 We'll start in another minute or so. That's fine. Okay. Got plenty of time. It's nice to not have to talk for a few minutes. So anyway, so that's fine. Is that your real window? It's beautiful outside your house. Yeah, I'm on a deck. Yeah. It is. It's raining here. So I hope the sound is okay. Good afternoon, everybody. The COVID-19 pandemic. Is an unprecedented event in our lifetimes. And the extent to which it is permeated. Our everyday lives. Obligates us to live out. The everyday ethics. Of contagion. We've heard some of that. A few weeks back from John Barry. Who had studied the influenza epidemic of 1918. But today it's, it's a great honor to introduce an old colleague of mine. We go back a number of years. Larry Gostin. Larry Gostin is the university professor, which is at Georgetown, the highest academic rank. He holds the founding O'Neill chair in global health law. Professor Gostin directs the World Health Organization Center on national and global health law. And is also professor at Georgetown and professor of public health at Johns Hopkins. The WHO director general appointed Larry Gostin to this high level committee, including appointing him to expert panels on international health regulations and mental health. Larry served on the director general's advisory committee on reforming WHO as well as on the WHO expert advisory committee on pandemic influenza, smallpox, genomic sequencing and migrant health. Gostin holds international professorial appointments, including those at Oxford University, University of Witwatersand in South Africa and Melbourne University. He holds honorary degrees from the State University of New York, Cardiff University, Sydney University and the Royal Institute of Public Health. Larry is the legal and global health editor of, of the Journal of the American Medical Association. Larry is also an elected lifetime member of the National Academy of Medicine and currently serves on the Academy's Global Health Board. The National Academy, the American Public Health Association and the New York Bar Association all have awarded Larry Gostin their distinguished lifetime achievement awards. In 2016, President Obama appointed Professor Gostin to the President's National Cancer Advisory Board. Professor Gostin has written many books on health law, human rights and global health, principles of mental health law and others. Professor Gostin's book, Global Health Law from Harvard University Press is read throughout the world and has been translated into many languages including Chinese and Spanish. The National Consumer Council of the United Kingdom bestowed Professor Gostin with the Rosemary Delbridge Memorial Award for the person who, quote, has most influenced parliament and government to act for the welfare of society, end quote. Today, Professor Gostin will speak to us about the COVID-19 pandemic in a talk entitled Public Health, Civil Liberties and Equity in the Age of COVID-19. I am so delighted to introduce you to the distinguished Professor Larry Gostin. Larry, welcome. Thank you very much, Mark. As you've said, you and I go back so many years, many stories to tell. But I guess, you know, in neither of our lifetimes, have we ever faced anything quite like this. And it's, you know, it's quite remarkable for all of us. As I'll be saying in my talk, you know, we're kind of all in it together, but we're in it together inequitably. And I'll talk a little bit about that. So really what I want to do is take us back to the very first days of the pandemic and what's happened with the pandemic and then move on to examining how we can think about the pandemic from the perspective of civil liberties, equity, justice and human rights. But I think we want to start probably in early December of 2019. And the scenario that I'm going to give to you is one that most of us in global public health think is the most likely to have the same origins. But I should say, you know, as we speak now, there's a joint WHO, China delegation that's charged with looking into the origins of COVID-19. As I've been saying to the media quite a bit, the chances that we'll have a really understand the origins are negligible because it's like going back to the scene of a crime 10 months later when the crime scene has been scrubbed and trying to figure out who did it. I don't think we'll ever quite know. But to the best of our understanding, on some time in early December, there was a zoonotic leap from a bat to an intermediary animal to a human being. And although there was quite opaque reporting from China to the World Health Organization, nonetheless, the event seemed to be the beginning of the spread of a highly transmittable respiratory virus, which is now known as SARS-CoV-2, or SARS-2. That, you know, tiny microscopic virus, which nobody can see, quickly spread through Wuhan and then wider Hubei province and then throughout mainland China, then to East Asia and on to Europe and then the Americas. And now it's marching throughout the world from the Middle East to sub-Saharan Africa and Latin America. So in a matter of literally weeks and certainly months, this tiny virus gripped us all in ways that we never thought possible. It's really astounding to think how much control it's had over our lives. Mark and I were talking about, you know, the past epidemics and things like that. Well, when I was asked, I was asked by the U.S. CDC after 9-11 and the anthrax attacks to draft the Model State Emergency Health Powers Law, which I did. And it's been adopted throughout the United States and used widely during this pandemic, as well as internationally in many countries. And I first saw most of what we're seeing with COVID-19, but I couldn't have even dreamed in my wildest imagination that a city the size of Beijing would be shut down, locked down tight, or New York, London, Paris, and of course, the greatest lockdown in the history of the world. The entire Indian continent was locked down, was certainly India, and including Delhi. At one point in the epidemic, there were one quarter of all of humanity in absolute lockdown that's staggering understanding about how much this has gripped all of our lives. So we've seen this tiny microscopic virus. That's almost the perfect biological specimen. It's highly transmissible human to human. It's highly lethal and also has compound disease-producing effects on multiple organs of the human body, including what's now known as long COVID, of a longer duration, probably due to scarring of the lung tissue. We've seen it linked to dementia and a whole other things. But it's a very wily virus because it's fatal, but not so fatal that it kills all of its hosts so it can continue to propagate. So it's not like SARS or MERS or Ebola, which can quickly peter out because its hosts are killed. The other perfect thing about this virus, if you're looking at it from the virus's point of view, is that something over one quarter of all cases of transmission are asymptomatic or pre-symptomatic transmission. And so we don't know who's infected. So all of these things have made this a wily foe, very, very difficult. But on