 Welcome to the Australian National University's big picture series. My name is Sean Ennis. I have the privilege of leading the university's public policy and societal impact hub. Today, I am joining you from the beautiful lands of the Ngunnawal Nambri people, and I'd like to pay my respects to elders past, present and future and extend those respects to the first nations of all the lands in Australia and beyond throughout the world. The big picture series is part of the 2020 ANU Crawford Leadership Forum. It is designed to stimulate ideas and discussion around the issues that will really define our world into the future. Today's event is focused on global public health, and there can be no more important topic confronting the world right now. The pandemic that's sweeping through the world has changed the way we live. It is something that a year ago, for all the planning that some countries have done, has come as a bit of a shock. Almost every nation, rich and poor, has worked quickly to protect their people from the virus, but not all. Success has varied as have the social and economic consequences. As we move forward, perhaps our biggest challenge is both in the prevention of future pandemics, but also more immediately, how the world distributes and manufactures an effective cure or vaccine should one be found. It's a challenge that I think the panel that we have today is well placed to talk about. Our Chair is the wonderful Lyndall Strasdans, Director of the Research School of Public Health at Population Health, rather, at the University. Lyndall is joined by Jane Pilpoch. Jane is former Minister of Health in Canada and will soon be taking up position as Dean of the Faculty of Health Sciences at Queen's University. Associate Professor Camilini Luj leads the Humanitarian Health Research Initiative at the ANU College of Health and Medicine. Camilini has considerable first-hand experience of responding to pandemics from a time as a physician with a range of international organisations. Tiki Pangestu is Professor at the Lee Kuan Yew School of Public Policy in the National University of Singapore. Tiki is a former Head of Research, Policy and Coordination at the WHO. And we also have Amanda Glassman, Executive Vice President and Senior Fellow Centre for Global Development. Amanda has more than 25 years of experience working on health and social protection policy and programs in Latin America and elsewhere in the developing world. For those watching the broadcast today, I encourage you to submit questions to our panel throughout the discussion using the Q&A function in your toolbar. I think that's enough for me, really keen to hear from the panel. So over to you, Lyndall. Oh, thank you, Sean. And I would first welcome and echo our gratitude of being able to conduct this webinar on the lands of the Gambri and Gunnarwal people and our gratitude to those people and to all First Nations people. And I'd also echo your admiration of this panel, which I share, and it really is an honour to be part of this process talking with such fine minds and thinkers who have been grappling with these issues not just now, but over decades. So thank you. You know, I think you make a good point, Sean, that we are seeing a real patterning of how this pandemic is playing out across countries. And it's true that the countries most hit have so far been in the Americas and in Europe. But there's a long way to go yet. And the patterning that we're seeing, although affluence may have started this pandemic through travel, the patterning we're seeing is showing up different cracks and seams and fault lines. And I think here in this country, we can be proud of the response that we have had, 102 deaths so far. And one of the reactions of the Australian government who was goaded, I would say, by our public health community and here on our panel are one of the people who was integral to the Australian government's response, Camillini, into shutting down early and fast as a way of controlling the pandemic. And the recent analyses of this go-hard-go-early approach has shown that it has paid off in terms of its containment. But there's a long way to go yet. One of the things, however, that's showing up is that this pandemic is not simply about an infection. It's deeply, intimately connected to inequality in both how it starts, who gets it, and then who bears the consequences. Homelessness, domestic violence, the mistreatment of children and women, the issues that have the acceleration of racism, all of which are showing the seams through which the pandemic is flowing and amplifying. What history shows and bears out is that pandemics from the plague to the smallpox to COVID are not only to generate social economic upheaval, but they amplify inequality as does the response to them. And this is a challenge we need to learn from. To look for the clues. All the countries are different. But what could we learn from those countries who are doing this well? There are low rates in some states and countries like Australia, Taiwan, New Zealand, Kerala in India and their counterpoints, Brazil, Russia, the UK, the US. What could we learn about leadership? About how we think about responses, how we plan them, how we execute them. About the social systems and the stats that governments take towards their citizens. So, in this panel today, we've got a series of questions. I will try and weave in some of the questions that are coming up. Some have come to us before the webinar, but please feel free. Anyone who's on the webinar to be posting a question and will try and weave them in. And although my questions are directed to some panellists, I invite all panellists to raise their hand and chip in where they want to add their viewpoints because they have a depth that I think we've rarely seen brought