Pharmaceuticals and Vaccines

Jennifer Nuzzo, CFR senior fellow for global health, provides an overview on the COVID-19 omicron variant and information about testing. Shalina Chatlani, healthcare reporter for the Gulf States Newsroom, discusses framing stories on this topic for local communities. Carla Anne Robbins, adjunct senior fellow at CFR and former deputy editorial page editor at the New York Times, hosts the webinar.   FASKIANOS: Welcome to the Council on Foreign Relations Local Journalist Webinar Series. I’m Irina Faskianos, vice president for the National Program and Outreach at CFR. As you know, CFR is an independent, nonpartisan organization and think tank focusing on U.S. foreign policy. We take no institutional positions on matters of policy. This webinar is part of CFR’s Local Journalist Initiative, created to help you draw connections between the local issues you cover and national and international dynamics. And we put you in touch with CFR resources and expertise on international issues and provide a forum for sharing best practices. I want to remind everybody that the webinar is on the record, and the video and transcript will be posted on our website after the fact, at CFR.org/localjournalists. Today we will be discussing reporting on the Omicron variant and COVID-19 testing with our speakers, Jennifer Nuzzo and Shalina Chatlani, and host Carla Anne Robbins. I’m going to just give you a few highlights from their distinguished backgrounds. Jennifer Nuzzo is a senior fellow for global health at CFR. She works on global health security, with a focus on pandemic preparedness, outbreak detection and response. Dr. Nuzzo is a senior scholar at the Johns Hopkins Center for Health Security, and associate professor in the Department of Environmental Health and Engineering, and the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. And she’s also the lead epidemiologist for the Johns Hopkins COVID-19 Testing Insights Initiative within the Johns Hopkins COVID Resource Center. Shalina Chatlani is a health care reporter for the Gulf States Newsroom, a regional newsroom with coverage from public broadcasting stations in Alabama, Louisiana, and Mississippi as part of NPR’s collaborative journalism network. She covers health care access and inequity and has previously reported on racial disparities in the coronavirus vaccine rollout, and how the financial stress of the coronavirus pandemic is affecting communities of color in San Diego. And prior to that, she was a science reporter for KPBS in San Diego and the emerging voices fellow at WPLN in Nashville. And last but not least, Carla Anne Robbins is an adjunct fellow at CFR. She is faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. So thank you all for being with us. I’m going to turn it over to Carla to get the conversation started, and then we will open the floor to all of you for your questions. You can either raise your hand or write your question in the Q&A box. And we really want to hear from you as well. So get your questions ready to go, you’re reporters, we look forward to hearing from you as well. So, Carla, over to you. ROBBINS: Thank you, Irina, so much. And thank you, Shalina, if I may, and Jennifer, if I may. I’m going to call you guys by your first names, since we’re journalists and we’re incredibly informal. And thank you to everybody who’s here. Please, you guys—I’m sure you have a lot of questions. And so we’re just going to chat briefly up here and then throw it open to you. So, Dr. Nuzzo, Jennifer, if I may, I want to start with you. I’m puzzling through this statement, you know, from this top WHO official yesterday, Dr. Hans Kluge, I think is the way it’s pronounced, which had some news outlets predicting an end to the pandemic. You know, he said between vaccination and natural immunity through infection, quote, “Omicron offers plausible hope for stabilization and normalization.” What did he mean by that? And what does the new normal look like? NUZZO: Yeah. I mean, it’s a challenging thing to explain, in part because I think everybody has a different idea of what the end of the pandemic means. There’s no clear definition. (Laughs.) There’s no epidemiologic definition. Pandemic describes the whole spread. And I think it’s quite clear that this virus is not going to disappear from the planet. It’s going to continue to circulate. And, you know, we have seen evidence of mutation. We’ve seen evidence of reinfection. So with that, I think everyone has some reasonable belief that means that it’s going to find each one of us at some point in our lives, possibly multiple times. So but that doesn’t necessarily describe a pandemic, although it clearly describes global spread, which is usually how we define a pandemic. I think there’s another element to it, which is just how unusual or expected are what we’re seeing. And I think we don’t know for sure, but I think most people’s visions of when the pandemic is over is when our day-to-day efforts to try to stop the spread greatly change and manage it more like the way we manage other routine infections that we deal with. Doesn’t mean that we won’t have challenges from time to time. And I think probably the best recent example is influenza, where we had a pandemic in 2009 that probably a lot of people have forgotten about. But that same virus that caused that pandemic is with us every flu season. And some season we have a bad season. Not so much usually from that particular virus, but from other flu viruses that also circulate. And some seasons it’s not. We have tools that we use to try to mitigate the impacts, but we haven’t shut down societies typically for it. So in terms of what I think is one possible scenario, Omicron is leaving a tremendous amount of immunity in its wake. It’s my hope that everybody can protect themselves with a vaccine before they have first contact with the virus, but a lot of people are becoming infected, including people who have been previously vaccinated. And so when you add up all of the vaccines, plus the natural infections, it’s starting to feel like we’re building a base of immunity in the population, such that future occurrence of viruses are going to have a harder time causing big surges. That’s one possible scenario. But the asterisk here is whether a new variant will emerge that changes the game. Now many people think that we will—I mean, I think we should expect to see new variants. But whether we will see new variants that are more severe and as transmissible, I think there’s an open scientific question. And there’s some possible reason to believe that there are certain limitations on how severe a virus can be, and how immune it is, just given the amount of immunity that we’ve seen. We have different parts of our immune system that kick into place. And when people have had prior infection or if they’ve been vaccinated, they come to the fight against the virus with advantages that the totally unprotected population in 2020 didn’t have. So I think that’s what he was trying to describe. Was this thing is moving really fast. It’s moving around the planet. It’s really hard to dodge. And when it’s—you know, as it makes its way around, it’s building a base of immunity that will make it harder for other forms of the virus to cause huge disruptive surges in quite the same way, we hope. But, you