 All right, Mark, we're at 100. We're doing great. Yolanda, did you put in that, those letters? They're in, good, good. Okay, I think I will, with everybody's permission, welcome you to this week's meeting of the year long conference on ethics and COVID-19 pandemic, medical, social and political issues. We are so excited that our speaker today is Professor Alta Chauro, graduate of Harvard in 1979 and Columbia Law School in New York in 1982, who then joined the University of Wisconsin in Madison in 1989. And believe it or not, I just found out a retired associate's emeritus professor there at the University of Wisconsin this past year in 2020. Alta is an elected member of the American Academy of Arts and Sciences, the American Association for the Advancement of Science and also the National Academy of Medicine. Professor Chauro was a member of President Clinton's National Bioethics Advisory Commission and also served on President Obama's transition team focusing on the NIH, the FDA and bioethics and women's reproductive health. Quite extraordinary work. Professor Chauro was worked in government as a policy analyst at the Congressional Office of Technology Assessment at the U.S. Agency for International Development and also with the FDA. She's co-chaired the National Academy's committee on embryonic stem cell research and human genome editing and now serves on the World Health Organization's committee on global governance of genome editing as well as on the National Academy's Standing Committee on Emerging Science Technology issues. In 2020, Alta Chauro was a member of the National Academy of Medicine's committee on equitable allocation of COVID-19 vaccine and served also as one of the organizers of an Academy workshop on the allocation of monoclonal antibody therapy. We're so honored that Professor Alta Chauro is joining us today to speak on the general topic of COVID-19 vaccine allocation. I'm gonna turn the case over to Professor Chauro right now. Alta, thank you so much. No, thank you very much. That was a really generous introduction, Mark, and thank you for thinking of me and thank you, Laini Ross, for having initially contacted me. I'm going to hit share screen just so I can get started here and let's see. Can you tell me, does that show the slides? It does. Great. And now you're in present mode. Great, thank you. So I wanted to take the opportunity today just to kind of talk through a number of the issues that have come up with regard to vaccine allocation. It's certainly the topic of the day. But as I began, just a reminder about kind of where we are right now, almost a year out from the first case or maybe just a year out from the first cases in the US now with about 41 doses that have been distributed to about 18 million people or 21 million people, but still facing a pandemic of enormous proportions. We've lost over 400,000 people, most of you know. And on the upper left here, just as a reminder, we've got vast disparities in the United States as between the number of people or the kind of people who get infected. Here in the green bar, you see people that are basically in their middle years, 18 to 49, getting infected, symptomatic, roughly comparable. But when you look at the hospitalization, suddenly it shoots up and it's the populations that are over 65. And if you were to go deeper into the data, you would see that that number itself is a little misleading because it's really over 90 and over 80 that those numbers truly leap to extraordinary levels. And we're also still dealing with lots of hotspots. In this particular map, the darker the color, the more density of infection that you're seeing per 1,000 people. And as you can see, some of the states kind of resisted some of the non-pharmaceutical interventions like masks are still seeing tremendous hotspots here in the Dakotas in Arizona. But we're also beginning to see this uptick now in places like Southern California, which have been hit with a new... I discontinued that when I joined the National Academies Committee, so I'm no longer affiliated anyway with Johnson & Johnson. I wanna start really with this question of allocation because we knew that vaccines were coming, we knew that there wouldn't be enough, and we knew we'd had to figure out who goes first and who goes second and by what kinds of criteria. And one of the best stories that came out was that the mall Santas, this is back in November, were anticipating the holiday season and they wanted to get high priority. They correctly pointed out that they fit many of the categories that people have been talking about. They had a lot of contact with a lot of different people. So they had high exposure. They tended to be older and they tended to be obese. So in all these different respects, they kind of met those criteria. And more importantly, they argued that they were truly essential workers. I hadn't known this, but there is a fraternal order of real bearded Santas, which is devoted to the professional clause. And they actually lobbied actively with both the executive and legislative branches. And at one point, we're going to be given this higher priority through a quarter billion dollar federally funded effort. To be fair though, the idea had been that they would lead the public into a state of trust in the vaccine. So it wasn't only for their own benefit, but also for the public. I think partly the kind of hilarity around this was one of the things that drove it out and meant that the program never took place. But there were certain aspects of it that made some amount of sense. And it made sense because one of the things that we're having is a real problem with trust in the vaccine. And that in turn is related to several things. One is the way in which these vaccines have been developed. Traditionally, as you know, in a vaccine development paradigm, it would take many, many years, perhaps over a decade to get to the point in which you actually license and have large scale manufacturing of a new vaccine. Vaccine trials pose special ethical dilemmas because basically you're testing something in people who are at this time healthy but putting them at some risk of some kind of adverse event. So unlike the typical kind of trial for a therapy for somebody who's sick, here you really have a more delicate cost benefit balance or risk benefit balance when it comes to the trials. It also requires a certain density of exposure so that you can create a placebo group and a placebo group in an active arm that would give you a reasonable difference in infection rates over a reasonable period of time so that you can measure the efficacy of your vaccine. That's one of the reasons these things can often take a long time. But here there was a real need to move this much, much more quickly. We did have very high density relative to other infectious diseases. So that part of the problem was taken care of but the second part of the problem had to do with how quickly companies invest in the kind of scale up necessary so that something that turns out to work can be turned around quickly and put out in quantities necessary for the population because most things fail, most manufacturers are not gonna invest in that kind of scale up until they've gone far, far into phase two and phase three and even then we'll still not be quite at large scale manufacturing. They'll be at a kind of tentative commercial level. What was different here was a really interesting set of public-private partnerships to try and take the risk out of this large scale manufacturing and give the private sector sponsors the opportunity to scale up to meet all of the GMP requirements and to create the supply lines needed for all of the other kinds of things you need whether it's the glass vials or the syringes or whatever and make those investments without the risk of loss because there was a guaranteed market at the end of the day as well as some amount of insurance against a vaccine failing. That was the so-called operation warp speed but it also meant that there was a kind of collapsing of some of these phases moving through them as quickly as possible and so for that reason there was some amount of concern that maybe the safety data and the efficacy data was not as strong as it might be. For sure, there wasn't the opportunity to do the extended studies of subpopulations that you might want. Subpopulations that were differentiated according to age and sex and fertility status and race and ethnicity and dietary concerns and et cetera, et cetera. So we did not have some of that data nor of course do we have the long-term safety data presumably fairly low risk but nonetheless the kind of thing you'd ordinarily get. In addition, the endpoint here was not the ordinary approval it was what's called an emergency use authorization from the Food and Drug Administration. This is something that can be given based upon this more collapsed kind of schedule if the Secretary of Health and Human Services has declared a public health emergency and it allows for the marketing of this product consistent with federal law for the duration of that emergency. Once the emergency declaration terminates so does the marketing privilege for that vaccine at which point it does now need once again to have its data presented to the FDA for a normal approval process presumably in an ideal world your post authorization period which