together before. So, I'll start with Jane Philpott, who's the former Canadian Health Minister. Dean of Faculty of Health Sciences and Director of the School of Medicine in Queens University. And Jane, I would like to hear your views about how will this pandemic change the way global health challenges, this and others, are met for better, for worse or for whom? Well, thank you so much, Linda, for the question and thank you to all those who have put this webinar together. It's certainly a fascinating conversation and I think that the context that you have set for the conversation around inequality is a real determinant of where this pandemic continues to move. But in terms of your question about what the virus will do to the broader picture of global health, I think that's a fascinating place to start because we are increasingly hearing concern expressed from many communities, many countries about what this pandemic is going to do to the big killers, the big concerns that we've always tried to prioritize in global health circles. And you think, of course, of HIV, tuberculosis and malaria being the top three killers that global efforts have traditionally tried to focus upon. But of course, chronic diseases as well has to fall into that. And I think one of the challenges that we've seen in higher income countries, but it actually is affected around the world, is that the great COVID shift or the COVIDization of all spheres of health systems, whether it be clinical care or research, COVID has led to a tremendous shift, which means that all of those resources, the energy, the research, the ability to scale has been taken away from other areas. And there is going to be an extraordinary amount of collateral damage. We're already seeing indications of the excess mortality that's taking place in many other parts of the system. And that's highly problematic and something that we need to be very mindful of. Certainly we're seeing a shift of resources from the funding, global funding streams in the charitable sector, the foreign aid sector. There's a shifting of money moving into COVID and or dropping off altogether, but also shifting of research focus, shifting of course of what health systems are making available to people where people being turned away from healthcare facilities around the world if they're not there for purposes of assessment of COVID. And then starting even to see indications of how supplies are being increasingly COVIDized. There was an interesting piece in the Lancet last week that talked about laboratory techniques and the reagents and everything that is not only are all of the manufacturing facilities moving towards supplying the COVID needs, but also actually repurposing testing kits that would have normally been used for testing HIV or something else now starting to be repurposed for COVID. So this is going to take a lot of work to get our heads around how we actually address this ongoing, very dangerous pandemic, but don't take our eye off the ball on these other extraordinary global health challenges that people have been working on for a very long time. Thank you, Jane. And I think what's become clear in this pandemic is that health, without health, there is nothing else and that we could shut down everything, an unimaginable shift in how we think about how societies function to respond to health. And I think what you're saying is that health won't change, won't go away once the pandemic is controlled. It sits there and into some extent, I think you're suggesting it may in fact be expanding. So, Tiki, you're a professor of public policy. You've had a long engagement with the World Health Organization. How do you think this pandemic and if you like the kind of the surfacing of so many other problems around health and social equality, how will that change governance and the systems, the health system and the cooperation between as well as within nations? What do we need to learn about these connections between the pandemic, other health, inequality, global relations? Okay. Thank you very much, Linda, for this opportunity to participate in this forum. It's a particular pleasure for me because I'm actually an alumni of the ANU and the great pleasure of actually receiving my degree from Sir John Crawford himself when he was Vice Chancellor back in 1977. So, particularly, pleasure to be here today. In answer to your question, yes, I think definitely there will be changes in governance, systems and cooperation. In the context of governance, if I take an example of Singapore, the optimal responses has always involved multi-ministry task forces going across all the line ministries, not just health. So, I think that's one lesson from many countries in the region. I think systems must be able to react rapidly to any fires that might sort of come up in the future and be seen that that's already happening in places like Korea. So, I think systems must be more responsive as well as, of course, being robust and going back to what Jane just said to make sure that other public health problems are not neglected. And just to add to what Jane said, Singapore, which has had a very good response to COVID, is now dealing with what might be one of their biggest dengue outbreaks partly because of this diversion of resources. I like what Jane referred to as COVIDization of resources. So, I think those other problems should not be neglected. Other infectious diseases, and my other worry, is a reduction in childhood vaccination rates. I think that's another risk of a health system being COVIDized the way Jane put it, as well, of course, as chronic diseases and also mental health and psychological problems post lockdowns. We are seeing that in all countries. So, that's in the context of systems, in the context of cooperation, that part of your question. I