 Good afternoon, everyone, and thank you so much for joining us for a really important conversation today about the vaccine rollout. We're here. Thanks to the public interest technology program at New America and Future Tense, which is a collaboration of New America slate magazine and Arizona State University that explores the intersection of technology policy and society. I'm Tori Bosch the editor of Future Tense and I'm so honored to be here today. We have an awful lot to discuss in only an hour so I'm just going to jump in and introduce our three speakers for the afternoon. First we have Dr. Helene Gale who has been president and CEO of the Chicago Community Trust since 2017. There she focuses on closing the racial and ethnic wealth gap in Chicago. She previously served as president and CEO of care, a leading international humanitarian organization. She has worked on global development, humanitarian and health issues. Dr. Gale spent 20 years with the Centers for Disease Control and Prevention, working primarily on HIV AIDS. She has also worked at the Bill and Melinda Gates Foundation and the McKinsey social initiative, which is now known as McKinsey.org. And she also serves on numerous committees and nonprofit boards and holds faculty appointments at both the University of Washington and Emory University. Thank you for being with us. I'm joined by Dr. Atul Gawande. Dr. Gawande is a surgeon, writer and public health researcher. He's practiced general and endocrine surgery at Brigham and Women's Hospital since 2003. And is a professor in both the Department of Health Policy and Management at the Harvard School of Public Health and the Department of Surgery at Harvard Medical School. He's also the executive director of Ariadne Labs, a joint center for health systems innovation at Brigham and Women's Hospital and Harvard School of Public Health. He's also been a staff writer for the New Yorker since 1998 and has written four New York Times bestselling books, Complications, Better, The Checklist Manifesto, and Being Mortal. And though it's not noted on his official biography, he also spent some time writing for Slate where Future Tenses based as well. And finally, we have Hannah Shang. Hannah is the strategy director for public interest technology at New America, where she works to develop public interest tech via research, storytelling and hands-on projects. Previously, as a part of the US Digital Service, Hannah was a director with the Department of Homeland Security. She is a frequent contributor to national publications and the author of three books. Her forthcoming book on solving public sector problems in the digital age will be published by Princeton University Press this April. So the four of us will be speaking for about 40 for 45 minutes, and then we'll open it up to Q&A. You can submit your questions at any point in the conversation using the Q&A function, though I don't know why I'd rather to say that since we are all very familiar with the Zoom interface at this point. So thank you again all for being here. Dr. Gail Haline, I would like to start by asking you to tell us a little bit about the work you did on the National Academies Committee to come up with an ethical framework for distribution of the vaccine. Great. Thank you very much. And I just want to point out one fact that you forgot for both Atul and me that we're both board members of New America. So I'm so sorry. I don't know why that's written in the bios I was looking at. But anyway, we're proud of our affiliation. So anyway, so, you know, I was one of the co-chairs this summer for the report that you mentioned that the National Academies of Science, Engineer and Medicine was asked to do by CDC and NIH and as many people know the National Academies functions to put out independent reports for tough and important social and scientific issues. And at the time that we were asked this was before there was any vaccine that had been authorized, and it was in the face of a lot of unknown. So, you know, we were asked to pull this together though because we knew that there would be a scarcity when the vaccine was first developed and that it was important to have a framework that would guide that. And so we had a committee of 13, 14 people of all different backgrounds, all different disciplines to really do the best we could in the midst of a lot of uncertainty to develop a national framework that would then be used by other policymakers, primarily the committee that advises CDC, the ACIP that advises CDC on utilization of vaccines once they're developed. We put together a framework and I would just point out that, you know, for us it was very important that this was this framework was grounded in some core values, and then developed a risk framework that really looked at the risk factors that were characteristic of this particular pandemic because as we know every pandemic has its own kind of personality and wanted this to be very specific. So, we had some foundational principles that we think related to this particular situation one that there should be maximum benefit in thinking about the allocation given the impact that it had not just on health but also on society that there should be equal concern because we know that the populations that were most impacted often didn't have the social status in, you know, think essential workers your, you know, low wage earning health workers, etc. But we really wanted to make sure that there was nothing about where you fit in society that dictated where whether or not you had access and that they're that mitigation of health inequities was incredibly important giving the disproportionate impact that it had on communities of color. So we looked at a risk framework that we thought characterized the most important risk the risk of acquiring or transmitting the infection, the risk of severe disease or or morbidity, and the risk of negative societal impact again because of the huge overall impact that it had. And by using that risk categorization came up with the four phases that you know that we developed a phase one that had a one a and one b phase two phase three phase four with the idea that this is a vaccine that ultimately everyone should have access to, but in the face of scarcity, needing to access different phases. We also said that again, given the focus on equity and the fact that communities of color particularly had been disproportionately impacted. We said that across all of the phases. There should be priority to the geographic areas that were highest on the social vulnerability index. That's the index that CDC has