Year Three: The Pandemic Continues

As we enter year three of the COVID-19 pandemic, three leading global health experts examine how the United States and the world have dealt with the evolving situation, the lessons learned, and the way forward.

BARRY: Welcome, everyone, to today’s Council on Foreign Relations, “Year Three: The Pandemic Continues.” I’m Michele Barry, the Shenson-endowed professor of medicine and tropical diseases, senior associate dean for global health, and the director of the Center for Innovation and Global Health at Stanford University.

It is my pleasure to be presiding today over today’s discussion with three of the most impressive thought leaders in the areas of public and global health.

Dr. Rebecca Katz is professor and director of the Center for Global Health Science and Security at Georgetown University. She’s also a member of the Council on Foreign Relations Independent Task Force on Preparing for the Next Pandemic and a CFR member.

Dr. Michael Osterholm works at the University of Minnesota where he is the regents professor in the division of environmental health science, director at the Center for Infectious Disease Research and Policy, professor at the Technological Leadership Institute, and adjunct professor at the University of Minnesota. He is also a member of CFR.

And Dr. Leana Wen is a public health professor at George Washington University. All of you must have heard her because she is a contributing columnist at the Washington Post and the author of Lifelines: A Doctor’s Journey in the Fight for Public Health. She’s also the former health commissioner of Baltimore and a CFR member.

Thank you, all of you, for being here to share your insights on what we’ve learned and how we’ve come forward. Let’s begin the discussion by situating ourselves in the current moment of the pandemic.

We hear today that four states are lifting the masking of children in school—New Jersey, Oregon, Connecticut, and Delaware—and even in California, where I’m coming from, as of February 5 we are lifting the indoor masks of vaccinated people, not schools.

So I’m going to—it’s clear that cases have dropped by 50 percent from two weeks ago. Yet, the virus is still claiming twenty-four hundred lives a day. Is this the pandemic, my panelists, of the only unvaccinated? Is this viral blizzard, as Dr. Michael Osterholm has called it, over with, and how should preventive measures be modified as we go forward?

So these are some of the questions that we’ll be delving into in the next half hour, and I’d like to start with you, Dr. Wen. In a Washington Post commentary published last week, you wrote, quote, “New and possibly dangerous variants are likely to emerge. But is it precisely because of this future threat that we need to allow normalcy today?”

Where do you see us now in the progression of pandemics and why do you think it’s time to begin relaxing restrictions? And do you think we should be relaxing them even in the hotspots around our country?

WEN: Dr. Barry, first of all, thank you for having me here today. I’m really delighted to be joining Dr. Osterholm and Dr. Katz for this important conversation. So I’m looking forward to it.

Now, I’m going to say some provocative things. (Laughter.) I welcome for our panelists and the audience to push back on these so that we can have a nuanced and thoughtful conversation.

Look, I think that if any of us are in the business of projection we would all be out of business, that I’m not sure anyone could have known that we would be entering year three of this pandemic, and the future is unknown.

My best prediction for where we will likely go in the next few months, a best-case scenario is that between the people who are vaccinated and the individuals who are exposed to Omicron and they’ll have some level of at least temporary immunity because of recovery to infection, that, hopefully, we will be in for a better spring and, maybe, summer ahead.

Now, we don’t know what variants might be in our future. But the point that I was raising in this op-ed is that we cannot be in a state of emergency forever. We know, based on other emergencies, that when you’re telling people that it’s a five-alarm fire all the time people get desensitized. They start tuning you out.

Best-case scenario, as in—I think the worst-case scenario is that public health loses even more trust and when there is a new variant, as it likely will be, I would be very concerned that people are going to say, well, why should we believe you now? We shouldn’t have been in lockdown all these last several months. We should have just enjoyed our time, and why should we believe you now.

One other thing here, too, is that the vaccinated and boosted are extremely well protected against severe illness, and I think there is a clear sense in this country that the vaccinated, who have been doing everything right, should not have to keep on paying the price for people who have not taken the same types of precautions.

And so I’m not saying, by the way, that the pandemic is over. I’m not saying that we should be letting up, but, rather, that we should be taking this time to prepare. So federal government needs to be ramping up tests, ramping up antiviral treatments, helping the immuno-compromised, for example, enjoy life, too, but also that we should not impose any more restrictions, especially on people who are vaccinated and boosted.

If I may just make two quick points here that I hope we’ll get to during our conversation, one is to continue for us to talk about change, as in sometimes it seems like there’s this narrative that, oh, these experts are changing their minds all the time.

But, actually, what’s happening and, in my case, I would have said a month ago that’s not the right time for us to be removing restrictions because we are, at that time, still seeing hospitals really becoming overwhelmed. Now, many parts of the country, Dr. Barry, to your question, are seeing a decline in hospitalizations. Those are the areas that should be able to let up.

So talking about this importance of change, last year at this time we didn’t have widely available vaccines. Two months ago, we weren’t sure how Omicron was going to be affected by—or how the vaccines would be affected by Omicron. So this idea of change is important.

And then I’ll leave you with one last controversial point, which is the importance of talking about nuance. There has been a lot in the news over the last twenty-four hours about governors announcing an off ramp for masking in schools, and I think when we talk about masks in schools we should—I think there are two things that can be true at once.

One is that masks are effective at reducing transmission in schools, and two, that prolonged masking, in particular, for our youngest children, do have some harm, harm in terms of language, in terms of cognitive development, social emotional development, and I think we need to have this nuanced conversation about risks and benefits, moving forward.

I turn it back to you. Thank you.

BARRY: Thank you, Leana.

So, Mike, I would like you to take that on. Do you, too, think that these restrictions should be lifted? And I have a few other questions for you but let’s—just take Leana on before I get to the questions I have for you.