think what the world has witnessed during this pandemic is not so much an indictment of globalization, but I think a reaffirmation of interdependence among nations. So, highlighting the need for collective commitment towards actions that in the future will deal with it. And having worked as part of the United Nations system, I still believe that multilateralism in the long term is still the way to go despite its problems. The second part of your question is obviously the very important one. In the context of this so-called new normal, I think equity issues are paramount. And I think the key to your question is how do we deal with sort of infections and inequality. And basically, that's a top one. And I think what we really need to be cognizant of is, how do you take care of the disadvantage and the vulnerable segments of society the next time this happens? We've already mentioned this, for the homeless, the elderly, the women, the minorities, migrant workers, for example, Singapore has had to deal with that problem in particular of migrant workers. And I think all these people that are not on the radar screen, you asked the question is, what do we need to learn and quickly? And what can we do differently? I just have three sort of fairly specific ideas on that score, sort of disadvantage people who are left out. Firstly, the idea of looking at emergency cash programs as one immediate response. Secondly, the idea of identifying and registering these people for government safety net programs. And finally, sort of the development of cash transfer programs. For the majority of these people who don't have bank accounts. And this is where I would like to allude to one of your earlier suggestions where the private sector can make a particularly important role here. When you say cash transfer for the unbanked, you're talking about innovations for cash transfer, and this is where the private sector, those companies working in the area of fintech and digital banking. Huge amount of experience and innovation there that perhaps can be used in future to take care and reduce the inequality of this large group of vulnerable people that as we can see in many of the low and middle income countries have been disproportionately affected by the pandemic. So back to you, Linda. And maybe add a few points later on. Wonderful. Thank you, Tiki. What I'm hearing you say is that to some extent the capacity to work across government but also to mobilise government. You're talking about cash transfers, welfare payments, safety nets. All of that requires a strong government. Exactly. And a deep government. And a government that is well developed and well connected to its community. So that's an interesting observation around the role of the state in its response, as well as the stance of the state in its response. Camillini, you are, I would probably say a humanitarian health legend working so deeply and closely with some of the toughest humanitarian crises from Ebola, sub-Saharan Africa. You have seen and worked with the suffering of these people and the marginalised and the poorest firsthand. What do you think we could learn about controlling the spread of infection and inequality? How might we best do this? I'll read out a question from one of our participants who I think clearly resonates with your own insights. The question is, international support during the crisis based on my experience working Sierra Leone, which was essentially beaten by mobilising national resources and local strategies to break the transmission change, changing behaviour at the community level. Flying in large numbers of international experts and resources into a handful of West African countries was a secondary success factor. Does the COVID-19 crisis also demonstrate the need to work more with local leaders to reduce unsafe behaviour and break transmission chains? As everyone said, it's an honour to be on this panel and have the opportunity to discuss with colleagues such as this. And thank you for that question. I love the question because I think what I've learnt over decades of doing this work is that communities are the ones who solve whatever problem you have and that's true for pandemics as much as anything else. But I think it's important to think about what's happening in some ways. It's even clearer. Maternal mortality, perhaps you don't make the connection so easily and so we can continue attributing problems to this and that without saying it's there because the community is not empowered and engaged. Whereas when you've got an infectious disease that is passed from person to person, and I've seen that. I've seen communities that have nothing. No running water control diseases like Ebola because they work together and they knew what they had to do. At the same time, we've seen very developed countries struggling with the best state-of-the-art health technology because their communities are not engaged, they're not working as one. I think what being involved in the West African Ebola outbreak made clear to me just like the many Ebola outbreaks and infectious diseases outbreaks I'd worked on before is that unless communities understand their central role in control unless their priorities and needs are integrated into the response you will not get control. That's something I think developed countries have had to learn. Developing countries know this whether they choose to respond that way or not they know that their communities are what guides response. I think many parts of the developed wealthy world has had to learn in this pandemic to learn quickly other ones who succeeded. I just want to go back to some of the discussion before about the COVID-19 of response. My first Ebola outbreak I did many years ago not because I had a particular interest in Ebola but because I knew until we