is now with people getting the vaccines also involves data collection which will feed into the ultimate approval decision where we might be able to pick up more of those subpopulations and long-term effects. That depends of course on a good system for collecting that information and one of the problems we're already seeing is that overstressed hospital systems overstressed pharmacies are finding it difficult to act essentially as service providers for the vaccine, caregivers for the people who are currently sick with the infection and at the same time also functioning essentially as research operations collecting and sorting information in a way that allows it to be used for the next steps for a formal approval. The result is that even with this enormous amount of effort we still only have two vaccines that have been approved and this actually should be authorized for use and a number that are in some kind of limited use in other countries. There are many others that are coming down the pike but the first two as you know the Pfizer and the Moderna are the ones that are the most innovative and therefore in some ways are the ones that have raised some public concern because the technology itself is less familiar as opposed to some of the vaccines that are coming soon that are going to use more typical kinds of inactivated virus platforms that are more familiar to us. But for the moment, Pfizer and Moderna are the only ones that are coming into use in the United States and we're looking at Oxford and Johnson & Johnson fairly soon although as I understand it the Oxford AstraZeneca has been having a little difficulty with its recruitment. The vaccines come with a fair number of uncertainties some due to the accelerated development and some just inherent in vaccine development itself. For one thing, the initial clinical trials for these vaccines have been designed to test for either reduction of symptoms or complete prevention from becoming infected but they have not been consistent in this. So a lot of the data initially at least was merged in which we were looking at data on people who didn't get infected and people who did but didn't get as sick or didn't need to be hospitalized. And the inability to break those apart becomes important because if it prevents infection completely that would suggest it also means this person can no longer be a vector to others. So it would tell us that the vaccine is both self-protective and protecting against transmission. If on the other hand it allows people to get infected but they don't get as sick, not only does it have less value for preventing people from being vectors but in a kind of weird irony it might actually increase their risk of becoming vectors because with fewer symptoms people will often take fewer precautions about staying home may not even realize they need to stay home and asymptomatic transmission has certainly been one of the difficult aspects of this pandemic. A second more recent development has to do with new variants that have popped up. We heard about them from the UK, from South Africa. We now have at least one or two confirmed cases in the United States. I think I just heard a couple of days ago there might be the first case in Minnesota. And so the question then is whether the vaccines that have been authorized will work against these variants. Moderna is the only one whose announcement I've seen so far, I could be behind the news. Moderna announced that its vaccine will work on some variants despite some initial rather alarming in vitro work. But nonetheless, it's also developing a booster as a kind of backup plan. But certainly that is again, going to be one of the questions as we see more variants whether this is going to become a problem for any or all of the vaccines currently under development. So with these kinds of uncertainties, we find ourselves a little bit unsure about whether to build a vaccine program around the idea of protecting people from getting sick to save lives, save hospitalizations, save people's ability to work, or whether really what we want to do is use vaccines simply to try to reduce transmission. One of the interesting aspects of the National Academy's work I did was to listen to people from epidemiology trying to model these possibilities as best as they could with these uncertainties and realizing that the use of the vaccine to reduce transmission even under the best of circumstances was really not going to be that efficient in the early stages and that working on preventing deaths and serious morbidity was probably going to be a stronger approach. Even within that though, we still were left because of the accelerated schedule with the problem of not knowing if we should actually hold off vaccinating certain subgroups because there's another vaccine coming down the pike that's really going to be better for them and we just don't have that information. And so for people with certain kinds of comorbidities or autoimmune diseases or people who are thinking about getting pregnant or are pregnant, we don't have the information we would love to have ideally to know whether these should be segmented groups and told, you should wait three months not because you're not important and not a priority but because there's a vaccine that would be safer or more effective or both in your particular case. Dogging all of this as I can't believe you don't know already is that we have vast issues having to do with health disparities and inequitable access to health care in the United States. There have been some really stunning differentials in the rates at which various subgroups have been getting infected or once infected facing serious morbidity or death. And in some cases up to 500% higher in some parts of the Alaska native community, African-American community, we're seeing rates that are in like three times higher. Some of this is related to the things that correlate with race and ethnicity, minorities in the United States because that in turn tends to correlate with lower income. Lower income in turn will correlate with higher density housing. So very difficult to stop transmission. It will also tend to correlate with jobs that don't provide comprehensive health insurance coverage or preventive care. So you have people who have a greater range of existing morbidities that have not been adequately managed. We also have from a dietary point of view a pattern of higher rates of obesity in lower income groups, along with diabetes. And finally, people working in jobs where they cannot self-protect as well as some others. I, for example, am lecturing to you from my kitchen. But most people in these income brackets are out there working in settings in which they're facing the public. Whether they're working in repair services or delivery services or driving buses or working as room cleaners in a hospital, they are unable to protect themselves from exposure. So they are both more highly exposed and more likely to be living in a place where once exposed, if infected, they will pass it on to others. And collectively, everybody in that crowded housing probably more vulnerable to a serious form of the infection. And the result being a really desperate problem now thrown up into high relief of having to manage these kinds of disparities. So that would suggest that we want to get all of these vaccines out as fast as possible and make sure, in particular, that we're going to get them out to people who are at the highest risk of becoming infected or if infected, getting very, very sick. And yet we're also facing the counterweight of the vaccine uptake, hesitancy, and refusal. This is something that we know from other contexts. We've seen it in the flu vaccines. We've seen it in the school vaccines. And it has been dogging us for years. What has been exacerbated in this particular pandemic has been the politicization of the vaccine development because of the pattern of federal government behavior over the last year, leading to many people to have less confidence in the CDC, in the FDA, and in the decision-making around those agencies so that you layer on to the ordinary level of vaccine hesitancy, some concern about the reliability of some of the governmental decisions. And even as we're beginning to see a little bit of confidence in vaccines rise now up to about 60% this is from December 3rd. So it's still rather out of date, but it was the most recent I found. We still have very large proportions of people saying that they aren't willing to try the vaccine. They want to watch other people get it first or they just don't believe in vaccines. And we're seeing a particular challenge in minority communities. One of the problems is that it has an intersection with the very nature of the trials themselves because there was some difficulty in recruiting minorities into the trials and then the trials were sped up to the point where you couldn't really get that kind of subpopulation analysis. You don't have the ability to say you in this particular minority community are well represented in the trials and here's what it looks like when people like you get the vaccine in the trial. We haven't been able to give that information out with the kind of specificity we'd like. And that then of course means that there are gonna be yet more reasons for people to be hesitant about vaccine. So with that, we still have about 