developed that looks at issues related to race, ethnicity, access to transportation household configuration and all the things that put one at greater risk for epidemic disease or other natural disasters and that there should be priority geographically across all those phases. So that in a nutshell, I won't go into all of the phases because we've, you know that that has now become something that people talk a lot about. And we never thought that the phases should be that they should be that there should be some flexibility which we've seen states have looked at phases in different ways but we did feel like those basic core principles and looking at this from a risk framework would actually help us get to the people who needed this the most, and that it would be a more equitable way of distributing a scarce resource. That's fantastic and I want to come back to the way this is all played out among the states, how this is aligned with what you were hoping for and has not. But first I want to get to the fact that this vaccine rollout of course or these vaccine rollouts have coincided with a pretty momentous change in administration in the US. Atul, I know that you served as an advisor to the Biden administration's transition team on COVID matters. Could you talk a little bit about how the Biden administration was approaching the fact that they were coming into this in the midst of a process that was already underway. Yeah, it was made complicated by a couple of things one is clearly coming in at mid course which meant that making major changes. For example, you know, there wasn't a lot of centralized software development the way that you would love to have seen, but now changing a pathway where everybody's on a different system is the way it is right and and trying to up and all of that is going to do. Second, was the lack of good information. So, you know, there are several things about vaccine rollout. Besides what the supply situation is, you want to know about the supply chains you want to know about staffing and what what the federal strategy policies are to make it so you have enough vaccinators. You need to know what you're going to do about software you need to know what you're going to be able to do around billing and resources and enabling all of that. So, I found in two ways both during the transition and talking to many states and and companies involved, but then also in Massachusetts, I am founder of a organization called CIC health that has been behind mass facts that mass testing, and mass vaccination and seeing on that and we run Gillette and Fenway Park and a place called Reggie Lewis track and field, which will be taken over management next week in in Roxbury the those problems of just all the nuts and bolts. There were, there were, they are a source of costs, a source of slowing things down. And that planning had not been in place should have been four or five six months. And so suddenly you're compressing into, you know, post Thanksgiving, trying to stand these things up in three weeks or four weeks and that was clearly Herculean and we're still just in the catch up mode right now. And it was something I was actually wanting to ask you all about, you know, there's certainly a lot of criticism about the rollout and, you know, I think probably extremely justifiably but a question I had is, to what extent are the problems, a lack of poor planning and to what extent are they just that this is all really really hard. Well, it is the poor planning. I agree with Helen. It's a combination of both. But I think that the thing you're getting at is, we're now, you know, about eight weeks from that point where people really got things underway, and the vaccine rollout is now moving at a significant speed, you know, we have 1.7 million vaccines now per day would have loved to have seen us ready to do that in December. We lost a lot of ground. But you know, now that means that we have around 40 million people who've been vaccinated as of today. We've just popped into the top five big countries for our ability to roll it out and that's despite a really broken fragmented health care system where you've had to build a lot of new capabilities that weren't there before. Yeah, I'll just add to that to say, I mean, I think this clearly this would have been hard regardless. And, you know, it would have been ideal to have more national planning. A systematic approach, more consistency across all states, less guesswork, all of the things that we know we went into this with. That said, this is hard. It's the, you know, this is the most complicated public health endeavor we, you know, any of us have been vaccinated for generations and generations before that. And I think it does highlight the fact that, you know, we still don't adequately resource our public health infrastructure. Nor are we what were we well prepared for an adult vaccination program, you know, we do childhood vaccinations really really well. We don't do adult vaccination we know that flu vaccine rates are not as high as they need to be and so I think, you know, I hope that coming out of this we will really take seriously the charge to fund our public health infrastructure and think about what does it take to have a functioning public health infrastructure that also serves adult vaccination because this is not going to be the last time we're going to need it. So I'm curious, Haline just following up on something on so you talked about the development of the risk framework. And so I live in New York City, where we are just plowing through phase one phase two we're now up to as of yesterday, people with comorbidities and a citizen and also someone who understands what's happening on the inside of government. There's, we haven't finished vaccinating people in the other risk categories we've just moved on because not enough people are can get to the vaccines anyway so it seems like on the inside. They kind of thought, well we'll just, you know, open it up and see what happens. So I'm curious if just sort of seeing how that's played out if there is anything that you think the CDC should have done differently in providing the risk framework just around and obviously I don't know like what level of guidance the state's got but we'd love to know your thoughts on that. Yeah, I don't think it's as much the risk framework. We, we know that, you know, throughout this, that people who have had greater access to internet for instance when you need to find a vaccine site or use the internet to be able to make appointments have had, you know, and, and all of the things, people who have greater