OSTERHOLM: Well, thanks, Michele, and thanks to all of you for having me. It’s great to be with Leana and Rebecca, friends and colleagues.

And rather than take it on, because I think that Leana laid out some very important points that I actually very much support, let me just take a step back and say it was actually one year ago today that I was reported in a major news media source in the United States saying that I thought that the darkest days of the pandemic could still be ahead of us, and that was as the numbers were dropping precipitously from that early January peak and vaccines were beginning to flow, and people thought, you know, what a wing nut I was, Dr. Doom. And I based the whole entire assessment on what I saw happening with the emerging variants.

At that point, we were beginning to see what Alpha was doing, Beta and Gamma, and it really dawned on me as an infectious disease epidemiologist, you know, forty-six years’ experience, we were in uncharted territories and that very well we could see new variants arrive just as Delta and Omicron did.

And so I just want to lay that out because I come at this moment with that very same sense. I don’t know what’s going to happen in the future and, in that regard, we have to be very humble, very humble, and say we don’t know.

This is the possibilities. It could be that this is the last go around of this virus as we know it, causing large surges and serious numbers of cases, serious illnesses and hospitalizations and deaths. Or we could see a new Omicron happen anytime soon.

Just in the last twenty-four hours, I’ve become aware of a number of new cases of individuals with BA.2 subvariant cases among individuals who three to five weeks ago had BA.1 infections and now are reinfected. What is that all about?

And so I think that this is an example of where any of us today are going to be able to provide you with some sense of the future but within a boundary that I call my guardrails of COVID, and they’re pretty wide.

So to ask the question, should we be relieving ourselves of some of these measures, absolutely yes. You know, I think we are at a point where we’re going to see case numbers drop precipitously over the course of the next month.

I don’t know what that’ll look like yet, and what I mean by that is if you look at what’s happening in South Africa or even the U.K. today, case numbers are not dropping back to pre-Omicron levels. Rather, that big peak is coming down and surely is much lower than that big peak, but it still has a pretty significant tail. And so we’re going to have to wait and see what that means.

But I think in our communities, you know, public health credibility is tied to what is reality, and I think as Leana indicated, really, right now, our credibility has been challenged substantially in the public health world.

I, too, will nuance. I’m in an article in the New York Times today and which I’m hearing a lot of feedback because I tried to nuance the mask issue.

You know, we can have wishful thinking, but there are no good conclusive data that show that any kind of masking in younger children actually is effective in reducing transmission. This is an aerosol, something that we should have gotten our arms around eighteen months ago. But because of the CDC and the WHO’s reluctance to deal with aerosols, we didn’t, and so we believed that anything you put in front of your face practically will protect you.

We do need high-quality respiratory protection. When you have that, then you know the potential for mandates can make a lot of sense. When you don’t, basically, it becomes more of a political move. It becomes almost a sign we’re for or against something by saying we’re going to mandate masking.

So for all these students that have cloth face coverings—and we can go into the data that say that they do or don’t work. I’ll tell you right now, many of the studies that have been conducted that support facecloth coverings work, if that was one of my graduate students who did them, they would have flunked. On the other hand, we have compelling data that high-quality respiratory protection works.

So to answer your question, I think, Michele, it’s a function of if you’re going to put those things in place then you consider mandates. If you’re not going to do that, I wonder why you do mandates at all.

BARRY: Mmm hmm. But, Mike, as long as you brought up immunity, what do you think the durability of—now we have a vaccinated population. Many of those have gotten Omicron. Can you give us just—and either Leana or Mike—a feeling of what that durability of immunity is and do you think that any vaccine today is the platform to provide durable and emerging variant protection to end this pandemic?

OSTERHOLM: Well, yeah. Well, let me just start out by saying, first of all, I don’t know what the term natural immunity means. If you go look up in any textbook of immunology, any textbook of epidemiology, the term does not exist. OK. It’s something that we’ve created for this potential situation here.

Immunity is immunity. The question as how you get it is important. How it corresponds to what we call durable immunity and correlative protections is very important. We don’t know either of those. We don’t know what correlates of protection are right now. What is the combination of kind of antibody with T-cell responses that actually indicate you’re now protected? Is there durability? How long might it last?

As we’ve already seen, with regards to the, quote/unquote, “booster dose,” something which I find very hard to say—it’s like sandpaper across my throat—it should be, I think, a three-prime vaccine all along, it should have been. And—but then we raise the question, what will protection be like after four or six months? We don’t know. This is one of those areas, stay tuned.

Let me be really clear, however. The data that we have to date and is compelling says that, you know what, if you’ve had a previous infection you do have some residual immunity, protective immunity, from that infection.

But that in of itself is not sufficient to prevent you from future infections. And if you look at a series of studies that have been done, and I just reviewed these in detail in my podcast last week, is the fact that you do need both that previous infection immunity and additional vaccine protection in order to really have the highest level of protection.

So I hope we don’t get bogged down in future debates about is it natural immunity or not. You know, do I need this or not. I think we’re missing a major point is the fact that it’s going to take multiple, multiple doses or previous infections, likely, if we are to achieve durable immunity to actually get to that point.

BARRY: Thank you. So people should not feel liberated yet if they’ve gotten the Omicron infection, which you’re hearing quite frequently.

Rebecca, I’d like to turn to you, and what needs to be prioritized globally for addressing us and moving us out of this acute phase of the pandemic? We know that there’s been terrible inequitable distribution. Almost 3 billion people have not received an immunization.

This morning, J&J just announced that they’re stopping production of their vaccine and that’s been the major vaccine going to Africa. What type of global governance construct do we need to really prevent what people have been calling vaccine apartheid or vaccine nationalism?