60% of Americans who say they're willing to get vaccinated. We're on a bit of an upswing this green over here is the upswing from September to late in 2020 as it climbs towards 60%. And the reasons for not choosing are not gonna be very surprising to you. It's a minority that don't trust vaccines in general, but you see a lot of people concerned about the rush timeline and wanting to wait for it to be confirmed. And there actually is a fairly good number of people who seem to be saying that they don't wanna take it when they think they might be or are planning to become pregnant. That might explain some of the resistance within the healthcare provider community where you have a high representation of women particularly in the allied health professionals. So it's against this kind of information backdrop that you have a variety of entities that began working on trying to organize advice to the federal government, national academies, the CDC and its ASIP and the state health departments where the advice was kind of rolling downhill, like the national academy report had recommendations, CDC looked at those but made their own based on hours and theirs. That then was sent to the states and the states then had their own opportunity to develop state level guidance that would be based on but not necessarily slavish to what was being recommended by the CDC or anybody else. In those discussions, there was a first kind of cut that had to be made. What is the most justifiable way to roll out a scarce resource like the vaccine? You could have something that simply said, we're not gonna try to pick among goals whether it's lower morbidity, lower mortality, higher level of functioning in society will just first come first serve or lottery, something without trying to pick a goal. Or if you're gonna pick a goal, there were multiple ways that you could try. Let's do the most vulnerable. So we're gonna focus on people with high exposures and people who are most likely to stick in and die. Or since a lot of those people are people who are older and might be able to stay home to protect themselves, maybe we should talk about who's most valuable to society. And I hate the phrase essential worker. I like to talk about essential services. I think workers are people, people are all essential but the services they offer may not be at certain times. So a lot of concern about keeping the healthcare system running, keeping transportation running, keeping EMT services running, keeping grocery services running. So that becomes a different kind of most valuable to keeping society functioning. And then there's another category of, well, what about simply saying if you were already given the short end of the stick for years, maybe now we should compensate for that and focus on those who are suffering the worst health inequities. All of these were competing ways to think about how to structure a rollout. In the case of the national academies, this was the cover for our report. We recognize that there were very important principles that underlie these kinds of decisions. We wanted to be talking about an equal concern for all individuals and at the same time trying to get the biggest bang for the buck or maximum benefit, but also focusing on mitigation of health inequities. However you do it, we did recognize that everything has to have these things. It has to be fair in the sense that whatever policy you adopt, it has to be administered in a consistent fashion. The policies rationale and functions and operations should be available to the public so they understand what's going on and it should be based on evidence and not just on instinct. The result is something that's not too different but does differ in some details from what we're now seeing rolling out. We came out with a report that started by saying we do need to put high risk health workers and first responders into the very first phase. It was a way of combining high risk with social value, but then moving on to people with comb orbit or underlying conditions that put them at significantly higher risk, that's vulnerability, as well as the older adults in congregate settings. Again, vulnerability and then moving in phase two to people who have moderately higher risk, people in other kinds of congregate settings and teachers and prisoners. Notice though that in terms of congregate settings, there is a decision to be made about whether to put prisons first and I'm gonna come back to that at the very end of this presentation. As I mentioned earlier, a lot of the factors we talked about, the kind of job you're in, the kind of housing that you're in, would correlate often with the kind of experience that many minorities have in the United States in terms of lower income and higher vulnerability. So many of these factors would have the effect of addressing the inequities that we had seen and the higher rates of infection and death we were seeing in these communities. Nonetheless, it doesn't get to everything about the underlying factors and racism that would lead to these kinds of disparities. And so to the extent that you can't even address all the people within a particular phase, we had said equity is cross cutting. If you can't get to everybody, let's say within phase one B, then you focus on those people who have been identified through a social vulnerability index or if you prefer another index like the area deprivation index. So that at least you are now trying to find the people who've got the most factors that would lead them to be justified by need, by risk, by socially valuable occupation all at once. The CDC proceeded in a fairly similar way when they themselves back in December said that again, we're gonna be focusing on healthcare personnel. Notice this is not just doctors, this includes anybody with the kind of contact with infected parties that would put them at risk. So people who clean the rooms, people who are providing the meals may very well have a higher priority than many MDs who are working remotely or working in parts of the facility where they don't have a lot of contact with individual patients. And building on this idea that you want to be transparent, we also saw the CDC's ASAP trying to make sure that people understood it's kind of ongoing thinking in publications like this one from JAMA. But they also noticed that the numbers here were challenging, right? So when they were doing their first numbers, they realized that in just their phase one, there are 200 million people. If you look at these individual numbers, depending on how you define essential workers, 60 million, older, elderly, 53 million, and you'll notice from the very first slide that we're only up to about 21 million now. So just getting through this first phase one itself has been difficult because the numbers simply exceed our ability to provide the vaccine or at least to date with the systems we have. The numbers do drop a little bit when you notice that there's overlap. So you can't just add these, there are some numbers, and some people here were being double or even triple counted, but still substantial numbers. But at the same time, the ASAP also recognized they had to basically be honest about something. If your goal is to avert deaths, then what you're going to do is vaccinate from the age 65 up. If what you're doing is trying to keep society functioning, then you're going to be looking at the people who are in the high exposure and essential work sector. So you really do have to be honest about what your goal has been or how you are balancing those goals, what percentage of your effort is aimed at death reduction and what percentage at societal function. All of these things are complicated. No matter what you decided, your goals were going to be as we're seeing now, all of these things are being complicated by, first of all, the availability of the vaccine doses and the ability to plan around it up until now states have been complaining they are unclear about what's going to be coming next week or next month. And second, whether you're going to have an option to use different kinds of vaccines for different populations. I think many of us are waiting with debated breath for the single dose formulation vaccines because the double dose presents some challenges. It might be that double dose makes the most sense in settings in which people will not be moving along. A prison, you know where they're going to be three weeks from now. In a nursing home, you know where they're going to be three weeks from now. Even in a hospital, hospital workers, you know they'll be back at work three weeks from now. But for the general community where you're relying on people to come back themselves on their own initiative in three weeks, you're probably going to have a lot of people who fail to get that second dose. So should we perhaps think about logistically just waiting for the general community for single dose formulations or you're going to try to get to those people anyway particularly if they're high risk. So we are seeing now despite the effort to come up with allocation systems some of the breakdowns in the actual ability to administer these vaccines. Right now we have almost all the states, 43 states and I think also the District of Columbia now giving shots to quote unquote older people which means 65 or older. Even though initially many of them focused only