access to health services to begin with, you know, have had greater access to, to the vaccine. And I guess there's a balancing act between the speed and getting as many people vaccinated as possible, versus making sure that we vaccinate the people who need it the most, because, you know, on, on one hand we want as many people vaccinated as possible. On the other hand, from a standpoint of minimizing harm and also minimizing the risk of spread, you go where the disease is most prevalent, you go where the impact is greatest and that's how you'll also have the greatest impact overall. But I think we're constantly balancing that because of the realities of the inequity that exists in our country in our health systems, and we want to get people vaccinated. So I think we, we need to think about what will it take for people who come from low resource backgrounds, where, or populations where there is vaccine hesitancy for a variety of different reasons. How are we making sure that we're putting the kind of effort into those areas, so that we don't have a lopsided and we're rolling things out without thinking about the, the people who have born the greatest burden of this, and where the infection has taken the greatest hold so I think it's a, it's a balancing act. I'll jump in a little bit on this one. It's interesting. There are, to me, has been how how much the state rankings about how fast they're moving the vaccine have driven the conversation in every state. And so the desire to move fast and efficiently to get as many of the vaccines out has sort of been paramount. I, I can't totally criticize it because of the need to, you know, this has been all about getting the people who are over 75 plus the people of two comorbidities who are the groups who are, you know, at greatest risk of dying, everybody was on board with Helene, you know, your, your team identifying early on that healthcare workers nursing homes and then first responders should go in the, in the first group, and then that we got to get to these high risk folks right away. The parsing out within them, you know, should we do all the 75 year olds before we get to the 65 year olds. That's been quite variable in Massachusetts in contrast from New York. You know, we had gotten, we'd open up to the 75 year olds, found that you got to 200,000 out of the 430,000 in the state very quickly. And then where other places would have then gone to the 65 year olds and the people with two core comorbidities, the determination was wait we haven't got to the other 230,000. And, and so there's been a lot of effort to move to those groups 75 it's made people in the 65 to 74 year old age group very angry about not having access. And it's required all the creativity that Helene's talked about to get to the, you know, to the folks who aren't coming out of their homes to take the vaccine aren't signing up, because it's online because it's because they haven't, you know, gotten the message because they don't have a three kids who are able to stand by their computer all day and, or make 100 phone calls to get in through the two different places. And the, the one creative thing that came out of it which has also gotten a certain amount of fire is the governor here said if you bring in somebody who is over 75 and get them vaccinated you will get vaccinated too. And that's led to people putting on Craigslist I'll pay you $200 if you're over 75 and need your vaccine. You know, I think it's incredibly creative because it's getting people with means to work to get the people without means in through the system. On the other hand, I totally believe we need to be moving fast to get to all of these groups. So we've seen that sort of creativity as you say in Massachusetts, other states have tried other approaches to try to maximize vaccination. But I think we also see a lot of criticism about how much has been left up to this state so I mean I'm curious whether you all think that a more centralized approach might have been better or would that have ended up throttling the sort of creativity that we have seen at a state level. You know, I mean, I, I do think that we suffered from not having a more coordinated approach to this. And the, you know, the role that CDC plays and other national actors, you know, is to give the overarching guidelines to the states. And, you know, public health is a state function. And so states do have the responsibility to its citizens. I think there, there ought to have been and there has been a fair amount of creativity and innovation at the state level. That said, there is a role, I, I believe for a stronger overarching, you know, here's, here are the core things that we will all do that will have a much more coordinated approach. And then within that, you know, allow for individual state innovation that meets the need of a particular state or a particular locality. But I do think that, you know, one of the things that we that we could have and I wish we had had more in the very beginning was a much more national approach. And really when it came to vaccine allocation by states, and you know, some of the just core infrastructure and capacity that is necessary to do this well. I want to ask Hannah, from your US digital service experience, you know, CDC built a centralized scheduling system the states didn't want to go forward it had lots of defects. Do you think that those functions, like the tech should have been centralized more or or is that really, was it just bad execution or is it a bad idea. So the problem with the tech not being centralized from the beginning the way that it should have been the system that the CDC produced was retrofitted for another for different for other users and isn't user friendly and wasn't had a whole bunch of reasons that the states didn't chose not to use it. And that presents a real issue because it's hard to retroactively centralized things like data. I just, I keep thinking every day of all the data that is being missed out on all the data collection that we could be doing at the state level that isn't happening. They're in part because there's no centralized response and all there are all these different systems that are communicating with each other and I'm not even I think what is being captured is really the bare minimum. And I think it's going to be really challenging as we move out of this stage that we're in now where more people are raising their hands to get vaccinated than we have vaccines but at some point, that's going to flip. We're going to need to know well where are the people who have not been vaccinated and the ability to track