the other hand, we've seen unprecedented advancements in science to combat this pandemic. Literally within the week of the first report from China of a novel coronavirus, the Chinese scientists had fully sequenced genetically the human genome of the virus. And widely circulated that genetic code throughout the world, which really gave us a head start. We've done quite well with therapeutics. We saw that with President Trump in the hospital. He was on rem densivir. And also had an experimental monoclonal antibody treatment, which looks quite promising. But the most spectacular advances have been in vaccines are currently worldwide there. And remember, we're only 10 months into this pandemic, where normally you would expect five years, a decade even to get a vaccine, or you wouldn't expect the vaccine at all. Think about the lack of a vaccine, for example, for many diseases that we face in the world, including SARS and MERS. And so we have 11 vaccines in phase three clinical trials in the short 10 months. We have well over 50 in earlier stage human trials, and well over 100 more in pre-stage animal trials at the moment. And of course, the biggest news came out of Pfizer this week, announcing preliminary data showing a 90% effectiveness for preventing the coronavirus disease. I have to say that the 90% effectiveness rate, if the data are validated, exceeded my wildest and most optimistic expectations. Most of us thought it would be a vaccine that would have 50 to say 70% effectiveness, pretty much on the order of an influenza vaccine. And influenza is still here. But if we're approaching a vaccine efficacy, nearing measles, which is about 93% efficacy, we've been able to eliminate measles in many parts of the world. Not eradicate, but eliminate. And so this is, you know, it's very, very hopeful. There are many problems with the vaccine. One of them, of course, is that this particular vaccine requires two doses. And so we're going to have to have data systems and follow up with millions of people. We think about, beyond America, billions of people to get them two doses because they won't be immunized until they're fully two doses. It's also a deep, deep, deep cold freeze virus, vaccine. It requires minus 90 degrees Celsius, deep freeze refrigeration, which makes it very challenging to get the vaccine, particularly to rural areas and to poor areas in the United States and globally. We'll also need an enormous vaccine infrastructure of vaccine workers, syringes, and other injection equipment. We'll need to have safe sites where people can be vaccinated. And we'll likely to have a shortage of supply. And these are all just the problems in the United States. Globally, the problems are considerably more daunting. They're more daunting for a few obvious reasons and a few that are less obvious. The most obvious reason is that in low and middle income countries, it'll be very, very difficult to deliver cold storage vaccines safely and effectively to the entire population. Think about your country with the population and size and rural composition, say, as India. And you'll begin to see what the challenges may be. And there are also a lack of vaccine workers. We've done some studies of vaccine confidence in the United States and globally. And at the moment, vaccine confidence is very low. And so in order to get any kind of herd immunity, we're going to have to get at least 70% of our population vaccinated and maybe more. And if there are large pockets of distrust in vaccines, that's going to be a problem. Although I have to say with a 90% effectiveness rate, many people may make the risk-benefit calculation more favorably toward the vaccine. And with President Trump leaving office and much more attention to science, less pressurizing the FDA, I think vaccine confidence will be boosted. So we face enormous hurdles. One ethical challenge that I wrote about with colleagues in JAMA was whether or not we should use certain priorities in who gets the vaccine first. Everybody agrees that first priority should go to health workers and then other essential workers. After that, many people think that it should be the vulnerable, the elderly, people with preexisting conditions and co-morbidities. And that they should get the vaccine first. And then after that, the question is who gets priority in our argument and I think CDC agrees is one that should favor those who have been socially disadvantaged, including racial minorities who've been subjected to major disproportionate impact from COVID-19. The case hospitalization and death rates among black Americans in the United States and among Native Americans and Latinx is roughly four times the rate of non-Hispanic blacks. And so we've recommended some kind of a social disadvantage index for priority in the U.S. So those are all the problems with the vaccine but many of those problems maybe solved down the road. Solved down the road in the sense that it's very possible that second or third generation vaccines will be better. Certainly, vaccines like Johnson & Johnson's don't require two dose and they don't require that kind of deep, deep freeze, which will make it much more feasible to get vaccines to more people. And while I'm talking about vaccines, I need to talk about global equity and global justice. And the reason I need to do that is because we've seen an unprecedented vaccine nationalism. I've seen vaccine nationalism in the past. We saw it with influenza H1N1 but I've never seen such fierce political battles going on. So just to give you some examples, the United States, the UK, Canada, and the European Union have pre-purchased hundreds and hundreds of millions of vaccine doses even before they're approved. And we've seen a lot of these vaccines for use on their own populations, which means that there's going to be greater scarcity for the world. At the same time, the race for the vaccine has been, you know, a sputnik moment like we've never seen. In fact, Vladimir Putin talks about his vaccine as the sputnik vaccine. In India, the United States, about vaccine prominence and who gets bragging rights. Even the Chinese vaccine, on the very week that Pfizer announced the US vaccine, it had such high effectiveness. Brazil stopped or halted the Chinese vaccine trial in Brazil for safety reasons. And then it came out that those safety reasons seemed to have nothing to do with the vaccine itself. And there seems to be a battle between the mayor of Sao Paulo and Jair Bolsonaro, the president of Brazil. At the same time, there are fights, you know, in India, Mexico, a whole range of other countries. This is not a good dynamic for the globe. There's only one strong equitable initiative, and that's COVAX. It's a facility that was formed by the WHO, the Gavi Alliance, and CEPI. And it's designed to purchase two billion doses of vaccines and then equitably distributing them to low-income countries. Most of the world has joined COVAX except for Russia and the United States. China recently did join. I do expect and I hope and I've urged the Biden campaign to join COVAX, but he hasn't announced that yet, although he