know, never—(laughs)—get too cocky with this virus, because it seems to be hellbent on trying to prove us wrong. ROBBINS: Well, that was—that’s great. I mean, I read all the stories, didn’t understand it yesterday. And I think I understand—like, I think I understand it a bit better now. Although, I must say that, you know, I immediately looked up the Greek alphabet and looked at all the letters to come, and wondered to myself, you know, why couldn’t there be something even scarier? And you’re suggesting that there is some potential scientific limitation here, and that the—and that we are developing this response. Because I think all of us have seen all those really scary Stephen King things on television that would suggest that we shouldn’t get too cocky about it. But you seem a little bit more confident. NUZZO: Well, I don’t know if I want to say I’m confident. I just think that it’s—we can’t discount the tremendous amount of suffering that has led us to this point, unfortunately. And it is possible that we go into the future having protection, and absolutely possible that we can do more to improve our protection by increasing the amount of vaccination. I mean, one of the things is, if you want to take that scary, scientific sci-fi scenario off the table, the way that we do that is make sure that the globe has vaccines and that we reduce the circulation of this virus, and we reduce the likelihood that variants will emerge. That’s another thing that’s absolutely within our reach. It takes political will, but it’s absolutely within our reach. And, you know, that’s how—if you want to, like, write the ending to the story, that is how you do it. ROBBINS: All right. Thank you. So, Shalina, so I was just sort of thinking. I mean, I have the luxury right now of being more of a reader than a writer, at least on, you know, running stories. I get to pick and choose what I write about now. And I would think that the biggest, you know, challenge is covering a story that’s been going on for such a long time, even though it’s changing. And as we’ve heard from Jennifer, it’s really changing right now. So what do the readers you speak to ask you? What are they—what are they asking you that they want to know about this virus right now? CHATLANI: I definitely think it’s true that I, as a reporter, and many of my colleagues have a little bit of COVID fatigue—(laughs)—when it comes to covering this topic. But I think that, and this is true of public media especially, where, you know, when it comes to service journalism, media that is free and available to the public, the goal first and foremost is to inform people about what’s going on. And so I would imagine that my listeners, my readers want to, you know, have stories that tell them what is Omicron, what is this variant, how transmissible is it, how will it impact me if I’m vaccinated, if I have a booster, if I’m not vaccinated? You know, what does it mean if I’ve already been infected. Could I get infected again? And I think, you know, from science journalism there, you know, there needs to be an emphasis on the fact that science is really hard to understand. And this variant and COVID has been a difficult topic for a lot of people to wrap their heads around. And so I think whenever I approach stories around every new variant, the first thing that I want to do is just inform people about what’s going on and how it might impact them and their families. So that, I think, is the main thing that readers want to hear. And from there, you can kind of go out and expand on the reporting and getting a little bit more niche, and go to, you know, specific communities and see how they’re dealing with it, or look at specific topics like how is this impacting hospitalizations or, you know, certain supply chains? But absolutely, the first thing is explaining the science and what this thing even is. ROBBINS: So this is, you know, fundamental news you can use. Which people love news you can use. That said, it’s also science. And people tend to get scared by science quite often. So when you go out and you—and we were talking before we started and I asked you whether you actually left the house to report. And you actually do leave the house to report, which is a wondrous thing. So you have the great joy of talking to real people in person. And you’re in the South. So do people, A, welcome you to talk about Omicron, or more generally about COVID? And do they ask you questions, I mean, about it? You know, we tend to—particularly those of us in the elite northeast—tend to sort of think that everybody’s in utter denial in the South about this. You know, what’s the interaction like, and how do you do your job explaining and, you know, what feedback and questions are you getting from them. CHATLANI: The South is a little bit of an interesting region, for sure. And I think I can say that because I grew up here. (Laughs.) So there’s a lot of different communities here that, I’ve discovered, have varied opinions about what coronavirus is, what the vaccines are, whether they’re effective. And I think the first thing I do whenever I’m talking to anyone is to just come at them with a sense of compassion and, you know, like we talked about. Science is hard. And it’s really difficult to engage with science journalism if you’re not really used to listening to the news that often or reading the news that often. And so whenever I’m asking people about whether they want to get the vaccine, or whether they believe in coronavirus, or how it’s impacted them, I try to just talk to them like they’re normal people and like I’m a friend or, you know, someone who is just wanting to have a simple conversation with them. It’s not a sort of, like, coming at you, give me information, I want you to be, like, this character in my story. It’s more of a tell me what’s been going on. Coronavirus has been with us for a long time. Has it been difficult for your family? Has it been difficult for you to stick with your job? What types of challenges have you faced? And then we can get into those questions of, so, how do you feel about the vaccine? And once you kind of bridge that human divide there, you know, and talk to people, like they, you know, do know something about what’s going on, I think it yields better responses from people. And that’s especially true in the South, where there is a history of skepticism, as we have seen coming out, and resulting in the hesitancy around the vaccine. There is a little bit of, you know, lack of trust in government and media institutions. And so I don’t want to come in like the person who’s trying to make a characterization out of anyone, because that’s absolutely not the goal and should never be the goal. It’s more about just approaching people as who they are and asking them where they are in their lives when it comes to the pandemic and the possibility of getting vaccination. ROBBINS: So I have some reporting advice questions to ask Jennifer, but I did want to ask you one very quick question. Do you wear a mask when you interview people? CHATLANI: I do. Yes. ROBBINS: Are they wearing masks? CHATLANI: Sometimes no. Obviously, that creates—has created some safety challenges and some concerns. But I was very quick to get my vaccine. And as I got my vaccines, I did feel more safe going out to some rural communities in the South