 Well, hello everybody. I'm Jonathan Citrin, and along with my co-host, Dr. Margaret Bordeaux, we're here for another session of COVID State of Play, a fitful set of check-ins every so often since the pandemic began in earnest last March of 2020, to see where things stand, where we think they're going, and today, as in past instances, to have a guest, an expert to help walk us through some particular aspect of the crisis. And today, that'll be Dr. Vanessa Kerry, who will be talking about vaccination strategies and equities worldwide. A very sad landmark that we've passed, our research coordinator, Will Marks, pointed out that since our last show, a month and three days ago, it looks like there've been about 100,000 additional deaths due to COVID in the United States. And it's a clip that is still quite rapid and that too often goes unremarked. And if remarked, just feels like a new normal, perhaps. So maybe that's one way to start by asking you, Margaret, if we were to have that word to invoke the state of play, which in prior instances, among us and our guests, they've pretty much always been negative and have ranged from devastating to horrible, et cetera, et cetera. Now with a vaccine here and with the parameters perhaps at least known, if no less pessimistic, what would you say? How would you characterize the state of play right now? Right. And I think last time the word I chose or the metaphor I chose was race, you know, a race against time between team human and team COVID. And I kind of talked about it in that way because then and now it seems like where we are in a race where COVID is trying to, that COVID is trying to win and team human is also trying to win. I think since then I've refined it a tiny bit to say chase, where team human is trying to catch up with team COVID. Team COVID is clearly ahead as the, you know, as the death rate and the infection rate, you know, continues to be, you know, deeply upsetting. But you're right, there is a sense of, well, a sense of, this is what, the 11th month that we have been meeting. And so, you know, there is that sense of like, oh, well, it's not a sprint. It's not, it's not wrapping up soon. But, you know, I think that overall if you wanted to just pick this particular moment, you know, since we talked last, this particular week, I would say team human has had a good week in that, you know, vaccine distribution, at least in this country has increased by about 20%. I guess they announced, the Biden administration announced even last night that they were able to increase by 20% the amount of vaccine that they're going to be able to give to states. And they're also, another positive development in that regard is that they're able to give states a heads up for the next three weeks, how much supply that they can count on. And that sort of reliability and consistency issue has really been one that is behind the scenes really plagued the US response. Because if you don't, you plan very differently, right? If you know what you're going to have a week from now, you're not going to keep and reserve or hoard, you know, vaccine, if you're sure that you're going to get more in the future. So that's great. Overall, cases worldwide are down 10% this week. Most of that coming from the United States and Europe. And it's been actually kind of a little bit of a puzzle as to why that is. You know, some are like, well, the vaccines, OK, yes, we have vaccinated about 10% of our population has gotten at least one dose. You know, maybe it's the sort of holidays, surge of cases that are starting to, you know, level off. I would say here in Massachusetts, we're back where much our cases are much lower. But now there's there's still consistent with the number of cases that we were at least recording at our peak in April, which is sort of an interesting comparison. But anyway, while you're talking, I'm just going to project real quick something from Science magazine. John Cohen shared a chart that in turn other researchers produced is trying to model with and without vaccines and with and without protection behavior. And if we did not have the vaccine, thanks to the variant, the B 117, you see the slope of the curve going down and then by April going up again. And then here, if we can really speed the vaccine rollout, you can see how much of an impact that has. And if we don't keep the other public health strategies going, including masking, even with a fast vaccine rollout, you can see the effect on the prevalence of the vaccine. Anyway, I thought I would share that while you were talking about this. I think it goes exactly well with the race or the chase, because that's right. So but what I would say is, you know, it's it's a little bit of a mystery, right, why our cases are going down so dramatically. So I was saying a lot of people think it's back holidays, vaccines. It's kind of interesting to me that there's no one thing that we can really point to why it's going down. And I my favorite hypothesis is that maybe leadership really does matter. I mean, you know, maybe that the one thing that has changed is we have a new administration, which is saying, hey, this is important. You should definitely wear masks. You should definitely take this seriously. And I was really reminded about the hardest thing, and maybe I've said this to you before, the hardest thing I've ever had to learn in my medical training was when to either declare an emergency or at least acknowledge an emergency was happening. Even in a hospital setting, there's a huge like desire to pretend to like everything's fine. And I always think about this case where I was at a really fancy dinner party and my husband was getting an award and it was really it was really a great event. And I was just there smiling lovingly at my husband. I was just drinking wine, having this great time. And right in the middle of the proceedings, another guest of honor just keeled over in the middle of the middle of the dinner. And I it was just took a very long time for anybody to to declare that there was something wrong. The speakers had to stop speaking. And, you know, people had to gather around this individual. And, you know, there's just a huge inertia. And I, you know, I as you know, I keep up a lot with the scene in Georgia and Georgia schools. And there's just a sense there, you know, OK, nobody else is taking it seriously. Should I really take it seriously? So I think some of the drop is because people finally have permission to take this seriously, to wear a mask, not feel foolish, not feel like they're going to have to pay a little social penalty of, oh, you're just so silly for, you know, being concerned, you're a chicken little is why I think we made a little bit of progress. So that's Team Human. But Team