dealt with Ebola we wouldn't be able to get kids treatment for malaria and pregnant women's safe delivery. You can either see it as one or the other or you can look for synergies. Last year we had the declaration on universal health coverage. If every person on this planet has access to essential health care we don't have to discuss how we're going to get the vaccine to them. We'll have the system that delivers it. If every mother can have safe delivery we will have a health system that can cope with the COVID-19. I think our role as public health people is to look for those synergies. We've had a focus on health security as a very vertical thing. You do your pre-development of your vaccine and it sits on a shelf until it's a problem for people that matter. We're investing. We'll deliver for people's problems now. We will automatically strengthen the way we respond to pandemics now and in the future. I'll stop there. I can keep going. I'd invite you to keep going just a little bit more. What I'm hearing you say is that the community has the capability but there is a but there, right? What are the circumstances that enable those communities to lead? What does that tell you about the governments and the whole social system and the whole social thinking and the leaderships in those countries that enable communities to take that role? I think it's trust. Trust in that you have expectations of what your government, what your health system, education system will deliver and if that trust is there, communities will engage. I think where it's challenging is where that trust has been eroded and you need to try and rebuild that trust within the timeframe of a pandemic. Which is what I've seen and what amazes me is even then you can, right? Communities that have had decades of civil war if you engage with them in the right way. Yeah, when I've worked on outbreaks I have 19-year-old young men who I literally but who work with me as disinfection specialists who truly believe that their role is to support their community and respond and that's why I love that question. These are the people that end pandemics and it's the same in developed countries I think and again the good thing about infectious diseases is that we're as strong as our weakest link. If we as a majority respond but we neglect subpopulations and Tiki brought up the example of Singapore, Singapore had a strong response but they had a particular subgroup that didn't have access to healthcare didn't have access to welfare. So again infectious diseases that's their job. It's defined the weaknesses, exploit them and I again think whether you care or not about inequality if pragmatically what you want is to solve an outbreak you need to address those things and as public health people instead of going back to West Africa I still find it it wasn't solved because of a vaccine true towards the end we had a vaccine but many of the trials couldn't continue because there were no cases right. We dealt with it because communities you know responded they supported the response they engage the trust was built with them and between them and response agencies in a similar way I think you know if you look at there's an Ebola outbreak that's been ongoing in DRC for more than a year we have a vaccine what we don't have is a community that trusts those who are delivering the vaccine so a vaccine is not the answer technology is not the answer it's just a tool it has to be built on a foundation of equitable access to healthcare and trust I can't remember I don't think I answered your second question well I think you've so thank you I think that's a beautiful summary and it gives I think a great opportunity now to turn to Amanda and Amanda who's the Executive Vice President and Senior Research Fellow for the Centre for Global Development you've been watching this unfold in the Americas what are you seeing what are you learning what are you thinking about as this is unfolding what do you think we need to learn do differently rather than wait for a vaccine to prevent the next pandemic or even prevent the next spark thanks thank you so much and it's wonderful to be on this panel and share this conversation with you so I think when you compare across countries we do have to take into account that the starting point is very different in so many different countries it's so obvious but when we look at the age structure in different countries or we look at the prevalence of comorbidities across different countries and we look at the different health system strengths at baseline even before we talk about a policy response there's going to be a different trajectory to the outbreak so some colleagues might have been doing some work looking at this and it's the case that an infected person in Uganda is likely to die from COVID compared to the United States even if we assume that every case that needed even if we assume that 20% of cases are hospitalized or something like that the age structure and the lack of presence of comorbidities is protective in that setting so we are talking about really different kinds of outbreaks at baseline and that's why when we look in the Americas these are middle income countries with very high prevalence comorbidities untreated by the way that's another thing we've forgotten to do in global health is to focus on non-communicable disease that turns out to be the risk factor for this outbreak and you see that they have health systems but those health systems are quite fragile and they exclude a number of marginalized groups so I think when we see that one question is the political response but if we look at a country like Peru that really did try to do the right policies quickly and yet they have complete overwhelming of their health system it's because of that at baseline that they have a slightly