on the healthcare providers and the nursing homes. And about 80% of the states have now also expanded to certain kinds of occupations. So they've got large numbers of people who are eligible not enough doses and very importantly not a lot of clarity about how to get one. Just in the minutes before I signed on to this lecture I got an email from a very savvy retired colleague of mine who was in the medical ethics program years ago. And he knows his way around the system going because I'm no longer a UW employee I can't get my vaccine through UW. How do I get it? And I went on the Department of Health Services website here in Wisconsin and was shocked that I couldn't find a link that said, where do I go? Or how do I know where I go? Or how will I know when I can know where to go? Nothing. And it doesn't surprise me then that you have these large numbers of people saying that they not only don't know when they'll be eligible but they don't even know how to find out when they'll be eligible or where to get it if they are eligible. This is a tremendous problem and it is a source of tremendous anxiety now as people are worried that maybe they're losing their opportunity to get the vaccine. And as a result we're seeing real variation among the states in terms of the vaccine rollout. These are shares of population. So in the lightly populated states we're seeing a fairly good rollout but in more densely populated places and I'm sad to say Wisconsin and Illinois both not such an impressive result. We're also seeing some fussing on the edges with these phases even though you're still getting basically an overall framework that's similar to the one from the CDC and the national academies. In Wisconsin for example, we started with the nursing home and frontline healthcare workers and first responders now have just moved on to 65 and over but unlike other places have not moved on to people who are under 65 but with significant comorbidities, unclear when that population is gonna become eligible. And because of this variation in the states and how they're doing things you're also beginning to see a real trailing in vaccination rates in certain minority groups. This is from the Kaiser Health Foundation looking at the vaccination rates among black Americans and this is as of about 10 days ago. So share of the vaccinated who are black but the state residents who are black and you can see this kind of really substantial disconnect between the orange and the blue representing percentage vaccinated versus state population. And that's despite the fact that the African-American population has infection at higher rates and so is it more risk and is also more intimately familiar with this pandemic because they're watching their friends and family get sick. Illinois actually tried to address this and very interesting. What Illinois did, I thought was intriguing. Recognizing that there was a problem with disparate use and uptake and access for the vaccines Illinois lowered eligibility from what it started at where it was in the 70s to 65 because people in these minority groups tend to develop some of these diseases of age a little younger than others. They have a whole lifetimes accumulation of comorbidities so that their chronological age at 65 might look more like the kind of health status that is more typical of somebody who's 70 or 75. And so by moving the ages down you actually also get a chance to address indirectly at least some of the disparities in minority access and minority uptake. But all of these efforts to make sure that we address these disparities have been running into some concerns. We have articles being written asking about whether it's even lawful to prioritize racial and ethnic minorities for vaccination despite the fact that we know that they are prioritized in a sense by the virus to be getting sick and dying because we have such a tortured legal landscape with regard to the use of race and ethnicity as a factor in a variety of social decisions. The social vulnerability index which is presented here you'll notice talks about minority status as well as English language skills as specific factors but it also has a number of other about 15 other factors having to do with education, poverty, age, disability and home situation. This is the SVI. This is the focus of attack by many people who've suggested that instead we should use something called an area deprivation index which doesn't use race and ethnicity explicitly picks it up indirectly through other measures but it's a much cruder measure. Nonetheless, it does give you a fair amount of overlap so some states have opted for it. This is Chicago and this is what the area deprivation index indicates. You see the darker blue indicating areas where you have a greater proportion of people who have disadvantage either in income, basically income levels mostly as well as certain kinds of other demographic indicators. So at least this can be used without as much disturbing opposition as the SVI. Although I will say as a personal matter I think the SVI could survive in court. The question is how much are you willing to take away from your efforts to vaccinate people in order to defend it in court? And I'm not making this kind of opposition up because here we have a headline from just a few days ago from Dallas in which Dallas County said that they wanted to prioritize residents in the zip codes that appear most vulnerable to COVID-19 which as you know is gonna be high density minority housing and they would have prioritized those areas when they don't have enough within a phase. So they weren't saying we're abandoning phases. It's within N1A, within 1B we're gonna prioritize these deprived areas. And what was really extraordinary was that the state said that, sorry, the state said that if Dallas County insisted on this the state would simply not give vaccine to Dallas County, period. A stunning degree of kind of a game of chicken over the politics around race in this particular state. The second area of real controversy as I had hinted at earlier on has to do with prisoners. Right now we know that there are about 35 to 38 states that are actually at least addressing the problem of prisons in their plans although not necessarily putting them in the first or even the second phase of rollout. Despite the fact that prisons have been hugely affected by the pandemic. These are settings in which the virus tends to run rampant. It's a setting in which the individual prisoners are not in a position to take protective measures for themselves. They're constrained into where they can go and how long they can be in a particular place. And ironically, even if you didn't care about the prisoners, which you should, it also means that prison staff become much more exposed and the prison staff can go home and expose their community. So whether from self-interest or from humanitarian concerns, prisons should be a focus. And yet we have at least 10 or 12 states that haven't even thought about where to put them in the phases, let alone putting them in one of the lower phases. It really raises questions about both the attitudes about race again, since prisons are disproportionately occupied by members of racial and ethnic minorities. And also our kind of moralistic approaches to public health in which we look at them and say those are bad people. Why should bad people get vaccinated before I do? Similarly, we saw in the conversation I had with some students just before this lecture began, some attitudes or at least some reports about attitudes concerning smokers and whether or not somebody who's vulnerable because of smoking and I would have added obesity, drug use should be given higher priority because they are higher risk since they engaged in behaviors that are at least preventable. But I will say at least on the prisoner setting that prisoners are sentenced in accordance with their crime for better or worse. I mean, many of the sentences are way out of whack that they are sentenced according to various guidelines and precedents in no way is exposure to illness and premature death supposed to be part of those sentences. And that's functionally what we do when we don't take care of the people in prisons. Indeed, one of the ethical principles for public health is that when people are being asked to limit their freedom that they then become the subject of an enhanced level of care by the state, whether it's telling people that they have to quarantine and making sure that they can get their food and that they can get education or whether it's putting people in prison. The state has an obligation now to minimize the burden that's placed on them because of these things and to act as a caretaker. I'm gonna conclude simply by noting that as of just a week ago or so, we now have a new set of approaches that are being announced out of the federal government too soon to see exactly how they will function. This is the list of goals under the recently announced national strategy under the new Biden-Harris administration. And I wanted to focus on just a couple of things here before I end. One was to try and ensure availability of vaccines. So first, the expansion of vaccine manufacturing and purchasing by taking full advantage of something that was talked about several months ago, but not necessarily used to its full effect and that's the Defense Production