COVID-19

Panelists discuss the challenges of ending the COVID-19 pandemic and what steps the Biden administration should take to curb the spread, including increased and improved testing and an equitable and efficient vaccine distribution. The Transition 2021 series examines the major issues confronting the administration in the foreign policy arena.

J. Nadine Gracia, executive vice president and chief operating officer at Trust for America’s Health, and Jennifer Nuzzo, senior fellow for global health at CFR, discuss the COVID-19 vaccine and ensuring it is equitably distributed throughout the United States.  Learn more about CFR's Religion and Foreign Policy Program. FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Social Justice and Foreign Policy webinar series hosted by the Religion and Foreign Policy Program. I'm Irina Faskianos, vice president for the National Program and Outreach at CFR. As a reminder, today's webinar is on the record and the audio, video, and transcript will be available on our website, CFR.org, and on our iTunes podcast channel, Religion and Foreign Policy. As always, CFR takes no institutional positions on matters of policy. We're delighted to have Dr. J. Nadine Gracia and Dr. Jennifer Nuzzo with us to discuss COVID-19 and domestic equity. I've shared their bios with you so I'll just give you a few highlights.   Dr. J. Nadine Gracia is executive vice president and chief operating officer at Trust for America's Health, where she works to develop and implement strategic policy priorities and manages their core business functions and internal operations. Prior to joining Trust for America's Health, she served in the Obama administration as deputy assistant secretary for minority health at the U.S. Department of Health and Human Services. There she directed departmental policies and programs to end health disparities and advance health equity and provided executive leadership on administration priorities, including health reform and criminal justice reform. She also led the Federal Office of Minority Health where she pioneered innovative multisector partnerships in the public and private spheres. She also served as chief medical officer in the Office of the Assistant Secretary for Health.   Dr. Jennifer Nuzzo is a senior fellow for global health at the Council on Foreign Relations. She's also a senior scholar at the Johns Hopkins Center for Health Security and an associate professor in the Department of Environmental Health and Engineering and the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. An epidemiologist by training, Dr. Nuzzo's work includes global health security with a focus on pandemic preparedness, outbreak detection and response, health systems as it relates to global health security, and infectious disease diagnostics. She directs the Outbreak Observatory, which, in partnership with frontline public health practitioners, conducts operational research to improve outbreak preparedness and response. And she's also the lead epidemiologist for the Johns Hopkins COVID-19 Testing Insights Initiative housed within the Johns Hopkins Coronavirus Resource Center. So thank you both for being with us.   Dr. Nuzzo, I think I'll start with you to give us a brief overview of where the vaccines stand for COVID-19 production, logistics, and the timeline for getting the country vaccinated as we now have a new administration—very nascent, under a week old—and what you see coming down the pike.   NUZZO: Sure, thanks so much and I'm really happy to talk about this issue. I know there a lot of questions about it, everybody sort of wondering where they are in line and whether they should take it. So just to offer my perspectives on the issue both as an epidemiologist, so sort of understanding what the value case of using vaccine in this context is, as well as someone who has been working on the field of pandemic preparedness and seeing, if we are to get ready for pandemics, what tools do we need. It's almost always the case that thinking about having a vaccine in hand becomes a game changer. So I'm oriented to the use of vaccine through that lens, which is that it's an incredibly important tool. And I am so very happy that we are lucky enough to have options to vaccinate now.   I get a lot of questions about the vaccine and often these questions are laced with concern in part because of perceptions that these vaccines have been developed in what seems to be an unprecedentedly quick time, a short period of time. And it's partially true. But I think what we have failed to acknowledge is that people have been working to develop coronavirus vaccines since the first SARS virus was identified in 2003. So, in recognizing that we had a new coronavirus that's circulating, another SARS virus, SARS-CoV-2, this virus is called, scientists didn't start from scratch. They built on the, close to, gosh, almost twenty years' worth of research that had been done before. There's a reason why we didn't have a coronavirus vaccine before now and in part that the way vaccines are developed, that the early stage research is often funded by government and it may be done through the NIH or through academic groups. They get the vaccine to a point and then inevitably it has to be sort of turned over to a company to do the very expensive and usually time-consuming clinical trials that will allow a vaccine candidate to be developed into an authorized or licensed vaccine that can be used in people. With the other coronaviruses, it's not just the 2003 one, but there was a later one that was associated with Middle East Respiratory Syndrome a few years ago, there was never a market for those vaccines. The first virus, SARS, disappeared and MERS was never really one that was contagious between people in a sustained way. And so the idea of turning over a vaccine candidate to advance clinical trials just didn't make business sense for companies that would normally take up that take up that work. So I just want to acknowledge all of the scientific progress that's been made to date.   But in the context of the vaccines that we have now, it is true, from isolation of a new virus to the availability of authorized vaccines in under a year, that is a fast time. And there's two reasons for that speed. The one is the vaccine technology that's being used. So the vaccines that we are currently inoculating people with here in the United States are based on a new technology called mRNA vaccines. And basically what it is, is a genetic code that gets injected in your body that can use that information to make a protein that it will present on some of the surface of your cells, your immune system sees that protein, learns to recognize it, goes after it, attacks those cells, and in the process gets trained to recognize that protein the next time it should invade your body. That protein is what the SARS virus, SARS-CoV-2 virus, uses to infect yourselves. So we've never used an mRNA vaccine like this. The advantage to this approach is that you can develop a candidate in really a matter of days. So that's a shorter period of time, because once you figure out what the genetic code is for that protein then you know how you're going to make your virus. What then takes time, and this is true of all vaccines, is to do the rigorous clinical trials that can establish that the vaccine candidate is both safe and effective. And there we have had an unfortunate benefit of speed, in the sense that the reason why we were able to go through the same rigorous clinical trials and get to a authorized vaccine more quickly than we would for other vaccines, is unfortunately because so many people have gotten infected with this virus that we were able to achieve statistical significance in the clinical trials more quickly than with other diseases where you have to wait a long time to accumulate enough people in your placebo group who get infected. So it's an unfortunate benefit of the pandemic that has really gotten to we're looking at almost a hundred million global cases being reported either today or tomorrow. But that has enabled us to get to the point of the vaccines being available.   Now, of course, comes the hard part. And unfortunately, while there has been a lot of effort that has gone on to the science and to assure that the vaccine is safe and effective, in my view much less effort has been put into figuring out how we were going to distribute this vaccine in a way that's both fast, because the sooner we get it into arms the faster we protect people, particularly seeing that the increased transmission of the virus in recent months, but also with respect to our knowledge of who is most at risk, both in terms of exposure and in terms of severe outcomes like hospitalizations and deaths. And one thing that's been abundantly clear since pretty much the start of this pandemic is that we don't all share those risks equally. And so in vaccinating, we must be mindful of the disparities that exist and make sure that we don't leave behind the communities who have been disproportionately affected by the virus.   So the Biden administration has set a goal of doing a hundred million vaccinations in a hundred days, which amounts to about a million vaccinations a day. We're averaging about that now. I think in the coming weeks there'll probably be some questions about the availability of vaccines that could affect our continued progress on that front. But other vaccines are in development and may help alleviate some of the supply bottlenecks that are currently being experienced. Now I think the hard work is figuring out how we administer these vaccines, both with an eye towards speed because we don't want this virus to continue to circulate and outpace efforts to vaccinate people, we want to be able to protect as many lives as possible by using the vaccine, but we also don't want to administer vaccines in a way that further entrenches the disparities that we've seen. And unfortunately some of the anecdotal reports is showing that the coverage of vaccine has not been achieving those equity goals. So there's just a report today that African Americans are underrepresented in those who have been vaccinated to date. It's both a function of access issues and the challenge of trying to vaccinate people quickly. There also mistrust issues that similarly need to be addressed. And it's also the fact that most states aren't even tracking their vaccination progress with respect to these equity goals. And so that will be, I think, a challenge in the weeks and months ahead is to make sure we're making sufficient progress while not leaving communities behind.   FASKIANOS: Thank you, that's a perfect segue now to Dr. Gracia to talk about your work addressing health disparities and what you feel needs to happen in order to ensure that the COVID-19 vaccines are distributed equitably and we're not leaving those populations behind.   GRACIA: Thank you very much and good afternoon, everyone. It's really a pleasure to join in this conversation today. I'm really honored to be here and, in particular, in the context of religion and social justice and knowing how much you as religious leaders and those of you of faith and civic institutions are so vital in the efforts to advance equity in the COVID-19 pandemic, not only in the response but also in the recovery. And we are certainly sitting here at a time in the United States where we have more than twenty-five million cases of COVID-19 and more than 420,000 lives lost and always remembering that these are individuals and not statistics, and that there are countless family members and friends and neighbors who mourn their passing. And as we're talking about here, the pandemic has exposed and it's exacerbating our deeply-rooted structural and systemic inequities, which continue to challenge us. And these disparities we know existed long before the COVID-19 pandemic. And while disparities show themselves during so-called normal times, they're certainly exacerbated during emergencies. And we see these not solely in health, per se, but we see these in the structural drivers of health that lead to what we see as differential power and resources in communities, such as unequal social and economic and environmental conditions, whether it's substandard or lack of access to affordable housing to lack of good jobs, to less access to healthy food grocers to less availability of health care services and poor quality schools, as well as greater exposure to pollution. And we often in public health will frame this as the social determinants of health, which have such a significant influence on health and how this is unfolded before our eyes. We're seeing how these conditions have put certain communities at greater risk of exposure, of illness, of hospitalization, and of death from COVID-19. And much of that inequity really has spanned generations resulting from poverty, from discrimination, structural racism, and disinvestment in far too many communities.   And when we think about the definition of health equity, that it's a fair and just opportunity to be as healthy as possible, we must really then center equity in our efforts as it relates to addressing the COVID-19 pandemic and now this opportunity that we have through the COVID-19 vaccine. But what we're seeing, certainly, as Dr. Nuzzo discussed, we see that Black and Latino, Native American, Native Hawaiian, and Pacific Islander communities are experiencing disproportionately higher rates of cases and hospitalizations and deaths, that Asian-American communities are facing rising rates of discrimination and prejudice, that their historically underserved communities such as low-income populations in rural communities, as well as certain immigrant communities that are encountering really significant challenges and barriers to accessing services. And that groups that typically have been largely marginalized, whether that's individuals who are homeless or who are in correctional facilities, are experiencing really concerning outbreaks and many others. And these are just some of the many stark realities that we're facing. And we know that these are not just disproportionate health impacts, but that there's also certainly the economic impacts that was alluded to as well.   But when it comes to the moment that we're in, it's really, I think, both complex but a critically important task of COVID-19 vaccine distribution and administration and ensuring that that distribution and uptake are equitable, for this is really an effort unlike any that we've undertaken as a nation. But we should bear in mind that as we embark in this, the vaccinations and barriers to vaccinations have long existed, for example, among people of color both in terms of the challenges in access to, as well as, as was noted earlier, some of the issues with regards to mistrust in government and health system, which is rooted in historic maltreatment through today where there's ongoing present-day racism and discrimination. And as you heard just last week, actually, the Kaiser Family Foundation released a report showing that people of color, in particular, Black and Latino communities, are seeing lower rates of vaccination. And so it really raises the concerns about access to the vaccine as well as ensuring that there is outreach and education to address questions and concerns that communities have.   So our organization, Trust for America's Health, we are a public health policy, advocacy, and research organization in Washington, DC, and just last month we released, in partnership with the National Medical Association and UnidosUS, a report on earning and building trust in access to COVID-19 vaccine in communities of color and tribal nations where we focused on recommendations for policymakers to address access to the COVID-19 vaccine in a safe and equitable way. We had over forty groups and organizations that participated in a convening in which we got their feedback to talk about how do we prioritize equity in particular as a vaccine distribution and administration began. And there were some key recommendations that we outline in this report. One, as Dr. Nuzzo described, and she did it really well, to explain the process of vaccine development, because that's really important to ensure that communities understand the process, that there's transparency and an understanding how safety has been a priority in the vaccine development process. That, two, you're equipping trusted community organizations and networks within communities of color and tribal nations to participate through the spectrum—from the planning, to the education and delivery, and administration of vaccinations—and ensuring that there's meaningful engagement of those trusted entities, including faith-based organizations, faith leaders, religious leaders, to have a seat at the table and really be involved in that planning. And not only that but ensuring that they have the resources and tools to do so. Thirdly, we talked about providing communities with the information that they need to make informed decisions and to deliver messages through trusted messengers and pathways. And importantly, we should recognize that all communities and families want to be healthy, they want to keep their families healthy and safe, but need access to information that is culturally and linguistically appropriate, that provides them with the services that they need. And so importantly as we turn to trusted messengers, it's also ensuring that there's funding that's going to those community and faith-based organizations to be able to do this work, to be able to do the outreach that's needed. Fourth, we recommend that we ensure that it's as easy as possible for people to be vaccinated and that vaccines actually are delivered in community settings that are trusted, that are safe, and accessible. And the challenge can be having vaccination sites. If they're not accessible to communities, especially those that are disproportionately impacted, then you're not going to see the vaccination rates that you're hoping to see. And so ensuring that, in partnership from the federal to state to local, tribal and territorial levels, working within communities, that those types of vaccination sites are truly accessible and trusted in communities. We also have a recommendation on ensuring that there is complete coverage of the costs that are associated with vaccines that are incurred by individuals as well as the administration costs that providers have with regard to vaccinations, because cost really cannot be a barrier with regards to vaccination efforts. And lastly, it's that we ensure that there is funding and the resources to actually have data that are disaggregated. As you heard, there are a handful of states in which we have the data that are showing, by race and ethnicity and other factors, who was actually being vaccinated. But we need to do much more to be able to actually have access to that data. And that's been a long-standing challenge in public health and the surveillance systems and really shoring up the system to be able to do so. Because that will then help us to know which communities are not being reached, where we need to target our efforts, and ensuring that they have access to the vaccine.   