that do have low vaccination rates. But I think that it is something that a lot of health care journalists have been thinking about, especially the ones that do go out and do reporting about what type of, you know, situations that they’re putting themselves in. And you just always have to make sure you take safety precautions. I double mask whenever I go into under-vaccinated communities, or if I’m going into a hospital setting. I make sure I have hand sanitizer, or that, you know, I have whatever precautions I need to stay safe. ROBBINS: And people talk to you, even though you’re masked? They don’t find—they don’t just—I find that, you know, wearing masks in certain circumstances, I feel like people are looking at me askance. Even when I just go in and I’m not even interviewing them. CHATLANI: In the South it’s—you know, some—I might walk up to someone and be wearing a mask and they might think that I’m silly, but there is an emphasis on individual freedom. And I come at people with, you know, my—you know, I’m wearing a mask because that’s what I want to do. I see you’re not wearing a mask. Interesting, tell me about that. It’s not, like, supposed to be accusatory. And so it builds a little bit more of a relationship with the other person that you’re talking to. ROBBINS: So, Jennifer, I sometimes—a question that plays off of this: In past pandemics, is this level of politicization on just basic sort of health hygiene, you know, mask wearing, getting shots—is this sort of a normal thing? And how much of this is an artifact of our current political situation? And how much of this do we just blame on the previous administration and people who want to be, you know, Trump mini-mes? NUZZO: Yeah. So I’m not a historian. I have sights on past epidemics, but real—and pandemics—but really other than the—you know, we’ve been fortunate that the ones in the—to the most part—that have been in recent history have been much more mild than what we’re currently dealing with. And flu was a different virus. You know, I think we can’t forget the fact that this for many people was a virus that they’d never really heard of. Even if you’d kind of heard of SARS in 2003, that was something for most people that happened over there. And so that element actually plays a lot into the reaction to it. When it’s a known virus that you’ve heard of before, that you’re used to people getting, plus, you know, all the experts know a lot about it, that’s just completely different. So I think one element is this was a new virus for many people. It was more severe. But in terms of the political response, I mean, there was just so much about how this played out that for me was absolutely predictable. Just give—I mean, we’ve done—I’ve done tons of, like, tabletop exercises with leaders. There are just some habits that you have to anticipate. Like, as soon as something happens, a political leader—particularly one who’s inexperienced—is going to try to shut down the border. And that will be the totality of the response. It almost never works to stop the virus from coming. And then suddenly they realize that. And then they’re scrambling. Like, there are just some things that you can absolutely predict. I think it is not uncommon for political leaders to try to make a political situation out of a crisis, particularly when they’re in charge and it’s not going well, or if they’re not in charge and they’re trying to make it look more to their advantage. I think we absolutely have to expect that that could happen. I really hope that as a society, as a democracy in particular, that we will elect leaders who just draw the line somewhere. You know, at some level of human suffering where it’s not worth their political careers. I really think that we have to, as a society, have a reckoning about that. But I will tell you, one thing that, to me, feels incredibly different this time around than I have seen in any past event is the degree to which disinformation is dominating our conversation. And it’s clearly some are willingly misusing the information for political gain. But there are just reasonable people who are trying to do their own research and just cannot find facts, based on the fact that our information environment favors the spread of lies. You know, the search algorithms and the social media platforms make it impossible sometimes to see the truth, and much, much easier to see the lies. And so I have seen—you know, I mean, I have talked to all sorts of people from top leaders to QAnon believers. And let me tell you, there’s some similarities in what people believe. And some of it is because it’s coming from the same sources that are being propelled forward by social media and the search engines. And so I had a very senior person in a D.C. circle ask me as question that, you know, a reasonable, like, minute of research would have debunked. But this person either didn’t know to do that, which I find hard to believe, or tried to do it and was unable to turn up the correct information. So when I see people who, frankly, have the resources and sort of should know better not know better, that just makes me think that it’s really impossible for people to navigate the information environment. And that is basically like gasoline to these political infernos that people are setting. ROBBINS: So, you know, we reporters obviously are trained to get information, to get information fast. But not everybody who covers this is a trained science reporter. You know, not every newsroom has the resources to have specified science reporters. There’s a lot of general assignment reporters that have to cover these things. So if you have something like yesterday, and you have the WHO making a statement like that—which drew a lot of attention, because there was this sort of light at the end of the tunnel reaction—so, Jennifer, where would you recommend people go to find the best interpretation of, you know, statements like that? There’s also just an enormous amount of, you know, because our knowledge of these things changes all the time, and, you know, the CDC says this about masks, and then they say this about whether kids should stay home or not stay home, there’s constant, you know, issues that are changing all the time, which feeds into a lot of political anxiety as well as personal anxiety. What do you think are the—you know, the five best places to go to get information if you’re on a deadline? NUZZO: Yeah. So, first of all, I mean, it seems abundantly clear to me that social media is driving news making, both in terms of discovering things that are potentially newsworthy—I think there’s probably no avoiding that. But it also seems to be driving who is commenting on the news. And that’s not necessarily bad. I think it’s a way to identify a diversity of voices and to kind of get more of a collective impression. But proceed with caution, because there are people out there that are just using that to gain fame, frankly. Or, you know, sometimes the loudest voices are the ones, frankly, with the least to say. And the other thing that I deeply lament is that there are some incredibly experienced people who have been through many events—many, many events, who just aren’t active on social media. Sometimes they’re older and it’s just, like, that’s not their thing. Or they just are busy. And I have noticed that they’re