will rescind the withdrawal notice for WHO and embrace WHO as the United States should. It was, I think, in my view, one of the most ruinous presidential decisions in my lifetime to see President Trump announce his intention to withdraw from WHO and to put WHO in the middle of a political firing line with China on the one hand and the United States on the other. I think that was unforgivable in the midst of a pandemic. And so, you know, we can see this fight between mother nature and our awesome force and human ingenuity, and it's awesome force through science, playing out in its struggle. My view is that we're going to see escalating deaths globally and particularly in the United States throughout the winter and the spring, particularly as people move indoors and they celebrate Thanksgiving, Christmas, and other holidays that are fast approaching. We've now in the United States reached record levels in both cases, hospitalizations, and in some instances deaths. And so, we're in a very worrying period. And the Trump administration has made very clear that it is not going to fight this pandemic. And so, the Biden campaign will be in until January 20th and it will have very little room for maneuver. So, we've seen this battle between nature and science. But there's another battle going on and that's a battle based upon nationalist populism on the one hand and human rights, civil liberties, and the rule of law on the other. And it seems to me that that's also a battle for the soul of America and for the world. We've seen nationalist leaders really try to extend their authority and their power using COVID as an example. The interesting thing I find is that of the five worst performing countries, probably four of them, maybe more, are led by populist leaders. So, if you think about it, it would be Brazil, Mexico, the United States, the United Kingdom, and India. All five of fairly strong men populist nationalist leaders. It's worried the UN Secretary General enough to actually establish a COVID human rights task force at the UN level. And so, the question is going forward, will we abide by the rule of law? Will we consider human rights? Or will we take nationalism into account? The other question is as well whether how we're going to deal with questions of equity. I mentioned earlier that the vast disproportionate impact based upon race and color and poverty in the United States, and that's mirrored throughout the world. And even before COVID, my view was that the prevailing narrative of the world was one of inequality. People were fed up with the idea that the 1% or the 10% got such riches and did so very well. And so many others were left behind. And of course, COVID-19 has really reinforced that inequity and shown a light on it in very vivid ways. I also don't think it's coincidence that we've seen the protests on the streets for racial justice and against police violence at the same time as we've seen COVID. I think both of those kinds of racial injustices have become very painful and intertwined in many senses. So what would we do about equity? What should we do about equity? It was, I say, the prevailing narrative even before COVID. But justice is more important now than it ever has been with COVID. And what we're seeing is really alarming because most people look at the COVID pandemic and they see ever rising cases, hospitalizations and deaths in our own country and globally. But the truth is, is that that's the least of our problems. As bad as those problems are. It's the least of them. Because what we're seeing is a sharp reversal. A stagnation and in many cases a reversal of all of the global health progress we've made since the Millennium Development Goals and now the Sustainable Development Goals. We've seen absolute poverty skyrocket. We've seen hunger skyrocket. We've seen women, more and more women, forced into child marriages because they need income. We've seen more partner abuse and child abuse and substance abuse and mental illness than we've ever seen. We're placing at risk major campaigns where we've made enormous progress like the Polio eradication campaign. We're turning backward with AIDS, TV and malaria. And of course I could go on and on and on about the devastating impacts of this pandemic, which is a combination of an economic hit, a social hit, a racial hit, and a health hit. All of them coming combined with one another. That's having a devastating impact. On civil liberties and human rights, we're all aware that something like 100 countries around the world have constitutions guaranteeing the right to health. The United States does not. And every country in the world, including the United States, is bound by the international treaty agreement on the right to health. Although the United States has not joined the International Covenant on Economic, Cultural and Social Rights, it has joined other conventions, which guarantee the right to health. And so there's the right to health, but there are also rights to civil liberties. I do believe, and I've always believed, that in a health emergency, you need to give some flexibility to health departments to fight it. And I absolutely am convinced of that. But at the same time, there are certain principles. There are principles of U.S. constitutional law, but there are principles in what's called the Syracusa principles. Those are an international document that really interprets international law. I was actually a very, very young man and was very proud to actually have been in Syracusa and helped draft those principles when I was young. They're now being revisited. The National Uniform Law Commission is now revisiting my own model law as well. I think it's justified that both domestically and globally we are revisiting those things. And we're going to have to really think about, what does it mean to lock down? What are the safeguards against locking down? Should we have such enormous travel restrictions? Should we have, you know, mass quarantines when you go from state to state? There are so many questions that are unanswered by this pandemic that it does leave you breathless. The WHO does have an inquiry going on into its role and into future powers with respect to COVID-19. I suspect and I hope that in the United States we will also have a reckoning and look back and find out what our major problems have been in the JAMA Forum. I've identified seven lessons learned from COVID. These range from, you know, leadership through to science, through to testing, tracing capacity, through to personal protective equipment and then support for international law and international institutions including the WHO. And there are many lessons we need to learn and there's going to be a lot of post-COVID commissions looking at that, much like we did for West Africa but even more so of course. And so where does this leave us? You know, I think we're likely to see COVID with us and not returning back to normal until the end of 2021 into 2022. COVID will probably still be around but we'll learn to live with it with a combination of vaccines, treatments and continued safe public health