older age structure than a low income country and they have an enormous quantity of untreated comorbidities and their health system is very weak so that's at baseline I think the other issue that you're bringing up is so important which is the inequality issue you know in the United States and the UK this is affecting African Americans or black English people much more dramatically than other populations prison populations, homeless populations people with intellectual disabilities there was a new study that's showing autism increases your risk by this enormous amount so it's clear that inequality is a huge explainer of the kinds of morbidity and mortality that we see associated with the outbreak I did want to take a moment to talk about the issue of leadership in this space that you raised early you know it's no coincidence that the authoritarian populace or as Tiki described them in a little pre-conversation to this panel the reckless leaders that would like to think that this outbreak is not happening in Brazil we learned that they are no longer going to be reporting deaths from COVID-19 imagine just pretending that a death has not existed at all so that's a huge problem and we are seeing those very much more pronounced outbreaks in the presence of that reckless leadership the question of what should we do differently I mean I do think we do have to do what we can to work on the medical countermeasures and to make sure that they are accessible to all and I do hope that the global collaboratives that have been launched really will be able to influence allocation of those technologies but as Kamalini is pointing out there are some underlying baseline conditions things we can do right away things we know how to do very well that we should use aid to do anyhow so things like water and sanitation things like cash transfers things like targeted protection of vulnerable groups these are things we know how to do that we can finance easily and that you would like to see a much bigger effort I would say I don't think we are even close to the orders of magnitude necessary in terms of the financing of the response this is a historic recession I think in a previous panel someone used the 375 billion in economic losses per month we are not spending enough to make this stop and to save those expenses that are going out we are still in our little global health we would like an additional 1 billion dollars and maybe we will help solve the problem so I hope that we get a bit more audacious and convey more accurately the order of magnitude of response that needs to happen through the health system and then in the social protection systems and welfare systems around that necessary to cope with what is happening right now thanks I have got some comments coming through which I would like to read to more there are less questions I think than observations and to some extent I think affirmations of some of the thick points you have been making so let me just read through them before we come to our final question so Ian writes admits more attention support is being paid to the health system strengthening overall and is this an opportunity to use the diagonal approach to ensure synergies for identified priority areas such as connecting these different aspects of health to make sure that they are actually fully addressed so that is his comment question I think you have really spoken to that Amanda by talking about how the infection actually connects back into the other co-morbidities all of which are about how people live and that is why they are so bound to social circumstances and inequalities Lee talks about how in the Philippines the frail health system was exposed and stretched and that the first casualties in those sorts of countries were actually the health care workers themselves Dr Clark then goes on to say a good public health system depends on good governance and a well coordinated curative and preventive health system and it is actually both isn't it and I think that is coming through quite clearly it is not just strengthening the curative system it is fundamental that you have a strong preventive system and thank you and she wants to especially thank you as you were one of her supervisors for her PhD so some great comments so let me just come back to our final question and some of the points that I am hearing coming through in your thinking is that there is a problem of the untreated co-morbidity that health is not something you can pick out pathogen by pathogen or disease by disease it is connected that universal access to health care is almost an almost an obvious need in order to prevent a pandemic yet one that is often not mentioned trust a vaccine seems so simple but how do you achieve trust what do countries look like that have that trust and leaders and this idea Tiki that you raised it is a government with the strong safety nets that can reach out and is connected to trust who can see and hear their citizens and reach out and protect and care for them that seem to be doing the best and finally the idea of the reckless leader Sigmund Freud once said that the sign of a healthy mind is one that can face reality no matter how hard and what you are saying is that reckless leaders don't face reality they disavow it they hide the statistics they select they are less pragmatic so these are some of the threads that I'm hearing coming through your insights and your observations so I'll come now to the last question and then we can have a Q&A with our audience and actually Tiki you kind of you jump the gun but you can maybe offer three different ideas or three more ideas but my question is what do you think we could do now be your top of the pops first picks what we could do now before either the next spike or the next pandemic to control this spread of infection