What's clear through this crisis is that we really can't succeed to getting to the other side of it without caring for everyone and prioritizing equity. And that includes in the COVID-19 vaccine distribution and administration. And with some of the more recent COVID-19 relief bills that were passed in December, there's more funding now getting to states and localities. That's going to take time with regards to the distribution and administration, and so really working in partnership to ensure that communities are being reached as it relates to having access to those resources for vaccinations. And as was alluded to with the Biden-Harris administration, that with this new administration and the priority on not only COVID-19, but on prioritizing and centering equity, there really is opportunity here to ensure that we can have equity in the COVID-19 pandemic response moving forward and in the recovery as well. And we all certainly have a role to play. And certainly you as religious leaders, your voice and engagement are so essential. So I look forward to the conversation that we'll have this afternoon on how we can further really address some of the inequities that we see and how we work to advance equity not only for COVID-19, but for the health and well-being and economic vitality of our nation moving forward.   FASKIANOS: Thank you very much. Let's go now to all of you for your questions. You can click on the "raise hand" at the bottom of your screen. If you're on a tablet, you can click on the "more" button and raise your hand there. And you can also type your question in the Q&A. And the first question comes from Bishop John Chane, and he was formerly with the Washington National Cathedral: "Given the mutation of COVID-19, why are the variants in Great Britain, Brazil, and South Africa different from the original COVID-19? And what are the elements in these countries that make these variants so different? And why in some cases, more lethal and more virulent?" And I would just add to that it's obviously here in the United States. We've seen it's now circulating here in the U.S. So Jennifer, do you want to start?   NUZZO: Sure, so all viruses mutate and this virus has, previously, pretty much since as soon as it was identified. But the mutations haven't really got the level of attention until now, in part, because they didn't really change much. I will call it for simply because the scientific name is so impossible, a string of numbers, it's really terrible, but this is unfortunate, I'm going to say the “UK strain” really got global attention because of an observation that it seemed to be producing more secondary infections than the previously circulating strains or the previously dominantly circulating strains. There is some question as to whether the virus is also more lethal though. I think that data aren't clear on that at this point. But anyway, the idea that the virus potentially could grow cases more quickly just because with each infected person they may have a viral load, we don't fully understand the mechanism, may affect more people than an average person who was infected with the virus that didn't have that mutation. That is obviously worrisome, because if the epidemic accelerates even further that obviously makes control much harder. I think the bottom line right now, just the public health takeaway, is what the discovery of these variants very much underscores is the need to act with urgency, but it doesn't, at this point, change what we need to do. So the more people who get infected with the virus, variants or not, the more opportunities there are for mutations, the more possibilities that these mutations could produce functional differences like either in transmission ability or in severity or potentially the ability to evade vaccines or medical countermeasures. We don't have data get to suggest that as a problem right now fully. There is a little bit of concern from the variance from South Africa that they may produce a different immune response. But so far there's still confidence that the vaccines will work. But it just raises the possibility that maybe perhaps one day we will be dealing with viruses that are harder to control with the tools that we have. So the takeaway is that these things add urgency.   One challenge in all of this is that not all countries are looking for genetic mutations. And the ones that do, we don't all do them at the same frequency. So the UK and South Africa are two countries that have done some of the most sequencing in the world. And they are unfortunate to have found these variants and reported them because now countries have responded with travel restrictions and all sorts of penalties that sort of hurts the messenger. The United States, for having the largest epidemic in the world, we have only a sequence of very, very small, like tens of thousands of our cases versus the twenty-five million that we've had. So that's just to say that our understanding of what variants are out there and where they are and where they aren't, in my view, is very much flawed based on completely inadequate surveillance. That said, what we've discovered so far suggests that we need to get serious about controlling COVID, pursue the vaccination efforts while we can, but also we can't give up on our public health efforts. And we must double down with urgency because again, the goal is to protect people with vaccine and not to let the virus outpace those efforts.   FASKIANOS: Jennifer, are we ramping up our sequencing here in the U.S.?   NUZZO: I do believe we're doing more sequencing than we were doing, but I think it's a marginal difference from where we were before.   FASKIANOS: Okay, I'm going to go next to David Greenhaw. And please unmute yourself. David, are you? Good. You just need—there you go. Please identify who you are.   GREENHAW: Yes, I'm David Greenhaw, president emeritus of Eden Theological Seminary in St. Louis, an ordained minister of the United Church of Christ. I watched and participated in a parallel event we did a week or two ago on global equity, and I've been thinking about the generosity that people have. And if we could engage their generosity, that is, they're not simply serving their self-interest by getting a vaccine, but by getting a vaccine they're actually trying to save another life. And it occurred to me given the need for financial support globally, has there been or could there be something like a March of Dimes where people would be called to save a life by "get a vaccine, give a vaccine," so they'd be encouraged to give five to ten dollars, whatever the global support rate is and do that. Do you know of such efforts and do you have any thoughts about the efficacy?   FASKIANOS: Dr. Gracia?   GRACIA: Thank you, David, for that question. And I am not familiar with specific efforts related to that, but there's messaging that you share that there are quite a few efforts as it relates to how to message the importance of the vaccination and groups that are really engaged, both from the public sector with regards to the federal and state and local public health agencies, but also in the private sector that are really working in, one, doing surveys to identify what messaging seems to be most effective in helping to inform communities about the benefits of the COVID-19 vaccine as well as to address concerns that may arise as it relates to the COVID-19 vaccine and importantly to understand that communities are not monolithic. That even in speaking of communities of color or even in speaking of, for example, the Latino community or the Black community that there is heterogeneity across communities and understanding what messages may really resonate and help inform communities to make the decisions with regards to vaccinations. And again, as I pointed out to understanding that individuals and families want to keep their families safe. And there was recently, from the de Beaumont Foundation, a survey that they conducted and some information that they shared and tips with regards to messaging as it relates to the vaccination efforts. And one is really importantly to describe the benefits of vaccination and not solely focused on or emphasize the consequences of not getting vaccinated. And so your point where you talked about that by you yourself getting vaccinated, that you can then help to protect others and encourage others is one of the messages with regards to saying, for example, that the benefit is that it's an important way to protect you and your family from COVID-19 and sharing that message. And then also, certainly not being judgmental as it relates to if individuals have concerns about the vaccines and listening and trying to understand when those concerns aren't being able to address those. So there are those efforts underway. The Ad Council is partnering with the COVID Collaborative, it has been doing work with regards to a public messaging campaign. The Biden administration is also planning, with regards to doing a national campaign as well. But let's also remember how important local trusted leaders are and trusted messengers are, especially as we think about advancing equity where local health-care providers, community health workers, community and faith-based organizations are so critical because they're seen as trusted messengers to really be able to answer questions and also to be able to connect families and communities to access to the vaccine.   FASKIANOS: Thank you. Somebody wrote in the Q&A, anonymously, that also, I think, that Group Luke 10 may be contemplating something like this. The group is collecting funds to help supply PPE to the suffering people of Iraq. And Moms For Peace may be a good place to check. So David, you can look there. I'm going to do a follow on question from Lawrence Whitney at Boston University. Lawrence, do you want to unmute or do you want me to read your question? I'm going to put you on the spot. Why don't you unmute?   WHITNEY: Sure, happy to ask the question. So the NIH recruited a group of religious leaders to in turn recruit a more diverse cohort of vaccine trial participants. So I'm wondering if you're aware of any similar program underway to specifically leverage religious leaders in addressing issues of equity in the distribution phase? And if so, do we have evidence that this strategy is effective?   FASKIANOS: Nadine?   GRACIA: So, I would say, one, there have been examples of states, for example, in execution of their distribution plans. There is variation across the states with reference to the distribution plans and where they've discussed and how they've prioritized equity. But there are states, for example, like Massachusetts, that has really invested in and providing grants both to faith-based organizations as well as community-based organizations to help with regards to outreach and education, messaging, and access to services as it relates to COVID-19. There are other examples of states where they've actually had a faith community liaison that is part of the task forces that are created with regards to the health equity task forces in the states to be able to, again, identify strategies and ways to bring together the various trusted messengers to not only provide them with the education of how to do this and become messengers and communities, but to help identify where those resources are needed in various communities. This is something that is not unique, I would say, to COVID-19. As we noted earlier, when I served in the Obama administration and led the Office of Minority Health, we did this effort as well as it related to the Affordable Care Act and outreach for the Affordable Care Act in working very closely with faith leaders, whether it was to help host town halls, to utilize their places of worship as places where you could actually sign up to get access to healthcare, to health insurance coverage. Similarly with other types of outbreaks such as Ebola and Zika. Similarly connecting with faith leaders and finding that was an important vehicle, again, because of the trust as well as the long established relationships and networks that leaders have in communities.   FASKIANOS: Thank you. I'm going to Rob Radtke next.   RADTKE: Thank you, Irina. I'm Rob Radtke with Episcopal Relief and Development. What consideration is being given to making vaccine distribution more patient-centered? My experience is that accessing vaccines, even for priority and vulnerable populations is extremely difficult. It requires access to computers, high levels of literacy, access to transportation often, and essentially, very, very high levels of personal motivation. And it feels like this has been very top-down. And if we really want to reach vulnerable people, and high priority populations, we kind of have to, my sense is that it needs to be rethought. And I'm wondering where or if that's happening?   FASKIANOS: Jennifer, do you want to start and then we'll go to Nadine?   NUZZO: Sure, just some high-level observations, which is, first of all, this is, I mean, what you're seeing right now is the start of a process that, in my view, should have been started a long time ago. But states have been begging for help and resources for a very long time and very only recently got money to help them start these plans, which I really think was a shortcoming in our rollout of these vaccines. But you're going to see the tension here where there is a need for speed and states are, every day they're being asked by the press how many of your vaccines have you given out versus doing the exacting work of achieving coverage in your highest priority groups. Trying to find those people, trying to meet them where they are, access them, etcetera. The first vaccination in many states focused initially on health-care workers. And so that was a captive audience, a captive population that was within health facilities that could be reached and scheduled. And even that failed to capture, say, staff that weren't on the email systems. So it's really difficult work that's being done.   I'll tell you, a friend of mine, I won't say where she works, but she works in a major city that was trying to schedule vaccination clinics. And they found out that one of their invite signup lists sort of went viral. And when they saw who signed up and the zip codes that the people were coming from and saw the zip codes that were completely not represented in those signups, probably reflecting who is more easily able to get on the computer and schedule and pass the word around, they actually cancelled the clinic and decided they need to start over again to figure out how they can make sure they're also reaching their hard-hit communities. So I think some of it is being worked on now. I think some of the approaches where it's been talked about, for instance, taking advantage of federally qualified health centers, I think we're going to have to go on multiple paths here where we are considering opening up more broadly and do more of these mass vaccination efforts in stadiums, but recognize we cannot only use those approaches because those will leave communities and people behind and that we need other options. And the extent to which the community can also self-organize, and I see those of you attending this webinar as particularly well suited to advocate for the communities that you serve, and to say people need help getting to their appointment and sort of volunteer to organize. I don't think there's a lack of interest. There's just a lack of view and a lack of time and a lack of bandwidth. And I think this is a moment in our history where everyone has to kind of roll their sleeves up and if you have a skill that you can bring to try your best to bring it to the table and help.   GRACIA: I would echo, yes, I'd echo several points that Dr. Nuzzo just mentioned, which is  bringing the vaccination to the community and recognizing that we are at the beginnings and not only where states and localities are just now starting to receive these dollars in funding. At our organization we had long called for the need for planning but needing resources to do that planning and preparation for the distribution and administration. But it's also recognizing that in particular with the public health system, the public health system has long been underfunded. They're at where there's now shortages with regards to the workforce and stretched, stretched for several months in responding to this pandemic. And so the need for the partnerships that you're discussing really are so critically important. And it will require expanding, for example, where vaccinations can be given. So whether that's in federally qualified community health centers or other community health centers in rural health centers, but also having the opportunity for mobile clinics that can go to communities and other types of community centers where they also have trust to be able to reach communities. This is going to be vital. And so not only in the advocacy that you can do to ensure that those types of sites are part of the plan with regards to ongoing distribution and administration, but also are there mechanisms and ways for you to actually engage in and be a part of that distribution and administration, a process as far as the sites that are in communities, because indeed transportation issues, ensuring that communities have access to information that is in multiple languages, that is culturally appropriate, and utilizes different mechanisms. When we, for example, were doing outreach as it related to the Flint water crisis, as well as to the Affordable Care Act, we tailored approaches to say how does the community also get information. So it wasn't necessarily to always only rely on internet technologies, but also the radio, television whether it was community outreach workers and really expanding the approaches so that we can ensure equity with regards to our outreach.   FASKIANOS: I'd like to go next to Sister Markham of Catholic Charities U.S.A. Do you want to ask your question yourself? You can unmute yourself.   