behavior. Now it may be that the vaccine is just so good that we will get herd immunity and we will eliminate COVID but certainly not what any of us had been anticipating and we'll just have to re-examine that. So when we get back to normal, what will the new normal look like? I'm often asked, maybe you asked John Barry this when he talked, what followed the great influenza pandemic of 1918? Most people guessed that it was World War I but that would be wrong because World War I was coincident with the pandemic. It was actually the roaring 20s. People are very social, they want to get back and we may see that again but we do face some clear choices as humanity. You know, we can either double down on my country first, me first and the whole idea of, you know, semi-authoritarian rule or we can take a path that's internationalist, globalist, that respects human rights that abides by the rule of law. We can make enormous reforms in our own system in the United States, strengthening our public health infrastructure like CDC and state and local health departments, insulating our prize public health agencies from political interference to the best that we can. We can do a lot globally, reform the WHO, give it the funding that it deserves, at least double what it has now, give it political support, give it powers under the international health regulations and so we have these two paths we can take, we can be inward looking or we can be outward looking. In my view, ethics requires us to understand that we are in this together. We also have to understand that we're in this inequitably, that some people suffer much more than others. That's great for us, you know, for me, I'm here on a deck. I've got my tea and my stocked fridge. I can work remotely with a steady income, but for many that's not possible. For many in the United States and around the world. So one of the first tasks after COVID-19 is one, is a national and global action plan for equity. I think that's extraordinarily important. So with that, you know, and hopefully you'll ponder and think about how we can make a difference in choosing that right path when this pandemic is over. I'll turn it back to Mark and Laney and I'll be very happy to answer any questions that you may have. Thank you, Larry, for that incredibly broad description and discussion from the first pandemic of 1918, all the way up to today. So we do have a lot of questions, some coming into the chat and some coming through in the Q&A and just to the audience, either is fine. The first question is from Eric Gum who wrote, we've had bats with us for as long as man has been on planet Earth. Why did this happen now? Oh, that's kind of an easy, it's a hard one and an easy one. Well, bats have, they have an incredible immune system and so they can harbor a lot of viruses that don't harm them but would harm others. And we know that, you know, of all emerging diseases and all novel diseases, at least 60% of those have zoonotic origins. So it was absolutely predictable and all of us predicted, I just have a book coming out at Harvard Press on global health security and I predicted it, but I wasn't alone or special. Everybody in my field did. You know, we couldn't tell you when there would be that zoonotically. We couldn't exactly tell you which animal it would be and we couldn't tell you which virus it would be, but we knew it was coming. And so the next one might not be a coronavirus. It might be an influenza virus, a novel influenza virus or it might be a novel Ebola virus or some other hemorrhagic virus. So we don't know. Basically, a lot of this is to biological chance. You know, when there is a zoonotic leap and how the virus might mutate to make it transmissible among humans and we've seen all kinds. We've had a lot of close calls. I mean, we saw a novel virus, H1N1, which turned out to be highly transmissible, but frankly, not that pathogenic. And we've seen some like H5N1 that were highly pathogenic but not highly transmissible. And eventually we were going to see one that was both and that's COVID-19. Great. The next question comes from Teresa Williamson. What do you think is the risk of prioritizing racial minorities to get the vaccine first, particularly in groups that have historically feared being experimented on? For example, the African-American community. How would you address communicating a strategy that has a priority for socially disadvantaged groups? Very astute question is one we've been thinking about quite a lot. No easy answer. I mean, first of all, using racial criteria explicitly does run the risk of being shot down by the Supreme Court, which now has a six to three conservative majority. The Supreme Court's composition now is not friendly to racial classifications to redress past injustices. It's absolutely true that racial minority populations often have deep distrust of vaccines. And it's in many ways justifiable. I mean, you mentioned Tuskegee and other studies where there's been horrible, unethical research that was experimenting on racial minorities. It's unforgivable. We need to build back trust. We need to try to work with community leaders. Right now, for me, I would be starting a COVID-19 vaccine health education campaign that would be funded from the top and guided by the CDC on health education principles and health literacy principles, but also bottom up using community leaders, church leaders, civic leaders, and really listening to what the concerns are about in the population about vaccines. We have one question from Ann Jesky, one of our current fellows. Where would you start in strengthening or reimagining public health systems in the United States? Yeah, I mean, I mean, most people would say, although this wouldn't be the first thing I would say, most people would say we need to have universal health coverage and consistent high quality care with no cost or deductibility for prevention services. But I think that the bigger problem in the United States, as much as I realize that lack of access to health care is a big problem, the problem is continually weakening our public health agencies, state, local, tribal health departments, in particular US CDC as well. I think we need to do a lot better at funding those public health entities, including, you know, their surveillance testing and other capacities, and, you know, principally their capacities for data systems and things like that. Many of us were really shocked at the poor performance of CDC. Part of that was not CDC's fault because of, you know, terrible political interference, literally not letting them change a word on their website without White House approval. But part of it was just historic neglect and lack of funding for the agency. And so we need to do better going forward. September Williams writes a two part question. First, what percent of people of African origin in the USA and elsewhere, including Latinx people as well, have been in the vaccine trials? In my community in Oakland, California, people are already saying they are not jumping to get the vaccine. And the second part is are there variable strains of COVID