Covid, you're absolutely right. That the that the variants are very concerning. You know, in terms of these variants where where where Covid is changing, like all viruses do, all viruses change over time. And the more opportunity they have to replicate, the more opportunity they have to change so much so that a vaccine might not be able to recognize that your immune system, even after vaccination, might not be able to recognize the variant. And so, you know, that has added this really different dynamic before we just kind of thought, well, you know, we'll eventually get the vaccine and that will be done, you know, just distribute it. And OK, it'll be challenging and messy to distribute, we'll distribute it and it'll be done. But the idea that there would be these variants that would outmute the vaccine is enormously is a profoundly big development in a couple of different ways. One, it means that this crisis could go on for a long time. It means that we have to get really serious about two things. One, vaccination and two, as your wonderful slide there showed the public health strategy, other public health strategies that are not based on the vaccine. And here is where I think team Covid just has this huge advantage. The public health strategy, the non-vaccine strategy that we've talked about over and over again, the three-legged stool, you know, the mask, plus the contact tracing, plus the environmental modifications and ventilation. It just still is too cumbersome. It's too cumbersome to implement because we haven't positioned ourselves really to implement it well. Or it's too ham-handed. You know, I mean, this idea that we're going to stay socially distanced for years is just so hard. I mean, we're just seeing the penalties we're we're paying. Right. I don't know how have you been. I mean, have you just a first in reaction to what you've been saying. It's interesting to have still is an open question. What's accounting for the drop in reported cases right now? And you would think that the answer to that question. I mean, your hypothesis is interesting that it's a leadership thing in the United States, just a perception of leadership thing. But really getting a solid answer to that question might help us know if the drop is temporary or permanent, what factors to lean in on. It's just so interesting to see, even after all this time, we have so many unanswered questions. And I think that probably cuts to a theme that you've invoked before of just a broken or never developed public health surveillance or intelligence system so that we actually can answer questions like these pretty promptly. The other thing it calls to mind is the prospect that if what so many people appear to be saying was a near miraculous effort by the scientists and companies and public authorities involved to achieve a vaccine and to test it as quickly as it could be tested so that it could be credibly rolled out with confidence that if that just hadn't happened, if it had taken as long as Anthony Fauci thought it might take at the beginning, we'd really be up the creek right now, wouldn't we? Because even with very strong three-legged stool interventions, the increased transmissibility of the variants might mean we'd be within transmission value above one. So it's just quite something that we were getting narratively for this chase, handed a vehicle or a boost, a turbo charge to our chase vehicle to catch up to the vaccine. And I guess what you were invoking is the possibility that we'd have to do booster shots and such is kind of like, all right, you got to stop at the pit stop every so often as you try to overtake team COVID. Yeah, I'm glad you're running with that metaphor. That's fantastic. No pun intended. Yeah, exactly. Yeah, you know, I still am a believer that we could that the public health, the non-vaccine public health strategy is actually workable and doable if we had put as much effort into it as we did into developing the vaccine. I don't think there's anything actually conceptually difficult about it. And what I mean by that is things like doing, rolling out a screening testing, let's say, at every work site or, you know, before you go on an airplane, you spit in a cup and do a strip and see whether you are positive. And if you are, you receive immediate supports for being in for being in quarantine or isolation. You know, I think this is all possible. I think we just when I say we didn't position ourselves, it was a matter of will and in why did you need will or political will to do it? Because you had to cobble together different systems that were complicated, you know, and I know I think I've talked to you before about the construction company and construction effort to to roll out work site testing on construction sites. And, you know, we had to line up five different partners, the lab, the transport, who's going to take the sample at the employer had to be involved. And of course, you know, there need to be a medical partner. So getting all those sort of systems aligned and processes in place is what takes a little bit of effort. It's not it's not, you know, you don't have to be a genius to do it. You just have to work with others in the public sector. And that is a real challenge. But anyway, so I am not, you know, I think we still need to double down and get better, and I'm never going to give up on that on the public health strategy. I think we've not done that to date, but I'm hopeful, I'm hopeful. And I know that you weren't putting it down, but I was. Yeah, yeah. Let's talk a little bit more just about the vaccine situation for a member of the public who's eager to get vaccinated, wants to avoid COVID and is keeping an eye on the various complicated tiers and sub tiers and such, which might be worth talking about as an allocation question. Should they care one bit, whether once their number comes up, which of the categories or labels of vaccine they take, knowing that they might have different efficacies estimated so far? So, you know, my answer to that is like, not at all. They should not be concerned at all. Just get what is available, because the the efficacy of a single vaccine, the major driver of the efficacy of the shot that goes in your arm is how many other people have gotten a shot in their arm. So that's the real value. It's the common good that is is the value to you personally. And dare I ask, is that true without yet having a bead on so-called sterilization immunity? How much the vaccine prevents onward transmission versus coming down with symptoms and troubles if you should be infected? I think there are two things that really are unclear in this debate. The first, as you've mentioned, is the transmission issue where they say, okay, you know, we know these vaccines protect you from