MARKHAM: Sure. Happy to ask it myself. I'm Sister Donna Markham and I'm the president of Catholic Charities for the U.S. And I just think from a practicality perspective right now, we're been really trying to encourage our vulnerable communities, especially communities of color, the homeless population, etcetera, to get vaccinated but it's a tough sell because they're not real patient and they're less patient than the rest of us even are. And so when we're encouraging them, they're dispirited. There's no information about how long it's going to take them, even if they're in one of the risk categories by virtue of age or health condition. So I guess my question really is, are there any plans in the works to be transparent about what's happening, to communicate with the public to say, okay, twenty thousand people are ahead of you in line in Oshkosh, Wisconsin? It'll be about it's going to be three months before we call you. I mean, that kind of information, I think, would be really helpful and it would help those of us that are trying to serve those communities if we weren't just kind of sending them down a black hole of mystery. So that's just a question and maybe it's just difficult because nobody wants to get in the public and say, "We really don't know." It is very frustrating. And it does stand in the way of helping those communities.   NUZZO: So, I mean, I think the issue is that the states and the local health jurisdictions just don't have the information that they need in order to be able to tell the public. I mean, one of the challenges is they don't really understand how much vaccine they're going to get and when. And so that's an incredible planning challenge. And then there's also the fact that the federal government announced an intention to expand vaccination efforts beyond the initial priority groups before any state had a heads up. And the day that then secretary of Health and Human Services said we were calling on states to offer vaccines to people sixty-five and up, I mean, no state had advanced knowledge of that. And based on my friends and family I know, a lot of senior citizens got on the phone and started calling to find out when they were next. And there were no systems in place to receive those inquiries. So now they're trying to set up the systems and to bring people in but that that kind of logistic, that kind of scheduling? It's one thing to do it in a clinical environment with health-care workers. But health departments don't have that infrastructure and so they're standing it up. In some cases, private sector organizations have reached out to offer help. I think that's encouraging. There's, of course, always worries that we have to be transparent about those efforts and make sure that that doesn't gain access inappropriately to vaccines. So I don't have an answer for you other than it's not a question of nobody wanting to tell, I think people very much want to be able to say to somebody, "This is when you're going to get your vaccine." And I just think there's no way to do it right now. I mean, even the CDC director, the new CDC director, said the other day that they basically have no idea how much vaccine is coming. I think this is one of the biggest mistakes we've made in this vaccine is that we have overpromised how quickly it was going to be delivered. And my mental picture for me, as someone who's not in the high-risk group, was always that it might be sometime late summer and that was never aligned with what I was being told. But it's based on my own knowledge of how these things are likely to go. And so I think we just have to set expectations, which is that we have never attempted a vaccination campaign of this magnitude. The systems that are needed to do this have not yet been built. And the information that's needed to inform the messaging is not yet there. I think it will get there. I am quite hopeful that we are in for better days, but it's going to take some rocky terrain in the next few weeks until we get to a better place.   FASKIANOS: Nadine, do you want to add to that?   NUZZO: Yes, I would just reiterate that this being such an unprecedented logistical effort and trying to, as was said, even note how much of the vaccine that you have coming to you for the states and localities to be able to do that planning. It has been a challenge. And so I think that's why you're also seeing certainly with the Biden administration wanting to say there needs to be more communication/collaboration from the federal to the state and local levels, to have that awareness, to be able to also manage expectations. And I think with this being certainly a new vaccine rollout effort, knowing that there is going to be limited supply in the beginning phases and that the emphasis is on initially vaccinating those with the greatest exposure and understanding why health-care workers and those in long-term care facilities were the first groups to be to be vaccinated. And that as more and more vaccine becomes available to expanding those populations with regards to who has access to the vaccine. It's not easy. It is not easy to message but communicating, and regularly communicating, providing clear communications are important and updating communities to have that understanding so that there is transparency. But that we can also manage expectations and have an understanding that as communities are waiting for vaccinations, the importance of continuing with the public health measures that are so vital, from wearing masks to the physical distancing to the frequent hand washing, etcetera, and how important that is, as well as part of all of the tools that we have in really working to controlling and stop the spread of the pandemic.   FASKIANOS: I'm going to go to Adem Carroll next. If you could unmute yourself?   CARROLL: I work with diverse communities and a lot with the Muslim community. I see a lot of trust issues. And it's not necessarily among people who won't wear masks, it's people who do. But yet the depth of distrust is so pervasive. So a lot of outreach efforts will be needed. I did want to ask, though, beyond the cultural aspect, reaching the most elderly, it seems that the categories have been made very broad, as you just said, Jennifer. The states were surprised by suddenly throwing open the door to anyone over sixty-five. But somebody over eighty-five is a lot more fragile or vulnerable, I should say, generally speaking. So why were the categories made so broad? Do you have any sense and also, New Jersey is allowing all smokers to be vaccinated. So how do states allow such odd criteria for vaccination? And of course, this all relates to the question of supply, which I think we all have to ramp up production. How can we manage to do that?   FASKIANOS: Who would like to take that first?   NUZZO: So, there's a few things there. I mean, first of all, the decisions are going to be made by the states. That's just where the constitutional authority, the Constitution puts the primary responsibility for public health on the states. The priority groups were set as guidelines and states have always been free to implement those guidelines as they wish. Many states did follow them. But what you see is that identifying priority groups based on either exposure categories or risk factors for severe illness and death is, I think, in my view, a very ethical way to go about allocating scarce resources. It's just slow and exacting work to try to find those people, particularly when you don't have enough vaccine to cover the entire priority group. And we don't have an infrastructure to say, okay, let's find all of the people who are eighty-five in the community or all the people who are sixty-five plus. It's just, it's really tough and what we saw in the first month of vaccination was very slow rates of administering the vaccines that states had received, in part because they were doing this very exacting work of trying to schedule people according to priority. And in some cases those prioritization schemes were directly hindering vaccination efforts in the sense that some states didn't just say, okay, give it to everyone who works in health facility. But they said, okay, well, we don't have enough to do that so give it to the people who are most likely to be exposed in the health facility. Well, if you're a facility manager that means that you needed to find those people, schedule them, bring them in. You have to figure out which vaccine they're going to get and then you had had to figure out what to do with if you had extra doses in the vial and who you can give that to. You didn't want to be the one health facility that was in the news for giving it to the wrong people. So in some cases, we heard stories about health facilities rescheduling everybody for another day when they could get more to come and take those extra doses. Some states prevented health facilities from offering it beyond once they covered everybody in a certain job category, they had to wait until all the health facilities could catch up. So you're seeing the kind of challenges in working through these things, these plans in real time and realizing where they work and where they don't. And so as there is an increasing recognition that at some level getting the vaccine in arms is better than not, there is going to be this tension between speed and trying to just get coverage so that hopefully we can protect as many people as possible to also wanting to make sure that we cover the people who are most likely to be exposed and most likely to be harmed by the virus. And it's just really, really hard. There's always going to be, I think, that tension there. I hope it'll get easier.   I just want to say one more thing on the misinformation and why it's so hard. So, of course, there are the historical issues. And the fact that hesitation about vaccines predate COVID in all communities. All of us have some level of hesitation, it's just for different reasons. But COVID, I believe, is unique in the sense that, at least in my professional life, it is the first time I am seeing an incredibly organized set of groups that are coordinating and using tools that we never had before to spread disinformation. They're intentionally trying to mislead about not only the vaccine, but the virus for different goals. Some are anti-vax groups that are seeing COVID as a historic opportunity to expand hesitation about vaccines. And all they need to do is just sow doubt. And they are targeting groups that have historic mistrust of vaccines as a way of doing that.   There are also groups that are trying to sell things—alternatives. And so they're spreading disinformation as a way to boost their profits. And we live in a situation where the virus itself has been politicized and groups that are aiming to sow doubt about the vaccines recognize that continuing to sow doubt about the virus is a way to sow doubt about the vaccines. And so some of the work that I've been doing and looking at the rollout of COVID vaccines among health-care workers and hearing about lots of refusals, sometimes because of the vaccine, but also sometimes because even in hard-hit hospitals, they don't believe that the virus poses a threat to them as individuals. And I don't blame anybody for this other than the fact that there are very powerful forces at work trying to sow doubt and we haven't appropriately amassed counter-campaigns to spread the right information and to counter the disinformation that's being unleashed,   FASKIANOS: Unfortunately we have finish early, so I want to give the last word, so my apologies to everybody who still has questions, but I want to give Dr. Gracia a chance to make any closing thoughts on the heels of what Dr. Nuzzo said.   GRACIA: Sure. I was actually just going to pick up where Dr. Nuzzo left off with regards to both misinformation and disinformation and how, indeed, that spread of misinformation, as well as the intentional efforts through disinformation, is widespread and really challenging as it relates to addressing concerns and questions that communities have. I’ll share some resources, certainly for those of you who are actively working on this and wanting to try to really help communities and getting access to information, in addition to the access of information that you may have from local agencies and state agencies, as well as the federal agencies. There's also a Public Health Communications Collaborative that our organization is one of the members of and that has specific resources and actually is tracking some of the misinformation that is out and provides either strategies of how do you respond, do you respond, what are some tactics and techniques. And we know much more needs to be done because the information that is spread is moving at such a rapid pace that that is going to be something that we will continue to grapple with to be able to ensure that communities are getting accurate and timely information.   FASKIANOS: Thank you. And we will circulate these resources. We're going to go back to both Dr. Gracia and Dr. Nuzzo for their thoughts of resources we should share with you all. You both should sign off now because I know you have a two o'clock and I want to give you an opportunity to and I'll say thanks to you while you're leaving. Just some housekeeping notes for the group here. Thank you both very much.   GRACIA: Thank you.   FASKIANOS: So you can follow Dr. Gracia on Twitter @HealthyAmerica1 and you can follow Dr. Nuzzo @JenniferNuzzo. We also encourage you to follow CFR's Religion and Foreign Policy Program on Twitter @CFR_Religion for announcements about upcoming events and information about the latest CFR resources. As always, reach out to us at [email protected] with any suggestions on future webinars or events. We will circulate the transcript and video of this webinar along with resources. Thank you all again. Please stay well, stay healthy, and we will be convening again shortly. So thank you all. Enjoy the rest of your day.

Anita L. Barkin, co-chair of the COVID-19 task force at the American College Health Association, leads a discussion on the role of colleges in disseminating vaccines and provide rollout recommendations for campus communities. FASKIANOS: Thank you. Welcome to CFR's Higher Education Webinar. I'm Irina Faskianos, vice president for the National Program and Outreach at the Council on Foreign Relations. Today's meeting is on the record and the video and transcript will be available on our website, CFR.org/academic. As always, CFR takes no institutional positions on matters of policy. We're delighted to have Anita Barkin with us to talk about the planning for vaccine rollouts. We have shared her bio with you, but I will give you the highlights. Dr. Barkin is co-chair of the COVID-19 task force at the American College Health Association, known as ACHA for short, and a member of the board of directors for the Healthcare Georgia Foundation. Previously, she was a district nursing director of the North Central Health District. She oversaw operations of the district office, thirteen county clinics, and the Hope Center. She also served as director of Carnegie Mellon University Health Services for twenty-seven years. Dr. Barkin is a board-certified nurse practitioner and an ACHA fellow. Over the course of her career, she has held offices in local, regional, and national college health associations, and the Georgia Public Health Association. And she previously served as chair of the nursing session of GPHA and president of ACHA. She is a leader in pandemic planning for colleges and universities and this is the perfect audience to address today. So Dr. Barkin, thank you very much for being with us. Will you begin by talking about the role of colleges in disseminating vaccines on campuses and in their communities and provide your recommendations for campuses and what they're doing in their communities? BARKIN: Certainly, I want to, first of all, thank you for the opportunity to join you and your members this afternoon and discuss this very timely issue. And there are lots of questions that folks have out there regarding the vaccination rollout. If I may start by going through the PowerPoint presentation I gave as kind of a warm-up to our discussion. [To CFR operator] And so, yes, you can move to the next slide, please. So, we'll start with a short introduction, overview of the approved vaccines: what does the phase distribution plan look like? And then discuss some of the action plan items that we're recommending for institutions of higher education. Next slide. So currently, there are two vaccines approved under the Emergency Use Authorization, the EUA, and that is Pfizer's vaccine and Moderna. Now, if you look at them, the efficacy is about the same for both and even the dosing schedules are very similar. Pfizer is intended for use in sixteen years and older individuals and Moderna is eighteen years and older. They are, however, already starting trials to see what happens in younger folks. And so I think we'll see some information coming forth on the applicability for children and young adults, as well. There are some challenges with the Pfizer vaccine in terms of shipping and storage in that they–—that requires an ultra-cold freezer temperature of minus ninety-four degrees approximately, where Moderna is easier to store and ship and it's stable in a refrigerator for longer. And you can order less of it, fewer doses, and that's a big advantage for smaller organizations or smaller schools that really couldn't make use of 195 to 975 doses of Pfizer, in addition to the fact that the storage, as I said, storage capabilities are quite challenging with the Pfizer vaccine. Next slide. So two facts about COVID mRNA vaccines and those are—that is the technology that has been used to develop the Pfizer and Moderna vaccines is that the—and these are circulating, and so I thought it was important that we address these two particular issues. First of all, the vaccine cannot give you COVID-19. mRNA does not use live virus. It is a small fragment of the RNA that prompts the cell in the human body to make the protein. It does not affect or interact with cell DNA. It never enters the nucleus of the cell where the DNA genetic material's kept. Once the cell breaks down, it gets rid of the mRNA. And as soon as it's finished using the instructions to make the protein piece. So there's a lot of misinformation out there regarding how it works and its ability to interfere with cell DNA so I want to put those two myths to rest. Next slide. And there are more vaccines in the pipeline using different technologies. AstraZeneca, Janssen, Novavax are all in phase three clinical trials. And we need lots of vaccine in the pipeline. The limitations on the ability to manufacture enough vaccine to vaccinate the U.S. population quickly is really going to be dependent on having a variety of vaccines available to immunize the population. Next slide, please. So there are three questions that are yet to be answered. Does vaccination stop asymptomatic transmission? How long will the protection last once a person is vaccinated? And how will vaccines deal with various mutations that are making their way on the scene? Next slide. So