and inequality and what do you think are the most urgent changes that we need to make so I'll open that to all of you I'd be happy to jump in because I've been listening to this really terrific conversation and you've all raised such interesting points I think one of the things that came out I think it was with what Kamalini was saying was how this pandemic has really turned some of our assumptions on their head in terms of who has done well and who hasn't done well and we would have liked to imagine somehow that the countries would all line up according to access to resources overall and that the more resources you have and I'm talking largely financial resources that you should be able to beat this thing and if you're a less resourced country that you're not going to do so well but that hasn't turned out to be the case at all it just doesn't line up that neatly and so that I think does allow us a chance to dig into the underlying causes that some of you have already commented on and what I think Canada is a great example of that we're a high income country we haven't done very well of thousands of deaths in this country and they're continuing a pace and continuing relatively flat numbers of new infections we've flattened the curve but we haven't managed to tilt that curve downward and I think what it's revealed to us is that it's not just the inequities that exist between countries but the inequities within countries and it's I think in terms of what do we need to do urgently is we need to transition to an equity first lens and Canada I would say has been one of the examples of a country that did a fantastic job right out of the gate on making sure that all of our acute care institutions were ready and every hospital they just turned things around so quickly, cleared out the beds, cancelled all the elective surgery procedures everybody was waiting at the doors of the emergency department for the flooding of cases to arrive and meanwhile as all of this work was taking place to get ready the virus was starting to spread in those pockets they found the virus found the crack of vulnerabilities in institutions particularly long-term care facilities in workplaces where there's overcrowding in migrant workers in the agricultural sector and it caught everybody off guard because the first lens was not to say where are those vulnerable populations and are they ready and do the long-term care facilities in group homes and shelters have the personal protective equipment that they need and have they been trained in infection prevention and control and we've been playing catch up ever since and starting to get a grip on it with good better and better testing and tracing protocols but equity first vulnerability first has to be the lens of public policy leaders regardless of the global assets that a country has and learning from best practices around the world those who have had that lens I'm not sure how strongly it's come out in our narrative so far but we've discussed in our preparation for this a little bit around leadership that looks to community and community based responses and often you know I think as a woman I'm happy to say that the countries that are led by women have done really well perhaps because they have leaned into that community based response as opposed to an individualistic response and that's obviously an over generalization but we need to look to places that have done well and find out what lens have they used to design their response and the rest of us who haven't done so well are going to have to be good learners. Thanks Jane I'm just going to weave in before I hand over to you Tiki a couple of the comments that are coming up or observations because I think that they're well they're asking us to think a little bit more so I've got it on the issue of trust that to some extent particularly in countries like the US the trust has been placed in the market so what is let's think a little bit more about what is that trust what does that trust mean and what does it look like and what is it we need to trust and create trust between that's one point the second was inequalities obviously an issue but what about the issue of how the West and the East and that way of thinking about how West and East have handled the pandemic so countries like Korea, Japan, Taiwan Vietnam, Singapore and China were inequalities there but also how the respondent of the pandemic looks different what's your comment about that so I'm throwing them into the mix and I'll hand over to you Tiki and Amanda and Caroline let me just make three quick points on what we can do now the first point is building exactly on your last comment what we need to do now is build social capital and I think it's already been alluded to that countries where the form of government is sort of maybe a little bit authoritarian but importantly where the population trusts the government is compliant to following instructions and directives and places of community before self so that's number one build social capital secondly I love Kamalini's point about local knowledge we should make an attempt to systematize and disseminate local knowledge which in many cases are sort of just passed on from one generation to another I've reminded of the Ebola outbreak in Uganda back in the 80s where by the time the government people got to those villages the communities already put all the public health measures in place banning gatherings, banning funerals, isolating the elderly so huge amount of local knowledge so that's the second point can be systematized that so that it becomes part of the public sector response the third thing that I'd like to mention which we haven't mentioned so far and I think reckless leaders tend to be selective so my third point is go always back to science and evidence as your