severe and even mild disease, but could you possibly be a carrier even if you've had the vaccine? I'm going to go out on a limb here and just say I really feel like that has been overblown. It's a limb because they don't have good data to support why I'm going to say that. But, you know, most vaccines don't work like that. You know, you're not a carrier of measles if you get the measles vaccine. That's just an unusual thing for a vaccine to not at least significantly cut down on transmission. It might not be perfect. But, and I also just think as a public messaging thing, that's terrible. We need people to go get the vaccine. And the more vaccine we have, the less virus we're going to have circulating. And to be told, well, you should get the vaccine, but you can't change. There's no personal benefit to you if you get it. You still can't go see grandma. You still can't have a birthday party. You still can't hug me. I mean, that's just not. Oh, you know, I was reading somewhere. They said, oh, but don't worry. You can now catch up on all the medical stuff you've been deferring. Like, you can go get a colonoscopy now if you get the vaccine. It's free with your vaccine. This is not a winning argument. And so I just think that that is, it is a possibility. I think, you know, scientists need to take it seriously. Public health, people need to take it seriously. The general public just don't, don't, don't think about. Go get the vaccine. Do wear a mask because it's helpful to everybody. You know, if you're wearing a mask in public, especially in indoor spaces or crowded spaces where you can't distance a little bit. But, but, you know, I really think that people should deserve to get some, to have some hope after. And I think among the many things you were sharing was the fact that while the efficacy rates may be quite different, those are pegged to whether somebody comes down with COVID symptoms. And even the ones that may not be as efficacious there appear to be quite good at preventing hospitalizations and death, which is of course, what makes this different from a cold or, you know, despite its death rate, even the flu, which might mean then that a, one of the vaccines that is not as well regarded from a pure efficacy percentage standpoint may still be quite helpful for one's purposes to know you can go see grandma and neither you nor she will die as a result of that. I do wonder, I guess we don't quite know yet whether long COVID is a function of mild COVID, but indefinitely, or if that is lumped in with severe hospitalization, et cetera kind of thing. Well, these vaccines, is it too early to tell if they help with long COVID? Yeah, that's, it's really interesting you asked me that, because a friend just called me up and was like, I don't know if I want to get this Johnson and Johnson vaccine, should it become available? Because what if I get a mild case and, you know, I get long COVID? And I don't have a great answer to that, that is true. I'm not exactly sure. Right, some people that have long COVID, meaning these persistent symptoms of COVID in terms of fatigue and, you know, respiratory issues for months after the original infection, whether you can get sort of long COVID after a mild course originally of COVID. So then the question is, if you get a vaccine and then you get a mild case, will you then go on to get long COVID? I, you know, I really think that I don't have an answer. I'm not sure anyone does yet. And I think it is being studied. But what I would say is you can just hear in my description of the, in the description of what would have to happen. You know, you're talking about one risk multiplied to another small risk, multiplied to another small risk. So, you know, the risk that you're going to get mild COVID after you get a vaccine and the risk that you're going to go on to develop long COVID, I think is, you know, many ifs. So I feel like at this point, the message needs to be pretty simple. Yes, there's all these complexities, there's all this nuance, but hey, we let's just go get vaccinated. Let's let's do it and find out. And I do think that a lot of this will be much more manageable if we're dealing with much smaller caseloads. So, you know, if we're just dealing with crop, you know, outbreaks here and there, we will have some time to be able to figure this out. But right now, the name of the game is just a drive down rates as much as we can. Now, is there anything we should know about the state of FDA approvals? Right now in the United States, it looks like the only games in town happen to be these so-called mRNA vaccines from the two vaccine companies. Is that right? Or has FDA approved any others? Yeah, I think that they are on the verge of approving the Johnson & Johnson vaccine. And I think that would be the third in the United States. The European Union and Britain also have been a little bit faster down the track and improving some others. And, you know, this gives me an opportunity to pivot a little bit more to the thing that I'm really starting to think a lot about that is sparked in part because of this emergence of variants. You know, I said it has some profound implications. One of the profound implications that the emergence of variants has is that it really connects all of us to what is happening in the rest of the world with respect to vaccination in a way that it didn't before. We can't be safe until everyone is safe. And that used to be kind of like a aspirational statement, I feel like. Like, you know, there is no, you know, there is an injustice everywhere. Right, right. So that used to kind of be a, you know, yeah. But here we're talking at the level of cellular biology. This is in fact a truth, which is that if we have a big pool of COVID virus that is circulating and replicating in a far flung corner of the world, that matters to us because it may be that that strain of COVID is, will out mutate the efficacy of our vaccines. That means all the money and time and effort that we put into vaccinating all of ourselves in this country might be undone by the emergence of a variant in another place. So all of a sudden we have to think very differently about our relationship to other people on the planet. It's really, really, it's very tangible, right? So, and you talked about different vaccines being approved by the FDA in this country versus around the world. So, you know, all of a sudden it's not just how efficacious is Pfizer and Moderna and Johnson and Johnson. And if I should get it, we also have to think how efficacious is the Sputnik vaccine that the Russians developed? How efficacious is it? The Chinese, there's several vaccines that they have developed. There's a, Cuba is testing its own produced vaccine. So all of those vaccines are really important