especially relevant to the higher ed population are two phases of the ACIP recommendations. ACIP is the Advisory Council on Immunization Practice. And this phase structure was accepted by ACIP and rolled out. In phase 1A, the jumpstart phase, first group to be vaccinated says high-risk health workers and first responders. It is important to know, and ACHA certainly was interested in ACIP understanding and being very explicit in its intent to include healthcare workers on college campuses and first responders on college campuses. So if you have a health service and EMTs or paramedics, first responders on your college campus, they do fit into phase 1A of the distribution cycle, so they should be first in line. In phase two, you'll note that it says K-12 teachers and school staff and childcare workers. That has been interpreted to also include faculty and staff of colleges and universities. So “teacher” used in the broader sense of the word. And so we are seeing some places where faculty and staff are being vaccinated. And that is most commonly happening in schools that have—schools with health care professionals: medical schools, nursing schools, dental schools. But in, for example, in West Virginia, they have gone ahead and distributed vaccines to college campuses so that faculty are covered under phase two. So now that's jumping ahead of the phase-in recommendations of ACIP, but I do want you to know where this all falls in the conversation as it relates to higher education. Next slide. So the vaccine rollout plan from a federal standpoint was to—that the vaccine would be rolled out and managed at the state, tribal, territorial, and local level. And that states would be responsible for promoting confidence and uptake. The second set of partners that were engaged on a federal level were private corporate partners like CVS and Walmart. And some CVS and Walmart sites have received vaccines and many others haven't. And the major role that they anticipated CVS would play was especially in vaccination efforts for nursing homes and other conjugate settings, like prisons. Next slide. The federal plan has presented a number of challenges and missteps. There's been no unified nationwide government plan or strategy as a result of the decision to move this to the state level. There has been miscommunication and miscalculation on how many doses states would receive. States are already experiencing lack of human and financial resources to manage the rollout. And so many states are struggling, more so than some others, dependent on what their resources and human capabilities are. This is resulting in inconsistencies across the country in the prioritization of residents to receive the vaccine, how to alert people to sign up, promoting vaccine acceptance, and configuration of immunization sites. And I think you—just one example that I will give you is, for example, in Georgia, the governor decided to expand phase 1A to include individuals who are sixty-five and older. And that was a jump ahead of what had been planned by ACIP. Other states have not done that. So we're seeing a lot of inconsistency. As I told you, WV, you know, West Virginia has gone ahead and distributed to colleges and universities to immunize their faculty which fell into the second phase according to ACIP. So we're seeing a lot of inconsistency. The states are overwhelmed. Complicating the matter is a surge in cases, which is overwhelming the healthcare systems in states. So there's a shortage of personnel to even conduct these mass vaccination clinics. And I think also what we're seeing is a lack of funding for public health over the years has come home to rest. And the lack of funding in public health has resulted in strained resources in terms of the ability to conduct mass clinics and to inform the public about the benefits of vaccination and the safety of these vaccines. Next slide. So what can institutions of higher education do, given that there is all of this confusion about the distribution? It varies from state to state. How do we proceed? How do we become proactive in this situation so that when that vaccine becomes available to our populations, we have already worked to inform resistance to vaccination? Well, right now, our advice to institutions of higher education would be to immediately develop a comprehensive communication plan and health promotion strategy that increases vaccine acceptance and confidence in the community. And you need to do that while continuing to reinforce the need for ongoing public health strategies for mask wearing, social distancing, and hand hygiene. All of those strategies as mitigation strategies that were in place in the fall need to be continued and reinforced in the campus community, while also providing this information that will facilitate vaccine acceptance and confidence when the vaccine becomes available to you. And just some general principles about good communication. You want to communicate often and in a transparent manner. Anytime you receive updates on what's happening with the vaccine or your ability to access vaccine for your populations, you need to be communicating that and remain current. And also establish an advisory group that's comprised of diverse members of the campus community and student leaders. What messaging is going to resonate with the different populations that are on your campus? And who are those individuals on your campus who serve in leadership roles, who are respected sources of information and trust, who will be out there and willing to communicate their confidence in the vaccine and in reinforcing the public health messaging? Next slide. Of course, maintaining close contact with the appropriate public health authority to discuss planning and distribution of the vaccine is critical because these decisions, at least under the current strategy, and this may change with the new administration. The new administration may decide that they need to create and develop a national strategy for more consistency across the state lines. But right now, as it stands, it is critical that you be in touch with the local appropriate health authority, public health authority for the location near your campus. And you need to do some advocacy work upfront. Public health authorities need to understand the role that healthcare providers and first responders play on campuses. And I think many are aware of the important role of student health services on campuses, but some may not be. And understanding that they are providing patient care, they are at risk for exposure to the virus from their population, and that they need to be considered in the vaccination plan when that distribution occurs locally. The other thing that ACHA has done is to explain and advocate the importance of vaccinating college students before the end of the spring term, if at all possible. We have identified the end of the semester as a mass migration event. Students go back home, not only to different communities within the United States, but they are traveling internationally. And we're not sure what the travel requirements will be for international students. Their countries, their home countries, may develop travel requirements, and vaccination may be one of them. So if we can get our students vaccinated before the end of the spring term, right now, the way ACIP phased-in vaccination program is structured, college students would kind of be at the end of the line, unless they have a comorbidity or a pre-existing medical condition that pushes them further up as a high-risk individual. So we're trying to lobby for students to be vaccinated before the end of the spring term. And that advocacy at the local level will be critical because these decisions are being made at those local levels. Next slide. You need to start thinking right now about your institution's ability to serve as a distribution site for vaccination. This is a resource intensive activity. And certainly, colleges have experience with mass vaccination programs. Certainly, that experience comes with the meningitis outbreaks that we've experienced on college campuses where mass vaccination strategies were employed. But it takes a lot of resources to pull off a mass immunization strategy. And there are some particulars that come with mass immunization as it relates to the COVID vaccines because we need to think about social distancing, having people six feet apart, which typically we wouldn't have to worry about with other types of mass vaccination events. We need to worry about having the ability to react for an anaphylactic reaction, a severe allergic reaction, and rendering the appropriate care. You need to have your protective equipment, masks and gloves and gowns. And there's also paperwork that's involved because we will need to be informing the state of who has been vaccinated and then tracking who needs the second vaccination. So, there are certain specific criteria that would apply in a mass immunization event for COVID that will need to be taken into consideration. If after you assess your institution's ability to do so, a conversation with your local public health is important, right? ‘Hey, we believe we have the resources available to do this.’ And then they will expect you to fill out paperwork to apply to be a pod for a vaccination. We did—during H1N1, many campuses acted in this role as a pod for distribution. I know that at Carnegie Mellon, we vaccinated students, staff, faculty, and their family members during that event, and so it was a great help to our local public health in Allegheny County. But if your resources do not allow you to move forward with a mass immunization event on campus, it's important to have discussions with local public health and with a network of surrounding providers to see who can act as a referral source for vaccinating community members. The other option is to consider hiring a company to provide the on-campus experience vaccination. And then, of course, you need to continue to assess the effectiveness of your current mitigation strategies and adjust them accordingly. Next slide. These are a couple of resources available on the ACHA website. Our COVID resources are open to the general public so you don't have to be a member organization to access these resources. The first one is specific to mass vaccination guidance. The second document listed is a consideration for reopening in the spring and includes everything from how you—considerations for opening your health department, your mental health counseling services, and communication processes, and athletic considerations. So it's a broad umbrella in that document. So I will leave it there to kind of kick off the discussion and open it up for questions and answers. FASKIANOS: Terrific, thank you very much. That was really comprehensive. And I know we want to invite you all now to ask questions, to share what you're doing on your campuses. So if you want to click on the Participants icon at the bottom of your screen to raise your hand there. You can also click on—if you're on an e-tablet, on the More button in the upper right hand corner to raise your hand there. And we also have a Q&A box where you can type your question if you would prefer. And I see that our good colleague Mojubaolu Okome has her hand raised and if you could identify your institution to give us context, that would be terrific. And please remember to unmute yourself. Q: Thank you. My name is Mojubaolu Olufunke Okome and I teach political science at Brooklyn College, which is a commuter campus and an institution of modest means. So one of my concerns is that it does not seem as safe this—I mean, the presentation is wonderful, but it does not seem to be tailored to the needs of commuter campuses. And anyway, for the spring semester, we're still doing online education mostly. That's one thing. The other thing is if we have a—I know we have to focus on the U.S., but we have international students. And if there is no worldwide strategy on this vaccine, I mean vaccination, I fear that we're just going to be facing increased challenges because people are traveling back and forth. So I wonder the extent to which there's going to be a difference in strategy by the incoming administration on whether or not the U.S. should still do unilateral decision making and administration of whatever strategies there are, or multilateral. Then the other thing is, for poor institutions with commuter students, what kind of strategy is going to work, really? BARKIN: Okay, well, let's start with your first comment about commuter campuses and being online. So if students are online, there still is an opportunity to use social media platforms and your internet to educate your student population about the vaccines, vaccine safety, and strategies, public health strategies for keeping themselves as safe as possible. The other thing you might consider for a commuter campus is a drive-through clinic. So if you have large parking lots, students can sign up and drive through. Now, obviously, that's going to require you to develop some kind of a sign-up structure or engage public health and see if they can help you with the drive-through clinic. Because it is resource intense, and our public health departments are under a lot of strain. So how much assistance they're going to be able to provide institutions of higher education is really in question. And whether you can even secure the vaccine to conduct the mass immunization strategy, again, it involves a pretty significant conversation with your local public health. In regard to the challenges we face with international students, I'll give you one example of a challenge that came up with ACHA in the fall. The Chinese embassy had determined that they wanted to put testing requirements in for Chinese students who intended to return home for the winter recess. And the testing requirement was going to involve test results that were delivered within seventy-two hours of departure, which, in many locations around the country would have been extremely challenging. We heard from our partner institutions that have Chinese students who were struggling with this requirement. We did contact the Chinese embassy and we advocated for them to consider either forgoing or loosening up, changing that requirement to allow for more time. They really didn't change their strategy. But they did say that they were receiving a lot of concerns, not only from colleges and universities, but from Chinese students saying that they were having difficulty meeting the requirement or they were concerned they couldn't get the result in seventy-two hours. Now, fortunately, they did assure us that they would work with every student to help them through the process. But I think it certainly supports the point you're making. One issue is what if a student manages to get one shot of the vaccine here in the U.S.? What happens when they're due for the second shot and they're back home? Will they be able to access that same vaccine? These are questions that we certainly are thinking about, you obviously are thinking about, and it would require a national and international conversation. So I know that isn't an answer to your question, but I think that your concerns are well-placed. FASKIANOS: Thank you. Let's go next to Nicolle Taylor. Q: Hi, thank you so much for this opportunity, really appreciate your time. I serve as the chief business officer at Pepperdine University and work closely with Dr. Lucy Larson, who is our medical director. And I was wondering if you could just elaborate a little bit on the first responder description that you gave earlier as to where they fit in the phases. First responders, we have a public safety department on our campus. And so would all of those folks who are—I understand administration is probably separate than officers, but is there even a further differentiation to, EMT service versus dispatch or something like that? BARKIN: Yes. So, again, the decision ultimately rests with your local health authority. But the way we are interpreting the first responder is anyone on your campus who serves in a capacity that they would be first on the scene for a medical emergency or responding to a student injury, accident, illness. So we would include—if your security forces, your police department, are serving in that capacity and have that role, then we would include them in that phase 1A, according to our definition. However, again, I have to say that it largely will be dependent upon how your local health authorities interpret that. But you can certainly advocate for that. And I think the way you advocate is by giving them real examples of how your security staff, police department, EMTs function on your college campuses because public health, all public health folks, may not be aware of how medical services, emergency services are delivered on college campuses. So I see your role as an advocate and as an educator in that regard. Q: That really helps. I apologize, I appreciate that. Can I ask you a follow-up question with a different population? FASKIANOS: Sure, go ahead. Q: We have a very limited number of essential staff who are working on campus, whether that is in a facilities role or in something related like that. Would those folks fit into the phase two definition that you were describing when you talk about teachers and staff? And then I'll certainly yield the floor. Thank you. BARKIN: Yes, there is not—if you go to the ACIP guidance, they spell out kind of whom they include as essential personnel. I think that what we have heard from some public health sources is that there is a real interest and concern about getting our educational systems back up and running. And so to the extent that we can make, again, make a case for the importance of having specific staff, employees engaged in critical functions for the university, you certainly can advocate and make that case, even though you may receive one answer in California and someone in Georgia may receive another answer. It's certainly the advocacy and the explanation behind it is important. And so if you have those relationships established with your local public health, it's worth making sure that you continue to nurture them and stay in close contact with them. But I think there is an interest in that and it would fall under essential workers in the second phase. Q: Thank you. So Richard Arnold, who is a professor at Muskingum University in Ohio, wrote a question: "I live in Ohio was under the impression that college faculty did not fall under the teacher category. Does this vary by state or can you just clarify on that?” BARKIN: Again, it very well may vary by state. I can tell you here in Georgia, faculty have been told that they do fall under the teachers group. I can tell you that in West Virginia they have already started to vaccinate faculty. So it could very well be that Ohio makes a different decision. And that's part of the problem with the rollout. As I said, without a firm national strategy, you have lots of iterations on the theme. And the interpretation for this has been placed in the hands of the states. Now what I will say is this. And again, I'll use Georgia as an example, simply because I'm real familiar with the Georgia public health system. Governor Kemp made a decision to expand 1A to include sixty-five and older. So if you have faculty and staff who are sixty-five and older, you can certainly message to them, in Georgia, at least, 'Hey, this decision has been made by our governor and this is how you can get in line for an appointment for vaccination.' So I think the institution has to stay abreast of the decisions that are being made by the governor, by the state departments of public health, so that if there is an opportunity for folks to get vaccinated who, maybe it's not a faculty designation, per se, but it's some other designation, maybe anyone over the age of fifty-five with another health condition, you want to be putting that information out because the more folks that get vaccinated, the safer your community becomes. We know that. And so this does become an advocacy point. And I think it's more—it's been a struggle to get the vaccine out. And if you— there is information that I've looked at recently where they've actually ranked the states in terms of who's doing a better job of using the vaccine that has already been shipped to them. And there's great variation on that. So I would say that, yes, you need to be in communication with your Ohio officials and say, 'Hey, I've heard that, in other states, faculty are being included in that teaching category and beyond K-12. What's happening here?’ And that may be an advocacy point for you. FASKIANOS: Anita, is ACHA doing any kind of—do you have any plans to do a sort of a tracking project that would sort of collate what all the states are doing to be a resource for the colleges across the country and administrators? BARKIN: We have not developed any kind of toolkit that we are currently using for those decisions. When ACIP—and these decisions were just made recently. And the ACIP just firmed up that phase distribution process in December. And we were at the table and we were advocating for, as I said, anyone in college health and emergency medical services to be included. We also are looking at and making the case for schools, professional health schools, dental schools, medical schools, nursing schools, and saying to them, 'You know, if you vaccinate those individuals, they can help you with mass vaccination clinics.' And that was not spelled out in that phased distribution process. But now we're calling attention to it. And this is another advocacy point for folks on the call. If you have a dental school, if you have health professional schools, on your campuses, you can make that case to your public health authorities and say, 'Look if you help us get these folks vaccinated, they can provide—they will be a pool of human resource for you as you develop you mass vaccination clinics and as we get more vaccine in the pipeline to the public.' But lowering our resistance to vaccines will be critical. And there are populations that are more likely to resist vaccination than others. And we know that the African-American population holds a high degree of skepticism about these things based on historical events. And some—I saw a very good PSA done by Howard University that featured leadership, student leaders, diverse population, talking about why they're getting vaccinated, kind of in front of the camera, to try to build that confidence up in the community so that when that vaccine becomes available, people are ready and willing to accept it. FASKIANOS: Thank you. So I'm going to go next to Rey Koslowski, who has his hand raised and so if you can accept the unmute prompt. Thank you. Q: Hi, Rey Koslowski, I am a professor of political science at the University at Albany, part of the SUNY system. And we're actually going to have a—I guess, it's a drive-through mass vaccination beginning on our campus tomorrow. BARKIN: Great. Q: Yeah. And things have moved very quickly this week. And seeing messages from our United University Professions, our union, President Fred Kowal, saying basically, that when that definition of teacher was put out to say we want college professors as well. And what has happened is that the state put out its list and it's for professors or faculty who are teaching in-person classes. So that's the way it's working for us. Now, if you are teaching online, no, but for example, our campus, thirty percent of our classes will be in-person or hybrid this spring. But here is the thing that has happened—which, as I said, it went very quickly—but on Tuesday, the I guess it's phase 1A went to including people sixty-five and older with comorbidities. And there's a website where you can sign up, the New York State Department of Health, and friends of mine started trying to get in there. One got an appointment in March. And then, if you missed out and didn't get in, got booted out for whatever reason, you waited and another one got in April, and by Tuesday night, no more slots at our university, and they would get it at our university through the State Department of Health. I'm somewhat skeptical about your suggestion that we might be able to inoculate students because, as I understand it, as this 1A has redefined and opened up to sixty-five and older in so many states, we're up to about one hundred fifty million people who are eligible as this happens, and I don't think the production rate is getting anywhere near that to be able to handle that. My question for you is actually about, in a sense, triaging and thinking about those prioritizations. Could a negative antibody test be utilized in prioritizing? Because, again, the question's that somebody has been infected with the coronavirus, perhaps has been asymptomatic, do they have some immunity ready and perhaps shouldn't be prioritized? For example, again, with some students, if they have a negative antibody test, maybe that they haven't had COVID, for example? BARKIN: Right. Well, that's certainly an interesting thought. However, I can tell you that in discussions with—in presentations that I've heard from the FDA and the CDC, they've said that to do any kind of testing to determine who's qualified to get COVID, to get the vaccine, is not going to be practical or feasible. That it adds another layer of administration, resource, and expense. So while it's an interesting proposition, it's really not a feasible one. I share your concern about how much vaccine will be on the market by April, May, which we would commonly call the end of the spring term. But what we are saying is that the reason that college students should be prioritized is because that is a mass migration event. And that the advantage to vaccinating those students in terms of preventing infection and outbreaks in the communities to which they're returning and the countries they are returning to outweighs concerns about—or outweighs the idea that they're in the main healthy and their chances of sustaining serious consequences as a result of infection are not great. So we are making the argument that these people are highly mobile, they have the opportunity to spread disease, right? So it's a mass migration event. We should prioritize that. Now, whether we'll have enough vaccine on the market, who knows. Moderna has promised eighty million doses for 2021. Pfizer is far less than that. However, we are looking. AstraZeneca is pretty close to ending their clinical trial and may be considered for EUA as early as before the end of this month. I think that we need to get more vaccine in the pipeline, and it's going to take more than just Pfizer and Moderna to do that. So, yes, I hear your concerns. I wonder about the feasibility. But what we're saying is there's good reason to prioritize college students because of because of that migration. FASKIANOS: Thank you. I am going to go to Pearl Robinson next, who chatted her question. But, Pearl, do you just want to ask it? Pearl is at Tufts University. [Pause] Okay, I will read it, then. "As someone who personally benefits from the strategy outlined that seems to be promoting special treatment for privileged educational elite, who stands to lose from higher education's gain?" BARKIN: Okay, I'm not understanding the question. FASKIANOS: I guess it is, by putting the higher ed community first, there are going to be a lot of people in the community that are disadvantaged and are further back in the queue. BARKIN: Okay. Well, first of all— FASKIANOS: Pearl can jump in and clarify if she wants. BARKIN: Well, first of all, I don't know that we can call all members of the campus community privileged and elite. And I think that there is—but there is a good bit of concern about ensuring that there's equity in this distribution process. And so, I think that we're not asking for institutions of higher education to be placed above people, but that there be consideration for where you get the greatest mitigation effect from vaccinating different populations. We are—I would argue that it is going to be tough to penetrate underprivileged populations, populations of color, they—and that is part of the problem here is the, again, the messaging, the communication about safety, the outreach. There's a lot of work to be done to bring people to the table, especially communities where we know there is greater resistance historically to vaccinations, areas where folks are disadvantaged in a number of ways in terms of transportation and shelter. That is a big part of why they put essential workers in so early, because we know the folks who are essential workers, your grocery store employees, the folks who are serving us in fast food restaurants, there are a lot of minorities that are working in those capacities. Custodians, custodial staff. So, that was an attempt to ensure that we get people who are working in those types of situations covered. So it is a very difficult situation to maneuver. This is a complicated issue and nothing short of having a lot of vaccine and enough vaccine is going to remedy it. I can tell you even here—I am seeing a lot of frustration by people trying to—who now are qualified as sixty-five and older, trying to call in to get an appointment. Well, if I'm an economically disadvantaged sixty-five year old or older and I don't have transportation to a clinic that is an hour away, I may get the appointment, but I can't get there. Q: May I speak? BARKIN: Go ahead, I am sorry. Q: Oh, yes, I just had to unmute. I just wanted to—I thought it was important to raise this issue. So I teach at Tufts, and I am African American. Last spring, I heard that our university was trying to get this opportunity that you're talking about. And already, people were saying we're in a situation where this is a zero-sum game, limited amount of vaccines, the communities where the disease is in higher incidence, where you have a problem trying to persuade people to take it, quickly, the available vaccine is taken up. And so it's like the privileged people who know how to lobby and everything, they grab up what's available and then later on, somebody says, 'Well, that's too bad.' And then somebody else says, 'Black lives don't matter.' So I just wanted to put that on the table as we're thinking about this. BARKIN: Right, and if you– Q: And I will benefit from this policy. BARKIN: Well, I think if you—and you probably may very well be aware of this, but if you look at the CDC site under an ACIP site on how they made these determinations, the ethical considerations are outlined there. And many certainly speak to what you are pointing out. And it is a real, difficult, and complicated matter, especially when states are, at this point, not well enough resourced to address those issues. And we can say, 'Oh, yes, these populations should have access to vaccine and we should be able to educate them about the safety issues and certainly talk to them about public health strategies in addition to the vaccine.' But saying that and actually doing that are two different matters. It requires a lot of resources and our states have not been well resourced in that manner, nor has public health. I mean, public health in Georgia, we serve the folks who are those disadvantaged individuals that you are talking about. And for many of them, the transportation issues are overwhelming even to try to get to an appointment. How they access vaccines, how they can—whether it is online, some health departments have online forms. Well, you have to have a computer, you have to have adequate internet. And we haven't even addressed the issue of rural areas where internet capabilities are pretty compromised. So yes, I appreciate your comments and, as I said, the ethical considerations in that discussion is available online through the CDC. FASKIANOS: Thank you. I think we have time for one question. If you all are looking at the Q&A questions, there's some—Craig Klugman has put in there—people have shared what's going on in their communities. And Craig Klugman has cited an article, Inside Higher Ed, that talks about—I'm not going to click on it because I'll be taken out of this—but how faculty and staff outside healthcare fields become eligible for the vaccine, I believe. So I'm going to take the last question from Diana Newton, who is at Southern Methodist University in Dallas, Texas, who asks that you speak to the health risks to a campus community where the large majority are vaccinated, but a small minority refuse to receive the vaccine for a variety of reasons. And I wanted to tack on to that. I think in your presentation, you talked about asymptomatic. And what do we know really about if you get the vaccine and asymptomatic transmission? Because I think that there's not a lot of clarity around that. It may be there has not been enough—we do not know enough about it. So that would be great. BARKIN: We still do not know enough about that. I just was on a call with, as I said, with leadership in biologics at the FDA. And those three questions that I have in my PowerPoint were the three questions that they said keep them up at night. So they feel that the vaccine will handle the mutations, but they are not sure about the asymptomatic transmission. And when you talk about herd immunity, which is referencing the first part of this. What if we have students who get vaccinated and some who refuse to be vaccinated? What does it take to create a safe environment? I think that, without a doubt, we are going to be wearing masks and social distancing even after folks become vaccinated for some period of time until these questions are answered. What does it take on the herd immunity side? I've heard number percentages from sixty to eighty percent of the population, somewhere in that range, they feel that this rigorous surveillance, rigorous testing can stop. College campuses have set up these robust testing strategies which have been critical, I will tell you, in mitigating against outbreaks and identifying cases early on and containing those cases to a smaller number. And we are advocating for twice a week testing in terms of surveillance and certainly testing students upon arrival. But I think we are going to be in this cycle for a while until we get more experienced with a vaccine and the scientists can determine and our epidemiologists can determine how this is all playing out in terms of asymptomatic transmission and the effectiveness of the vaccine. How long we are protected. FASKIANOS: Well with that, Dr. Barkin, thank you very much for being with us and for your presentation. I have gotten a few questions about whether or not you would be willing for us to circulate it to the group because they would like to share it with their administrators on campus. So that's fantastic. And if there are any other resources you would like to share with me that we can disseminate to the group, we'd love to do that. BARKIN: Yeah. FASKIANOS: But it's really—thank you very much for this. This is obviously—it's changing quickly. BARKIN: [Laughs.] Yes, it is. FASKIANOS: And so we just keep on the news every day. And just as we discover more about this awful disease and how to deal with it. So we really appreciate it. And we hope that all of you will continue to follow us on @CFR_Academic on Twitter and go to CFR.org, ThinkGlobalHealth.org, and ForeignAffairs.com for resources on COVID-19 and much, much more on international affairs. So I hope you're all staying well, good luck with the beginning of your semester, beginning of 2021. And again, Dr. Barkin, thank you very much for being with us. BARKIN: Thank you. I enjoyed it and stay safe, everyone, out there. I'm happy to share the PowerPoint and any additional resources I think would be helpful. FASKIANOS: Thank you very much. (END)