Act. It allows the government to essentially get manufacturers to turn over their processes in order to produce what it is that we need and make sure that the supply lines and supply chains stay secured. To also have more purchasing power so that we again, the guaranteed market again give the manufacturers an ability to invest without fear. And to prioritize the kinds of supplies the kind of unsexy supplies that you need like the stoppers and the syringes excuse me to actually make the vaccines physically available. And then to accelerate the actual process of vaccination. I didn't put it up on the slide but there's a whole set of programs that they're planning to roll out to increase public education but also to end the policy of holding back significant levels of doses so that people have their second dose available. Instead they're gonna try to push the manufacturing faster so more people get their first dose and we manufacture faster to make sure that they can also get their second dose on time. That's a very difficult little ballet dance over there so it'll be interesting to see if that can work. Trying to move through priority groups more quickly and focusing really on the older population because they're really trying to get the death rates down but at the same time, wanting to be overtly, openly, honestly, intent on making sure that people who are at highest risk and that is gonna be disproportionately minorities and the poor also get priority access. And then two other things really crucial. Giving states the ability to plan by having very clear and consistent projections about what's gonna be coming to them and when as well as to create venues. So the federal government stepping in and using their VA hospitals but also using stadiums and conference centers and urgent care centers. In other words, having the federal government assist the states in creating more sites for vaccination. I didn't have this on the slide because it only happened, I think yesterday but I noticed in the news that the governor of New York was hoping to maybe purchase vaccine on his own separately and that certainly builds off the experience earlier in the pandemic where states were competing with one another for basic supplies but now is being told that, no, this is gonna run through the federal government so that we will actually have an allocation of vaccine to states that is based upon a set of criteria and a consistent policy. So again, we're beginning to see a different approach in which there's a less chaotic and a more planned kind of approach to these things. With that, I wanna stop. I know I took just a little bit too long so I'm gonna stop and say thank you and if there is conversation to be had, I'm happy to answer whatever I can. Thanks very much. Thank you, Alta. The rest aren't able to talk so I'm gonna be doing all the talking. That was a fabulous talk. We have some great questions coming in through the chat and those who have questions should put it there. Let me go with the first one which is this idea of waiting for a different vaccine given that these studies are by definition limited in the number of people, how can we say that one vaccine is better than another for particular groups whether it's pregnant women or people with particular comorbid factors? Well, right now it's very difficult as you correctly said because we don't have that kind of sub-analysis. One thing that is possible depending on how well things roll out is to see what kind of pattern of adverse events we're seeing in the current vaccines and whether or not it suggests a hypothesis about any sub-group for whom the risks seem to be somewhat higher than others if we're seeing a pattern in the adverse events. That's gonna be difficult because this is a signal and it can't be tested properly but at least it's a signal. The second is some populations may be better not because of their physical characteristics but because of their logistical characteristics. As I was saying, it may be that for community members it's much more effective to do a single dose or for people in occupations where they are moving. I mean, you've got long haul truck drivers they are providing an essential service because they are moving things around that we all need but they are also not always in the right place at the right time if you're gonna make them come back to the same place where they got their first dose. So you either have to change where they get it or you've gotta change the kind of vaccine they get. So let me push you on that a little bit it addresses some of the questions here as well which is that's a US focused where we could change the way we do it so that the truck driver forget the first dose in New York and the second dose in California. I'm more concerned in developing world countries where people may be traveling miles by foot for getting the second dose. So is there any thought about the two dose maybe is better to work in developed countries and the one dose we really need to be doing it in places where we may really not be able to get back for that second dose. Yeah, I mean, this entire talk focused only on the US which is incredibly provincial but it's absolutely true that the logistical issues are very different in other countries. It's not just the travel time that might make a single dose vaccine more feasible than a double dose at least in the rural areas. A lot of these people live in cities but also in terms of the warehousing and transportation requirements that some of these particularly the ones that require the extraordinarily cold storage and limited time out of refrigeration. But I don't wanna speak in great detail about that cause it goes beyond what it is that I really know about. There enough. So Will Parker wrote, is it possible that we've actually exacerbated disparities by focusing one A on sort of the healthcare community only because of the racial ethnic breakdown of who works in our healthcare services? And he wanted to know if you could do it again and start over with that still be the first group that you would want to be vaccinating? Well, if you look at physicians only you're gonna wind up with a population that is disproportionately middle and upper middle class and white American born. If you look however at the groups that are really being targeted which is healthcare workers not just physicians what you find and I didn't show this but the CDC slides did if you go back to ASAP that when you begin to bring in the cleaning staff and the cafeteria staff and the nursing staff and all of the PAs and other people and that's combined with the physicians then suddenly you actually are looking at a population that has a very good representation both in terms of gender and ethnicity and race. So by focusing there you actually do get a nice coverage. So I can't speak for all hospitals but I do know a little bit about the Chicago hospitals and one of the issues with that for example is that the uptake amongst physicians since these are voluntary vaccines and that we'll get to the question of voluntary versus mandatory has been very high with over 80% of physician healthcare workers and residents and house staff accepting the vaccine and yet quite low in those other groups. So it does raise issues of one question was while there's a shortage why not just give it to the people who want it? Why are we trying to push for people who are hesitant given that we don't have enough for everyone anyway? Well, I think we try to push it for people resident for several reasons. Number one, because of a kind of parentalistic attitude then it's good for them. I mean, really it's good and public health is parentalistic, let's just face it. And that is part of its function is to help people do better for themselves than they would if they had their own brothers. The second is that those people who are hesitant or refusing are also now providing a vector to other people who either are not able to get the vaccine or contraindicated to the vaccine are particularly vulnerable to the illness. They are a public health threat. They're walking public health threat by not being vaccinated. So you do want both for their own interest and for the interests of the rest of us to push the vaccine. And there's been a real effort to overcome the kind of distrust and discomfort with the medical system that we see in certain subpopulations by having people from their own community speaking to them. So they're now coordinated efforts to work with among other things, African-American physicians or ministers and other kinds of religious institution leaders and celebrities that will provide a kind of reassurance. I mean, going back to the Santa Claus, it's kind of finding what person is it that you trust who says it's okay and then making sure that that person is available to send that message. So I also just want to point out that our original policy that we had been thinking about just include those who are over the age of 75. And one of the decisions was to lower it to 65 in the notion of health equity in that just life expectancy that if you only included those over 75 you'd be getting a much wider community than you would if you went down to 65. But going back to the question about mandatory vaccination. So two questions come up about that. One, can you ever justify mandatory when it's only under an EUA and doesn't have