for us to understand their profile, how efficacious they are, and be able to distribute them around the world rapidly. And you may have seen this issue with the AstraZeneca vaccine, another, you know, big, big time vaccine, a lot of press. Well, it shows that it's only 10% efficacious against the COVID strains that are circulating on the African continent. So, and in Europe, they've started pulling back in some countries the use of the AstraZeneca vaccine on health workers. So these are major, major implications. And we are now really, and I think a very, very different place as a human species because of this type of problem than we were, you know, even last year. I think we are being driven toward a very different type of relationship with one another that is going to require a global cooperation and governance approach that we still really have to think through. Well, it's fortunate that there's such a high level of trust in our national governmental institutions around the world and in institutions generally. I speak somewhat facetiously. But that's a challenge to which to rise. And that's maybe a great opportunity to introduce our guest today who's been devoting so many efforts exactly to tackling this challenge. So, I know, Margaret, if you want to introduce Dr. Kerry. Hello. It's right. I'm just so excited to have my friend, Vanessa, join us, Dr. Kerry. So, Dr. Kerry and I have worked a long time together as close colleagues just to give you a proper introduction of Vanessa. So, Vanessa Kerry is Associate Professor at Harvard Medical School. She's an attending physician at Mass General Hospital in the intensive care unit. And she also founded a NGO called SEED that is devoted to building the health workforce capacities of different health workforces around the world. And she's also Faculty Chair of the Program and Global Public Policy at Harvard Medical School with me. And so, she has really been out in front and helping think through and articulate the challenges with this issue of how do we come together as a global community to develop and distribute global public goods like a vaccine. So, she's been sort of deep into those issues. And I just want to welcome you on and have you tell us a little bit about your journey. Well, thank you for letting me join you. And I should add to the bio. I'm a mom of two with kids who are home. So, prepare yourselves for whatever bombs start to come in during this talk. But it's a pleasure to join everybody today and to be able to talk about some of these issues. I mean, I think I've been very privileged to work with Margaret in the Program Global Public Policy at Harvard Medical School. And that program was really founded based on the concept that as we deal with health, we have to engage in the public policy space because as much as we may be implementers, as much as we may be thinking about ways that technology can augment our access to health or our ability to deliver health. At the end of the day, if we don't have policies that are actually supportive, invest and uphold and cherish health as first and foremost in our ability to not just survive but to thrive, we are always going to be swimming upstream. And I think COVID has demonstrated that for us in more ways than we ever expected. There's been growing data over time that has absolutely shown that health actually impacts economic growth, both on a microeconomic level for a household where you lose your main breadwinner to a disease. There's drops in income, drops in access to housing or people have to move, loss of running water, children less likely to go to school in those houses where you lose that main breadwinner. On a macroeconomic level, we know that countries that have invested meaningfully in health have actually seen growth in life, growth in their GDP and equally countries that have had devastating health challenges may not have those decreased life expectancy see a decline in GDP. And countries that have invested specifically in health have seen, like Vietnam, they made very explicit investments in health in the 90s and early 2000s that led to masses of sort of economic growth and boom. And that data exists for national security too. We've seen where governance actually is better in countries that have access to health and delivery of health services. We've seen decreases in corruption. You've seen more stability. And so there's... The fundamental is just that health is truly fundamental to kind of all the things that we strive for in the world. And COVID has shown that. So the Institute for Health Metrics and Gates actually noted that we've lost 25 years worth of development progress in 25 weeks through COVID, which is really speaks to the kind of disruption and devastation that this epidemic has created. And so even though seed global health, we partner with governments to train the needed healthcare workforce for those governments. It's not sexy to train doctors, nurses, and midwives. I think it is, but a lot of other people are like, no, no, no, I would much rather invest in technology and create scale really fast and bridge countries. And that feels like a much more sort of easy or facile thing to do with much more tangible outcomes. But the truth is that if we don't make these investments in people in a healthcare workforce, we're not able to deliver healthcare. We're not able to see Ebola when we have an outbreak. And we're not able to care for people in a COVID pandemic or deliver vaccines. And Vanessa, can I just ask real quick, when you say we've lost 25 years worth of progress, tell us a little more about the shape of that. What is it that we have lost by example? So we've lost our ability to deliver vaccinations to reach hard to reach communities. So there's been major disruptions in that. So you're going to see. Because of lockdowns in part. You're going to see, sorry. Because of lockdowns in part. Lockdowns, people afraid to go out of their system, the reallocation of resources from some of these core delivery and primary care towards responding to the pandemic. And so we actually know that there's more morbidity or there's more suffering and death in a decade after a crisis conflict or an epidemic. Then there is during usually the pandemic itself because of that long tail of disruption of services and the need to rebuild it. The Ebola epidemic in 2014 also showed us this that actually there was more death from the loss of essential services than there was from Ebola itself. And a lot of them in fact, measles has been modeled that there'll be more deaths from measles from the disruption of vaccination than there will be from Ebola itself in 2014. So the effects aren't always immediate. A lot of them are, but many are actually a very long tail over time. But it takes a