every everywhere as well right and so should should we be prioritizing ethics at a global scale. And he's thinking about the multi scalar nature of ethics during the coven 19 pandemic right that there are individual level sort of clinical medical ethics to think about their public health ethics to think about their global health ethics to think about. Right. And so, thinking a bit about this in the context of ethics in the multi scalar narrative raises questions about is it possible to understand the ethics of the pandemic, without understanding the scalar nature of the pandemic. Right, that it's important that we identify the tensions that exist between scales, and that we have discussion and debate to resolve these tensions. And I think what's been been interesting about this pandemic as well, given its pervasiveness is that how did this play out in the media in the sense that we were reading articles and there are articles in the media about ethical debates right and I think for the first time in a long time, this was sort of the mainstreaming of a whole host of different ethical debates. Right, that the general population was now engaging with with sort of dilemmas and debates and discussion that sort of we on the sort of ethics side of things have been doing for years. What does it mean to sort of mainstream some of these ethical debates right when they show up in the headlines. And so, some of the interesting sort of levels of contention that have played out in ethics over the course of the pandemic and that we tried to highlight a bit in this lecture series include sort of the scalar contents, of the individual versus the community. State versus federal response and nation sort of versus the global community. And then lastly thinking about bodily health versus emotional health versus economic health. Okay, and that when we think about the sort of the individual versus the community, right, that we've had discussions and lectures about sort of civil liberties. About mask wearing about vaccination and vaccine mandates that may infringe on one's individual rights, but that prioritize the community. You know discussions about vaccine passports. There have been discussions over the course of the pandemic about the right to assemble and protest. Right, whether these were for religious cultural or political events, or discussions about the protests against racial and social injustice, right, that bringing people together. How do we prioritize that and how important is that to the individual, as well as to the community. You know the individual versus the community sort of scalar this contention brings up issues around contact tracing and public notification around isolation and quarantine, and certainly around resource allocation that we've had a number of speakers that talked about sort of resource allocation that how do we sort of think about individuals within a community, and who should get those those resources, right. Thank you this played out in the media. Right and in a bunch of headlines right, especially around like, you know, death panels and who's in recent and resource allocation and who gets the ventilators and what happens when we run out of run out of beds in the hospitals, but also the again depending on sort of information ecosystem that that you tend to traverse. There was also the sort of the flip side when it came to sort of civil liberties versus sort of, you know, public health concerns about these attacks and threats to civil liberties about masks being socialism. Right and so politics very much sort of infected these these these discussions in various in various ways. And now if we sort of move on to think about sort of state and regional versus national versus global community, we had ongoing discussions about resource allocation right early on states competing for and sharing resources, rather than having a more sort of federal approach to this current discussions about resource, resource rich areas are nations versus resource poor, and how do we allocate resources between them. And how, you know, whether or not we even show it questions about vaccine production. You know the one recently in the last couple of weeks about what to do about intellectual property and patent protections right that what is our sort of overall goal in the patent mitigating the pandemic. When we have a global when we have a global approach. Should that include waving intellectual property and patent protection, right. We think about this too within vaccine allocation, right, that there's a current discussion about vaccine nationalism, right, that that as we move as the US moves towards adolescents, while other countries haven't vaccinated their at risk populations. What is what does that mean what does that mean how does that reflect our sort of values and reflect our our ethics, and then there are also questions about information share, especially early on, in terms of trying to figure out the genealogy, and also trying to figure out what the pathogen is, and when it comes to sort of sharing the genome in terms of, you know, who should have rights and access to some of this information, depending on what the different goals may be. Right. And then you know again a whole host of headlines and I've just been really interested in again how these narratives have played out in the mainstream media, when talking about some of these ethical dilemmas. Right. And this is sort of a sort of well well sort of circulated map about vaccine allocation at the global level, right, that that some countries, particularly those that tend to be resource rich, are looking at widespread coverage and, you know, late 