that at a granular granular level is really dependent upon the data that we're collecting now. So I worry very much about that on a daily basis, but that's going to be really challenging and they are there in the United States digital service is, I believe stepping into this and there's going to be more coordination at the federal level, but I think a lot about what we've already missed. My sense on centralization is that I sort of have to break it down into different categories, I think resources needed to be centralized with, you know, funding coming through and that's starting to flow from the December package but that was late to come out of $8 billion to be required for vaccinators and and getting to the large numbers we're trying to only 300 million was mobilized in the month of December so that was a that was a big hurt. The second clear area is staffing and the hospitals are already stretched we see in our area for example and getting vaccinators that you have to both get, you know, we're going state by state but it could have been a federal that said you don't need to have a nursing degree or a full paramedic training a basic EMT or a pharmacy tech can vaccinate and I'd argue that with appropriate supervision, we could be having lay people being able to vaccinate with the same training it's about three to five hours that we provide to the EMTs, as long as you have the kind of supervisory team available. And FEMA now is starting to supply significant amount of staff and support, as well as standing up vaccination centers and that's a really big deal and, and would have loved to have seen that started, you know, three months ago to five months ago. And on the tech, I think that my sense has been that having clear higher standards around one, you know, data lake which is what we have, and one set of expectations about what information is included, you know, having half the states, not supplying information about race and gender is extremely difficult, you can track by zip code but we can't track by education level to understand where the gaps are. Those kinds of that there's an opportunity to upgrade and set standards there and I'm glad to hear that digital service is potentially tackling that. And I think that having one system that has to enroll take in the massive volume of people there, there, nobody has been ready for this and add in be able to build the billing in. I think another centralized function is why we have to try to arrange for billing for every American from their insurer for $17 for a shot, you're going to spend five six $7 sending the bill. We just have every insurer allocate that you know they're going to hand over the payment for this to a Medicare or a HRSA in HHS to deploy those resources according to who gets, you know, where where vaccinations are being done, I think that could have been centralized more as well. Another thing is just diffusion of innovation because you know clearly a lot is happening across the country and there are ways in which people are learning how to be innovative around this, but there's really no good mechanism for collecting those experiences so that they can be shared. And you know I think a lot of innovation does happen at the local level at the state level, but being able to then scale that up and share that is something that I think would be better to build into the system as well. I mentioned something that we're going to see at some point in the coming months of time when we go from way more people wanting the vaccine, they can get it to people who are more concerned about the vaccine and are less willing to get it. I'm curious, Helene if you could talk a little bit about how you in coming up with the framework thought about the sort of justifiable distrust of the medical community among black and other marginalized communities, and how you think we can best approach equipping people to make a decision that they feel comfortable with there. Yeah thanks and you know, I think we had seven overarching recommendations and I think three of them were around in somewhere the other vaccine hesitancy. You know, and one thing we recommended was that it would be good again thinking about the national level to have a national campaign. You know there has not been anything that sets the general knowledge and information bar for the whole nation and we should be having a national campaign that puts out the facts talks about how these vaccines are developed what the risk or what the experiences etc so that everybody has access to just the core information. You know, secondly, we felt that it was really important, particularly for communities of color but not exclusively but particularly communities where there has been this historic mistrust of government of the medical establishment for very obvious reasons of bias discrimination and real harm that was done to populations that it would be important to also have engagement with communities and really thinking about who are the trusted messengers. What are the best ways to get messages out there and do it in a way that respects people's dignity. And people's ability if given the right information to make the decision that is right for them. You know, we all feel like it is the best thing to do to take the vaccine but people need to feel that themselves they need to feel comfortable with it. They need to feel like this is something that makes sense for them and their families. So really this not this two way communication if you will how are you receiving what people's experiences are, and then how are you actually providing information that's relevant to them by people that they trust. You know, I often say that I think, you know, Dr. Cosmekia Corbett, who helped to create the vaccine, do a lot of the research on the Moderna vaccine at NIH is probably one of the best folks persons because people seeing her, particularly, you know, African Americans seeing this young woman who was part of creating this vaccine brings a sense of okay, I maybe I can trust this because there's somebody like me there's somebody who I trust, somebody who I think, you know, has my best interest at heart. And I think we need to do more than that. I think, you know, the third thing that we recommended was that they really need to be a database and a research about again best practices in the area of communication and behavior change, because, you know, health professionals are not always the best communicators we need to really figure out what's, you know, how do we use communication technology in a way that really delivers messages. Would any of you support