I know that was a very—

KATZ: It’s a lot. (Laughter.)

BARRY: —complicated question, but I’m trying to get it all in.

KATZ: No, and I appreciate it. And, really—yeah. Like Mike and Leana, I’m so delighted to be here with you. And I’m not sure I can take on everything and I’m not sure I have the perfect answer, but a couple of thoughts.

You know, first, I am hopeful that this pandemic has illustrated where we need in some places to start drawing a distinction between global and domestic, from utilizing the same community engagement strategies that the global health implementers have used around the world to implementation science to building best practice in our own backyard. And we’ve drawn some strict lines over the years, and I think a lot of those lines need to be erased.

But I also think that also includes the critical importance of vaccinating the world and why vaccine equity is not just about social justice—which it, clearly, is—but also about effective public health response as well as international security. And when I think about what needs to be prioritized right now, I mean, clearly, getting vaccine and eventually therapeutics to those 3 billion people around the world who have yet to receive a first shot, clearly. But how do you do that and how do you think about these things in a global construct, and working on supporting global manufacturing, and assuring that what is delivered as gifts is not about to expire, and providing the support services to enable product delivery?

I think that there’s also an important piece here and a priority around information sharing, which is tied up in data governance, which, for many, is then actually tied up in that first priority of access to medical countermeasures.

This, to me, is the third rail of global health governance and we need to figure it out. And we have a lot of folks who are working on the technological side of things like sequence data and wastewater surveillance and new systems to quickly share and integrate data from around the world.

But we haven’t yet solved the data governance. Why should information be shared? What does the sharer get out of it? What do they, potentially, lose by sharing data, and creating this system that facilitates information sharing where everybody benefits, including science and population health, is going to be critical, and that also mitigates against punishment for sharing like travel and trade restrictions.

But I think this all gets back to—I’m talking in circles, but it gets back to your question about the global governance construct. The pandemic is, truly, a transnational threat. But, yet, going into year three we’re still sometimes treating it like a national or even a localized problem.

We have hundreds of thousands of small epidemics instead of a single interconnected pandemic and where variants are emerging in immuno-compromised populations and local communities, and it’s not just a local problem. It is a global problem. And the global system is not really great at dealing with transnational threats writ large, but, specifically, disease events.

And one of the reasons why I’m delighted that we’re having this conversation at CFR, right, because it is bringing everything from talking about the—being able to integrate the science and the public health and the immunology and the virology into this international security spectrum.

BARRY: Thank you.

Leana—or Dr. Wen—you’ve written about problems with the CDC and the erosion of trust, and a CFR member, Tom Bollyky, has just come out with a great article in Lancet talking about the fact that a study of a hundred and seventy-seven countries where trust was really critical to vaccination efforts—the one thing that came out—and gaining public cooperation when restrictions are necessary.

So my question to you is what can be done, especially in a country like the U.S., where a significant proportion of people believe in self-determination and have not bought into the social contract to protect others?

WEN: Yeah. I, first, wanted to say that I enjoyed Tom’s article very much, have cited it and I think he’s on today. So I appreciate your work in this respect. I mean, it’s something that we say in public health all the time, that public health depends on the public trust when we ask people to do difficult things. I mean, even something like isolating yourself and not being around others, that’s really difficult to do and so that compliance—the agreement really depends on trust.

And so I suppose I’m not surprised, although it’s helpful to see the data, that countries that have high levels of trust also have saved a lot more lives.

Now, in terms of how to restore this, I think that, for me, there’s a difference between what needs to be done on the individual level versus what needs to be done on the policy level, and I’ll explain. I think they are related.

But for me, as a clinician—and, I think, Dr. Barry, for you as well and for some others on the call, I think you’ll really relate to this—when I think about how the doctor-patient, clinician-patient, relationship works, it is all built on trust and it only works when it’s built on trust.

But what are the things then we do as clinicians in order to build that trust? Well, one is we are honest and transparent with our patients. We explain what’s going on. And we were talking earlier about this issue of change. I mean, our patients understand that things change.

I mean, let’s say that you’re treating a patient for cancer. If there is a new chemotherapy regimen that comes out, the patient would expect that we would present them with that new information. So change is not necessarily bad.

It’s just that it needs to be—there needs to be an honest conversation. There needs to be transparency and an explanation for why a change is being made and what the options are.

Another aspect for a helpful individual trust relationship is to meet people where they are. From the very beginning, I have been talking about the concept of harm reduction, which is something we do in public health policy a lot—the idea that if you’re asking people to just lock down and never see their family and friends and never go anywhere but they can’t, literally, comply, that’s not going to work.

You have to come up with strategies to help people to reduce risk. It’s not eliminating risk, certainly, not now as we’re entering year three, but it’s how do you reduce risk and meet people where they are in their understanding.

That also is the case for explaining to somebody about vaccines, not on an individual level, not assuming that somebody is an anti-vaxxer with crazy misinformation but, rather, approaching them with empathy and talking to them about the specific concerns that we have. That’s what we do on the individual level to breed trust and I actually think that that can then be extrapolated to your question, Michele, about how it is that the CDC can foster greater trust.

I think they need to do a much better job of explaining why recommendations are being made. You look, for example, at their isolation guidance. I think part of the reason why it got—it raised so many eyebrows was when they changed the recommendation from ten days to five days it didn’t really seem like the science changed that much. I mean, they were citing a study that after five days 31 percent of people were still infectious. That seems pretty high.