which are showing up racially geographically? I think about the papillomavirus strains and poor representation of strains seen in the black women. Yeah, I mean, to my knowledge, you know, SARS-CoV-2 doesn't mutate quite as much as influenza virus. It has mutated, but not in the part of the virus that really causes disease. And so it's thought that the vaccine, you know, will be stable over time, but we don't know that for sure. There's been a lot of concern about the lack of minority representation in COVID-19 trials. We try, you know, companies have tried their best and FDA has encouraged it, but it has been a problem of underrepresentation of these historically discriminated against groups and particularly important because they need the vaccine more than anyone else because of their disproportionate impact from COVID-19. Preston Reynolds writes, Philip Alston in December 2017 toward the U.S. is UN special repertoire on extreme poverty and human rights. His assessment of the U.S. is scathing and actually predicts what we see with poor minorities with COVID-19. How do we expand American understanding of human rights and our ability to honor the human rights conventions the U.S. has joined? Yeah, I mean, yeah, I know Philip and I know that report, it was very scathing. I think that was a little bit of a deservedly, so I don't think we've obviously, we haven't made any progress since then. In fact, we've slipped back. We can see that with, you know, all the dog whistles, you know, to racial bigots and things like that and the police violence and a whole range of things that are really worrying about, you know, racial justice in the United States. President-elect Biden will lower the tone, but I don't think it will eliminate it even under, you know, the wonderful presidency of Barack Obama. These, you know, that part of America endured. We're not one country that really prizes international human rights, you know, we're more likely to prize constitutional rights, freedom of religion in particular, second amendment. Things that not always are friendly to public health. The next question comes from Caroline Knowles. Do you think that pattern of human behavior that are now changing in response to COVID pressures could be more damaging than the virus itself? So that was, was the social, the social disintegration is more dangerous than, yeah, I mean, yes, I do think so. I mean, I think the social disintegration is, you know, could be more enduring than the virus itself. But they're, you know, they're both, they're different and they're, they interact, you know, the social disintegration, you know, causes surges and viruses in transmission. It causes disproportionate impact on, on minorities and poor people. And so we need both, you know, we need, you know, good public health prevention to bring this biological threat under control, but we need good social policies and good social togetherness really to solve this integration problem. But the integration problem only looks like it's going to get worse. I mean, we can just see it in front of our eyes with this election, which, you know, still there's not, we don't see a, the normal, the normal way that we want to see it a transition with compassion, with decency, with understanding and support, quite the reverse. So I, right now we're in a bad place in America because COVID cases, hospitalizations are surging and social disintegration is surging. There is no, there is no solution in the near term. This is going to be a long slog on both counts. I'm going to add in my own question here from a pediatrics set of questions, which are, would you consider teachers part of our essential, you talked about healthcare workers and I assume that includes doctors, nurses and all the other ancillary staff, but how about teachers and then as you talked about their need for 70% herd immunity, what are we going to do about kids since we really haven't done any testing on the kids? Yeah, right. Well, yes, I actually do think of teachers as essential workers. I don't think of the vice president or the president as essential worker, but I do, I, but I do think teachers are, I've been most perplexed about, you know, how to advise states in relation to school openings because, you know, it is a public health risk because, you know, there's particularly with older children, they do transmit the virus quite readily to their parents, grandparents and things, which is a risk. But the benefits of in-class education are truly important. And so I would find a way to make school openings safer. Not, we'll never get to completely safe, but I think we can make it quite safe. And, you know, there are a lot, very inspiring examples of people getting back to normal, you know, Denmark, South Korea with very, you know, going back to school in bubbles, not even wearing masks. There are ways to do this, but we just haven't done it in the United States. We haven't prioritized it. I guess I'm trying to push you on where you're putting them in the priority. We have our healthcare workers. Maybe we're going to have our teachers. We're going to have our elderly. We're going to have our minority disadvantaged. Where are the kids coming in this priority list? Well, you know, you mean children being vaccinated themselves. You know, I don't think there's been a representation or at least nuts. Do you know? No, well, the Pfizer study went down to 16 years old in, in September and went down to 12 years old in October, but clearly the numbers are quite small. So no, then the only trial to date that's actually did any pediatric. Yeah, well, that's, you know, as you know, you know, children might react differently to a vaccine than an adult. And so we should have, we should have been having kids in trials. I don't quite know why we haven't, but it is a problem. I don't know, you know, I would certainly, to me, I placed an extraordinarily high value in in-person education, particularly to redress inequalities that kids, you know, fall behind, you know, because there's some really good data to show that, you know, minority and poor kids, when they come to class, they do just as well as richer kids. And then in the summer vacations, they all fall behind. And then they come back and we're seeing that on steroids now. So whatever, so, so to the extent that we needed to vaccinate teachers and possibly students, I'm, I'm worried, you know, I want to hear from people like you about whether or not you think it's, will be safe and effective to vaccinate a young child when they haven't been part of the study. So I don't know. It's a connoisseur. No one's here to hear my opinion. I'm going to keep asking questions from the line. Eric Weill asked, should prisoners be higher up on the vaccine priority list given the outbreaks in prisons, are they likely cause more harm than good because of prior unethical research on prisoners? Well, I had the privilege of chairing the National Academy of Sciences Committee on Prisoner Research. You know, I think, you know, our committee suggested that you can be too restrictive of prisoner research. And that sometimes, you