long time to build that back. And that's something that we've, you know, it's so funny. We would say that over and over again. You and Vanessa and I, I mean, it's so funny. Because it was such a hard message to get across. It was like, it's not Ebola that kills you. It's these other things that kill you. You know, down the line, the loss of health services and then safe birth, economic, you know, being driven into poverty. All of these knock on consequences. I think it's now very obvious to most of probably the people listening that that is the case. It's our lived experience now. We haven't gone to the doctor. We haven't gone to take care. We haven't been able to have a job. We haven't, you know, there's a huge eviction crisis, housing crisis. You know, all of these things start to pile on top of one another. And I think that that the temptation is, and it's always the temptation to be avoided, but the temptation is like, well, then let's just ignore the health crisis and just try to deal with the knock on consequences. And of course that makes sense because you're just trying to, you know, try to, okay, I don't care about COVID. I want to stay in a house. I want to go to work. And so it's trying to make sure that we, you know, we have to, you know, obviously take care of the health crisis before we can stop the bleeding, if you will, the knock on consequences. But that's often a hard thing to do for some reason. No, I think it's absolutely true. And I think that the reality is that, you know, I've been saying since the beginning of this pandemic that health security is national security, individual and human security, right? Our ability to go to school, our ability to go back to work, our ability to grow our economy, all of these things are related to our ability to stop COVID. And well, that's our urgent medical thing, you know, in this moment. And so I think the reality is that people have to realize too, and this brings me to the whole vaccine discussion that I think is so critically important, right? Is that I think for Americans, we're sitting there just counting the moment until we get our vaccine. And there's 205 million Americans that are 330 that are eligible to get a COVID vaccine. And we will get a vaccine in this country. But what we have to think about is that our safety and well-being, just to be enlightened, you know, sort of self-interest, if you will, is related to the entire world's ability to be vaccinated and just shut down transmission. We live in a very global world now. So even if you do not have a passport in this country, even if you do not leave your city, your state, you are still very vulnerable to what is happening elsewhere in the world. And we have seen that. If you look at the way the variant, the way COVID hit the United States, there were two different genome types of COVID, one on the West Coast and one on the East Coast. One came in from Europe primarily and one came in from China primarily. But the point is COVID arrived here either way from somewhere else. We're now seeing the variants of COVID from Brazil, from the one that was originated in South Africa, the one that originated in UK. And now we have one that actually is homegrown in California. These variants that are forming, but they're moving around the world. Our ability to cut off the transmission of these new versions is going to be if we get everybody vaccinated in the world. Because it's just, we don't shut down movement at this point. It's unrealistic to think that you can build a wall and you will be safe. And just to distill your point about enlightened self-interest, you're saying that if there is a temporal hoarding of vaccine in only certain countries, generally the wealthy ones, the ones that have made the deals to stock it and get it, there'll be enough incubation and evolution of the virus in places that don't have those deals. And then international travel will mean those new variants will come back and the vaccine will not be protective even within the wealthy countries where the people have gotten. That's the... Very succinct farmer and exactly the point and I think just to give that example, there are three sort of live vaccines going out in the world right now. There's Pfizer, Moderna and AstraZeneca and J&J is about, it's now been getting approvals to be able to roll out but there's three primary vaccines. Moderna and Pfizer vaccines have been purchased almost entirely by the United States and about six other countries all in Western Europe and or Canada. Canada has bought enough to vaccinate its own population anywhere from five to nine times over, depending on who you speak to. The U.S. enough to vaccinate our population three times over. This is the vaccine that we have kind of pre-purchased and are holding on to. If I three times over just to be clear on the arithmetic, is that three shots or three... No, no. You can go get three full shots at some vaccine if you needed to. Three shots, okay. And so the reality of that is, is that that's not available for other places around the world. So AstraZeneca, and well, we can talk about the mechanism that AstraZeneca came through in a moment, but AstraZeneca, the third sort of live vaccine right now that was developed in a partnership with Oxford and AstraZeneca, became what was known as the world's hope because that was the only vaccine left over for other countries to kind of access that was far this and that was far along in the pipeline. So the AstraZeneca vaccine is now being mass produced and delivered to countries around the world, but they started to roll it out in South Africa where there's a new variant that has shown is incredibly contagious and the trials that there, the AstraZeneca rollout in South Africa has shown the vaccine only works 10% of the time. That means that if you vaccinate 10 people with the AstraZeneca vaccine, nine out of those 10 people will still be able to get COVID even though they are vaccinated with the AstraZeneca vaccine. So South Africa actually shut down its delivery of the AstraZeneca vaccine because it was not a good use of its resources to give a vaccine that is not able to manage the variant that is in the country. And the problem is then we are going to see that variant in the United States, we already have. And so if that is more contagious and we are not able to, we're going to be vulnerable. So even if we get ourselves totally vaccinated, there is the very real scientific possibility that there will be a variant out there that escapes, that escapes the vaccination that is able to mutate and all vaccines are no longer work against it. And that could create what we're calling the fourth wave. Although I would argue we've never emerged out of our first wave. Maybe a little question and then