quote the full FDA? And again, this whole question of just to what extent are people who really, really wanted should be able to sort of give themselves priority over the vaccine hesitant? But I think you've already answered the second half. So on the EUA, there's two parts of this thing. First of all, let's recognize that you can't force anybody to have a vaccine. The question is whether you can penalize somebody who doesn't have it, right? We're not gonna drag people into a room and then shoot them up with vaccine against their will. That's a battery. We don't do that. It's penalizing. And the penalties can come in the form of not being able to work in your usual job or not being able to work in usual hours or being fired. I mean, there's a whole variety of these things. So the question is really, can we mandate a vaccine that's only authorized under an emergency use and administer penalties? The answer is a little confusing. Legally speaking, there's a bit of ambiguity in the statute that allows the secretary to issue the public health emergency and the FDA to then give the emergency authorization. It talks in that statute about the requirement that people be told about their privilege to refuse, which suggests that you cannot mandate it, but it talks in other places about the kind of consequences of not taking it. So for one thing, a mandate's gonna be the subject of litigation almost immediately. And you may not wanna deal with that. And the second is that we find that outside the school vaccination programs, we often find that these mandates from employers backfire because they set up a kind of resistance based on that you shouldn't tell me what I have to do. But it is always appropriate for employers to say, if you are now a threat to our clients or to our patients or to the other workers, we may have to change your work circumstances so that you're not a threat. Can't make you take the vaccine, but can't also let you continue to be a threat to people who are in our emergency room. So employers will always have that option. Even if they can't mandate it, they can move people around. So you talked about penalties. What about giving people incentives? Why not pay people to take the vaccine? That has been suggested actually. And it could be paying people or it could be other kinds of perks. I mean, here in the winter climate, it may be getting a parking place that is closer. Or it could be that you get first dibs on whether or not you have to work on New Year's Eve. There are a variety of incentive systems that can be used, not all of them monetary. And there's absolutely nothing wrong with those. Keep in mind, however you do this in an employment situation, you also have to recognize a couple of non-discrimination measures that must be abided by. You can't discriminate based on disability. Some people can't take the vaccine because they're contraindicated. They cannot be disadvantaged because of that. There are religious exemption requirements as well for people who have got religious objections. So any kind of employment-based program, whether for incentives or for penalties, has to accommodate the legal constraints on how you treat those groups that are not complying for reasons that are protected under law. So I'm intrigued about the religious exemption and pediatrics, there's been a lot of moves in like California, for example, got rid of all religious exemptions and many states are. So does that really hold for the COVID vaccine? Employment laws are different than the laws for the school vaccines. Got it. Okay, the next question was, so the whole issue of how do you prioritize within phase one? And you were talking about starting with the physicians who may have the healthcare workers who may have other comorbidities or age and things of that. Reminds me of the issue that came up with the Stanford where at Stanford they had decided they were gonna go age order, which meant that they were gonna give it to the 75-year-old and older doctors who were actually working from home or versus the residents who were frontline in the emergency room. So how do you really prioritize within that phase one or within any of these and not create other unintended consequences? Look, I think that the answer is that you're not gonna have a perfect system no matter what you try to do. And at a certain point, the effort to be precise undermines your effort to be efficient. But in a hospital setting, you probably have the best opportunity of all because you do have job categories. So you can actually do it based on job categories in which you have an advisory committee working with the hospital administration saying, people who do this job tend to have contact with patients. People who do that job tend not to. And you can actually divide up fairly quickly and your payroll system will print out the names of all the people who are eligible in that category. It's in the community that it gets much, much harder when the random pharmacist has to decide whether or not you are in the right phase and has to evaluate whatever proof you're showing or has to decide whether they believe your self-report. That gets much more difficult. Lori Zoloth, by the way, is saying that there are no credible religious objections. All I can tell you, Lori, is that the courts are very unwilling to get into deciding whether or not people's religious claims are justified by formal doctrine or their own personal belief. Yeah, the next thing was the whole issue of give out the first vaccine as widely as we can and just hope and give resources to make sure that second vaccines are being created. So there were two issues about that. And one we know that the UK is trying to do that. One question was raised by Fauci that we don't know how efficacious some of those vaccines will be if we don't do three weeks to six weeks. But the other question that was being raised here is, isn't it possible that will promote harmful evolution? And since we're already seeing that this virus is mutating much faster than anyone had anticipated, is that a dangerous idea? Should we be saving those vaccines for people to complete their course? So I wanna be clear that as I understand what's coming out of the new administration, they are not suggesting that they double the number of people getting this and having only a single dose and then just kind of hoping that second doses come along. They are trying to get more first doses out at the same time that they're trying to encourage pressure or assist manufacturers in speeding up production and making sure that the second doses are available on the schedule of either three weeks or four weeks according to Pfizer and Moderna. So they are not trying to do the UK experiment as it's been spelled out. I'm not enough of a biologist to know about the effect of the single dose versus double in terms of the evolution of the virus. I will say that I saw a piece just yesterday the day before about some researchers that are looking at focusing on the human proteins that the virus needs as opposed to the proteins and the virus because then the virus can't actually evolve quite the same way and they're hoping this might help us in the future in preventing more variants from developing. But I can't say more than that because I'd have to go back and actually read through the article again to make sure I say it straight. So a lot of interest about the issue of prisons, Preston Reynolds writes that 75% of people arrested and sent to jail are never convicted of any crime and may stain jail for months because of inability to postpone. As a medical director of our local jail I'm proud to say we have remained essentially COVID-free by implementing every possible strategy including electronic home monitoring, we require face masks for everyone including officers, et cetera, et cetera with vaccine rollout. Though one of the issues again it's gonna be that it's gonna be voluntary and how do you get people to agree to take it? And so wondering do you and since many people may be coming in and out of the system do you just wait for the one dose or do we really wanna put them in priority in one B? Well, first I think that we're seeing a pattern across the country of certain localities having to release people from jail and jail as opposed to prison, right? Simply because of the overcrowding and the health risks these people have not been convicted or they have short sentences for minor crimes and the health risks are considered to be unacceptably high considering the overall kind of sentencing and punishment or whatever. That's happening across the country based on particular prisons and their situations. It is absolutely the case that prisons all over the country even without court orders are thinking about whether they can adapt their protocols to release more people into the community with community monitoring of some sort. You can immediately imagine why it is that you get pushback, right? From the local community that's fearful of an uptick in crime at the same time but realistically it's often gonna be the only option. Even if you take all of the measures possible once the infection gets into those facilities it is really, really hard to stop it from spreading and the initial introduction can come from visitors or from staff or from deliveries of goods and services. So very, very hard. What was the next question? So