know, it's justified. And then it's justified is when prisoners represent a very, very distinct population as they do with COVID. You know, obviously congregate settings are major risks, risks of spread. We've seen that in immigration camps, prisons, nursing homes. And so if you were going to have nursing homes as a high priority, I would absolutely put prisons on the same priority level. The next one comes from Leonard Slade. Even more than the virus and its physical effects, the mental effects it has on people, both those who do and do not contract the virus, but those who have other ailments that are emergent and fail to go to the hospital because of lockdown and fear of contracting the virus. And even because we closed down lots of elective surgeries, right? How are we tracking these incidences and what education is available to help these people understand that the illness is just as critical to get to the hospital as those with the virus? Yeah, that's a compound question. And it's kind of the question of our time. You know, first of all, on mental illness, I mean, I think, you know, there is an epidemic of loneliness out there. And that's, you know, it's not the virus itself, but it's the reaction to the virus. But as far as not going to hospitals, you know, we're seeing spikes in, you know, in cancer, heart disease, other problems. And there was a recently a study in JAMA of excess deaths showing that the excess deaths in the United States and probably lower life expectancy going forward are well beyond the actual deaths from COVID itself. And so the intuition that the question raises is correct. It's having a lot of knock on impacts. And in my work in global public health and public health, it's almost never the disease itself that is the biggest killer. It's always other things that, you know, that happened with Ebola. It happened with SARS, MERS, where just people, you know, don't get the care that they need. And also they suffer from other diseases and deaths because of loss of income and things like that. And I think that's why we're doing this. There's a whole configuration. There's a lot of research that we need to do to understand this better and to try to combat it. You mentioned the harms to the CDC because of the politicization. There are some questions from Martin Chan about what about the politicization of the World Health Organization? Yeah, well, I've been right about it. I've mentioned it. No, it's been unforgivable. It's been terrible. Imagine in a pandemic, W. H. O., you know, caught in the middle of a geopolitical struggle between China and the United States. And imagine, you know, that in 1948, when Truman moved us into the World Health Organization, based upon a joint resolution of Congress, all three branches of government supported it. And when we signed the U. N. Charter and W. H. O. Constitution in New York City, just to imagine that we might actually give notice of withdrawal from W. H. O. It's truly jaw dropping. That will be, that will be remedied in its formal sense when Biden takes on January 21st Hill, we're sending the notice of withdrawal from W. H. O., but I think it's going to have long-term consequences. There's a big trust deficit between the international health community and the United States. If one who says, since I started with the kids, what about vaccines for pregnant women? Should pregnant women be involved in these clinical trials? Yeah, I mean, pregnant women, it turns out that actually they're, they're at quite elevated risk for serious disease from COVID. So they, they are in a risk group. And so you've got two factors, you know, one, I think they're, you know, the risk that they face is probably similar to risks of other high-risk populations, you know, like the elderly or people with comorbidities. But at the same time you face this child problem that I'm not aware that there was, you know, that it was studied well what the impact of the vaccine is with pregnant women in the trials. And this is a constant problem. And we've talked about, I mean, you, Lenny, Mark and I know this and all of our, all of your fellows do that. There's been, you know, a long history of under-representation of populations in clinical trials, you know, women, children, pregnant women, prisoners, others. And then you're faced with, well, what do I do question? And you're, and you have to make a decision without full information, without even any really good information. Mike Masal, who's a developmental pediatrician here at the University of Chicago, I'll take the gist of his concern was, can we really have policy arguments without attention to the big disparity that the public loves grandmother's Medicare, but hates poor people, especially children's Medicaid? Yeah. And how are we going to deal with that with the COVID vaccine? Hallelujah. I mean, I, you know, one of the, one of my key messages to the Biden team, which they didn't accept, but they should have, is, you know, don't, you know, don't think about, you know, Medicare for all, it's not going to happen. And don't even focus on lowering the Medicare age to 50. I said, why not have Medicare for children, zero to 19? It would cost pennies and it would have political support and no one and the public health benefits would be enormous. It seems like such a no brainer. The Biden campaign loved the idea, but it's just not been part of the plan in the platform. But that's been one of my, one of my beliefs for a long time. We, you know, we really are in America. I mean, if we get really deep into this, you know, my generation is absolutely robbing the young generation. You know, we're taking all the resources through social security and Medicare, we're voting for, you know, things that are in our self-interest. And, you know, it's, it's, there is no ethical justification for not giving a child high, full and complete and affordable access to healthcare, including dental care. Eric Weil asks, can you please elaborate about how to try to resolve situations where conflict occurs between respect for patients, autonomy and public health challenges like pandemics, where health of one person can be impacted by choices made by other people. Similarly, do you see this vaccine possibly being mandated? And if so, for which communities? I think it's unlikely that it will be mandated. It could. I mean, by law, we could mandate it state by state, not federal government. But I don't see that happening. You know, we've, we've never, we've never had an adult mandate in modern history in the United States. The only exception I can think of is the recent Massachusetts decision to mandate adult influenza vaccines. So I don't see that in terms of how you make those trade-offs. You know, I've always thought you ask a series of questions. You know, the question is, is how bad is the problem? It's bad. How likely is the intervention to save lives and, and, and to save, save and cause less disease? Are there other less restrictive ways that you could accomplish the same objective? Are you doing it in a proportional manner? And what are you really asking the public to do? How