a bridge. The little question is just what data do we have and how reliable is it on the Russian and Chinese initiated vaccine programs and how their vaccines are doing and it seems to be Cuba in the mix as well. So curious if you have a lead on that. And then the bridge is to talk COVAX which is harkening back to Margaret's observations about a way to have a global approach to vaccinations to avoid these problems that you've been describing. So I mean I think these are great questions. The Russian vaccine I haven't actually had a chance to look in full force on all the data but the overarching and Margaret you may want to weigh in a little bit on this too but the my understanding is that it's 92% effective. It's a two dose regimen that is about 92% effective meaning that if you were to vaccinate 900 people, 92% would go on to be protected against COVID. It is very temperature stable so it can be stored at a normal temperature. Everyone's given a critique of Pfizer that has to be incredibly cold. And it's actually medium price compared to the other vaccines and so the sense is that it is probably pretty effective. The Chinese vaccine I think in the studies that have come out have had variable efficacy. I don't think we have a good sense of where that efficacy is on the Chinese vaccine and I've seen data come from where it's been rolled out in different countries come back with different results. It's very difficult to know how much of that is related to population to various discrepancies and trials. Margaret, do you want to look like you want to say something? So I think that Chinese remains a little bit more a little less understood and a little bit less known in terms of its efficacy. The one though that is getting a lot of attention is the one coming out of India because the Serum Institute of India has done a terrific job of producing a vaccine that has been homegrown in India and they actually have unbelievable manufacturing capacity because one of the things that also is going to come up in here is the ability of those vaccines that we do have available to make them available quickly. And so the ability to manufacture things rapidly is going to be very important when we do have an effective vaccine and the one in India has proven to be effective they've been able to mass vaccinate or mass produce it very quickly. They've actually been willing to license it to others to vaccinate and they've been actually providing vaccines for neighboring countries. So Bangladesh, which is traditionally a very vulnerable extremely dense country so high risk for having very bad COVID outcomes already has access to the vaccine because of India. So one of the challenges here isn't just about producing new vaccines in other countries. We have effective vaccines. We have vaccines that work. We're just not allowing them to be necessarily manufactured rapidly enough to make them available to people. Instead, we're waiting for other vaccines to come online, which you need all of them, right? We can't just say, well, let's wait for the Chinese to come online. We've three very effective vaccines in a fourth that's coming up. We should be producing those rapidly and thinking a lot about trade agreements and access to licensing and IP. That's going to be critical to our ability to deliver vaccines in a timely fashion. And I think that was a big, and I think the next question you were thinking of asking was about COVAX. I think that was a big purpose of COVAX was to take the research and development industry of pharmaceutical companies and to create a system of collaboration and bring people together to solve a common problem by creating kind of a unified global market for those pharmaceutical companies to be able to respond to. And so COVAX is the vaccine arm of the ACT Accelerator, which is a multi-entity effort by the UN, WHO, CEPI, and others to make vaccines, pharmaceuticals, and tests available. And COVAX is specifically the vaccine arm. And what they did was they created a consortium of countries that could pay and those that couldn't pay to basically crowdfund money to support the research and development of vaccines for all the companies and folks that sort of agreed to come into COVAX. They created money for research and development, which is usually one of the big barriers is that pharmaceutical companies don't want to lose money in research and development because it's about a billion dollars to do that. And they also created a guaranteed market which said we will buy doses if you have an online vaccine that you produce, we are going to guarantee you the ability to manufacture. We'll give you money for manufacturing and we'll give you money to buy the doses. So they basically de-risked the entire vaccine process. And what they also did was create a common market because if you think about it, Sweden doesn't have a huge market share in terms of its population. But if you combine Sweden with Japan with most of Europe with all the countries in Africa with Europe and Asia and South America, suddenly you have five, six, seven billion people of the world who need a vaccine and you're guaranteeing the market. That's why COVAX was so innovative and extraordinary. So to get into the nuts and bolts of this, it's interesting to call it a market because it's a pretty high stakes negotiation on behalf of a billion people to say what the per unit cost of the vaccine will be. Can you give us a little texture of how that works? How if you're the pharmaceutical executive, how do you set the price? And if you are... Oh, man. How do you say what you're willing to pay? And what's your... This is a terrific question and I'm not sure I can answer all of it because a lot of this is not necessarily... I think it's been huge amounts of back and forth and a lot of it has been kind of under various levels of secrecy and negotiation. But the idea was really... So COVAX brought together 190 countries that bought in. And it's about 50-50 of the countries that could pay and the countries that can't pay. And I think that what they effectively did was they kind of... There's some bargaining power of COVAX to say, look, we're guaranteeing you a market. We're giving you money for R&D and you've got to kind of work with us about what the pricing of your vaccine is going to be. And I don't know the specifics of sort of how it ended up breaking down to what the per capita price was. But by... And it's worth noting that Pfizer didn't join COVAX until about a month ago. It's worth noting that Moderna never joined COVAX. So there are some countries that sort of opted... I mean, countries... There are some pharmaceutical companies that said, we're going to do this our own way. And I'll talk a little bit about why they made some of those choices. There were other companies that said, yeah, we're going to do this, I think, because we actually... We either need the money. So in the case of AstraZeneca, they're not traditionally one of the biggest vaccine makers. So the biggest vaccine makers in the world have been Sanofi, Merck, and Pfizer. And Pfizer's a U.S.