often not quoted in papers. And I—you know, and news articles. And it’s possible that they’re not making themselves available, but I think more likely they’re just not being discovered by people who don’t know the beat. So, you know, I think one of the things is to evaluate not just, like, what is this person’s degree in, but do they have actual experience? Like, what is their experience in handling these issues? You know, and I have to say, as an outsider—and, you know, this will sound like a criticism of the industry—but I do really think that there is something lost when there are not subject matter reporters. And I know there may have been a trend earlier to kind of, you know, spin off science sections or reduce science sections. But, like, the biggest challenges society is going to face in the next century are going to be incredibly scientific and technical. And I think it’s really shortsighted, from a business perspective, to not have the right journalists on staff who can interpret that thoughtfully, and then, you know, answer the question better of who really should be a source on this topic. ROBBINS: I don’t think there’s anyone on this call who would disagree with you. But I think there are, you know, probably a few people on this call who, you know, have to pray every morning that their news organizations are going to still be there by the evening, given the— NUZZO: Well, let the rest of us be an advocate. You know, I mean, honestly. It’s—society will be better served with more of you all doing your jobs. ROBBINS: So we have a question from June Leffler. Ms. Leffler, do you want to ask your question, and can you identify yourself for everyone? Q: Hello. My name is June Leffler. I’m the health reporter at West Virginia Public Broadcasting. And I’ll just read what I wrote: So how should we go about reporting on crisis levels at hospitals? So this is a—“crisis level” is a term that I hear from our state health officer and, you know, our West Virginia Hospital Association. But I don’t know really—you know, just talking to those people, I still don’t have a deep sense of how I can illustrate what exactly that means for our listeners. And that’s definitely in part because, you know, I haven’t been in these hospitals before. And so I’m wondering, you know, how can we go about, you know, reporting on hospitals and what they’re facing during this pandemic? And which questions should we be asking them? What data should we be asking them for, knowing that these are private institutions, in my state. And, you know, they want to keep up the veil that they’re doing the absolute best they can. NUZZO: I can weigh in on that. I don’t know who it was directed towards. Yeah, this is a really important area of inquiry, and one, I think, that’s hard to do. I have a few suggestions of storylines that I would like to see explored. One is that it’s—I do not doubt that hospitals are absolutely stressed and operating at the max. It’s really interesting when you look at the hospitalization data over the course of the pandemic how flat the totals have been, but the categories shift. Which really speaks to there’s this upper, fixed capacity that has existed for the past two years, and in some cases has actually ratcheted down because they have lost staff. And when we’re talking about hospital capacity, what we’re really talking about is are there enough staff to take care of patients. And so they’ve lost staff. And that’s been discussed widely. But what are they doing to fix it? Like, what are we as a country doing to, like, raise the line? We talk about flattening the curve because we’re trying to—we’re trying to flatten the curve below the upper—the line, which is the upper limit of the health care system. But, you know, this, like, lean, just-in-time staffing approach to health care is clearly not working in this situation, and frankly doesn’t work in many situations. I mean, we talk about past pandemics, but the 2017 flu season was a killer. I mean, hospitals, if you spoke to them, if somebody actually showed up and talked to them in 2017, they would have found that they were really at the brink, from not a pandemic just a really bad flu season. So I think there’s a storyline which is just, you know, what are the drivers of this? I think some of it are about the business models of these places. I think some of it are about staffing limitations. Some of it may be in terms of limitations of what—who we can bring in to help work in these settings. That’s one area where I’d like to see. The other thing is talking to patients and finding out what they’ve not been able to get done because of the crunches. So, you know, the people who have not been able to get—to see a specialist because they’re putting certain procedures on hold. You know, hearing from people who are not necessarily needing to access the health system for COVID, but for other—just the other stuff that’s not getting done because we’ve had to kind of pivot the whole system. I think hearing about what is not happening from the perspective of patients is really key, because I think there it’s really more revealing when you hear about it. I had a friend whose family member was in the hospital and really needed to be transferred to somewhere that could give adequate care, but there were just no transfers happening. Not for COVID, but there was just capacity issues. So how has the provision of regular care degraded because of the crisis situation we’re in? To me, that’s more revealing than what the numbers say, because the numbers to some extent are—there’s some artificial constraints on them. But how we fix them and how—and what is the consequence of those numbers I think are the stories that are quite important. ROBBINS: Shalina, you’ve done quite a lot of reporting on this I know, about nursing shortages and all of that. So what stories have you been reporting? And have you been able to pry, you know, certainly what Jennifer was saying is absolutely essential. But I suspect, you know, we love numbers. We love data as well. CHATLANI: Yeah, I do have a few suggestions for June. I think that the first thing I would do, when I’m thinking about whether hospitals are going through a crisis, is to figure out what the state defines as crisis standards of care. So that’s a term that gets thrown out a lot when health departments are talking about hospitals being overcapacity. So what does that actually mean, from the state’s definition? So does that mean that there are more patients than there are beds? Does that mean there are not enough staff for every bed? Does that mean that they have to ask, you know, emergency management agencies to ask for certain types of help? Do they have to seek help from the federal government for something? And then I would go to the state hospital association and ask them if they have heard any reports of any particular hospitals that have faced these particular, you know, crisis standards of care. And then I would go to that hospital that they identify and ask them what’s going on. So, you know, in addition to that, some things that I do to figure out what the state of care is in a state is to go to the CDC. Because the CDC actually releases data every day on what percentage of hospitals don’t have enough staff to meet care. They also have numbers on transmission levels. It’s