But I think if they had said—and I don’t know that this is necessarily their reason—but if they had said, we are facing a critical shortage in our healthcare workforce and in critical infrastructure, we have to have people go to work, and that’s the reason why after five days you can go to work but with a mask on, I think that would make a lot more sense than simply saying, hey, we’re changing from ten days to five days. And so having an explanation and the rationale—explaining the rationale better, I think, is important.

Also important is intellectual honesty. Michael gave the explanation earlier about natural immunity. I think we need to acknowledge that there is immunity after infection. As Mike very well pointed out, we don’t know how long that lasts.

We don’t know—it may be inconsistent, depending on how ill you were. But it exists, and acknowledging that there is some level of immunity after infection isn’t saying no one should ever be vaccinated if they were infected.

But, rather, we have to acknowledge that both of these things can be true, right. You get the best level of protection if you’re vaccinated even after you were infected. But just because that’s true doesn’t mean that you don’t have some level of immunity after infection. So I think acknowledging the nuances is important, too.

Now, in terms of, going forward, what can be done, I think it depends on the part of the country that we’re in. Some places there’s great public health infrastructure, a lot of trust already. They have a lot of funding coming in. I hope that they will capitalize in that regard and make their public health infrastructure really robust because they could help the other parts of the country where it’s exactly the opposite.

And here I’m going to say something controversial that I hope that others will, again, speak to if they disagree. But I think there are parts of the country where COVID has become synonymous with culture wars, where it has become such a partisan divisive issue that never should have been the case.

But it’s bleeding into other parts. We’re seeing legislatures pass or introduce laws on prohibiting all kinds of other childhood immunizations as well, for example, or limiting public health powers for other things including, you know, in the future, if there is multi-drug-resistant tuberculosis maybe they can’t quarantine people—the public health authorities can’t quarantine people for that.

And so I would actually urge for much of the country in places where COVID has become a partisan issue to stop focusing on it, to instead double down on other aspects of public health, like maternal and child health or senior care, that don’t have such a political element attached.

BARRY: Thank you. That was all about transparency in a moving science, which is moving very fast. I would say that that’s important when we think about nuance.

Rebecca, can I ask you, since I do—since this is the Council of Foreign Relations, I’d like to get back to the global aspect and ask you how we might develop global health security for the next pandemic. In particular, how would the world fund this and how do we ensure political will?

KATZ: Those are two really hard questions. I mean, I think I’d say there’s a tremendous amount of work to do in the global health security and preparedness response governance space. Under the—there are a bunch of processes that are underway. Some may yield results. Some may not.

One of them is there is a working group on preparedness and response amongst the member states of the World Health Assembly that has been meeting since the summer on—this was the group that was meeting to start thinking about a new international agreement as well as to address the International Health Regulations.

So within that group, the United States put forward proposals for specific amendments to the International Health Regulations, which will need to be considered and debated amongst the member states of the WHO.

I feel really strongly that it’s important that we take the agreements that we have and try to strengthen them first but acknowledge that many of the things that we are looking at will be incremental changes, right. They’re not massive shifts.

But you start with that, and that will, hopefully, change and impact how disease events are governed. In parallel to that effort to look at amending the IHRs there is this effort underway that was agreed upon to move forward at the end of November, early December, to explore a new international agreement, the Pandemic Treaty, as it’s being referred to.

There is an international negotiating body that is supposed to meet this month to start those negotiations with a requirement to have a report back by the World Health Assembly in May 2023. That’s not quite all that developed yet, and I think that there’s—there are proposals. I may have had more proposals for specific articles from my undergraduate course last semester than have been put forward by many governments of the world yet. But there’s a lot of discussion about what that could and could not address.

But I think, importantly, there’s also a whole bunch of other international agreements that are out there that pertain to global governance of disease. So some of them are being utilized throughout the pandemic, some of them less so.

But we have WTO TRIPS, the Nagoya Protocol, and the Convention on Biological Diversity, links to agreements and influence factors that are linked to emergence of disease, and you can look at the Paris Agreements and Climate Accords for those.

So with all these agreements and governance structures, a lot of them have been broken during the pandemic, and some of them were predictable, right. We knew where a lot of the cracks were going to be. Some of those cracks have expanded into, I guess, canyons. And nothing really ties any of these agreements together, nor the national implementing legislation, nor the stakeholders.

So as we think about what we have to do, going forward, again, there’s a lot of work. So we’ve got to be thinking about how all these pieces come together, how do we strengthen the agreements that do exist, how do we identify where the gaps are, how do we meet—you know, fill in those gaps, and maybe the right way is through these international agreements.

But we also need to be clearly defining what we want out of our international organizations and to make sure that the resources match what the expectation is. There is currently a massive disconnect right now between what the world is asking WHO to do and the level at which it’s being funded.

So you either have to change the expectation or change the resources. But we’re not doing either right now. We also need to strengthen all those interconnected international agreements. Again, create those nuances necessary and then figure out how you implement them. I think the word of the day, of the year, of the pandemic, is equity.

But what does that actually mean? How is it operationalized and what incentivizes nations to actually work together? And we need to—you know, we need to figure this out. We need to explore the role of regional organizations, and to your question about resources, none of this happens without money.

So there is a lot of talk right now, a lot of it centered within the G-20 and the health and the finance ministers who have been contemplating setting up a new pandemic fund. The idea is that—current proposal is that it would sit at the World Bank. But this costs a lot of money and, you know, we’ve estimated it to be at about 124 billion (dollars) over five years for national level capacity and there’s estimates—other estimates out there for another 80 billion (dollars) if you’re going to build kind of, I guess we’ll call them the global goods, so things like R&D and manufacturing capacity. In the world of, you know, terrorist threats, that’s not a lot of money. In the world of—

BARRY: I’m going to—I’m going to end you now, Rebecca, because we’re supposed to end at 10:30—I’m sorry—so that we can let the folks online start asking questions.