one question was why has this become so political? And one of the people in the audience wanted to know why was the polio vaccine not so political? And what can we do to make sure that future epidemics and pandemics aren't so political? And or is this just a naive understanding of what really happened with the polio vaccine? So we do have some interesting history with both smallpox and polio where you have eras in which there is a higher trust in government and as a result you don't get the same kind of politicization but you do still have pockets of resistance. I mean, there was a demonstration in Milwaukee that went on for a month against the smallpox vaccine program in the earlier part of the 20th century. So it's not as if this kind of thing hasn't happened before. I think what really was interesting this time is how much it broke down along formal political party lines. And that in some ways, I think, got more commonality with the climate change debate than it does with the debate around vaccines. I think personally, and I'm going out on a limb here but I think it's really about the fact that the measures that have to be taken are more or less acceptable depending upon your political point of view. The kind of constraints on a company to operate at maximum profitability without having to install pollution controls or carbon dioxide reduction measures, et cetera, is more of a political issue. And so if we could solve climate change without having any kind of consequence like that I think everybody'd say, oh yeah, I believe in climate change. And if the pandemic response didn't require all of these kinds of liberty reducing measures, I don't think that we would have seen the resistance to believing in the seriousness of the pandemic or the importance of the measures that are being taken. Again, it's the kind of resistance to reality that's been the problem. I don't believe in the pandemic. I don't believe that masks really matter. So, and I don't know that this has been as clear a political party line in the past as it was in this particular era. That's exacerbated simply by the kind of extremism that's been built into the American political system now through the primary system in which elected representatives now are pretty much having to move to the margins of their parties to get elected in their individual districts. It's changed the composition of the house. And going far and field, I will tell you that the 1970s reforms in the house seniority systems and committee championships also had an effect on this kind of thing. There are structural political and legal formulations that have made it more difficult for people to actually compromise and collaborate across party lines than they used to. Last but not least, the internet. There are some wild conspiracy theories and fears out there. One of the ones I didn't even realize was this tremendous fear that the vaccine causes infertility. And this one's been circulated deliberately into the minority community where they do have a history of forced sterilization in the past. And so these kinds of concerns don't seem so far out. By the way, it's the same ones that were raised in parts of Africa in the polio campaigns. Then the Bill Gates microchip conspiracy, the vaccines actually the insertion of a microchip. I mean, this kind of stuff would not have gone to the amount of buy-in without an internet that we now have. You couldn't do that with newspapers. You'd have people on the fringes, but you wouldn't have whole movements of people believing this stuff. So just like there are people who wanna challenge the whole idea of giving it to people who are in jail and in prisons because of questions about why are we giving it to quote unquote, the bad people. One of our questioners said, what are your thoughts about including smokers in the list of persons with underlying conditions so that smokers are prioritized over non-smokers? Yeah, this is exactly what came up in the conversation with the students, smokers versus people with asthma. So here's where my medical knowledge is insufficient. I don't know if simply being a smoker is enough to put you at significantly higher risk, or if it is how many pack years of smoking you need in order to get to that level, right? I appreciate that there's a lot of disapproval of people who engage in behaviors that put them at higher risk. Smoking is now one of the least tolerated. Obesity is least tolerated, but there are other things that people do that put them at higher risk. I think it's important for public health to be non-judgmental in the measures it takes to actually prevent and treat while it can be very judgmental in the messaging that it uses to try to get people to stop being idiots. So you can have all the don't smoke messages, and being a smoker is a dumb thing to do messages, and I think that's great. But once it's about whether or not people are more or less vulnerable to illness, I think you have to drop that. Just like in public health, we had needle exchange programs being proposed because it's not about saying drug addicts deserve what they get, and if they get Hep C or they get, or Hep B or they get AIDS, it's their problem. It's whatever reduces the number of people who get sick and die. And now let's work on preventing drug abuse from another way, another measure, but not through penalizing them when it comes to something that might help them stay alive. And I take that view about smokers too. That's great. We have a couple of legal questions. One was, is there any immunity from liability for any of these pharmaceutical companies? Yeah, for the pharmaceutical companies, there are a number of protections that were built in. Those exist for vaccines generally because of the almost inevitability of a certain number of people having adverse events. So for vaccines in general, we have a schedule of vaccines, known adverse events that are correlated with them and are suspected to be caused by them and then a schedule of payments for people that have that particular reaction. And then there's a new system that was set up specifically for the COVID-19 vaccines that does something like that. The more intriguing area of liability protection actually came up when the question was, should employers have some kind of liability protection for employees or for clients, right? Whether it's protection because somebody got sick or and is arguing the employer didn't protect them enough or protection or liability for having incentivized or even tried to force them to get the vaccine. That's actually been debated quite a lot. I even held up some of the aid packages in the Congress for a while on this question of business liabilities. I'll say that with regard to liability for allowing somebody to get sick, I also talked towards it, the University of Wisconsin for many, many years. And I think that the ability to prove that your infection came from this source and not another is a causality element that'd be very difficult to manage. And so I think that the fear of liability there was a little bit exaggerated. But when it comes to the vaccines in general, opting into the vaccine liability programs and getting a scheduled payout would then supplant any kind of employer liability for having encouraged the vaccine. So I guess the short answer is, I don't think there's gonna be a lot of liability here on either people getting sick or on people having an adverse event from the vaccines. Before I continue, I wanna know what your time limit is and Mark, what is our time limit here? Can we go to 130? I think he said yes, he was on mute. So one question from Monica Peek. Is that okay for you, Alta? That's fine, hi Monica. What are the federal guidelines really the use of trusted community-based organizations such as churches as places for vaccine implementation, particularly for minority communities? I don't know. I mean, I know that they can be done because that was part of that national plan that I was very briefly showing in the last couple of slides. That was clearly about using non-medical facilities like stadiums and mobile clinics. If the concern is that you're using a religious faith-based kind of institution as opposed to a secular one, I don't see that being a problem. There are no limits on the ability to reimburse for a service that's provided. It's more about limits on providing funds for something that actually is involved in providing religious education itself. So I don't see an issue, but certainly we can look into that for you if that's a real issue for you. Is there anything in the Biden-Harris plan in response to vaccine tourism? Some of us may have seen yesterday with the case in Canada where a wealthy family went by playing to another area in order to get a vaccine and things of that. So I'm sure it's also happening in New York to Florida. Yeah. Yeah, I don't know. I've read through the plan. I don't remember seeing that. I do remember seeing materials having to do not with vaccine tourism, but with licensed professional tourism. That is making it easier for licensed professionals in one state to operate in another temporarily so that they can help out during a surge. We've had that here with, for example, just with the Zoom and doing a remote telehealth across state lines. So we have several states that gave emergency permission to do that. On the tourism, I don't