2021, whereas other countries may have to wait until early 2023. Right. And should we somehow compress that timeline. Right. If we're thinking from a global ethical standpoint, and thinking about solidarity, or if we think about the national scale. Should we just sort of let vaccine nationalism, allow some countries to vaccinate popular, you know, completely vaccinate populations, while there are other at risk populations that exist globally. So the last sort of sort of contention to think about that that came up throughout this this lecture series and throughout the year is sort of the bodily health versus emotional health versus economic health right that when we think about the extent and duration of the lockdown. We've been talking about when to open up. Right. What to open up, you know schools versus bars and restaurants, and how did this prioritization reflect our values. We've been thinking a lot about the emotional and developmental toll of the pandemic, particularly as the pandemic's duration extended. Right. As I mentioned sort of thinking about the temporal scales of the pandemic. As things have sort of carried on, and people were doing more remote work and particularly doing more remote school. The concerns about that the sort of developmental and academic and emotional toll that was taking on individuals. You know, may may have changed our initial calculations. Right. And certainly the epidemiology and the shifting epidemiology played into sort of how we think about some of those decisions, but it's interesting to sort of think about the wall emotional health has has affected the decisions that we make. And then to we are thinking about what is essential work and who are essential workers, and then the delay of non essential medical visits and procedures also sort of played into some of some of these sort of early calculations when thinking about bodily health versus versus economic health, right. And again, a whole host of headlines I doesn't doesn't, you know, take much searching to find a whole host of headlines about sort of lockdown mentality about when to open schools about, you know, closing the bars reopen the schools right like what how are these decisions, reflecting what we value and what we what we prioritize, right. The last sort of concept that I just want to quickly throw out there's almost at the hour is just sort of thinking about the coven 19 pandemic as a syndemic right that I would be remiss to not sort of think about how the pandemic sort of further further created vulnerable populations, right, that the syndemic model of health is really just sort of a bio social complex, which consists of interacting co present or sequential diseases, and the social and environmental factors that promote and enhance the negative effects of disease interaction. Right. And so really what this does is sort of look at multiple epidemics happening at once. And what might be some of the conditions of social inequality and injustice that contribute to disease clustering and vulnerability. Right. And I think in addition to thinking about health inequities and health disparities that were highlighted during the course of the pandemic is to think about the simultaneous infodemic that occurred, and how has that affected our ability, you know, as individuals but certainly as as communities to mitigate the damage and threat of the pandemic. Right. So just some concluding remarks that right in our lifetimes the coven 19 pandemic is unprecedented in scope and scale that their profound disruption of our daily lives and communal national and global activities. Now the broad scalar nature of the pandemic has challenged how we conceptualize operationalize and disseminate bio ethics, you know, and I sort of tried to situate bio ethics as a core component of the pandemic narrative right from when it first emerged to where we currently are that we have ongoing discussions within this narrative that are centered around ethical dilemmas and decisions. And certainly sort of this narrative framework will help us understand our pandemic experience that that the meaning making function of storytelling reflects our values and beliefs, and that the memory function memory making function projects this experience to future generations. Right. And so, where do we go from here sort of one of the questions I sort of want to finish up with right that we sort of go back to this phases of disaster and emotional highs and lows. Right. And where are you as sort of individuals I think, you know, people I've sort of asked recently we're somewhere on this sort of disillusionment right somewhere still down down here but how do we get here. And when will we get there. Right. The other thing to just sort of think about is where this fits in history. Right. So that that, you know, this is a well circulated infographic right that where we sit currently. Just something to sort of think about his historically in the grand sweep of things and so some concluding questions to think about. What is the impact that this has, and will the pandemic change bioethics, right that will there be a shift towards public and global health ethics, and a shift towards justice and equity. And we should think about what what is lost and what is gained, if we make some of these shifts. And should there be a push for sort of ethicist as advocates, particularly sort of in the media, with the mainstreaming of a lot of these ethical debate debates. And then what judgments will history make of the coven 19 pandemic, right that will this be considered a triumph of science and medicine, or a failure of collective action. Maybe a failure of our politics, or a