So, Carrie, can we—thank you. That was a great explanation for my question.

Carrie, can you start with the questions from the members? I think we have several hundred. So—

OPERATOR: (Gives queuing instructions.)

We’ll take our first question from Krishen Sud.

Q: Yes. Hi. Krishen Sud from Sivik Healthcare.

Dr. Osterholm, you talked about, you know, a three-dose vaccine as a standard protocol. Do you—are you convinced that three doses will be enough at this point in time or do you think that there will be a need for a fourth dose?

And then, secondly, would it have made more sense for the first two doses to have been spread apart a little longer than the, you know, three, four weeks that they were studied for originally? Thank you.

OSTERHOLM: Yeah. Well, thank you for that really very, very important question. Let me just be really clear right now, that if you look at the recommendations in the United States, it’s actually a four-dose recommendation for those who are moderately or severely immune compromised, and so that already is in place.

The three-dose recommendation, I’m more convinced than I’ve ever been how important that is. It’s been pretty compelling for the last several months about the importance of those at least fifty-nine years of age and older of getting those three doses. But now we have data, and we’ll be coming out with more data shortly, even down into the twenties we have evidence now reduction in hospitalizations, serious illness, and death even with three doses versus two doses.

So I’m absolutely convinced of that. But the question you raise is really the critical one: What is our path forward? And we don’t know. We have to admit that. Again, without a quota of protection, without understanding durability as a function of both B cell and T cell response, you know, we’ve got a lot to learn here.

I think the data that we’ve seen to date with the mRNA vaccines, in particular, would suggest that this concept of waning immunity is very important in those first two- and three-dose approaches. And so we’re going to have to figure that out, and I do not believe for a moment that we will continue to boost ourselves every six months for eternity for the whole world. It is not going to happen, and I think this is going to be one of our challenges is trying to understand that.

What does that mean? Will we, in fact, have to develop new and better vaccines? I think, in fact, one day we will have a SARS-CoV-2 vaccine, point two, you know, point three, point four kind of levels and we’re going to have to be looking at that very, very carefully.

So I think that’s where we’re going with the vaccines as such, and I think the second question—I’m sorry—was—could you repeat that second question? I’m not sure we have him. But I think the bottom line message is now is the time, again, to be very humble about these vaccines and know they are very, very remarkable tools but they’re not perfect, and that’s going to be a challenge as we go down the road to understand what they can and can’t do.

And I do remember your second question on dosing. Yes. Remember, when the dosing was put together in terms of studied protocol it was all about getting a vaccine approved as quickly as possible for the early days of the pandemic, and the idea of vaccinating on day one and then either a third week or fourth week post second doses, I think most vaccine immunologists would say that didn’t make a lot of sense to maximize on protection.

But at the same time, we were trying to find, could we find, an approach that would allow us to get emergency use authorization with some element of protection. Remember, initially, the FDA said if it was only 50 percent protective it would likely still be approved.

But we now know today we have a lot more work to do on doses, on dose spacing, on the actual dosage of the vaccines, et cetera. How do you mix and match? You know, we’ve seen variable data now that would suggest, you know, some very different responses by using the adenovirus vaccine platform and the mRNA intermixed. What does that mean?

So I think this is all part of now we’ve got to catch up with the long-term immunology of these vaccines to understand the best way to use them.

Q: Thank you very much.

OSTERHOLM: Thank you.

OPERATOR: We’ll take our next question from Jenny Lu Mallamo.

Q: I am a CFR term member and I am also the mother of a twenty-one-month-old. So I’d like to ask this question of Dr. Wen, and that is could you provide any insights or clarity on the expected rollout of vaccines for the tiniest toddlers? I, like so many other parents, have found myself on the side where, you know, we don’t want them to have that immunity through infection but there also aren’t vaccinations available just yet. Thank you.

WEN: Jenny, I really appreciate the question and I think one of the reasons you’re directing the question to me is you might know, and some of our members might know, that I have two little ones of my own. I have a four-year-old son and a—well, she’s not a baby anymore, but I have a baby born during the pandemic who is actually turning two soon. This is how I measure time or the passage of time because she was born in April at the start of the pandemic.

So I think about this all the time. I mean, I think about, you know, how my husband and I, who are generally healthy, vaccinated, and boosted people, we are taking many precautions in our lives that we wouldn’t take if it were not for our young unvaccinated children, and our young kids have really suffered a lot. I mean, I pulled my son out of preschool for the first year. He’s back in school.

We haven’t seen grandparents. The baby has actually never—who’s not a baby anymore, but she’s never met her grandmother, who lives in South Africa, because of travel restrictions and because we haven’t wanted to take a sixteen-hour flight and so—eighteen-hour flight. So all of this, I relate to your question very much.

Now, in terms of what’s going to happen, we have—actually, we have no data yet for the six-month to four-year-old group. My understanding is that we probably will get the data this Friday ahead of the FDA advisory meeting on Tuesday. Next Tuesday, February 15, FDA advisors will meet at that time. They’ll make a recommendation to the FDA. The CDC advisors will meet after that and make a recommendation to the CDC.

If the data are positive, we could see the vaccines for younger children for that six-month to four-year group available as early as, say, the following week. But I don’t want to prejudge. I will say the following. Number one, I trust the process. I very much trust the careful, deliberate process the FDA and CDC have been going through. I’ve, personally, spoken to many of the advisors and I know that they are taking even more precautions with this very young group.

I will also say then the second thing is I do have some—I have some questions, right. I mean, I want to see the data. We had heard before that the six-month to two-year group there was actually a strong immune response from the three microgram dose. The ten is what’s used for the five- to eleven-year-olds. Twelve-year-olds and above are getting thirty micrograms. So for that younger age group, that the six-month to two-year group had a strong immune response but the two- to four-year-old group did not, and this is the reason why they were testing a third dose.