starting point for decision making so I'll leave it at that lovely, okay Amanda and Kamalini great thank you so much Linda so I think I really like Jane's point I think it's really telling the first response of the global community was ventilators to this illness it was ventilators, it was a hospital based response and of course that's normal because that's where we saw the cases coming out of Wuhan, that's where we saw people struggle but it's probably the case that in any outbreak the idea of starting with those vulnerable groups and also to think about public health as a part of the health system one thing that I'm struck by is that we always think of public health as oh that's my CDC or that's my public health institute and it's under finance down the road no one goes some epidemiologists are there they just weren't able to even operate through the health service in an effective way and I think we're seeing that in the UK as well with public health England when I look at the US honestly I do say to myself it's just the basics at large scale that we're missing but it's like we don't have the will to do that large scale test trace isolate across the entire country and I think eventually we'll get there but we're learning by doing I think in the United States people felt like infectious disease threats were over unlike in some of the Asian countries that had experienced SARS that had experienced other kinds of infectious disease threats at scale so there's some learning going on here and that learning has a cost unfortunately in human lives I think the other thing I would say about the accessibility of medical countermeasures of vaccine or therapeutic this is really really important I think there are two things that I would think about as we see these candidates come down the pipeline one idea that people are talking about is to produce and manufacture some of the promising vaccine candidates in countries with small populations so even if there is what they call vaccine nationalism which is where I vaccinate everybody in my own country first if I'm Singapore I'm still going to have a lot of doses left over to vaccinate high priority groups in other countries so that's a strategy that we can use as a global health system to make sure that there's not as much of a trade off between vaccinating my own people and vaccinating people elsewhere in the world in a more equitable way I think the other issue that we still have to think about though that's much more upstream is sort of the raw materials that go into these vaccines if we have 200 candidates at once they're all out there in the market trying to get there's apparently a glass shortage that we would need to fill the vaccine you know to deliver the vaccine so there's a lot of sort of issues like that to solve to even get to the equity of the distribution further down the line so I'll stop there but thank you so much I'm getting a lot of commentary around trust and there's two two kind of themes emerging here and Camelina this seems just so fitting that I can raise these before you have your turn to speak but the idea what I'm hearing is that there's there needs to be trusting government in some form as well as a government that has the capacity to have strong social safety nets and as willing to invest in universal health care there is the reciprocal trust back up to that government from people and citizens so that's one theme that's coming through in your comments and also in the questions but then there's this fascinating idea about what about trust in science because that because not only is trusting government on the way down particularly in western democracies but so too and perhaps by no coincidence is the trust in science and yet we're signalling that both those things are fundamental to dealing with pandemics prevention, response treatment and inequality so Camelini I hand over to you I think it's not not complex you know it's complex maybe to achieve but I really like the example of Kerala so for the last five decades every time you talk about public health stories you talk about Kerala what have they got they have high female literacy, good health care so despite India having you know challenges and looking like it's going to really suffer from this we have the state of India led by a school teacher who has passed outbreak experience with NIPA who recognised so I think maybe the west focused on ventilators certainly not low resource settings that have done well she said my health system is not going to cope my community is not going to cope she shut her borders but you know she knew she was going to have a whole lot of very poor migrant walkers crossing borders so she set up systems for quarantining them tens of thousands of people they got three meals a day good living conditions they were happy so again it's not rocket science but you build that trust by delivering for people why do you trust anybody you know whether it's your colleagues or the postman or whatever it's because you have there has been an established relationship where if you do what is expected of you they deliver for you so I think it's the same with governments we can learn a lot from the ones that have succeeded and again you know you look at places, poor places like Kerala where you you have much more you would think challenges than say Canada let's compare to Canada right but if you have fundamental assumptions that people, all people have an equal right to healthcare to education look I think we're talking about you know we can say it's it's not good to be poor and uneducated but I think it's good to look at examples that have achieved you know have been able to progress against those sorts of things with relatively little resources but you know I know Australia I live in Australia and I think our governments