compulsory vaccination when we reach that point. I'll jump in. No. Yeah. It's very hard to I mean, they're the first of all it's a emergency authorization, not a full approval, it is still technically experimental. And we're still having to gather information and data about what what's happening now with 40 million vaccinated in the United States plus, you know, many times that many around the world. We're now not seeing the rare kinds of things that can emerge that are dangerous or alarming. And that's excellent. And that'll give people much more confidence. I think the powerful thing that we're seeing that it's related to Helene's point is that we have not had the advocacy campaign that goes out and it's been stymied in some extent to some extent by the lack of supplies and the Biden administration is held back on saying hey let's let's encourage people to go get a vaccination they can't get the. But at the same time what we've always known is that knowing somebody who has been vaccinated and your clinician and what they think about it are the two things that make the biggest difference and as people have gotten to know somebody who's been vaccinated that has made a huge change so we went from pretty high levels of vaccine hesitancy and it's worth distinguishing between the people who are hesitant and want to wait or see more data and those who are actually against vaccination. But both of those groups the vaccine hesitant and the anti vax numbers were high the people had said I I will not be taking the vaccine and you know I might be taking the vaccine but I want to see more. Those numbers are down so that we're below 10% now in the in the black community and in other groups that have been very strongly opposed are now less opposed people are more likely to know somebody who's been vaccinated and then the fear is dropping that said if you are reaching less people of color they're less likely in those communities to know someone who's been vaccinated and you start falling further behind, which is the situation we have been in. There's lots of interesting things to talk about if we want to get to it about what does seem to be working to reach those populations. Yeah, just to say, I would totally agree and I think it's more the carrot than the stick. I don't you know I think that it again given right information given the right messengers done in a way that is appropriate that respects people's autonomy and dignity. I think most people will want to take this vaccine for those who have a reason that they don't. I think we should honor and respect people's ability and that and also recognize that this, you know, do a tools point that this is a moving train. You know what we saw huge hesitancy when there was no vaccine when it was theoretical and how that shifted once we had a vaccine was so effective and efficacious that that, you know, it really changed people's minds and so I don't think a no necessarily means a never. And I think we should give people the respect to make up their minds when they make up their mind. And I don't, you know, there isn't a medical intervention that is compulsory otherwise and so I'm not sure this would be the one to start I think it. You know, there's, there's enough time for people to make up their minds in the meantime. But there are some like, you can't enroll your kids in public school if they don't have certain vaccines, for example. So, I mean there are there are ways you can actually get I mean there you can get exemptions. I think that I think here one of the challenges we'll have is around healthcare workers and whether they, you know, they, we have more and more healthcare institutions that mandate flu vaccination, so that they're not passing it on to their patients. Now, one of the things about the vaccine, we don't know that it reduces, you know, stops transmission. So, you know, at this point, it's only about whether you're protecting yourself from getting sick. We believe it will also knock down transmission and we'll have much more data about that in the next month or two. And then the challenges will become, you know, the nursing home worker, the ICU worker, and what those options are. And, but, but we have to weigh it on the other side like, you know, WHO has not supported making polio vaccination vaccination mandatory, despite the polio eradication effort because we've all seen it backfire with conspiracy theories and other things that make people think, you know, people are there's, there's a lot of distrust, especially in the Islamic communities about whether this is being used to sterilize young boys or other things like that and in polio. And it's been far more effective to, you know, use every method of persuasion, accept coercion in those kinds of efforts. Whether you have privileges, like, you know, being school attendance that has higher bar to withdraw from not doing it, or flying on airplanes or things like that, those will become contentious issues and right now, I think it is absolutely critical that we bring everybody on board without making them feel that they're being forced to take a still a vaccine. We have a lot of information about it's clearly better to get the vaccine than to get the coronavirus. But, but we have more that we'll still have to learn. It's interesting hearing you both talk about the vaccine acceptance as really societal change like any any kind of societal change that when you know somebody who's had a personal experience that that really makes a difference. I think that's just an interesting parallel. I think it reduces the fear because fear is behind a lot of this. And so I think it reduces the fear to see somebody, you know, somebody like you somebody who you trust doing fine afterwards. I think it reduces a lot of that and you know I think the combination between reducing fear and increasing information. You know, a lot of the early hesitancy was really around things that were all that that were more rooted in things that could be true. So, as an example, the fact that this is an mRNA vaccine, people made the link that there could be some genetic outcomes as a result of that well that's not so far fetched, but it is also something that you can then talk through the rationale why in fact, even though it has RNA attached to the name, why that is not genetically altering yourself, but you know and so I think there's a lot of the reasons why people have concerns that are linked to things that you can actually provide facts to get people to the other side of it and so I think, you know, the burden of proof is on all of us to make sure we're giving the