Now, I don’t actually know what they have found since then. One of the benefits—if you will, the silver linings of Omicron—is that there were so many children who got infected in that December-January window that, perhaps, there are more data than Pfizer was initially expecting.

So all this is to say I reserve judgment on what I’m going to do with my children until I see the data on Friday. But I, certainly, would very much trust the process on Tuesday and, hopefully, within two weeks we’ll—is the soonest that we might even be able to see vaccines going into the arms of young—of very—of our young kids.

OSTERHOLM: Michele, can I add a context to that? I think the—

BARRY: Go ahead.

OSTERHOLM: Thank you, Leana, for, I think, a very thoughtful response.

One of the challenges, I think, we face right now goes back to that concept of trust, and if you look at the five- to eleven-year-old age group, only 31 percent of those kids are vaccinated, and this vaccine has been available for some time.

Those parents that want those kids to get vaccinated really want them to get vaccinated. But those parents that do not really don’t want them to get vaccinated. And I worry a bit about the six-month-old to four-year-old age group right now because, based on what data we do know—and I think Leana is exactly right, we’ve got to see the final data—is that there was a sense that the companies were asked to bring their data in. It was not them applying, per se. It was FDA’s request. Because of the idea that if this is a three-dose vaccine, let’s get two doses approved, get it out the door so that, in fact, if a third dose is what’s necessary we’ll already have a head start of getting that.

Now, as a public health person, that makes great sense to me. But you know what? I’m not sure how that’s going to sell in Peoria. That will seem as if there are shortcuts being done. You’re going to put a vaccine out that’s not quite yet ready for really primetime approval but you’re going to use it to get started?

And I think sometimes we’ve not fully appreciated what it appears like to the public in what we’re doing and how we’re doing it. You know, I was one of those individuals early on that very strongly supported the need for third doses as the very first data were being generated. Boy, did that run into a buzz saw of disagreement, saying we don’t have enough data.

Well, we were in the middle of a crisis. You know, John Snow did not wait for consensus to pull the pump handle off the well—contaminated well in Soho. You know, he pulled it.

And I think that part of the challenge we have today is how do we translate that kind of public health response like, potentially, approving these vaccines if the data is sufficient to say only two, but at the same time keeping the public trust with us?

And I think this is going to be really a very interesting story unfolding of how the FDA looks at the data, what the data tell us, and how we try to convince parents that these are vaccines that they want their kids to get as soon as possible.

BARRY: Next question, please.

OPERATOR: We’ll take our next question from Ethan Bronner.

Q: Thank you. I think it’ll be to either Dr. Osterholm or Dr. Wen.

Dr. Wen, you said we who are boosted are, really, quite well protected. What I’d like to understand is what risk can we run by being in the presence of the unvaccinated? Do we have data that show that unvaccinated people pose a risk to us? I understand they pose a risk to themselves, to empty hospital beds, and so forth. But are they a risk to us? I had never gotten very clear on that. Thank you.

WEN: So I’ll start but I would look to Mike and Rebecca, too, if you have comments here. So I’ll say the following.

So this is my several pieces of information—data, if you will—and this is how I would put it into context. One is that people who are vaccinated and boosted are extremely well protected against severe illness. David Leonhardt in the New York Times had an analysis where he showed that your chance of dying from COVID as somebody who was vaccinated and boosted is about one in a million in a given week.

For comparison, your chance of dying from a car accident is two in a million in that same time period. Chance of dying from other respiratory infections about three in a million. So this is a pretty low risk.

That said, not everybody is only worried about death and severe illness. There’s also the chance of long COVID that we don’t like fully understand. Also, you could be an asymptomatic carrier and if you are around people who are elderly, immuno-compromised, young children, et cetera, even if you’re a vaccinated boosted person you might also be concerned about your risk of transmitting to somebody else and may still not want to or may still want to reduce your own risk as much as possible. That’s one piece of information.

The other piece, I think, is what is the risk of an unvaccinated person to a vaccinated person or to somebody else, and I often get this question in the context of why do you care—if you’re vaccinated and boosted why do you care if others around you are unvaccinated? There are data—one piece of data from the CDC showing that people who are unvaccinated are five times more likely to have COVID compared to somebody who was vaccinated. L.A. County, in the middle of Delta, found that, I believe, it’s two point six times.

So somebody who is unvaccinated is about two point six times more likely to have COVID compared to somebody who is vaccinated and boosted, even with the more contagious Omicron variant.

And so as a vaccinated and boosted person, if I had to choose to be in a room with a whole bunch of people, I would much rather that the whole bunch of people were vaccinated and boosted because they are less likely to have COVID. Therefore, they’re less likely to transmit it to me. Therefore, I’m less likely—even if I don’t care about dying from COVID, I’m less likely to get COVID myself and to be able to transmit it to others. That’s why it matters to me if others around me are also vaccinated.

OSTERHOLM: Yeah, and I’ll just add—I think Leana did a great job laying that out—I think the big question is what is the absolute risk if I’m around people who are not vaccinated versus people who are and likely to transmit the virus to me.

We do have more data supporting that those who are fully vaccinated with three doses are, when they do get infected, likely less infectious, less likely to transmit the virus on. So I’d much rather be with that same group than people who are unvaccinated.

BARRY: I think Ethan is also asking what is the risk of being in a room with an unvaccinated person.