really, really, really detailed. And it gives you a really good picture of what level of hospitalizations are at in the state, whether there’s enough staff. And then, again, I would take that data and go to the hospital association and say: This is what the CDC says. Is this what’s actually happening? To an extent, I agree that, you know, private hospitals might be wanting to save face and say, you know, everything is fine. But on the other hand, I’ve noticed that hospitals, they’re also trying to be really transparent, right, because they can’t do the best job that they could possibly do caring for patients that are there if they’re overcapacity. They’ll have to care for patients in hallways. You know, I’ve heard of that happening in a lot of rural hospitals that are overcapacity. They will have people waiting in emergency rooms that they can’t see. They absolutely don’t want this to be happening because it is—it just puts unnecessary pressure on the staff and the hospital, right? So I think that there’s definitely a healthy level of skepticism. But for a lot of hospitals that are operating at really low, you know, budgets that are dealing with this crisis, they’re just trying to get by. So I would go and check out those data sources. Look at definitions. Go to the health department. Go to the hospital association and ask them: Where is this crisis standard of care erupting in the state? And go there and go to those communities. Go to the hospital. Talk to the leaders. Go, you know, talk to people in that community and ask them, like, have you had a situation where you need to go to the hospital? Have you been able to go? Did you have to wait? I think there’s definitely a way to approach that. And that is definitely, to your question, Carla, what I’ve been trying to do with the nursing—the staffing crisis stories, is—basically, those were all the steps I took. I looked at the CDC data, figured out what the situation was. I went to the hospital association. I’ve asked, you know, are there any hospitals that are on the edge right now, that are closing beds, you know, because they don’t have staff. And that’s how I’ve been able to find hospitals. And a lot of them have been very honest about the situation because they don’t want it to be the situation. They have lots of patients that they need to see. And a lot of people in health care are burnt out and sad that they can’t, you know, treat some patients as well as they would like to, because they are so overburdened. And I think you should play into that fact. You know, creating a villain, I think, out of some staff is just not going to get you what you want. And approaching them from a standpoint of, like, hey, I know this is a crazy situation. Tell me about—a story where you had to make a snap decision because there’s a patient that is on a ventilator and, you know, could die. Do you care for them, or do you care for the person who just came into the emergency room? Like, asking them about those situations can really yield a lot of results. ROBBINS: So we also had Alexandra, is it Pare or Pere, from Tucson Local Media had her hand up. Alexandra, can you share your question? Q: Hey, can you guys hear me? ROBBINS: Absolutely. Q: Hi. My name is Alexandra Pere from Tucson Local Media here in Tucson, Arizona. I just wanted to know, you know, I’m really interested in how to properly communicate and explain how vaccines help to stop mutations of the virus? I haven’t really gotten a good explanation on that, and I would just love to hear your perspectives on how to explain that to the community. NUZZO: So, you know, I think it’s really more of a simple math, which is every time the virus replicates there’s the opportunity that it’s going to copy itself incorrectly. And because of that, that’s one reason why mutations tend to occur in people who—not exclusively, by any means—but people who are immunocompromised, because they often have the virus in them for longer, so there’s just more copies being made over a longer period of time. But the way you see that at the population level is the fewer people who have the virus, the fewer viruses that are copying themselves, and the fewer opportunities for mutations to occur. Also, when mutations occur, they may not have any functional ability on their own, but over time they may gain them. And so that the more you pass that virus onto others, the more opportunities for it to, you know, try to perfect—(laughs)—the mutation. So generally speaking, the fewer copies of the virus there are on the planet, the less—the lower the likelihood that mutations will occur. ROBBINS: So that actually raises this question—I’m sorry, Alexandra, did that answer your question or do you have a follow on? Q: No, I think that did answer. I think I just hear a lot of pushback from people who are like, oh, why don’t I just, you know, end up getting Omicron, and then I’ll have natural immunity, as opposed to getting the vaccine. And so I just wanted to clear away to kind of explain how the vaccine halt the mutations. NUZZO: Can I just chime in on that, because I think those are two separate issues. Because really I think we have to think about the vaccines, above all, as protecting you against severe illness. We certainly do see fewer cases reported among people who have been vaccinated, but clearly people who are vaccinated get this virus, including—you know, and we are seeing people who are multiply infected with the virus naturally, including people who have been vaccinated. So my answer to that is less about the variants, and more about, listen, Omicron has some features that may make it less likely to make you severely ill, but part of why we’re seeing less of an impact in terms of severe illness is because we have prior immunity in the population both from natural infection and from vaccination. So people are going into that first contact with Omicron with armor—(laughs)—you know? Their immune systems are ready to fight. And we have certainly seen people who have not had previous immunity through vaccination or prior infection, who have gotten Omicron and died. So the answer to why you want to get vaccinated is because you want—you don’t know where you’re going to be on that curve of people. Sure, most people who get infected don’t die, but you don’t know on an individual where you’re—if you’re going to be the rare case or if you’re going to be the average case. So the vaccines are the insurance that really buy down your risk in terms of having severe illness. ROBBINS: Can we talk about—I’m sorry. Yes, Shalina? CHATLANI: Well, just to add to that, Alexandra, I think as a reporter one thing to really equip yourself with is a set of really simple metaphors. Like, if you were to write down a twenty-second explainer for why the vaccines are important, and just keep that with you, because you’re going to be engaging with people that don’t think about, don’t read about, don’t know about science. And the vaccines are unlike other ones. I mean, the technology has existed for a really long time, but most of the time when people think about vaccines, right, they think, oh, you’re getting a little bit of the virus so then your body learns how to fight it off, and so you build up this immunity. These vaccines are different from that, the first ones that came out. So it’s really difficult to