questioning of our priorities when people look back and say they were opening bars before schools, right, and this to plays out in our media, right, that on this side over here right like will this be a story of scientific triumphalism, in which we developed a vaccine and record time and distributed and you know quantities in the hundreds of millions. Right, or will it be that no our politics sort of blew this moment and failed to respond or that our global systems broke down, or that we had sort of herd immunity and reach, and we didn't achieve that. And then just sort of this last sort of comment here or will there be multiple histories told, right, that will be very partisan and how they're told that on one hand, it will be that the pandemic is widely seen as one of the biggest public health failures in history, or will it be considered a massive hoax. Right. I mean that's sort of extreme but you know, just to finish up, you know, throughout the question of what is your pandemic narrative. Right, that is as you sort of go through as you've experienced all of this. What is the story that you're going to tell. Right, both personally and professionally, what is your pandemic narrative and so that's all I have I know we're at time. In terms of the lecture portion and I just want to sort of make a make a number of acknowledgments right this being the last lecture that the McLean Center, as well as the lecture series organizing committee committee for helping pull all of this off but of course none of this could have been pulled off without the great work by by Yolanda you and Renee Nadine in terms of just outreach to our speakers and making sure that that every all of this sort of actually happened. I acknowledge to the box ball Institute for clinical excellence which cosponsored all the speakers the weekly participants, the savannah Institute on the formation of knowledge which supports a lot of the work that I do in terms of my course work. And then, of course, the friends colleagues and essential workers who have worked tirelessly to mitigate the damage and harms of the pandemic. And with that, I'm happy to feel that any sort of questions that exist. Here's my email if anybody wants to email me about anything that I talked about today. So, okay. Thank you very much Brian. That was an incredible 30,000 foot view. So I really appreciate it. The first question I'm going to ask is from will parker who says great talk Brian. What's in the idea of belonging solidarity in the face of the pandemic how can this be reconciled with the US is current policy of extreme vaccine nationalism. Example reluctantly sharing AstraZeneca doses we have no intention of using export bands etc. The way that I sort of set this up is to ask a lot of questions that I'm not sure I know how to answer. And so I think when it comes to the global level right and sort of thinking about upscaling our ethics. What are some of the main drivers of why a particular scale becomes a privilege scale, right, that if we think about national, you know vaccine nationalism what are the politics that might drive resource allocation in particular or vaccine allocation at that national level. And here's where I think politics become very important, right, that those countries that tend to take, or those countries whose leaders tend to take a populist approach tend to be more realistic about their resource allocation, right, versus politics that may shift that focus to a higher scale, right, I mean and again I think the Biden administration has been doing more of this I think certainly been doing more of it than the Trump administration would have. But this raises that sort of the question about why a certain scale may become that sort of privilege scale like I said at which things are operationalized. And part of that becomes I think because the ease at which things can become operationalized, right, that it is, you know, we now have a system in place in which we can distribute those at our vaccines at a national level. But when that becomes more challenging to do an operationalize at a larger scale. Maybe we're not up to that task. Right, and then maybe we'll be look back and see that that sort of it's a failure of our collective response to sort of take it to that to that scale. But I think this really does sort of raise the issue of why a privilege scale becomes a privilege scale and how politics and power within that scale, driving the decisions that are being made about whether or not to sort of upscale or downscale a particular thing so I'm not sure that sort of and you know hopefully that's that answers your question a little bit but but we sort of can't deny the role of politics and what government may be responsible for. Right, there are those arguments when it comes to sort of vaccine nationalism that isn't the role of a government to protect its population. And that it should do that nearly everything possible to do that, and that if you don't have a global mindset, then it's going to be challenging to do that. Right, to take it to that sort of global resource allocation level. Mike missile gives a wonderful follow up to the point you just made he wrote I was in Melbourne at a Melbourne Australia at a conference in early March 2020 before lockdown. I returned to the States in early April 2020 I was so much more at risk returning to the US given the lack of public health structure equity and political arrogance putting me in harm's way from non mass queries is the lesson that we do not share health equity health insurance for all solidarity for the common good and scientific literacy. I think you certainly yes I like we this. You know, sort