right information, make sure that we're making it accessible to people, because I, you know, I think again, most people provided with the right information and taking out some of that fear will really affect opt to take the vaccine. But if we tell people you must, it is going to create a lot more of a hurdle than providing the right kind of information to help people understand what the value is for them. I'd just like to note for our audience that in maybe five minutes or so will be transitioning over to Q&A so if you have any questions for our great panelists now is the time to drop them into that handy Q&A box. I want to shift gears a tiny bit to talk about the other vaccines and the pipeline. Do you think that we're going to be seeing, you know, the AstraZeneca vaccine here soon? Are you expecting that we're going to be able to approve more soon? Or do you think that we'll have a different sort of vaccine regimen here than elsewhere in the world? First of all, Johnson & Johnson has submitted its data to the FDA. They'll be reviewing it next week, I believe on the 25th or the 26th. And a few days after that will be a decision about whether Johnson & Johnson's one-shot refrigerated lower cost vaccine will get approved. And I think it will be approved and make a very big difference. The prospect of a one-shot refrigerated vaccine really changes your ability to distribute, including get to the homebound and others. That's very important. Novavax has had some very good results and is a protein-based subunit vaccine, has parts of the proteins in the virus that your body reacts to, and that is something we know how to produce and have produced in mass quantities before. So the Novavax vaccine, I think they expect to be closing their trial in the next month, and that will also offer a lot of potential. The AstraZeneca vaccine has not been submitted to the FDA, and they're completing a U.S. trial, I suspect, by April. We'll see results there. So we really could have five vaccines that will be ready to roll by the time we get to the general public. It will provide much more supply. It will certainly create a certain amount of confusion with people wondering, you know, do I take this one or that one? And does it make a difference? One thing I put in an op-ed with several colleagues in USA Today last week was that when you get a choice for a vaccine, the best vaccine is the one you can get compared to the coronavirus at this moment. My biggest concern is the strains, and the UK strain in particular, which is spreading rapidly across the United States, doubling every 10 days, 30 to 50% more contagious, and the vaccines are effective against it. So we need to be moving the vaccine out and making sure we're doing everything we can to keep the pedal going on our mitigation measures, too. And so we had a lot of criticism in the U.S. about how all of this is gone, but as Noah Smith and Bloomberg Opinion pointed out per capita, the U.S. has administered more vaccines to our population than all, but I think it's four other countries. Helene, do you have any thoughts about what the U.S. can and should be doing to make sure that the rest of the world gets better access to vaccines as well? Yeah, well, you know, obviously, no one is safe until everyone is safe. There is no such thing as wrapping ourselves up in some kind of COVID vaccinated bubble that the U.S. that can't be permeated. So, you know, I think it's important for us to remember that we need to also be thinking about the rest of the world, both because it's the right thing to do because we have many parts of the world that won't be able to afford vaccination for its population. And we have always been generous when it comes to global health, but it's also, you know, so it's the right thing to do, but it's also the smart thing to do because it's a global pandemic. And just as we're talking about strains, you know, from the UK and from South Africa and Brazil and, you know, we're talking about them because we know that they've already been introduced and they will only continue to be introduced. And so, you know, it will make a difference for all of us to make sure we all it's in all of our best interests to make sure that vaccine vaccination levels are as high around the entire world as possible. I also just think that is, you know, health has always been one of those areas where we can collaborate globally, even when we may not be able to collaborate politically on other issues and global health diplomacy is, you know, as it is called, is such an important aspect of our overall global role in the world. And so, you know, I think we have no choice. It was the right thing that immediately the Biden administration talked about reengaging with the World Health Organization, contributing to the vaccine covax facility, all of those things that I think will make a big difference for the safety of the world as well as our own safety. So I think we're going to transition to Q&A in just a second. But first, I wanted to ask all three of you a quick question, which is if you had the power to change one thing related to the vaccine distribution we're seeing now either something really small to do with the availability of gloves or something huge about making it a national rather than a state by state system. What would that be? You know, I guess I would say, I don't know, there is no one thing. So there is no one bullet that is a magic bullet that is going to make this all better. I think time is important. And again, while we've all been frustrated by, you know, maybe not perfect roll out, some of these things just take time. So I think one, you know, we need patience, we need to recognize that this is tough. I do think the supply of people is an important ingredient. And, you know, a tool mentioned it earlier, you know, being able to train a wider range of people to administer vaccines, I think is a very important part of this that we haven't paid as much attention. And that includes not only people to administer the vaccine, but people to outreach to communities. So I do think the people capacity aspect of this is an important one, along with supply, along with a better surveillance system, you know, all the things that we've talked about, but I guess those would be some that I would highlight. I'll jump in just to say, I think actually the administration is doing most of the things I would want to pull for, but one that I would say would be high on the list for me that I haven't seen yet plans about is really removing the billing component of setup it takes an enormous amount of work. It's a high