on earth is it? You know, it's one thing, you know, to be locked down and, you know, with the, and, and you can't get out. It's quite another to be asked to wear a mask or to stay six feet apart from someone or not join a political or motorcycle rally. All of these things, you know, seems to me that in most of the kind of conversations we're having, public health should win. Not all of them. We can go too far and we can use public health as a subterfuge. But I do, but I do think that the things that we're asking of the American public to protect not just themselves, but others is quite critically important. Another priority question comes from Jumana. I'll shake one of our former fellows. What are your thoughts about unblinding vaccine trial participants after an EUA has been issued for the particular vaccine they volunteered in and prioritizing the placebo group to receive a COVID-19 vaccine? I don't have a strong feeling about that. My instincts would be I wouldn't necessarily, I wouldn't favor that. You know, I think people enter trials, you know, you know, for good reasons. But I would not. I don't think they get special treatment over other groups. And so the fact that you joined trial wouldn't lead me to believe that you should then get vaccine priority. I mean, if you're in the control group over say, you know, a health work or a teacher or somebody like that, you have to make hard choices. I'd like to give it to everybody. I'd like to say yes to everything. She can't. Laurie Zola, who's from our Divinity School, asked the question, why are there public health dogma that was simply wrong? Like if we could do it again, would we or should we close borders? Well, I mean, there were dogmas that were wrong. Borders are tough, you know, there's a long article in the Times and the Washington Post that I contributed to border, you know, basically closing borders can buy you some time. Whether or not it actually prevents epidemics. Most of the evidence is that they don't accept an island nations like New Zealand or Pacific Island. So travel is tough, you know, I mean, basically my message to the media and the report reporters was that, you know, travel restrictions are a dogma of public health in the sense that global public health has always been against travel restrictions. And there were very good reasons for that, which I can go into, you know, basically, if you look at like Ebola and when you slap on a travel restriction, you punish the country, but also you prevent humanitarian assistance from getting to that country. But it's been a long dogma and it's in the international health regulations. I would ask me, you know, what do we know about whether travel restrictions work, what kind they work, and when they work. I would tell you a truthful answer, which is, I don't know. Nobody does know, because we've never studied it because it has been a dogma. We need, we're flying blind when we do things like that. There are areas like, you know, people talk about masks, that CDC and WHO are very late and they change their guidance on masks, on asymptomatic transmission, on aerosolized transmission. You know, I think most of that is due to evolving science. And I don't necessarily think the scientists got it wrong as much as, we're constantly learning and we adjust. Maria Donahue asks, as an advisor, does the transition to a Biden administration includes strategic and tactical plans for the next pandemic, for who USA globally harmonized plans as a result of this experience, such as expanding division of viral diseases here in abroad, travel monitoring data collection. As the autonomy is a barrier to full response by Americans, what message you have for effective quarantine? Oh yeah, I think so. And one of the two senior advisors for Biden is Beth Cameron and she ran the pandemic response group in the White House in the Obama administration. She's also one of the leads of the Global Health Security Index, which I've involved in. Yes, absolutely. I think pandemic preparedness should be and will be front and center. Mark, Brian, do you have any other questions? Can you hear me, Lanie? Yes. I was fascinated. I was fascinated, Larry, by the opening of your talk, when you spoke about the WHO in China meeting to figure out where the origins of the coronavirus pandemic might have been. Can you say anything more about the options or the possibilities? The options for WHO in China or what the options or possibilities are about what probably did happen. That is to say that it originated as you would point out. I think that the conspiracy claim that it originated in the Wuhan laboratory. Oh, there's no evidence for that. Almost all of us think, all of us really, that it was a zoonotic leap. We think it came from a bat because we've seen coronaviruses in bats. And then it went through some intermediary animal and then it had a leap into human populations. But we don't know where and when or how that leap took place. Whether it was at the Wuhan market, when it was, how it occurred, was the animal eaten, was it in close contact? Because it's very obvious that when we thought that the leap occurred in late December, that wasn't when it happened because there are too many community cases of COVID-19 at that time that were not linked to the market. So most of us think it was circulating in China, at least since early December, and I've heard even November or earlier. Will we ever get to the bottom of it? So I mean, I think there was a chance early on, there was a joint China WHO commission early in the pandemic, within several weeks of the origins, when we could have had the chance to do it. But the problem is, is that WHO was only allowed by China to send in a skeletal team. The team was really based in Beijing, not in Wuhan. It didn't have access to scientists, whistleblowers and others. I think the access will be greater now to those groups, but I do not anticipate any certainty or even any advancement in our knowledge of that zoonotic leap. And frankly, you know, the truth is, is that when the WHO China report came out early in the pandemic, it looked to me like pretty much of a whitewash. I don't think we'll see quite a whitewash now because, you know, China doesn't feel as threatened as it did. It's actually flexing its muscles quite a bit. But I don't think we're going to get to the bottom of it. It's most likely some animal reservoir that then had an occasion to jump to a human. So we're going to take a final question from Brian calendar, one of our panelists here. Go ahead, Brian. Right. Yeah, so, you know, sometimes it takes a good pandemic to shine a harsh light on public health ethics. And so I'm just interested in what you think the future of public health ethics will look like in light of this pandemic. Yeah, that's a very good question. You know, it's, you know, it's, it's, it's really, it's, it's hard to know. We've seen, we've seen a lot of, a lot, a lot in the literature on public health ethics and also on equity, but frankly, I haven't seen anything. But I think it's all that innovative. And, you know, in the bioethics community, there