explain it to people. And then once they get another variant, they wonder what happened. You told me this was going to give me protection. So, you know, maybe, Jennifer, you have an idea for what those metaphors could be, but I think really sitting down for a second and thinking: What is the simplest way I could possibly explain this to someone, can be really useful to you. And I guess one way that I think about it is the vaccine is like a code in your body that tells you to fight off the virus when it—when it gets to you. Like, there’s a code there. And sometimes that code has to be tweaked, and you get a booster shot. So, I don’t know, that’s one way I think about it. What do you think, Jennifer? NUZZO: Yeah. I mean, you know, I try to stress to people that they’re not bug zappers. (Laughs.) Like, the vaccine doesn’t repel the virus from your body. (Laughter.) It is a set of instructions for how to defeat the enemy. And your—it trains your immune system for the fight. And I say that because some people are, like, but I eat a plant-based diet. I’m healthy. And you’re like, that is great. I’m glad you’re doing that. But that’s necessary, but not sufficient, because, you know, you could be a generally healthy, fit person. But if you showed up to run an ultramarathon never having trained for the race, you’re probably not going to do very well. So vaccines really train your body specifically for the fight, and so that you have a better chance of defeating the virus when you meet it for the first time. And you’re right, it’s not the same as natural infection, which has strengths and weaknesses, truthfully. And part of the reason that it’s not the same is that your body never sees the virus until you get infected. It just sees a piece of it. And it’s the piece that the virus uses to hook onto your cells and to enter into your cells. So, you know, there is now some evidence that people who had prior vaccination who then got reinfected probably together have better immunity than each of those separately. ROBBINS: Do we have another raised hand? Liz from New Jersey Advanced Media. Liz, is it, Llorente? Q: Yes. Yes, Llorente. Can you hear me? ROBBINS: Perfecto, si. Q: Oh, muy bien, muy bien. OK. (Laughs.) Thank you, Carla, for knowing how to pronounce my last name. (Laughter.) OK, Jennifer, question: Just, you know, I’ve been writing about—like we all have, I guess—about the pandemic. And of course, you know, one of the issues that I find is that, especially in New York and New Jersey, we have a lot of restaurants, a lot of businesses saying, you know, get a vaccine for yourself and for—and to protect others. But does my getting a vaccine protect other people? I mean? NUZZO: Yes, it does. I think not as much as we had hoped. (Laughs.) And when—I think when we were probably in the blissful period of sort of the end of June/July, I think we had a belief that breakthrough infections—which I actually hate that term, because I think it was setting the vaccine up for an impossible standard that vaccines can’t possibly meet. But I think we thought that if you were vaccinated the likelihood that you would experience symptomatic illness after becoming infected was much lower than it has turned out to be. But it is clearly lower. And one way that it does help is that if you do become infected—and some portion of people are going to become infected and literally never know it—that the time period in which you can transmit is actually probably shorter. So if you’re walking around and you don’t know it, the period of time in which you’re exposing people potentially in a dangerous way is shorter if you’re infected. And if you think—like, if we all did that, that would add up to a much higher level of protection in the community than we would have if people weren’t doing that. But I really think—I mean, I continue to stress for people that, yes, do it for others. And, you know, there’s some evidence that maybe it helps a little bit in your household. But really, do it for yourself. I mean, it is, again, arming yourself against the worst possible outcomes. It’s the free insurance against the worst possible outcomes from this virus. ROBBINS: So thank you for that. John Allison, who’s the director of content for the Tribune-Review, has a comment in the Q&A, and who notes that we may not have subject-matter experts in our newsrooms but we do have many in our communities, such as the Johns Hopkins Center for Health Security Fellow Dr. Amesh, is it, Adalja? NUZZO: Amesh. Amesh Adalja. Yeah, he’s a colleague of mine, yeah. ROBBINS: OK. Great. And we routinely ask him five questions and present as text and video. And he’s got a link. This is a really interesting feature that you guys have set up. John, do you want to talk about it? Is John still with us? Maybe not. Q: I’m unmuted. ROBBINS: Oh, perfect. You want to talk about how you guys set up that feature? That sounds like a great idea. Q: Yes. He is—Amesh is very media friendly. And he’s—I’m in Pittsburgh. He lives in Pittsburgh, and he’s associated with the Baltimore Institution. NUZZO: Yeah. We work together. (Laughs.) Q: Yeah, exactly. NUZZO: And we’re friends, yeah. Q: Yes. Yes. And that’s good. I didn’t want to step into some rivalry, so I’m glad you’re friends. NUZZO: No, not at all. No. (Laughter.) I ask him questions all the time, yeah. Q: Great. For us, this has been a perfect way to present it succinctly. Five questions is a nice round figure. We do it a lot. We’ve established him as an expert. And we’ve followed others, we have a couple of big health care centers in the Pittsburgh area. And we pull them in. We are not going to be able to hire a medical doctor on our staff. I’ve worked at other newspapers that have. So, Carla, thank you for—you know, but we are stable financially, but just by being the size that we are we couldn’t maintain that. So thank you to Amesh. Thank you to you, Dr. Nuzzo, for speaking clearly. Your work on Twitter is very important. It leads us to experts who can speak and thank you. NUZZO: Thank you. Yeah, Amesh is wonderful. He is a rare person because he has expertise in multiple medical fields—critical care, infectious diseases, and emergency medicine, which is basically a unicorn. So you’re lucky to get him. But he just loves—he’s an educator, and loves sharing what he knows. So if we could clone him, it would be good for the country. ROBBINS: Shalina, do you have any unicorns of your own you want to share with us? CHATLANI: In terms of sources? Well, there’s a lot of sources that I go to in the South when it comes to specifically equity issues in science. There’s Dr. Thomas LaVeist at Tulane University, who works in public health policy but also has a background in understanding health in diverse communities. And so he’s a source I go to pretty often because you can’t really talk about health equity in the South without talking about socioeconomic and racial divides. And so I try to incorporate that into a lot of my reporting, and find subject-matter experts like him that sort of, like, know about health but also know about community issues. ROBBINS: So that’s another unicorn. That’s great. Love unicorns. Catherine Marfin—Catherine, do you want to ask your question and tell us with whom you work? I’m sorry, I don’t have the list right in front of me. Q: Hi. Can you all hear me? ROBBINS: Yep. Q: OK. Sorry. I’m in Starbucks. It might be a little loud. My name’s Catherine Marfin. I’m with the Dallas Morning News in Texas. I was just wondering, Jennifer, if you could elaborate a little bit on why you take issue with—or, I guess, kind of have a problem with the term “breakthrough infections.” And I guess is that possible—is that, like, are “breakthrough,” quote/unquote, infections possible with other vaccines? NUZZO: Yeah. So, again, you know, if you think about how—what vaccines do, they train your immune system to recognize the virus and then to react quickly, hopefully before you have any symptomatic disease but certainly before, you know, too many of your cells become infected from—by the virus. But again, they’re not forcefields. Like, they don’t repel the virus from your body. And so how does your body know that the—that the virus is there? Usually, it’s when the virus invades your cells, which is the technical definition of infection. Now, it may be possible if we had a different kind of vaccine for this virus, maybe, like, an internasal vaccine, that there would be more immunity at the site. But it’s still even unclear—I think we’re sort of rethinking, like, what vaccines actually do, and whether this idea of preventing infection is even that feasible. Part of what we’re seeing too is that we are aided by a level of diagnosis and testing that we don’t see for other diseases. And if we had—you know, often hold up the measles vaccine as, like, the standard of the best vaccine. But if we had a lot of measles circulating, and if we did a lot of testing, would we see a lot more breakthrough infections that we just don’t notice because the symptoms are so mild? So that’s why I just don’t like that term, because it implies that the vaccine filed, when in fact maybe it—I’m not sure failure is actually right. I think the vaccines are doing what we need them to do. I think people would love to feel less lousy when they get infected, but I view any infection that doesn’t send somebody to the hospital as success, because if this virus could never put people in the hospital or kill them, most people would have never heard of it. And I think losing sight of that is, one, fueling a level of anxiety that I think is just unhelpful, but also underselling the vaccines and how incredibly powerful they are in gaining freedoms for us, and removing worries, at cetera. Obviously, there are people who still we worry about, for sure. And I don’t want to downplay the risks that they experience. But they’re not risks that we don’t see for other viruses as well. And so that’s where we need other tools to try to protect people. ROBBINS: Jennifer has a Ted Talk, and we’ll share the link with that, which I recommend. I do do my homework for these things. But there’s a very interesting question here. We have unreasonable expectations, I think, of people who are in the world of medicine. You know, you go to a lawyer and ask her a question and she says: Come back in a week and I’ll give you the answer. And no one says: Oh my God, you’re not prepared for this! You go to someone in the medical world, you expect them to give you a definitive answer, and the answer to stay, right? And so the fact that this has been a moving target, and that we’re getting different answers over time has not only created anxiety among people, it’s reinforced the skepticism that Shalina was talking about. And it’s certainly played into the more general anti-government feeling that exists out there. And, you know, this raises a really interesting question about looking forward about communications strategy. You know, we, as recipients of communications strategies, as reporters, I think also have the responsibility. And we’ve been dealing with questions of the big lie, you know, have truth sandwiches, and all these other things. How do we do this? What sort of caveating do we need to do when we’re told something that sounds definitive—like, masks, you know, do this, or vaccines do that, and knowing how many times it’s turned out, you know, as great as Fauci may be, he may have to change his mind or change the message three months down the road. Should we, as reporters, be presenting things that sound definitive with more caveats, but without, at the same time, running the risk of undermining the important message? That’s for Jennifer, but I’m sure Shalina’s thought about it too. NUZZO: Yeah. I mean, it’s tough because you’re either faced with not answering because you just don’t know definitively, or answering and saying, listen, this is my best guess based on—this is why I think this. I tend to fall in that camp, because particularly—I mean, the most frequent questions I get asked from people that I encounter are just, like, how to live life, right? And so people need to have an answer to that question, because they can’t not live life for the next six months while we gather data. So I fall on the camp of saying, listen, this is why I think this. This is possibly what would make me change my mind. So in the future I’m going to be looking at this. And if this changes, then I’m going to do this. Like, I try to describe the scenarios. But I think where officials have erred has been on not setting up—not describing the process that they have come to that conclusion, and then describing what is currently not known that could lead them to change their minds. And that when they do change their minds, describing very clearly what evidence was used to make that change. Because sometimes I think we are just getting these very clipped, summarized statements that are doing a disservice because they are not being accompanied by the supporting material. And I think that sometimes that’s done for the purposes of message clarity, but I’m not sure that’s what it’s achieving. ROBBINS: Shalina, how do you think about this? I mean, you must have covered many things that sounded definitive and then you had to change them, without writing a correction, three months down the road. CHATLANI: Yeah, it was definitely—in terms of what to trust when it comes to the science, that was definitely hard when I was a hard science reporter in San Diego at KPBS, because this was something that we had never dealt with. And, you know, talking to different scientists and getting news alerts, getting press releases, it was really hard to wade through what is news? What do I report on? What do I tell people is something new? One example I think about, as I was covering, you know, the search for the vaccine, because San Diego has a lot of research institutions. So I would be getting a lot of press releases about it. You know, every other day I’d hear about an institution that found an antibody. And they were, you know, an antibody, which is something that the body produces to fight off the virus, right. So they could isolate an antibody and use that to create a vaccine, or think of a different therapy. And everyone was looking for antibodies. So it’s, like, do you—do you report that a research institution just found another one? Or do you just go to—you know, or do you just let it go, because then you’re giving people false hope? So it was really hard. And the way I kind of dealt with that is I had some key scientists that were kind of straight shooters, that, like, would tell it to me straight. And I would go to