OSTERHOLM: Well, if it’s Omicron, I’d say if you’re in a room with somebody who’s smoking and it’s a twenty-by-twenty-foot room, do you think you’ll smell the smoke while you’re sitting in that room with him? If you do, you’re likely getting exposed to the Omicron virus and it doesn’t take much to infect you. I’d say it’s not good news.

BARRY: Thank you, Michael. Next question, please.

OPERATOR: We’ll take our next question from Thomas Bollyky.

Q: Great. Hi. Tom Bollyky from the Council. I had a question for Rebecca Katz.

You mentioned before the dynamic for WHO, that it does not have the resources to fulfill the mission we would like it to perform in this pandemic. This was a topic, of course, discussed at this year’s executive board meetings, not resolved, and some conflicting press reports as to why that lack of resolution happened.

What do you think is the path forward to resolving that issue? Is there a path to getting WHO the resources it needs to function more effectively in a pandemic?

BARRY: For those on the call, the WHO budget is equivalent to a good hospital in the United States. So it’s one hospital.

So, Rebecca, take it away.

KATZ: Well, hey, Tom. That’s a great question and I don’t—I’m not sure I have a perfect answer. I think the proposals that were—there was a working group that came together to review what WHO would need to—what kind of finances it would need to function at the level that it’s being asked to, and the proposal that was put forward and reviewed at the executive board was for an increase in assessed contributions.

So WHO sponsored—it functions through both assessed and voluntary contributions, and the idea was that if you go up to, say, a 50 percent increase in assessed contributions then that would help the organization.

Many nations rejected that. United States was one of them. And I think the question of the path forward is complicated. I think that, one, you—clearly, the organization needs more resources. Clearly, what we’ve studied from everything pre-pandemic is that the—there is a preference for those resources to come through assessed contributions from member states and not voluntary contributions, which is, basically, the equivalent of earmarking.

And so, therefore, you know, certain projects go forward and certain areas happen not because it’s the decision of the countries of the world or the organization itself but because that’s where the money is coming from.

So I feel pretty strongly that this is going to have to be tied to a system of assessed contributions. But I also think it’s an opportunity to be really quite thoughtful about what the nations of the world are asking this organization to do.

Do we want it to do everything under the sun or do we want it to have a couple of areas that they build capacity, that they are resourced appropriately? And I’m not sure those conversations have been had in their entirety yet.

BARRY: Next. Thanks very much. Tom, thank you for the question. Next.

OPERATOR: We’ll take our next question from Esther Dyson.

Q: Thank you. I’m curious what’s happening with the data about long COVID and, specifically, have we had time yet to see whether Omicron is producing long COVID the way the other versions have and whether that there are all these different parameters, and I’m curious where the long COVID one sits on that.

BARRY: One of you want to take that? That’s a tough question.

OSTERHOLM: Let me start out, first of all, and say that long COVID is, clearly, a critical, critical issue that has not received the attention that it should, and depending on what estimate you believe is the most accurate in terms of the incidence of long COVID, it’s anywhere from 3 (percent) to 30 percent, probably closer somewhere to that 3 (percent) than 30 (percent). But, nonetheless, when you think of the number of people who have been infected it’s substantial.

One of the challenges we have is before COVID ever existed we had chronic fatigue syndrome. We had chronic Lyme disease. We had any number of these chronic conditions that are real. They’re not psychological illnesses, as such. There are a real biologic basis for these, which we did not understand. We did not understand and still had a huge challenge with those.

Now you overlay COVID on top of that, and those didn’t disappear—those previous ones—but they’ve now been assumed under the kind of rubric of long COVID, in many cases.

So I think what this is really begging for is, truly, a much greater emphasis to understand. In most cases, I think we’d agree that these are post-infection sequelae, post-infection conditions that occur, and that we have to understand from an immunologic standpoint what’s happening, and we don’t.

Now, there’s centers that have been set up through the NIH. There’s also a number of other individual centers through private source funding that have been set up. But I just want to take and emphasize I think that this is an area that we truly need a major new initiative in to understand, and it’s going to be not just to describe the epidemiology, the clinical care, but also measuring long-term outcomes and what do these mean, because this has a potential to be a real drag on our society as a whole and God knows what it means to these individuals who were highly productive members of our society who wake up every morning in a total brain fog and with chronic pain. That’s a real challenge.

BARRY: So, Leana and Michael, can I push that question a little bit more? Is there any data now on the difference between Omicron and Delta for long COVID?

OSTERHOLM: Oh, sorry. It’s just too early. We’re already hearing of cases that may be long COVID. Remember, we’re only about twelve weeks into long—into Omicron in general in the world, But I think it’s, surely, a concern that we have to be mindful of, and God knows how many more people we’ve infected over the course of the last twelve weeks. So that number, even if it’s a very small percentage developing long COVID, could be very, very substantial.

KATZ: I would also add—Mike mentioned the—kind of the brain fog long COVID stuff, but I—there’s deep concern around cardiovascular and what this—and some warnings that are starting to come out around what might show up six months, a year from now, and also something that’s being—I mean, we’re talking about the general population, but also a concern amongst our—I don’t know, I’m at a university; many of us are—our athletes, our student athletes, and what the long-term cardiovascular impact will be on the athletes who become sick.

BARRY: Thank you. Next question, Carrie.

OPERATOR: We’ll take the next question from Katherine Hagen.

Q: Hello. I’m Katherine Hagen with the Global Social Observatory based in Europe.

I am very interested in the dynamics of U.S.-European relations as well as with other countries. And, Rebecca, you’ve talked quite a bit about the issues with regard to getting more vaccines out around the world. And I, certainly, appreciate the fact that the American role has been crucial in terms of increasing not only the quantity of doses but increasing manufacturing capacity around the world.