remember seeing anything in the plan. I know that individual states have been taking measures to restrict vaccination to their own residents, but then they get into, am I a resident? My driver's license may be Wisconsin, but I've been living in California for a year. Where am I a resident? And do I have to show you my tax forms? Not going for a resident, but to get a vaccine. Okay, got it. But that's easy enough to check going back into the document. So Bob Shung asked the question, how much risk is it that the practice of medicine will be quote, contaminated by public health ethics post-pandemic? In other words, this whole notion of social value, whether it's essential services and the workers who work in those essential services, then we'll become part of the equation at the bedside. So pushing back on the fact that many of us think that this was the first time we could finally justify re-engaging and reconverging medical ethics and public health ethics. I'm a little bit confused. Is the concern that we're gonna revisit things like rationing organ transplants according to some notion about who's more socially valuable? The old organ equipment, is that the concern? I think that is the concern, right? If we're giving the vaccines to quote those who are an essential workers and healthcare providers, we're making a, and even in your ASIP, right? I mean, you use the language of social value. Yes, I did. I can't be sure, but it does seem to me that public health deals in large numbers. So you're dealing with large numbers of people whose presence or absence from being a functioning part of society has an enormous ripple effect on the rest of society. If you can't have a full or at least substantially full battery of people who are engaged in crucial manufacturing or in crucial transportation, then everything falls apart. Whereas in most medical settings, the numbers are just much smaller, even if you're talking organ transplant, the numbers of people are not large enough to have that kind of enormous societal effect. And so I think it gets harder to justify trying to ration according to societal impact of giving it to this person versus that person. I mean, in addition to the instinct that that's just not a good way to do things, I think that it's logistically hard to justify. So going back to your issue of the social vulnerability index, we had a question from Dana van de Haida who wrote, can you discuss a bit about the approach in Florida with an open call for anyone over 65? My understanding is that the phone lines and appointments were immediately overwhelmed, but it looks like their percent vaccinated is relatively high. But I don't know about the distribution of socioeconomic racial ethically, should they have prioritized within the 65 plus group, particularly as a state with a very high proportion of older adults. Yeah, Florida and older adults, I think is a very special kind of political thing going on there. Also about who's going to go to the polls, who's going to vote, because older populations do tend to vote at higher rates. So there's a real push by most politicians there to gain the loyalty of that population. Just listen to the rhetoric around social security and Medicare in that state. I think that the answer to that is largely in how the state manages the distribution down to the county level, because you can address the need to make sure that among the older adults that we do not overlook those who come from more impoverished backgrounds or minority backgrounds, simply by making sure that the distribution within counties reflects our concerns. Because there won't be enough for everybody over 65 immediately. So if county A has 100 doses and there are 300 people on the wait list, they'll give out 100 doses. And if county B has 100 doses and they're in a poor county, they'll give their 100 people. If it's going to be a single distribution from the state, you may have all of the best well-off people getting it first, but you can avoid that. Basically, you can do what Dallas was doing until they were stopped by the state of Texas, right? They were just, they were going to focus their efforts on making sure that they got more of this stuff to the impoverished areas as they distributed around the county. Great. I actually think we've accomplished all the questions. And I just want to say thank you. I mean, your knowledge is just so vast. It was just awesome for all of us to just be able to think about this from both in ethics as well as policy and political perspective. So on behalf of everyone, I want to say thank you. I'm going to turn it over to Mark and then give you the last word. Mark, is there anything you want to add? You're on mute, Mark. No, I think you've covered it beautifully in the discussion and in the questions. And I'm deeply thankful to Alta for spending time with us today, both in the seminar and in the lecture. So Alta, any final words of thought for us to your neighbors in the South, no piling up? Well, first, my thanks for inviting me, truly. It's an honor. But the second is actually to pick up on something that one of the students was saying in the session before this that I thought was really insightful. And I apologize that I didn't catch the name. The point had to do with the communication strategy because at this stage, a very big part of the puzzle is communication with the public. And the point the student had been making or the fellow, I could have been a fellows, was that as long as the communication is, we want you to get a vaccine, but you're still going to have to distance, you're still going to have to mask, you're still going to have to behave. Exactly as if you didn't get vaccinated, it's not the right way to pitch it. What we need to be doing is explaining to people why they're still going to need to take certain precautions. But once you've been vaccinated and you have a group around you, a friends or family that have been vaccinated, there's a real change in how you conduct your personal life. You can expand your bubble, basically. And that is the most important part of the return to normality is the ability to once again have human interaction over something other than a laptop screen. And so my last comment would be that the area I know the least about is one of the ones I think is now the most important. And that is public health communications with the public and explaining the advantages of the vaccine so that we can get as many people as possible to take it when it's finally being made available to them. That's going to be the long-term solution to this whole pandemic. And that is going to be really challenging since given that even within the hospital systems, granted, there's a huge diversity of people, as you pointed out, we're not getting close to the 75% that Fauci says we need for herd immunity. Absolutely true. And if healthcare providers themselves, particularly the ones who are in the highest skill levels with the greatest medical education are themselves saying, I don't need it. I don't want it. I don't see the point or I... I don't think it's that. I think the rest of the hospital, to be honest. I mean, I do think we're seeing a very high update among the physicians and the house staff. It's more all of the other, from the nurses, respiratory therapists, EVS, catheteria much lower compared to the physician. But it's still, we all work in the hospital. We all see these people. We see people sick. We see people dying. You would think that we would all sort of be... By our anecdotal experience. There's one other population, I know we're kind of making this the long goodbye, but there's one other population we should pay attention to. And that's people who are highly educated and somewhat left of center, the same people who are kind of nature worshipers and think natural is always better. There's some overlap in terms of resistance to other kinds of technological innovations, whether it's engineered foods or whatever. There's a whole group of people who want natural immunity. They think natural immunity is better than vaccines. And if they've had COVID and have survived it or had very few symptoms, there is a population of people who think that therefore they don't need the vaccine and they'd rather get it naturally. And that also has to be addressed. I mean, that misunderstanding really needs to be addressed. And that's a very different population to deal with. No, you're absolutely right. It's actually interesting that you say that because I actually try to argue that the messenger RNA, the mRNA platform is a much more natural, right? I mean, it's teaching your body. It's like, take off and it goes away. And now it's your body creating these antibodies which is much more natural than some of the other vaccines where we're giving you an adenovirus vector or something of that sort. So I've actually been trying to push the Pfizer and Moderna on the ground that they are the natural vaccines. But again, I just wanna say thank you very, very much on behalf of all of us and you're always welcome down here. Thank you very much. Really appreciate it, Lanie. Thank you, Mark. Thank you. Thank you. Beautiful. Thank you, Lanie. Worked well. Absolutely. I'll see you at three o'clock where I'll be giving my next talk. Oh, are you speaking at three? Yeah, I'm doing it. We're doing the case, yeah. See you then. Good, thanks.