-based company, as is Moderna. So there was the option to kind of go into the U.S. system. So under Trump, the U.S. said, we're not going to buy into COVAX. We're going to do our own thing. And we're going to incentivize companies in the U.S. through Operation Warp Speed and some other companies to be able to... They basically became a competing mechanism to COVAX, did the same thing, de-risked, but took control from a U.S. government standpoint. Pfizer is interesting because they didn't take federal funds. Pfizer actually said, we're going to stay in our own little lane because I think they took an approach of it's too dangerous to take the federal funds for a variety of reasons. I think they also felt like it was too dangerous to join COVAX initially. So they said, we have the ability to do this on our own. We're just going to go forth, develop our vaccine with our partner, the German partner, BioNTech, and this will come out on the back end when we hopefully have a successful vaccine and we can get paid for it and it'll all work out. So really interesting analogy to the campaign finance system in the U.S. and whether you buy into public financing of your election in exchange for caps on what you spend, or if you just say, I'll opt out. If you are the stronger, more experienced, better supported candidate. No, I think it's a very good analogy and Pfizer, interestingly though, did reserve some of its vaccine for developing and for non-U.S. countries. They wouldn't sell their entire package to the U.S., although they have sold a lot and they are slated to make $15 billion off the vaccine. So I think it's complicated on saying, but a company like AstraZeneca that felt like they had a handle on this new technology but wasn't a major manufacturing giant, there's a huge advantage to go into COVAX to be guaranteed some of that R&D money, guaranteed a market and guaranteed the ability to kind of produce a vaccine. And so that was part of the incentive for them to join COVAX and to be a part of it. The way it works is those that COVAX has to crowdsource the funding to basically fund the vaccine delivery and distribution. They were very successful in 2020 to raise the $2 billion they needed to kickstart it, but they need $4.6 billion now to manufacture and deliver the vaccine at only 20% of the world's population for 2021. That's the goal, is to get 20% of every country vaccinated which should be enough to cover the most vulnerable, those that overwhelm the health system and to be disruptive enough to transmission patterns. I mean, Margaret, you're an optimism about leadership and I am too. I think the change in leadership made a big difference in the numbers we're seeing, but I also think the sad truth is we have hit a first bump towards herd immunity where we have had enough people vaccinated, I mean, infected that it's a little bit harder to transmit at this point than it used to be when everybody was entirely vulnerable. That's not a reason to not wear a mask. Everybody has to wear two masks. Everybody still has to socially distance in this moment, but it's simply to say that I think we're a little bit farther along, unfortunately, towards that herd immunity with a great cost of life, a great cost of opportunity and economic growth, and with a really important realization that those that are most vulnerable going into this epidemic, the ones that are either socially or economically disadvantaged, the people of color, those are the folks that are going to be, that are remain paying the highest price of this epidemic and will for years if we don't figure out how to fix it. The other interesting, fantastic, and I'm glad you feel that some of those questions, Vanessa, because I'm starting to, I'm just starting to kind of parse them. I think one of the interesting things about COVAX was that it was essentially, it was offered up or sold a little bit as an insurance policy. So they basically knew that countries like the United States would go and try to cut their own bilateral deals with various pharmaceuticals. But doing that was placing a big bet, that the pharmaceutical company that you invested in or that we invested in, Pfizer, was going to produce a workable vaccine. And so they said, okay, what we will do is our R&D will invest in a whole portfolio of potential vaccines and will then, if you pay into it, you'll have access to the ones that end up being successful. So it was a kind of nice, I felt like there was a really creative and thoughtful idea about how to make this kind of global government structure work. It was like, go ahead and pay in, we'll be this insurance policy, we'll bet on all the horses for you so that you at least have some access. I think that the variant issue is really throwing a wrench into everyone's plans here because it's not just like, oh, let's get along, it's nice to have some global cooperation and have a little insurance policy for us in case our stuff doesn't work. It's not like, oh my goodness, it just means the bets that you placed might be much more risky than any one country envisioned. But I think it's those types of things, I think COVAX, I hope will become a household name in the United States because I think those are the terms in which we're going to have to be thinking as a country, just like most households knew the phrase, the Marshall Plan after World War II, they knew what that was, it was to reconstruct Europe. And COVAX is an idea, I think it's gotten off to a slow start potentially, but I think that's the kind of, those are the terms that people are going to need to start thinking in as citizens. And does COVAX, so far been described as a way of unifying and making more consistent the production and market clearing, pricing and funding of provision of vaccinations around the world? Presuming supply still remains limited and therefore there's going to be a question of who gets what even because it's not like there's going to be a bidding war. There's a whole point was to negotiate a price, everybody's paying the same price, but there isn't enough of it to go around and a raised price isn't going to happen to figure out who gets it. Does COVAX then make the decision about where that next batch of fresh vaccine is going to go? It's a very complex algorithm and that's, they basically, they're fairly vague on sort of how that algorithm comes out, but effectively the idea there is, there's a distribution model that gets created about as the