cost, and it gets in the way of the resources and time for deploying the vaccine. I also think it blocks people from signing up every, you know, when you're coming to these communities you tell them it's free, but I want your insurance card. You know, we've seen this before with testing, lots of people got billed anyway, and it makes people very reluctant so I think there's some straightforward things that we could do that that access the resources that the insurers have in hand and have pocketed for that goal, but doesn't mean you're sending a bill one by one by one to everybody every for every vaccine administered. But I would just just to say, you know that was again one of our recommendations in our report is that there should be no out of pocket costs, including the administrative costs because that often gets forgotten and people make a big deal about the cost of the vaccine, but not the cost of the vaccine. And it then means that cash strap states, localities end up also being saddled with bills that are unnecessary so I think that is a huge issue that, again, it's not, it's not sexy it's not, you know, it's, it's kind of arcane for many people but it's So new America. Yes. And Hannah what would your one change be if you have one. The one thing I would love to see at the state level is, I would love for everybody who wants to sign up to be able to sign up. And I think that there and right now, the whole process is very reactive like, oh we got some more vaccines and so now we're opening up sign up. But we also know that we're in the middle of a mental health crisis, where people feel very hopeless and I think that if at least a date, even if it's like, maybe, you know, New York has estimated that my vaccine date is August. Fine. And maybe they're going to move it six times. Fine. As long as I know that they have me in the system, and that when it's my turn they'll let me I think that that would also on the other side, allow the states to see how many people are raising their hands, and how many people how much work they need to do, and to start proactively thinking about how to reach those populations. So that is my, you know, peace of mind for people, and also starting to think about doing outreach. Great. Well, I have about 7000 more questions for all of you, but I think I have to move to the audience now. Our first question, we got a couple of questions from anonymous people on zoom about the new strains we're seeing. Are there any concerns, for instance, on the use of the AstraZeneca vaccine when it sounds effective against B1351. I'll jump in on this one. Right now the. So yes, so B1351 is the strain in South Africa P1 is the strain in Brazil, both have some evidence of diminished effectiveness. There was a recent report from a study that's not. The methods are challenging to but raise the possibility of almost no effect from the AstraZeneca vaccine. South Africa has paused AstraZeneca routine distribution but scaled up, giving it to 100,000 people and monitoring what the outcomes are and that study is going to be critical because we really don't know what what I pay a lot of attention to is how effective are the vaccines in stopping what matters. Severe illness hospitalization death, and all of the vaccines have had a very, very, have been very effective against serious illness, including the AstraZeneca vaccine. The variants in South Africa and Brazil would be a concern, but the fact that that for B117 they have been equally effective in averting serious illness means I would not slow any of them down at all. Right now what we have is the UK B117 variant, moving very quickly across the US. It's 30 to 50% more likely to put you to to to infect you it's more contagious. And there's also now much more evidence that it's more likely to put you in the hospital or cause death, and we need to move the vaccines as quickly as possible. The other variants, we don't know as much about them are they more contagious do they spread more easily when compared with the others, and they just have arrived in spots here and there in the United States they're not widespread we clearly have to develop the the updated multi valent vaccines that have the ability to attack different versions of the virus, and those will count those are coming. The question comes from new America's own and Marie Slaughter, who asks, Do you see a possibility to use the systems that we're creating to distribute the vaccine as a basis for a renewed and stronger public health system, creating permanent positions for community health workers. Yes, for all of the above I mean I, and I think those are somewhat separate multiple different things in that, you know clearly. And I think I said this earlier, you know we really don't have a good system for adult vaccines, like we do for for childhood vaccinations and so I think this is a good opportunity to really build that because I think we're going to increasingly have diseases and epidemics that impact our whole population and so I think thinking about how are we using this to develop that system. I also think is the question implies is that there's also a job and an economic component to you know here in Chicago as an example, you know we've created a vaccine core that is both helping to on the vaccine effort, but it's also a way of getting people who weren't in the health care system into the health care system and then thinking about what's a career pathway beyond just developing helping with the vaccine effort so I think there's a there's both the health component, building that infrastructure, as well as, you know, looking at the economic, I will say, you know, every time we have something of a serious public health nature, and we say, this is the time that we're going to pay attention to the public health infrastructure and it doesn't happen. And so I just think I hope that we are really resolved this time to think about this because you know one of the biggest challenges for this is that we were caught off guard. We had not invested in our public health infrastructure, and we would have been so much better off had we had strong surveillance systems had we had strong testing capacity, had we had the kind of human resources and infrastructure that we need to mount a vigorous response so you know I do. I am hopeful that maybe this time we have learned enough lessons and it's been extensive enough that we will go ahead and make the investments in the public health infrastructure that we need. We are getting several questions from audience members about vaccination and children do you expect that we'll be seeing