know that if you mess with Medicare which is our system of universal health coverage you'll lose the election so whatever form of government you have they do know that there are things people value and we early on brought in a scheme where casual workers receive wages and for the people I know who are casual workers their supplement was higher than their previous way so they have every incentive to stay home if they were sick or you know get tested I think I always learn from past experience I think there's a lot we can learn from the places that made mistakes so building trust it's easy once you have it it's quick to lose and I also think we don't need to do more research we have examples and we know how we build trust with each other and we know how good governments build trust thank you we have four minutes to go and I'm just wondering whether there's any final points you would like to raise or make before we close something very quick from me I just would like to emphasise what Linda you mentioned the importance of science in this sort of anti-science, science denial world that we live in I'm reminded of what you said we humans know more truths than any species on earth and yet we believe the most false leave it at that, thank you okay Amanda I mean just to end on a positive note I would say that actually it's been a I think we'll see a resurgence of interest in science and evidence to build trust for the future although you know of course what people are witnessing in real time is how data is used to understand where the outbreak is and what their levels of risk are that knowledge is evolving it has to be corrected and contested the fact that we've seen this enormous scientific production in the public domain so quickly of course there are problems with peer review and things like that but that is really inspiring I was on another panel where some of us think we have like 20,000 new papers every month coming out on COVID-19 and its effects so the pace of clinical research and science is intense and people are demanding answers from both economic and health authorities about how this outbreak is going so well I agree with you that we're certainly in a period of low trust and there has been a period of great skepticism about science and evidence and data we're also in a period where we might be at the front of a renaissance of that as people turn to experts to understand what they have to do and who to listen to and I think it's quite interesting there was a poll in the United States that found that many people trust the World Health Organization for example as a source of data on what's happening so a lot of people didn't even know that the WHO existed before that so I say let's perhaps end with a positive note that things might be getting better on the margin thank you Amanda so Kamalini and Jane Jane well thank you again to the organizers for this and I think my closing remarks maybe just build on what Amanda talked about in terms of international institutions and you know we've talked about trust in national leadership and trust in science and I think one of the other areas that's at risk is trust in international global bodies like the World Health Organization and UN agencies etc and this is not a time for isolationism and protectionism this is a time to continue to build those those institutions that will allow us to work together collaboratively to continue to build trust and understanding amongst one another and there's no question that those institutions have been put to the test and have been challenged by some very powerful leaders but we can't deny the linkages amongst ourselves and we will not succeed without looking out for the best interests of the entire planet and so let's close on a note of positivity around the fact that people have worked very hard for a very long time to build those institutions and I believe that they need their support rather than our abandonment of them thank you Jane Camillani I think the two are connected so trust comes from transparency and honesty and again you've seen that the governments that were clear you know and individual leaders I read an interview one of our premiers who was one of the first to shut down and somebody who had lost his business because of it said I'm annoyed as a businessman but as a human being I'm going to vote for him his party for the first time ever because I'm proud of the fact that he prioritised our community and our well-being that was about you know acting on the information you have and people have very have been very capable shown the community has shown their capacity to shift as information shifts if they are kept informed and they are told we're not sure where we are when we know we'll let you know but in the meantime here's what we think and I think it is about treating communities with respect acknowledging uncertainty and that again it's about I'll stop there I think we know what we need to do which is the great thing well what I'm hearing really we're ending with this connection between trust and science and human decency as well as human governance and systems and knowledge and it is these interplays between knowledge and qualities character and values that seem to be so important to navigating the crisis we're in you know I just want to thank you for what I feel has been an extraordinary stepping through and into the insights of that you've all brought to this question of the global health challenge that COVID-19 has brought forward to continue and I'd like to thank Sean and the Crawford School for hosting this program remind the readers listeners sorry but there are other panels that will be coming this is not the only part this is one of the many under the Crawford leadership series and to thank you and honour you speakers again for your contributions