Fatema Z. Sumar, vice president of global programs at Oxfam America, and Trevor Zimmer, co-leader of the COVID-19 Vaccine Equity Project, discuss equitable distribution of the COVID-19 vaccine around the world. Learn more about CFR's Religion and Foreign Policy Program. FASKIANOS:  Good afternoon and welcome to the Council on Foreign Relations Social Justice and Foreign Policy webinar series hosted by the Religion and Foreign Policy program. I'm Irina Faskianos, vice president for the National Program and Outreach at the Council on Foreign Relations. As a reminder, this webinar is on the record, and the audio, video, and transcript will be available on our website, cfr.org, and on our iTunes podcast channel, Religion and Foreign Policy. As always, CFR takes no institutional positions on matters of policy. So we're delighted to have with us today, Fatema Sumar and Trevor Zimmer.   Fatema Sumar is vice president of global programs at Oxfam America, where she oversees the regional development and humanitarian response. She comes to Oxfam with a distinguished career in the U.S. government leading efforts to advance sustainable development and economic policy in emerging markets and fragile countries. And she most recently served as regional deputy vice president for Europe, Asia Pacific, and Latin America at the U.S. Millennium Challenge Corporation, where she managed investments focused on international growth and poverty reduction. She also served as deputy assistant secretary for South and Central Asia at the State Department, and as a senior professional staff member on the U.S. Senate Foreign Relations Committee.   Trevor Zimmer is a co-leader of the COVID-19 Vaccine Equity Project, a joint initiative of the Sabine Vaccine Institute, Dalberg, and the GSI Research and Training Institute. He also leads Dalberg Designs's Health and Innovation practice. Mr. Zimmer's recent work includes supporting countries to coordinate their responses to COVID-19, launching a global professional association of immunization managers and helping to scale a maternal health system across Haiti. Prior to Dalberg, he worked with the Clinton Foundation on an HIV treatment optimization study, and on a program to increase access to essential medicines for children in India, Kenya, Nigeria, and Uganda. And he's also worked to mitigate the threat of Zika and Ebola with USAID and focused on reducing neonatal mortality in Nigeria. So thank you very much to you both for being with us to discuss this very important topic, and which is very much on everybody's mind about the COVID-19 and global equity to distribute the vaccine.   Fatema, can you please begin to talk about the relative wealth of a country how that might affect the COVID-19 vaccination distribution and what is happening?   SUMAR:  Sure, well, thanks, Irina. And first, let me just say I'm so delighted to be able to spend this time with all of you, thank you so much to the Council on Foreign Relations, Irina, special thanks to you and your team. And, Trevor, it's such a delight to share this virtual stage with you. So thank you all. And thank you all from all around the country for taking time to join us today. You know, we're kicking off a new year. And Irina, my first thought I wanted to share with everyone is we're all kind of here making history together. And what's really remarkable about this moment is that we have the power to decide how we want to really push an equitable distribution system as a vaccine, here in the United States and all around the world. And the choices we make literally today and tomorrow will really affect the future of our world, and the future of our economy, our health, our political, and our security all around the world. So we're here, we're in it together, we're in it together. And this conversation couldn't be more important. So thank you for taking the time to pull us all together. So the first question is we're here to talk about religion and foreign policy and really with the anchor around social justice. So why does equitable distribution matter? Why are we talking about this? And why does it have to be ground zero of every conversation we talk about? If there's one thing I've taken away, I'm sure all of you, over the past year with COVID-19 is that it doesn't discriminate. This vaccine does not discriminate in terms of we're all affected wherever you are around the world. But that being said, it's exposed different types of inequalities, and some of us face them more than others. They intersect in lots of different ways, whether it's economic, gender, racial, social, or geographic inequalities. We know about 2 million people or so have already died globally from COVID-19. And there's currently close to 100 million cases reported worldwide, according to Johns Hopkins. So we know that we can't keep on the train and tracks that we're on right now with our with our economies with our school systems. Our public health systems continue to be really destroyed and eradicated in so many different ways with devastating impacts, particularly in vulnerable populations on refugees, and women, on girls, and those facing conflict and famine. So the vaccine could be our way out of this global public health nightmare, but only if we do it right. So what I want to leave you with all today is that the way forward really needs to be framed in terms of a people's vaccine, a vaccine that's free, fair, and fully accessible. The way to think about this is around a global public good, right? And so you shouldn't only be able to afford it, if you can pay for it, whether it's your country, or your company.   There's four major challenges today when we think about widespread access and equitable distribution. The first is the price of the vaccine. The price of the vaccine is too expensive, and it's too out of reach for many people and governments all around the world. So unless you're one of the governments or you live in a country that's able to afford the price, or it has already bought up supplies, it may be completely financially out of reach for you. Second, vaccine nationalism. This has been led by the Trump administration. But a handful of rich countries, which represent around 14 percent of the global population have already cornered more than half of the global vaccine supply. This is going to have devastating consequences, particularly for around 67 countries, low- and middle-income countries that are at the risk of being left behind as the rich countries move forward. And really use up more than half the supply. Five of these countries. Kenya, Myanmar, Nigeria, Pakistan, and Ukraine already have nearly 1.5 million cases between them. These are massive populations, massive economies, if we leave behind two thirds of the world, if we leave behind nine out of ten people in poor countries, which is what we're on track to do, Irina, today. This has massive consequences for how we think about living in a global society, not just next year, but for years and decades to come. The third major challenge we're facing right now is that vaccine production is just way too low to meet global demand. We've made tremendous progress, incredible progress in 2020. But despite receiving massive amounts of U.S. taxpayer dollars around more than 12 billion dollars so far, and making record profits during the pandemic, private vaccine producers, exercise monopoly control over vaccine technology, which has artificially constrained the supply. So we really need public officials to take every step possible, including ending monopoly control of production and suspending intellectual property protections for the COVID vaccine, so that we can rapidly scale up production and drop prices, so that everyone everywhere has the right to be protected from COVID-19. And then the fourth major challenge is really about inadequate and unequal investment in public health infrastructure. I know Trevor is going to talk more about the challenges around distribution. But suffice to say, even the last few weeks here in the United States have raised bear the challenges of how difficult it is even here in the U.S. for distribution to actually take place in an efficient manner.   Think about what that means for poor countries all around the world, that are already under-invested in public health infrastructure, and the challenges it takes to reach people, particularly in rural markets. Women, of course, will face the brunt of the challenges and absorb the cost of these under investments in public infrastructure the most. I want to take a minute, Irina, to talk about women in particular, because too often we talk we make our problems gender neutral, and COVID-19 is not gender neutral as all of us have known and experienced this past year. Women before the pandemic and especially during the pandemic have really shouldered a disproportionate burden around unpaid care. And that is stepped up during COVID-19. I'm sure some of you see that in your household when it comes to education. When it comes to childcare. A McKinsey study found that employees at 317 companies, that one in four senior women, so senior women, are already considering downshifting their role in their careers to reduce work hours. The trickle-down effect throughout all parts of the economy are really severe. And this can stall and reverse improvements that we've made in the wage gap over the past decades. So these inequalities with the vaccine will only deepen these gender inequalities, particularly around distribution and access. Women in care roles in particular are going to have to give up their time and either paid or unpaid jobs, to either travel to get access to vaccinations, to be able to actually get distribution and access and majority of healthcare workers all around the world are women. So the delivery and their role is particularly acute and requires some study to really understand how we can really support women during this time.   So I want to talk a little bit about the way forward and what we can all do here today with this incredible group together. Oxfam has worked with many organizations, including Amnesty, Frontline Aid, Global Justice Now, and over one hundred former and current heads of state, economists, public health experts, and artists to launch what we are calling the People's Vaccine Alliance. It's on our webpage if you go to oxfamamerica.org. And our vision is really simple but profound. It's the vision to ensure that the approved COVID-19 vaccines are available for all people everywhere equitably. We've made a concerted effort, particularly for the People's Vaccine Alliance to reach out to a number of faith leaders as part of our push. And many have signed on to our public letter to President-Elect Biden, which you can also see from our webpage. There's three really simple components, and I'll end here with this around it. First, if we're going to have a free people's vaccine for all, it needs to be free of charge to the public in all countries. No one, not any of us should be denied the protection of our health and livelihoods because we can't afford the vaccine. The second is fair distribution, which I know Trevor is going to talk about. And that should be based on need and risk, not wealth and nationality. And those are very powerful ways we can think about shifting the paradigm of how we think about working to do free and equitable distribution. And the third piece is around openly licensed, free of monopolies, and propriety protection for the vaccine, because that prevents the rapid scale up of production that we need in order to meet the global demand. So those are the different components, we've been really blown away by the type of support that we've received here in the United States and all around the world. And people understanding that the solution and the way forward, even as we all rush and can't wait to get our vaccinations and our shots that were protected, that our lives, our societies, our borders will never open and reopen in the ways we want them to, unless we're all protected wherever we are, and whatever we can afford. So that's the work we're doing at Oxfam in partnership with so many others and delighted to be able to talk about with you. Thanks, Irina.   FASKIANOS:  Thank you, Fatema. That was terrific. Trevor, over to you about the logistics of vaccine distribution around the world, lessons learned from your experience in dealing with Zika and Ebola, and what barriers you see preventing equitable distribution and what we can do about it.   ZIMMER:  Thank you. I first want to reiterate Fatema's gratitude for being part of this forum. Most of my day is spent talking to doctors, ministries of health, epidemiologists, logisticians. And the moment to actually zoom out with religious leaders and social justice advocates, and talk about equity, which is at the core of my personal mission and values, is a real treat for me. So I can't wait to get to the Q&A and discussion portion of this conversation. I also think Fatema did a great job at providing an overview of major supply issues related to vaccines in the advocacy that Oxfam, The People's Vaccine Alliance is doing to address that. And so I don't want to give that short shrift, but I'm just going to be speaking about the distribution. So assuming that the vaccine is there, which is the big assumption, because that is what I'm working on and thinking through. But before getting to that, there's really, two mechanisms countries are really tapping into in order to access the vaccine. That's the kind of self-financing bilateral agreements with pharmaceutical companies themselves, that's both countries, as well as providers of private health.   And then there's also what's been called COVAX, which is a consortium of over 150 countries who have come together to have massive purchasing power to pull resources and go through equity distribution across the countries to figure out as they're doing these bulk purchases, and have that bulk purchasing power to negotiate with pharma themselves, to not to kind of address that vaccine nationalism and make sure there's some kind of fairness and equity of distribution across countries. But where I pick up is once we've got, let me also note that COVAX is very underfunded. We're grateful that the Biden administration is seemingly going to prioritize funding this and providing the funding gap that currently exists between what we need to fully inoculate 150 countries, especially the 92 countries that need to be subsidized for this vaccine that can't sell finance, to subsidize COVAX to provide those vaccines, there's still a big gap remaining. So that's why the advocacy work that Oxfam is doing is essential. But assuming the vaccines actually arrive in country, what are the challenges countries have to then make sure that it is getting out to the right target priority populations in an equitable way. Now, there's, I guess, a couple of different considerations that are front of mind for countries. First, is emergency use authorizations, for countries for vaccines that are kind of rushing through clinical trials, that have shown great efficacy, that they need to actually kind of address some of those issues. Once they've actually kind of prepared the regulation emergency use authorization based on what's coming out of the clinical trials and WHO emergency use authorization of lists and procedures, it's been really about costing in fundraising for the distribution within the country. And that is where there's a role, potentially, for interfaith organizations in fundraising as well as multi and bilateral donors such as the WHO, USCDC, World Bank, Asian Development Bank, and their various development banks, other donors like the Gates Foundation can pitch it. After that, it's really about countries need to target and prioritize population. We know these vaccines are going to be coming out in different tranches. So it's not like we're going to get enough to create herd immunity from day one. With the estimates, countries that are committed to receiving vaccine through COVAX will be able to inoculate up to twenty percent of their populations by the end of 2021 calendar year.   But who are those folks that should actually receive those vaccines? First, COVAX, and a WHO organization called Sage has provided guidance, and those are guidance put forward by bioethicists. But there's only so much that global standard setting bodies can actually encourage countries to adopt that guidance. Countries are, and we have to make sure there's not political chicanery going to prioritize populations based on favoritism, I want to be clear, this is not just an issue in low-income countries, we see that in the U.S., in other countries, and similar levels have huge challenges around this too. But what we're realizing is countries really do want to prioritize and target vulnerable populations. I'm defining vulnerable populations in two ways. One, there's really those health impacts, folks that are at risk of mortality with COVID, those are elderly, those are people with comorbidities, such as type one diabetes, those are also people with outsized impacts on households' well-being, those are essential health, essential workers. And we need to consider essential workers as also women heads of households. We need to actually think about as we think about who are the central workers are and really be honest about how we define that. So a lot of my work is helping identify and target those priority populations. Because right now, there's not a lot of clarity. They might have a register at a country level, who has type one diabetes, but that's not broken down to the sub-national or even household level. Once those priority populations have been identified, it's been a matter of making sure that vaccines get to those populations. So in those health catchment areas, making sure they have, if they're getting a Pfizer vaccine ultra cold chain requirements, which is a huge infrastructure logistical challenge. And if it's say that Astra Zeneca, which is more normal refrigeration, make sure they have the capability capacity for that, if they capability capacity to track those vaccines. And then they start canvassing the population to identify those target populations, convince them to come in for the vaccine, mobilize interfaith leaders and influencers with the community to make sure that people accept the vaccine. And once they accept the vaccine, they go in and get it at the right place at the right time. And then they also get their second dose.   Related to that is really training the health workforce. So both vaccinators themselves, logisticians, as well as community healthcare workers that aren't vaccinators themselves, but really those people at the frontline in the communities that really can get ahead of misinformation around vaccines. Vaccine safety moderating and managing adverse events is something that you also need to create and establish mechanisms for and then of course, there's monitoring, ongoing surveillance of COVID-19 outbreaks as well as going to vaccine introductions. So the wrap around with all of that, the good news, is the world is experienced with vaccine production. We've done it before. And we have a lot of lessons learned. However, some things make COVID-19 unique. One is really the urgency of it. This needs to be done as urgently as possible. And across the population. Another challenge is, it's a different population that is typically getting vaccinated within programs. And so this includes elderly, this includes folks with comorbidities, most vaccination programs in most countries target those under five years old. Some other challenges include the ultra cold chain requirements I alluded to, as well as living in a world awash with misinformation, and relative distrust of the institutions that we really rely on for collective action. I'm hopeful we can address this, not have this crisis go to waste. And I do have to say a lot of low-income countries, in some ways are better equipped than countries where I'm from, like the United States, because they've had experience with outbreaks such as HIV, where they've really strengthen the primary healthcare system in Ebola vaccine rollout in the last few years there also require ultra cold chain. So we also have lessons learned from these environments as well.   