doses come online, who gets access to it, part of it has to do with whether it's getting manufactured and who is closest, but it's supposed to be equitable distribution. I think the thing to remember is that we really have only just come to the point where we're distributing the vaccine through the COVAX mechanism of AstraZeneca. And I think that there's a, to Margaret's point, this is completely right, there's a complete wrench now in this plan because an entire continent is now potentially needs a different vaccine than they had been originally slated for. So originally as the doses were rolling off the manufacturing press, there was you're going to get one million doses, then you're going to get two million, and based on population, it was an algorithm based on population, based on how many people were infected, based on vulnerability and a whole host of things that allocated how much of that vaccine you got. And as it was produced, you would be given your first million doses and then you get the second million at set time as it came off the manufacturing press with a variant that has been shown to be basically resistant to the vaccine that is available. It's very complicated because the assumption again is that the variant that originated in South Africa is probably the predominant strain now over at least South Central and Eastern Africa and probably the whole continent. And so that means that all there's 54 countries that are not necessarily going to want to use AstraZeneca. And that's a problem. That said, I think there, you know, countries are still bringing it out and are planning to deliver it because I think there's still an approach that that might be better than nothing. Pfizer is now trying to increase its manufacturing capacity for non-US doses. And I think the question becomes sort of how do we access the serum Institute of India and others who've been primarily going to neighboring countries. The Chinese vaccine is in stage three trials that has had disparate data anywhere from 50 to 91% effective depending on what country you're in and which study you're looking at. So we don't know if that's coming online. So I think this is a constant scramble and any information I gave to you today would not be accurate tomorrow or next week. So... Well, as we start to bring this in for a landing, is there any low hanging fruit left that hasn't been seized? For example, and this is inspired by Hannah's question in the Q&A. Might there be pharmaceutical companies whose vaccines didn't pan out but have a ton of manufacturing capacity for which there could be some way to have them licensed and then produce the vaccine that had been created by their rivals? Is that happening? That's happening. That's actually already happening where there's been licensing agreements that have been given to... I'm now going to blank on it but I believe that... I want to say I don't think it's Merck. I can't remember which one, Margaret, you may remember but there have been licensing agreements where the big three that kind of failed are either bringing in boosters to make vaccines more efficacious and they're being licensed to do that which I think is what Merck is doing and then I forget which one has just been licensed to produce like 200 million vaccines for in partnership with AstraZeneca. Yeah, I'm not sure. I mean I guess I would say I saw Hannah's question I thought it was nicely put. I think there are two things to say. One is that that's right this vaccine licensing thing is really a big deal now and there has been some degree of sharing of life permission of licensing to produce in other places but there's also been some complaints filed with the World Trade Organization around whether countries should be allowed to produce a vaccine as a generic essentially in their own countries and that's going to be adjudicated I think in March. Number one but the larger point that I thought was pointed out by the Council on Foreign Relations was I think is really relevant. We're one year into this pandemic and to date there has not been a convening of world leaders on how to figure this out. I'm very interested in ideas about I think leaving this up exclusively to the World Health Organization which I totally respect and love wonderful. But like we need to go big here. This needs to be the center of gravity for our global diplomacy community I mean this is really complicated stuff how is this going to happen and we need to get together just like if we were fighting World War II we wouldn't sort of sit back and be like oh well let's have this all depend on a contract agreement between this company and this I mean no this is something we all have to sort of get into on a high level here. So that's where I think that that would be the thing that we should look for is a convening of world leaders to really map out a global strategy that's not just leaving things like COVAX which is awesome but it's just it's just it's gone beyond there you know the problem is so great that it needs a much greater degree of attention. And I might add all health problems do I mean health is central to almost all diplomatic negotiations I mean sanctions have huge health ramifications there's you know when we think about trade agreements and the things that we give up so I would argue that health has plays a role in diplomacy at every level even beyond the vaccine. Well we surely do need convenings that match the gravity of the problem not just this problem but as you say Vanessa the larger persistent range of problems where health is not just between a doctor and a patient but is truly an interdependent and community thing. I'm so grateful for this gathering that we had as another snapshot in time I'm aware of your point that anything said here might not be true two weeks from now it's still a quite a dynamic situation and I hope we'll have a chance to keep checking in as we go but Vanessa thank you so much for spending time with us for sharing what's going on there's any other resources I put in the link to seed global health site into the chat room feel free to paste anything else in that might be of use for our attendees and I also want to thank Chris Small for her logistics for the series and offering logistical help Will Marks and Sophia Carter for their research help and advice and Lydia Rosenberg and Ruben Langeving for making the broadcast itself happen so thanks again so much and Margaret always a pleasure even if in these topics a grim one talking this stuff through and trying to puzzle it out thanks so much Jonathan it's always a pleasure I feel like I have my arms around a little bit more after talking with you all at these sessions so thank you very good all right everybody we'll catch you for the next one thank you cheers