One of the questions I have about that is that a lot of people are saying that the Americans have done enough and so now it’s up to others to do more. Is that really the case? Or is there something more that the U.S. can be doing to increase the availability and accessibility including, in particular, this issue of manufacturing capacity, which then ties into the question of how you get the manufacturing companies to play a more active role in terms of engaging in a global approach to availability?

Thanks. Thanks for everybody, too. It’s a great session.

KATZ: Can the United States do more? Yes. Everybody can do more. Can the Europeans do more? Yes. I think that this is saying that we’re—I think, clearly, that we have not finished the global response, we, as a global community, and there’s a lot more levers that can be pulled. There’s a lot more resources that can be put towards this. It’s just a matter of prioritization.

The question about manufacturing—you know, there has been a very long, detailed conversation with industry around the—around IP, and this gets tied up with the conversations around a TRIPS waiver and the conversations around, like, how do you make the recipes available to build out manufacturing capacity around the world. I think we’re seeing a really quite interesting example happening right now in South Africa and the recreation of the Moderna vaccine, and that maybe that becomes a model and what we might see replicated in other parts of the world.

Now, because this wasn’t done with Moderna the South Africans, basically, have to start from scratch in terms of doing the clinical trial work. So that slows down the process. But, you know, again, lots of complicated conversations around this.

But the very easy answer to your question can the United States be doing more, yes. Can the Europeans be doing more? Yes. I think this is a situation where every nation has to lean in and we could and should expect more.

BARRY: Thanks, Rebecca. Next question, please.

OPERATOR: We’ll take our next question from Dee Smith.

BARRY: Dee, you have to unmute yourself and—

Q: Sorry about that. Can you hear me?

BARRY: Yeah.

Q: Yeah. Thank you very much. Really, really interesting discussion.

I would love to hear a bit more explanation on the whys of the resistance to taking vaccines among certain people. Does it have to do, I’m wondering, with simply a lack of education of how science works and that science is not settled—it’s not ever fixed, it’s always in flux as new data comes in?

Does it have to do with simply the desire for a simplistic answer or simplistic explanation, which seems to motivate so much of political discourse these days? Does it—is it the culture wars that’s the primary thing? To what extent do these various threads feed into—particularly in the U.S. but in other countries as well, if you have any considerations on that? Thank you.

BARRY: Leana or Michael, you want to take that?

WEN: I mean, I can start on the U.S. front and, perhaps, others can chime in, too.

So I will tell you, so I have two very different perspectives here. One is as a clinician and one is, again, wearing a policy hat. So I’m going to give these separately.

In the patient population that I see, and I work mainly in an urgent care clinic here in Baltimore so serving underserved patients who otherwise are not able to—they’re all patients who are uninsured or vastly underinsured—I would say that still maybe about half of the patients that I see are unvaccinated. These are not people who have fallen prey in some way to culture wars. I mean, I say this as a—you know, it’s not—of course, it’s not a hundred percent.

But I would say that the majority of these individuals really have concerns. They heard something from someone. A lot of them are concerned about long-term consequences. There are younger people who are concerned about fertility. I mean, they have concerns that really require someone to speak to them one on one.

And this is still the case. Certainly, that was the case earlier in the pandemic. But there are still many people who need that one-on-one engagement, empathetic conversation, to really meet people where they are and address them. I think that’s still a group that’s there, and I think a lot of people also don’t really see what’s in it for them. Nothing changes once they’re vaccinated.

They can’t—it’s not like you get vaccinated you can now take off your mask. I mean, I argued all along that there needs to be some tangible incentive, and I think a lot of people still are on the fence because they just don’t really see what’s in it for them and they have questions about the vaccine.

On the policy front, I do think that there are a lot of people—not necessarily in my area but around the country—who do see it as a badge of pride, in a way—that being unvaccinated, not wearing a mask, that that is so core to their identity at this point that I think that that becomes very difficult. And you’re right, Dee, that disinformation, misinformation, weaves into that.

But that I worry that by digging further on the—so, again, individuals, I think we should be addressing their concerns one on one. But as a policy matter, digging in further could have real adverse consequences and bleed into resistance to other vaccines.

BARRY: So—oh, go ahead, Michael.

OSTERHOLM: Can I just—add just a quick footnote to that?

I think your point is not only really important but, I think, incredibly sobering. Recently, the Financial Times did an analysis looking at what would it be like in the United States if we had the same vaccination levels as some of the countries in Europe, and, in fact, if we had the similar vaccination rates as Denmark we could see half of the hospitalizations we see now in this country. Think what a difference that would make.

The point that I want to really emphasize, though, is we do not understand the difference today between vaccine hesitancy and vaccine hostility, and I think they’re two totally separate issues and they really go back to what Leana just said about identity. I mean, think about the fact that we cannot explain why, you know, we had—the people who received two doses of vaccine willingly and, yet, only 40 percent of them have gotten their third dose despite the fact we’ve made the case loud and clear how important the third dose is.

These are not vaccine hesitant, vaccine hostile, people. They’ve already had two doses. And, yet, that has contributed substantially to the increased number of hospitalizations and serious illnesses.

So we have a lot left to learn that we don’t know about why people have come to this point. I don’t think it’s going to be one simple thing. But, nonetheless, it’s going to be important to understand that.

BARRY: Well, thank you. I’d like to thank the audience for their provocative questions and also thank the panelists. I started this off by saying you were impressive thought leaders and I think this session has confirmed that.

So thank you very much, and thank you to the Council for Foreign Relations.

Oh, please note that the audio and transcript of today’s meeting will be posted on CFR’s website, and I believe—Carrie, am I right that this will be publicly available?

OPERATOR: That’s correct.

BARRY: Great. Thank you, everybody.

(END)