FASKIANOS:  Thank you very much, Trevor, I appreciate that. We're going to turn now to all of you for your questions. There are already a few questions, people have written out their questions, I also encourage you to raise your hand, if you click on the look at the bottom of your screen, you can raise your hand there, if you're on an A tablet, on the upper right hand corner in the "more" button, you can raise your hand in that way. And we also raise hands. So I'm going to first go to, because this picks up on your last point, one of your last points, Trevor, from Elaine Howard Ecklund at Rice University. How can religious leaders and others work together to address the suspicion of COVID-19 vaccines, which we're seeing here in the U.S., and you can tell us how much of what's being what's happening around the world too.   ZIMMER:  Thanks, I really appreciate that.  I think many people on this call actually know how to inspire and motivate people more than I do. So I would say you have the tools to do that. But, some of the sources to actually surface that information is first of all, sharing, listening to people's concerns in addressing it, and just creating a forum for people to discuss and share information. One of the partners of the Vaccine Equity Consortium, the project is working with is called the Meedan Digital Health Lab that actually provides real time information to address misinformation. And so there are resources out there, that while acknowledging the misinformation being fed out there, really can provide better information. But it's really hard work. I would say, one thing as influencers within communities, it's very important that you can keep a consistent message, you acknowledge people's misinformation, and don't give legitimate people's source of frustration and mistrust. This is a time that a lot of people feel alone. This is a time and a lot of the institutions that we rely on for collective response, is it as ever, but I would say, encourage, provide people great information, say you'll get vaccinated yourself, have people share around testimonials, if they've gotten vaccinated and why it's important to them. You maybe encourage vaccination drives within the community. Reinforce that message is going to be as important as possible. Because it is something that really concerns me, and there's no one-size-fits-all, different communications, and different mistrust. I know in the U.S., communities of color, especially, African-Americans have a lot of distrust for pharmaceutical testing on those communities in the past. So they're very well-founded. And that's a little bit different than perhaps misinformation around Big Pharma seeing this as an opportunity to create a dependency in money. So I would say start with listing and then pointing to the right resources, and then showing as a proof point, that you've gotten vaccinated and then encourage people to share those testimonials and do the same.   FASKIANOS:  Thank you. Let's go next to Seemi Ahmed, who has raised her hand and if you could tell us who you are.   AHMED:  Hi, this Seemi Ahmed. Thank you so much, Fatema and Trevor, for all the information you provided. I just had a thought which I wanted to share with you. You were talking about the, we were addressing the equity as far as vaccination is concerned, and so, I felt that at a time, when there's a pandemic, it's, I think, rather than expect the rich countries to be altruistic and all that, I think the poorer countries also should try and do something themselves. I have heard India has come up with a vaccine on their own. They're also using Astra Zeneca from the UK, but they've also come up with a vaccine of their own. So I thought it might be helpful to encourage the poor countries to also work hard to come up with something rather than be dependent on others during such a time, thank you.   ZIMMER:  Thank you, Seemi, I think that is being discussed as a medium-term solution, to create manufacturing, research, and development capacity. I know India this year is a great example of that. I know, there is support to create manufacturing facility in South Africa as well, and this is something that Africa, CDC is a high priority of theirs. And so it's been addressed. One thing that has been revealed in this is the importance of that very much. And one way poor countries are accessing the vaccines is volunteering, raising their hand for clinical trials. But the problem is a lot of misinformation in that for the kind of aforementioned reasons, a lot of times, less, I guess, countries with less, financial resources to buy vaccines have raised their hand for pharmaceutical trials, it's been seen almost as like a dumping ground and not as much quality control. So there's a lot of misinformation there. So I think in the medium-term, definitely countries have the capacity and capability to manufacture themselves. And I know this is a high priority agenda. And we'll be starting to see some movement in the space in the next six months, building off for example, this institute in India, within the sub-Saharan Africa as well.   FASKIANOS:  Just curious, what is the price of the vaccine? The cost?   ZIMMER:  Yeah, I mean, it depends. It's a great question. It depends on the vaccine, if it's Pfizer, if it's AstraZeneca, and it depends on who's purchasing it. So is it COVAX? Is it the U.S.? Is it Canada? Is it Ecuador? And so, you know, across the different candidates, anywhere from about five to twenty dollars.   SUMAR:  Could I just add to Trevor's point, to Seemi's question around as we think about expanding to 2021 and beyond, one of the things so that we want to really keep pushing, particularly leadership from the United States and others, is that in order to empower other countries, to be able to either expand manufacturing, in their own capacity, or countries or regions, the technology and the know-how of how to make the vaccine should be shared with the world. There's no reason that we need to recreate the wheel every single time and that every company, countries don't have time and capacity. And there's no need for that. So the patents need to be licensed, the data published, technical assistance provided to teach appropriate vaccine production, so that qualified manufacturers, wherever they are, whether they're in India and South Africa, they can really help us quickly expand world supply and prevent artificial scarcity, which is otherwise the world we're headed towards, right, we're artificially keeping supply low, even though the technology and the know-how actually exists. And so as we think about whether an equitable means in this context, it's beyond altruism in the way I would think about it in order to really making sure that we're setting a stage where if you don't share the technology, it'll be hard to do that on a timeframe that actually leads to the kind of progress we all want to see.   FASKIANOS:  Fatema, is the will there to do that? I mean, is there movement to loosen that kind of control in the intellectual property?   ZIMMER:  I think leadership is what's really needed here, and putting political leadership from the United States and others, I'm hopeful we'll start seeing that type of leadership. And it's going to take a concerted effort with the manufacturers, with pharmaceutical companies, and with governments to really set the scene for what the expectations are. And frankly, it's going to take voices from people on this very call from the faith-based community, from social justice communities to demand this, and to say that this is what we expect, this is what we expect. And anything short of that, it's not just enough for you and I to go get vaccinated in the next few months, it's not going to solve the problem until we get the world vaccinated. And so that demand signal from civil society, from our religious communities, our social justice communities is more important than ever as well.   FASKIANOS:  Thank you. Let's go next to Shaun Casey, who typed his question and raised his hand. So Shaun, unmute yourself and ask it yourself.   CASEY:  Thanks so much, Irina. And thank you, Fatema and Trevor, this is just a hugely important issue. I have two quick questions. One is I haven't been able to see if the existing faith-based and religiously affiliated global healthcare delivery networks, for even part of the WHO discussions. I think the analogy here would be to the distribution of ARV drugs in the HIV pandemic, where, in many parts of the world, the existing indigenous healthcare provision network is religiously affiliated, they have to be brought into the delivery conversations, and I don't see that going on. And maybe it's just because my perspective is too narrow. But secondly, I want to push you a little bit beyond just advocacy when talking about religious communities, particularly here in the U.S. Again, in terms of underserved neighborhoods, and addressing communities where anti-vaccine sentiments are very deep, many times the only ecosystem or providing social services is yet again, churches, synagogues, mosques, and NGOs that are religiously affiliated. I'm watching all over the country, and it seems that none of those communities, none of those religious communities are actually being integrated to the state distribution plans, which I think is a huge mistake, that state governments who seem to be handling the vaccination distribution, are not connecting with clergy. They're not trying to systematically knock down the misinformation. And I think there's a lot of confusion in underserved populations and in some of the more conservative anti-vaccine parts of the country. And it's really only going to be religious leaders collaborating with the state governments that are going to knock down those problems. Do you see any coordinated efforts at the state level to reach out to religious communities beyond advocacy, but actually for service delivery?   SUMAR:  Maybe I'll take the first part of Shaun's question. And Shaun, great, it's nice to see you and hear from you. One of the things when you talk about the World Health Organization, I think there's a real opportunity when President-Elect Biden is saying that one of the day one priorities for the United States is to rejoin the World Health Organization, I think that type of U.S. leadership in the WHO, in particular, to make sure that we are partnering, we are bringing in religious communities, faith-based communities on day one, the new Biden administration is going to be really key and important. And it's going to be beyond just hearing from voices of different members, it's going to be integration of both distribution plans, but also the additional in my mind, the additional support financially, and otherwise, they're going to need to actually do the public disinformation or the public information campaigns as well. So it won't be enough to just do distribution in terms of, getting the technical, the hardware, so to speak of the shots and the cold storage, it's also going to have to be the software around public information campaigns that are really tailored to distinct, to specific communities, and really speak, as Trevor was saying, where they're starting from and where they're coming from. And I don't want to speak too much in the U.S. context, but I'll say in the global context, where Oxfam works in dozens of countries, we saw that also in West Africa, we saw that in many places around pandemics in the past where it took both the hardware and the software, and resources for that or, you're right, Shaun. It's not just the advocacy, but it's also the resources and this has to be a priority for how we think about partnership, particularly at local levels for local distribution to succeed. So those are areas that I hope we see some political leadership that hasn't been there to date but I hope we can start seeing that in really loud force in seven days, in a week.   ZIMMER: Yeah, great, and just to add on to Fatema, my experience, my work right now is not in the U.S. So I can't speak about service provision at the state and federal level and not necessarily collaborating on the service provision with faith leaders. However, in the international context, it just made me think that this is absolutely an opportunity that's not being utilized in most of the countries I'm observing and working in. I'm just going to be honest with you, people are tired. People in ministries of health and working in kind of global health and vaccine distribution and COVID response are tired. What are they tired from? Well they're tired from this outbreak, of first testing, and diagnostics, and surveillance, and then maintaining a certain level of primary health care amongst this. Routine immunization programs. People are, women are still having children and delivering kids, people are still getting in car accidents, all of these other things, the world's not stopping. And so when we're getting to vaccines, I can tell you the focus right now is on just securing those initial tranches of vaccines and getting them out the door. And so this, there is really an opportunity, I think, for faith leaders, to not just be involved, but take a leadership position, and don't expect that it's going to happen on its own. I think folks are going to be receptive. I know, both at kind of global standard setting bodies, and partners like the WHO and the multi- and bilaterals and the regional and country offices, as well as the ministries of health themselves. There was an acknowledgement that communities need to be mobilized not just in vaccine acceptance, but in service provision. Some countries have more capacity and focus on doing that than others a lot. They just don't really have the capacity energy right now to do that, and do need help. So that's kind of a long-winded way of saying that, I think you're really hitting on something, Shaun, that is a big opportunity to pace right now, in the resource constraints is not elevating as much as a priority as it should be. And I think it's a real opportunity for the faith community to take some leadership.   FASKIANOS:  Thank you. I'm going to go next to Jessica Therkelsen, if you could ask your question.   THERKELSEN:  Hi, and thank you for inviting me to this forum. And thank you for taking my question. So we have about 80 million forcibly-displaced people worldwide, 45 million internal, 26 million refugees. There are a lot of forced migrants right now. Internally Displaced Persons will likely represent a population within a country that is less favored, and may have less access to the vaccine. And we are definitely seeing that refugees are not being able to access the vaccine at the moment. And I was wondering if you have thoughts on how we can work together to ensure that we include vulnerable migrants in the vaccination pools since we are all in this together, as you mentioned, and whether you have thoughts on whether it is more effective to include migrant populations in existing systems or for us to work together to run specialized campaigns.   FASKIANOS  And Jessica's with HIAS   THERKELSEN:  I'm with HIAS, thank you.   FASKIANOS:  Who wants to take that first?   SUMAR:  Should I take that first, Trevor? Okay, so hi, thank you, Jessica. We have the largest number of people on the move in human history right now, right, because of conflict, because of climate, because of forced migration. And then because of economic migration issues. And so we are we are seeing that we were not meeting these needs before COVID-19. We were struggling to meet most humanitarian needs before COVID-19. And now we are adding the burdens of COVID-19 on an already stretched system worldwide. One way that I think we're going to have to start thinking differently about 2021 and the way forward, is really prioritizing protections for those most in need, those most at risk, and those most vulnerable. And those conversations need to really happen in a deep way within each country and globally. So that it's not just first come first serve or whoever can afford access and where we can afford to get it the quickest. Those conversations done through a social justice lens really then forces us to think about well, who really needs it the most? And how do we then plan distribution and access to those communities in ways that are successful? So obviously, here in the United States, we've started with prioritizing frontline healthcare and social care workers, essential workers, moving on quickly to old, our older populations, to people with pre-existing conditions who are at higher risks. And then we're looking at higher transmission communities here in the United States before we get to a general population. And there's something here where we have we have accepted that kind of in our social construct that not everyone's going to get it first, we are going to prioritize.   Similarly, we need to be thinking for global distribution around communities most at risk communities, most vulnerable, whether those are migrant communities, whether those are refugees, IDPs, what is going to be the distribution system in both formal camps like we have in Jordan and other places, but in the informal settlements as well, where it's been a challenge and a struggle. Here, I think we have tons to learn from previous vaccination efforts that have taken place. And, thinking even in hard places, in Pakistan and elsewhere, in reaching very hard areas around polio vaccination and strategies that we've employed to be able to do that. The good news is I actually think we have strategies, and we have research and evidence of what works, we've actually seen this not with COVID-19, but we've seen this in other contexts, whether that's with Ebola, whether that's with Polio, whether that's with other things that we've worked on. It's now time to take all of that and making sure we are both doing the analysis and then bringing those learnings and applying them to these populations. But just, I think it starts also with political will, that these communities are worth protecting, and that we're going to prioritize, and we're going to make sure that we then figure out the access and distribution plans. And so that really, the social justice piece of that starts first and foremost, to make those decisions. Because once you make those decisions, then we know actually how to do this, we do know how to do this. And I do want to leave you all with some hope. We know how to do this in the international community, I firmly believe that we have decades of experience in this space. But we do need to make sure we're all on the same page in terms of how we do it. And once we are then then it becomes, then it's just a question of logistics in some ways to make, and resourcing to get it done.   