vaccines for children sometime in the near future or is that farther out. I mean, the tool you probably have a good sense as well, you know, probably within the next few months and you know what, often with with any medical intervention. First tried an adults and then gradually tried in younger and younger age people and so with this vaccine, you know, the trials did not include children did not include the pediatric age and there are now trials ongoing that will look at the next tranche down so the 16 to 12 and then ultimately 12 to, you know, six, so that we will have that information and we don't have to do it all over again. You know it will really look at safety, look at how the immune response works in younger people, and then be able to authorize it for pediatric use but that should be within the next few months that we have will have some of the data, because those trials are ongoing. The earliest one is Pfizer, which will have their results for their 12 to 16 population. Not until summer they reported a couple days ago. So that means maybe late summer you'd see it for over age 12 Oxford just started the first trial I'm aware of in six year olds and up. So the six to 12 age group and below six will follow after that. And the critical thing I would say that makes clear is we will not have the whole country vaccinated at the end of the year. We will only just barely be rolling out for the pediatric population so vaccines are not going to be the only answer and the only part of our response we're going to need good therapeutics and continue to develop good treatments. And we're going to have to continue to figure out how we maintain ventilation and do all the things we need to do in schools and that means testing will continue to be a significant part of our, our world and that. And, and I'm worried because testing is way down. As people get vaccinated they're sort of saying, we don't, we don't, when they're not coming in for testing at the rates they should be. So, that's a concern. We're continuing to wear masks and distance and all the other things and I, you know, I think it just makes it another very important point is that as, as much as we know that vaccine is kind of the ultimate in, in preventing disease, and hopefully also in preventing infection that we don't let our guard down too early, you know, I'm already happening. Which is a big concern. It's, it's, it's hard to get these multi layered communications right but we've got to make sure people continue to also do the things that they were doing before vaccination. I think the really difficult thing that Helene is going to be that we're going to have gotten to the adults and we'll see the hospitalizations. You know, below flu levels, right. And, and once that happens, arguing that take off that we don't take off the mass arguing that we can't just be normal again and be in concerts and everything else, waiting for the kids. That's going to be that's going to be a big, a big debate. Yeah, along those lines, somebody asks, we've been told we'll need to keep masking and socially distancing after we get vaccinated. I've not heard much about when we'll be able to return to a more normal life. Could you give us some guidance and hope on this. Would you schedule a vacation for some time in 2021 or is that probably not realistic. I'm waiting until 2022, but you know, again, I mean, I think it is the world. We're not safe until everyone is safe. And I think tools comments about the fact that children won't be vaccinated. You know, I, this is not going to be simple. I know everybody wishes that there was a straightforward simple. Read the tea leaves read the crystal balls and we can give you an exact answer. This is this is not an exact science. And we're going to be ramping up some things as we ramp down other things and we're going to have to deal, you know, except the fact that we are going to be kind of multi dimensional in the way that we're thinking about this. And know that we're going to have multiple phases of this going on at the same time, not it's just not simple. Yeah, I'm going to bet that I don't I do not think we'll be able to eradicate the disease. And given that we won't be able to, if that's the case, if we can't eradicate it, then it's going to be something like an endemic flu that goes through the population and changes over time. And if the hospitalization and death rates are low, below flu for that, then we're going to have that challenging discussion that we did over, you know, driving 65 miles an hour instead of 55 miles an hour. And that is the tolerable level of hospitalization and death that we, you know, is it zero, or is it, is it somewhere north of there, before we start returning to normal and that's going to be. That's, that's not just a public health question that's, that's a political question that we'll be working through. Yeah, I think the, as you mentioned, the focus on treatment is also important because I think, you know, we've kind of swung from one direction to the other, and not realizing that this is really about integrating all of the things that we have so it's not all vaccine or all treatment. It's really how are we thinking about these in an integrated fashion, along with, you know, mask wearing, you know, we know that mask wearing will help us with the flu, as an example. It, you know, I hope that while I know 100% of our population won't continue to wear a mask that because people have gotten into the habit of it. When flu season starts when cold season starts that people will think well you know maybe I should just put a mask because I'm coughing. Maybe I should, you know, not stand right up against somebody in the grocery store line because, you know, this can help so I just think we're going to move into a much more complex nuanced world when it comes to protecting population when this becomes endemic. Sounds like a vacation but expecting to wear a mask sounds fair. I would take that deal. I have about, again, lots of questions I would love to keep talking to you for several hours but you are very busy people so I will not do that to you. I wanted to thank you all so much for joining future tense and the public interest technology program at New America for joining us for this important discussion. Please follow these three on social media at Helene Gale at a tool underscore Gawande and at Hannah shank for more future tense events like our discussion next Tuesday on the future of entertainment please follow at future tense now. Stay safe everyone and have a great rest of your day and thank you again for joining us. Thank you.