still is a tendency to focus more on traditional biomedical questions, doctor patient relationship questions, autonomy, respect and all that. Justice is part of it, but I don't, you know, I don't see a leapfrogging in, in our field to have a kind of a full hole embrace. Of public health ethics. It's expanding, no doubt. And it has expanded quite a lot, but I haven't seen any exponential expansion since the pandemic. I don't know, maybe you have, but I haven't. Well, I just want to say thank you very much. This was an incredibly stimulating lecture. And as you can tell by the number of questions that you were asked to field. So I just want to say on behalf of everyone, a big thank you, Mark, are there any final words that we need to say about next steps? Well, I think the fellows will be asked to participate in an informal discussion with, with Larry Gostin. And it would seem to me that anybody remaining in our program might want to just stay on and continue this, the informal discussion for another 20, 25 minutes. Because I know Larry has an event that he must be to buy by two o'clock his hour time. So I saw that that would be my suggestion only to say that our talk next week is by Keith Walu on inequalities unmasked, what pandemics reveal about American society from the Spanish flu. That should be very interesting talk. Larry, the talk today was extraordinary. And should we take a five minute break? No, I'm kind of, I've got a dual problem. I mean, one, I'm really exhausted. Two, but two, I've got another call that I need to take at, at 235 my time, 135 your time. So maybe could I take like a one minute break and then just do it for 10 minutes? Let's do that. Is that okay? Okay. That was more exhausting than I expected. There's a lot of questions. Larry, if you promise to listen to my question as the first question when you come back in one. I absolutely promise. Okay. So I'll, so do I, I'll just stay on this line and come back in a minute. And then we'll just take a few minutes more with the students. Perfect. Thank you. Okay. Thanks. Thank you. Thank you. Thank you for, for running the question period. That was wonderful. So since you're not changing lines, Mark, how do you want to be addressing the questions? The fellows, unless there's something that. I don't know that anybody can get them to ask questions, except with the Q and A. Yeah, I mean, we'll only have 10 minutes to do it. I think, I think the fellows at the moment, I see nothing on chat. Is that correct? Well, there has been, I mean, Preston wrote that, that she had some of her students from global health. So we've had a few, most have been in the Q and A. I would love to have our fellows. Feel free to ask questions. If they wish to do so. Otherwise. We'll open it to anybody. What I'm just trying to say to you is they can't ask the questions. They're going to have to write it. Yeah. Yeah. It would be good to write them right now. While before he was back. And when I asked him my dreadful question. Okay. Okay, I'm back. I'm going to start with, with a question that doesn't deserve to be asked. But in the face of, of the United States leading the world in, in the impact of this pandemic, 4% of the world population and 20% or more of, of the pandemic in this country. Do you have any sense living in Washington, DC. On why the Trump administration. Did not and will not. Fight this pandemic in a more aggressive way. Well, I, I mean, I think it all, I don't have any. It's no secret. It's the person at the top. It's Trump, you know, he. At the beginning appointed, you know, reasonably good people. We had people from CDC, Tony Fauci, others was on the task force, Deborah Birx had, at least at that time, a fairly reasonable reputation. But he undermined them. He, he, he knee-capped them. I just had a conversation yesterday with, you know, the head of the COVID work at CDC and basically was told, you know, and then it all happened. So many of their guidelines. Were either blocked by. White House or they were. Or they were rewritten. That any word on their website. That was changed had to be cleared with the White House. I mean, he's just was totally toxic. a nationalist populist and we just decided that he was going to rail against science and experts and public health and it's all the anti-expert stuff that's going around in nationalistic populism. So it's been a disaster and it's going to just keep going until we get a vaccine which is a shame. We're going to lose probably at least another hundred thousand lives. The next question that comes is from Chinasa Emo. What would you say could be the contributing factor for why Africa has had low infection fatality rate in light of the fact that early projection showed a different outcome? There are a lot of different theories. Among the various theories, one it's got a very young population. Two that a lot of the living and the partying and things are outdoors and kind of under open air tents. Three that they actually had pandemic experience from Ebola and AIDS and that they actually performed better than in many western democracies. Those are the three prevailing theories and it's impossible to actually know which one is the most important but they're not through it yet. They might see surges there, we don't know and certainly places like South Africa have been very high. Another one of our fellows just wrote, I just watched a webinar in which the CEO of Rush Medical Center spoke about sharing resources with health thought institutional finances. Rush is a role model for seeking out high risk patients from safety net hospitals and having them transferred. Rush is one of the other academic medical centers here in Chicago and having them transferred to Rush so they can attain the benefit of Rush's resources. Has there been talk about creating some sort of system in which hospitals become part of a collective sharing their resources with the government being the payer at least in pandemic times so that we can maximize resources and health outcomes? No, it sounds like a very good idea. I'm not aware of any of that. I certainly know that when Ebola was here during West Africa, we quickly pivoted to having just a few centers across the United States that dealt with Ebola cases. I haven't seen that with COVID cases at all and I haven't seen a lot of sharing. I've seen a lot of competition but I haven't seen a lot of sharing but it is a good idea. It sounds to me a very good idea. Well, it seems like our questions are more or less complete. So again, I just want to say that you get a five minute break before your next phone call so thank you very much and we really appreciated it. Thank you very much. Okay, take care. Larry, it was wonderful to see you here. It was great to see you, Mark and Laney. Maybe next time in person. I have a lot of good reasons to come to Chicago because my daughter-in-law is from Chicago. Oh, wonderful. Yeah. Anytime you want to come, just let us know. Yeah, well, when the pandemic is over, I'll contact or contact me. Thank you. Thank you. Bye bye. Thanks, Laney. We'll gather again at 2.55 for the three o'clock.