ZIMMER: Just to dovetail just on that last point, not specific to the question because I feel like Fatema did a brilliant job, in terms of we know how to do this, what makes this different is the urgency and speed of it. But that can't come, we can't cut corners around equity. And that is the big thing that I have my “spidey sense” out for. Oftentimes, we said we know how to do it, but we need to make little sacrifices, to make things as urgent as possible, coming at the expense of equity of not just outcomes, but also partnerships and process and true collaboration. And we know that often leads to big unintended consequences. So I don't think haste and speed has to come at crosshairs with equity. But not everyone agrees with that. So I just think holding decision makers, policymakers accountable to that, and ensuring that all the best practices around equity that's being learned is not being put by the wayside, to cut corners, is something that's paramount and also a role for, you know, faith-based organizations, and folks that are focused on ethics and justice.   FASKIANOS:  Thank you. And Adem Carroll raises a great point about picking up on the displaced people that were discussed, adding to that prisoners. While international access to incarcerated populations may be limited, it may be that faith communities need to work to include these among the most vulnerable. So I think that is a terrific point, especially as we see here in this country, how COVID is on the rampage in our prison system. I'm going to go to Darius Makuja, who asked what is the impact globally of those who cast COVID-19 as a hoax, especially in third world countries. Fatema you did mention though, that other countries know how to do this better than we do, so maybe this isn't an issue. But if you could pick up on that, that would be great.   SUMAR:  Sure, Trevor, go ahead, first, go ahead.   ZIMMER:  Sure. You know, the incarceration question, I think it's a great one. And you know, it really depends who's making the decision. If bioethicists and epidemiologists have full decision making power, I can tell you incarcerated populations will be probably prioritized. If policymakers and politicians accountable to populations, are making big decisions, they may be de-emphasized, but we know the importance of holding their feet to the fire and making sure that they're led by justice as well as epidemiology and bioethics, and that those folks have a seat at the table. So when I would assess how decisions are being made at the state level, seeing within the leadership who's making the decisions, that's going to be a pretty good indication of who gets prioritized first. And if it ends up being politicians accountable, election cycles, and swaying public opinion, that's a role for advocacy and persuasion. Over to you, Fatema.   SUMAR: Thanks. Thanks, Trevor. So I think to the, I'm just going to go back to the question here from Darius. So Trevor said this a little earlier. so let me build on this point around, we have to start where people are at in local communities, I think that's really important. And if we're working in certain contexts in different countries where there's deep suspicion of the virus first, perhaps, before we even get to the vaccine, we need to work on solutions that really help educate and inform. And really going back to science, and using science as a way to communicate out with what we know, with the best information possible. The impact, Darius to your question, if enough political leaders and countries treat both either the virus as a hoax or the vaccine as a hoax, it will be devastating. Because the reality with a pandemic like this is there is no safety and security for any of us whether we get vaccinated or not, if enough of us and all of us don't get vaccinated, and have that kind of herd immunity that we need. And that's the way our economy is set up, our global economy, our borders, our cultures, our people, we live in a global society. So this is happening here in the United States, you don't have to go very far to see, with pockets of that here in the United States, as well. So I think there's a real challenge we're facing in our society, broader Irina, than this conversation around the role of information, the role of science and making those types of policy choices, that's been under attack, frankly, over the last few years. There's a rise of authoritarianism all around the world. And in the West, as well, that's impacting the way we have these public policy discourses. So just say I don't want to underestimate the real, the context of the world we're living in today. And how challenging it's become to then respond using science using best practice using evidence. That's all doable, but the political and social environment in which we coexist right now makes it really challenging. And in some ways, because we're in a race against time, and there's such a speed and urgency to do this, we have to deconstruct quickly some of those contexts that we live in. And it it's going to be deep. And it's going to take a lot of dialogue and healing, I think, in certain contexts to be able to do that.   FASKIANOS:  Yes, and I will just note that a week ago today was an insurrection on our U.S. Capitol. So we have a lot of work to do here at home. Let's go next to Mohammed Elsanousi, who has his hand raised, thank you.   ELSANOUSI:  Yes, Irina thank you so much, Irina, thank you for putting this together. I am Mohammed Elsanousi, I'm the executive director for the Network for Religious and Traditional Peacemakers. And I'm delighted to see that both of you, Fatema and Trevor, you lifted up the critical role of religious actors and leaders. And I just want to build on what Shaun Casey has said earlier, and the critical role of religious leaders in terms of the distribution strategy, in terms of their moral influence. So what I'm saying here, I want their role to be part of the strategy of distribution, because they could issue theologically motivated opinion that will reflect positively in people taking the vaccine. And we have experience from this. I remember you Fatema mentioned polio, and particularly mentioned Pakistan and that border of Pakistan or Afghanistan, and Nigeria. We have three countries in the world, Nigeria, Pakistan, and Afghanistan that are still struggling with the polio situation. And I remember clearly, we worked with Bill Gates on this. Actually, he met with us, with scholars, to appeal to Muslim scholars to gather and issue opinion to encourage people to take vaccine. And we did that meeting in Senegal, hosted by President Mackey Sall. And we brought physicians, they talked about the ingredients of the vaccine to convince the scholars, then the scholars made the opinion. And the photo was distributed in Nigeria and Pakistan, Afghanistan, and, and considerably help in the reduction of polio because it encourages people. So the point I want to make, let's learn from this experience, let's get religious and theological leaders, and rulers, and imams, and these people as a part of this distribution process to basically uplift their voice, they should not be after thought, like what we have done with polio, but let's integrate them into the strategy so that we can have an effective distribution and have people to accept it, and basically address all of this,  conspiracy theories that are going, and the hoax that you talked about. Thank you.   FASKIANOS:  Thank you. I'm going to go to Katherine Marshall. Katherine, do you want just ask your question? I know you've typed it as well.   MARSHALL:  I think you've made very strong cases for the ethical, but also the political needs for equitable vaccine distribution at the global and the national level in a very moving way. But then the question is what comes next? So I'm interested in where you see the potential for leadership coming? What institutions? Are you looking to the WHO? To the G20? The UN? How is this, who would you put the onus on? And then secondly, there are a lot of people thinking about this religious issue on the vaccine, particularly on the misinformation issues. But the religious communities of the world are immensely complex. And I'm interested in any views you have on how this strategic religious engagement, where do you see pressure points, or potential avenues, beyond just saying the faith community, which frankly, doesn't really mean very much, because it's so big.   ZIMMER:   I'll just jump in here, I'll talk and then pass it over to you.  I would say in kind of well-resourced countries, to put pressure on a federal level to contribute to COVAX. That's a very concrete way, because that is how most countries will, low-income countries will access vaccines, that's one immediate intervention point, I would say. Following up on that, so there's a need for more money and resources to be addressed to that. I think, within countries, be it the U.S. at the state level, or countries in West Africa, then making sure that political leaders are held accountable for equal distribution and access, that's a bit in the advocacy that we're talking about. And then in terms of actually parishioners, people of faith, I would say, really kind of above line and below line marketing, right, it's the example of that Senegal convenia putting out that faith within the vaccines, in the above line way in that's widely distributed. And then more of the below line, within the actual churches, mosques, place of worship itself to convince to support that above line message, to reinforce that message is going to be very, very important itself. And then also we know, in a lot of countries I've spent a lot of time, the last year, within, for example, Tanzania, in Ghana, for example, you know, faith-based providers are some of the biggest providers in the country. So there's a role even right there within supporting those institutions directly as well. Over to you Fatema, if you have any thoughts as well.   SUMAR:  Sure, Katherine, thank you for the question. And I'm going to also just really appreciate Mohammed's comments earlier to which really resonated with me and I think there's so much for us to learn from. Katherine, I would first start with the United States. So when you say who and what comes next. I mean, for me personally, I mean, look at what happens when you don't have U.S. global leadership, look at what happens here in the in our own country and around the world and the position we're in today. I mean, if we, if any of us question why the United States is important for global and national leadership and what it looks like when we don't have it, that for me was at least my 2020. And so the first and foremost is really looking at the role of the incoming U.S. president. President-Elect Biden will have tremendous, tremendous power to help decide who gets access to the protection from this virus when, and at what cost. So with that, really tremendous power comes a historic opportunity for the United States to lead again, by leveraging both the strength and know how, and the generosity of the American people and spirit to combat this disease here in the United States, and all around the world. Now, we can't do it alone, we never could, and we won't be able to do it again. So it's going to really require very sophisticated public health and vaccine diplomacy within the international community. So that means rejoining the World Health Alliance and World Health Organization, the WHO on day one. It means really empowering WHO, the United Nations, the G7, the G20, to prioritize this, and to making sure we actually have a really effective plan going forward in terms of one of the top priorities of our entire global architecture.   One of the things I'm struck by in President- Elect Biden's messaging so far is that the COVID-19 vaccine, it doesn't matter where you sit in his government, you could be sitting in DOD, you can be sitting in the State Department, you could be sitting in DOJ, you could be sitting in HUD, you're going to be working on COVID-19. And that really for him reflects his vision that this is something that affects anything we do, because we can't do any of our jobs, we can't do anything if we don't have that kind of security, if we don't have health security, so that's the first set a very global level in terms of really bringing us global leadership back and reigniting the global architecture around this enormous public health challenge. The second, to get more granular from that level, is really thinking through well as those decisions are made around who, when, and how much. And those are three critical decision points that have to be made at a global level, making sure that civil society, the faith-based community, social justice leaders have influence around making those decisions, which means you need a seat at the table, you need to have a voice so that it's not just an afterthought at the end when it comes to local distribution. But really making sure that at the very top levels, that those inputs are crafted at the very top in terms of making those decisions and determinations. Then, as those decisions are made, and you think about, okay, we now have a plan, the plan looks like this, whatever the plan is, then there's a role at national and local levels to thinking about whether it's distribution, whether it's socialization, whether it's the marketing, whether it's manufacturing, there's so many different roles and elements that different groups can play, and we'll need to play to do that.   But it starts with a plan. It starts at the top. And I think again, the good news, there's a silver linings as that's now is this moment to have these conversations. And that's why Irina, I think this conversation today, the timeliness of it is so important. And then Katherine, just at a local level, as you think about, you're right, it's so complex to say "religious communities," or "faith-based communities," it means so many different things depending on where we are, we need a much more localized approach. So Shaun was asking, for instance, at the state level, are governors reaching out and making sure that they're on their COVID-19 task forces at the very start? Our provincial leaders, our mayors. I mean, I'm thinking about countries like the Philippines, for instance, where mayors are so incredibly powerful in making sure that they can work with their community leaders and making and making sure they have these types of community distribution plans. So I think there are many opportunities. It starts at the top, I think, in terms of having global leadership and a global plan. And the time is now I think, to help influence, not just lobby and advocate, but to really make sure that you have a seat at the table, your voices are heard, and you're informing your points of view for the way forward, because I don't think it's going to work globally, otherwise, if it's an afterthought.   FASKIANOS:  That is a great place. There have been a number of rich comments in the Q&A, Shaik Ubaid talked about how important it is for religious leaders to be proactive in defending modern medicine, and teaching people to trust scientists and doctors, so that we can even talk about vaccine equity. And I don't want to leave without just touching upon Cecelia Lynch's question about the effect on the indigenous population and are you working with the indigenous traditional religion leaders, and if so at what capacity? Because we know this population has been severely affected by this disease as well. So if you could answer that, and we'll wrap up. Sorry to go over, but I didn't want to leave without talking about that.   ZIMMER:  Fatema, would you like to say something? Okay. So, again, I'm not working in the U.S., but I am working in the Andes region in Latin America, and there are big distribution challenges, both based on historical inequities and geography, that we are working closely with indigenous leaders in communities and really influencers there to address that. So the short answer is yes. In the U.S., again, I don't have purview over that, but it's absolutely essential. And I'm concerned that historic inequities up to this day, we're not going to get there as quickly as we need to.   FASKIANOS:  Fatema, I'll give you the last.   SUMAR:   Oxfam works in so many countries around the world, and I know it's a concerted effort to really reach out to the most vulnerable and different groups, including indigenous groups. And so I know that's always a really important type of partnership. Maybe I'll just summarize by saying if you go to our website, oxfamamerica.org, there's a lot of information and we'll definitely share the links with all of you, I've lots to share in terms of resources with all of you about our People’s Vaccine, open letter, our alliance, and if you're interested in joining, or helping spread the word.   I guess I just wanted to end with maybe on a more personal note Irina, if that's okay. We're all doing this in terms of our communities and the organizations we represent. But we're all doing this in solidarity as people, as individuals. And one of the ways I think faith-based communities in particular can really help change quickly, some of the conversations we're having is through our youth. And we didn't talk about youth today in particular, but I mean, I learn so much from my kids actually learn it from their Sunday schools, that they're going to, or they're learning it from activities or their public schools. And so also not underestimating the role of our youth. Our youth are online, every second, at least my kids are, every second of every day now, they're learning. They will never forget COVID-19. They can be part of the solution too, in terms of helping really shape our thinking of how we can, how different faith communities can really think about you talking about science, talking about modern medicine, talking about the vaccine in ways that resonate with the ethos of our respective faiths, and the ethics of where we stand on social justice. And our children, our children have such an incredible role, I think they can play with us as well. So anyway, I just wanted to end by a huge personal gratitude from me to all of you. The work you're doing, your voices, your leadership, there's never been a more important moment to live the ethos of our collected faiths, and to fight this fight. So thank you all for your tremendous leadership, and just gratitude to be with all of you today.   ZIMMER:  Thank you, and gratitude as well.   FASKIANOS:  Thank you, Fatema Sumar and Trevor Zimmer, we really appreciate it. And as you mentioned, we will send out links to everybody on the webinar, to the resources mentioned and other things that we pulled together. We encourage you to stay updated on Fatema's work on Twitter, @FatemaDC, and Trevor's work @DalbergTweet. We also encourage you to follow CFR's Religion and Foreign Policy Program on Twitter @CFR_religion for information about the latest CFR resources, and reach out to us at [email protected] with any suggestions on future webinars or speakers, topics, etc. Thank you all again. We look forward to continuing the conversation. Stay well, stay safe. And we will reconvene. Thank you.