of American culture and sort of the idea of a sort of American exceptionalism and American individualism. During this pandemic I think has done sort of great harm to our ability to mitigate the effects of the pandemic. And that this was also driven by the politics right the fact that there are stark differences between how one viewed the pandemic that broke down by by sort of Democratic versus versus Republican and that have we lost site right there's a hand wringing sort of in this country about whether we've lost site of what America is, and what Americans are sort of a sort of national population, rather than now sort of divided up by by our politics, and that how do I sort of partisan views. How are partisan views reflected in our response to the pandemic. And then we just don't have that that sort of more national mindset that other countries do. And I think part of this is because Trump for the, you know, the duration of the pandemic took a populist approach that was in part driven by division. I'm going to mispronounce this name but MK sir, we have sir, sir, okay, thank you, Brian when looking at early COVID narratives yesterday, a few of our students expressed a surprising kind of pandemic amnesia already. If we got critical details of just a year ago. How do you can to actualize that in light of the pandemic narrative is that phenomena something you encountered in your readings. So, yeah so so MK is one of the sort of the co directors of the course that I'm currently teaching and this just happened to be the week that we were talking about sort of COVID COVID 19 pandemic narratives. And we were reading an anthology in which Trump appeared a few times in the comics and students like, I forgot that he was even our president, right and then there's a sort of like idea like what happened, like a year ago. And this sort of plays into sort of the temp, you know, how time unfolded in the pandemic and how much we may have forgotten or have amnesia about. Right, and this is sort of come up to sort of in the historical timeframe when when talking about sort of the 1918 that people were just sort of ready to move on and that it wasn't as well as well remember. I think what it will be interest, you know, interesting about this pandemic is the role of technology, right that there is going to be so much data and information that's recorded about this pandemic that it's going to be hard for at least future generations to forget that this occurred. Because, right, like, look on your phone how many photos do you have on your phone of various pandemic related things how many photos are on there of people wearing masks so very like, there's just so much just raw data related to the pandemic itself. Right, but then also sort of just cultural data that that exists that I think is going to make it hard for the future to forget that this happened, but I think there is this sort of aspect of boy, like, we are ready to move on, right that we do have pandemic fatigue. And what happened a year ago is not part of our sort of readily recalled memory. Pam Gonzalez adds, How did the false narratives lack of trust in science and government impact our ethical view. Yeah, so this is where right that. I don't know I what's been interesting to me, and I'll try to sort of answer answer this question and a little bit of a roundabout way has been what information how information has been circulating in different information ecosystems. And what has been prioritized so I, you know I imagine a few of you out there maybe many of you at some time sort of flipped between sort of left leaning media, right leaning leaning media and maybe even far right sort of media. And what they were talking about was so drastically different and what they were prioritizing sometimes seems so drastically different. And so it's not surprising how embedded in an entrenched various false narratives, or, or misinformation or disinformation becomes embedded as part of a sort of broader pandemic narrative, if that is the only information ecosystem that you're traveling in. So, lose lose sight of what again is that sort of collective those collective facts. I'm not sure we know what those collective facts about the pandemic are depending on sort of what information ecosystem we traverse. I'm not sure that are there going to be sort of multiple different histories of this near of this pandemic that are very much sort of anchored to these different information ecosystems that often seem to be sort of conceptualizing the pandemic with different different different facts. Well, that's our questions we're sort of coming up to the quarter after Mark do you want to give any final comments before we break so that the students can get a bio break before the last meeting thank you again, both for all the work you did on this wonderful posting lecture Brian. Thank you Lainey and thank you Brian for an extraordinary final talk. It resolved and summarized many many of the earlier talks among the 27 total 27 that that you gave. Thank you for your appreciation. I just want to tell the rest of the participants that our, what time will, you'll be meeting with the fellows at 130 130. Today's conference of three and next year's lecture series is being released today, believe it or not. And it will be 28 lectures on the history of medicine and ethics. And Mindy Schwartz. And I sort of put it together, and you'll get the, you'll get the schedule. I hope by later today or right to my office. If for some reason you don't get it. And we will send it to you. Again, thank you Brian and thank you Lainey for a wonderful, wonderful session. Thanks. Thank you. Take care everyone be safe.