them. And I would say, hey, this person just told me that this thing happened. What’s your opinion? And a lot of times the scientists that I had developed this relationship with—that I honestly think had no skin in the game when it came to whether their vaccine was the one that was going to be—you know, the one that got picked, or anything like that—would say, eh, that’s just another antibody. We don’t have a vaccine yet, you know? And that would help me. So I had, like, a lot of trusted people that I would go to. When it comes to things like masking, whether the vaccines are safe, I think pretty generally we know at this point that masking helps give you protection. Like, that’s the—that’s the (net grab ?) on masking. Vaccines help build your immunity. And those are really the only two facts I think you need to know when it comes to reporting on those two issues at this point. And those are the only things that are really going to be in people’s brains when it comes to how it impacts their day-to-day lives. And I think the reporting has to shift to real-world impacts for masking and vaccination. For example, here in New Orleans, we have carnival season coming up. There’s Marti Gras. Marti Gras last year wasn’t that great, because a lot of people, you know, were scared to go out and, you know, get infected. Of course, that did happen. And we had a huge surge in cases. But I think a lot of people at this point just want their kids to be back in school. They want to be able to go to their jobs. They want to be able to have Thanksgiving and Christmas with their families. And the messaging should be masking helps protect you so that you can do these things that you want to do. Vaccines help protect you so that you can do these things that you want to do and you can get back to your normal day-to-day lives. So I think now it’s this. ROBBINS: So, just to follow on this—and we only have two minutes left—Vicky Diaz-Camacho from Kansas City PBS, can you ask the question in a minute, so we can give Jennifer one minute to respond? It follows on exactly what Shalina was saying. I think— Q: Yes, it does, actually. So I lead the Journalism Engagement Initiative at Kansas City PBS. And so I get a lot of public questions about vaccine efficacy and all of that stuff. And I think that I’m sensing a lot of fatigue from the message “vaccines are safe.” So I see that there are less people going out to get their boosters. And so I’m hoping you can explain, how do you get the clear message across about societal responsibility and the need to still get boosted? NUZZO: Yeah. I’m not sure that that’s the best message for everybody, I’ll just say honestly. I mean, I think people when they’re making a medical decision are largely making it for themselves and their loved ones. I think there are some people that that broader, like, protect a grandma that you don’t know, like, resonates with them. But I would tell you, by and large, like, when I talk to parents who are wondering about getting their kids vaccinated, I talk about how it’s going to take some worries off their plate. You know, so I’m not sure the message is do it for somebody you’ve never met. It’s, listen, we’re all going to come in contact with this virus. And if you have the third dose, you’re less likely to—you know, you may be sick for four days instead of two weeks. I mean, I just—I think that message is more compelling for a lot of people. ROBBINS: Well, I just want to thank Shalina for sharing all your—including your sources, which is—which is—(laughs)—usually we don’t do that. And Jennifer, for extraordinary insights. And we will, you know, push some information out to you guys, including the link to Jennifer’s Ted Talk, and links to some stories that Shalina has written. And I turn it back to Irina. And this has been a great conversation and great questions from you all. FASKIANOS: It has. Just to echo what Carla said, thank you all. And we will be sending out a follow-up email with a link to this webinar so you can listen to it and share it with your colleagues who could not join us today. And I just want to point out, you can follow Jennifer Nuzzo on Twitter at @jennifernuzzo. Some of you already are, but if you aren’t, follow her there. Shalina at @chatlanis, and Carla at @robbinscarla. So go to Twitter to follow their sources. And please visit CFR.org, ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on coronavirus and international trends, and how they are affecting the United States. And as always, we look to you to share suggestions for—suggestions on topics, speakers that you would like in future webinars. So please send an email to [email protected]. So thank you all and stay safe.

Panelists discuss global vaccine distribution efforts, the barriers to achieving vaccine equity, and what this means for global economic recovery. 

John Fea, professor of American history at Messiah University, and Michelle Mello, professor of law and medicine at Stanford University, discuss the history and legality of religious exemptions to vaccines in America. Learn more about CFR's Religion and Foreign Policy Program. FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Religion and Foreign Policy webinar series. I’m Irina Faskianos, vice president of the National Program and Outreach at CFR. As a reminder, the webinar is on the record, and the audio, video, and transcript will be made 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 with us Dr. John Fea and Dr. Michelle Mello. We’ve shared their bios with you, so I will just give you a few highlights. Dr. John Fea is professor of American history and chair of the history department at Messiah University. He’s the author or editor of six books, including Believe Me: The Evangelical Road to Donald Trump. He authored an article titled “Cherry-picking the Bible and using verses out of context isn't a practice confined to those opposed to vaccines—it has been done for centuries.” Dr. Fea is the executive editor of Current and he is currently working on a book on the American Revolution in New Jersey and a survey of American Christianity. Dr. Michelle Mello is a professor of law and a professor of medicine at Stanford University. A leading empirical health law scholar, Dr. Mello is the author of more than two hundred articles on medical liability, public health law, pharmaceuticals and vaccines, biomedical research ethics and governance, as well as many other topics. Dr. Mello is the recipient of a number of awards, including a 2014 election to the National Academy of Medicine, formerly known as the Institute of Medicine, and it was one of the highest honors in the fields of health and medicine. So, Dr. Fea and Dr. Mello, thank you very much for being with us today to discuss vaccines and religious exemptions. So, John, I thought we could begin with you togive us the historical context for the use of religious exemptions to vaccines in America. FEA: Yeah. Sure. You know, you gave me five to seven minutes to discuss—(laughs)—the history of this. For the sake of a talk like this, I think there are, as I see it, I think there are essentially four kind of eras in United States history in terms of religious opposition to vaccines and other attempts, like inoculation for example, to stop the spread of disease. Until you get the first vaccine—Edward Jenner’s smallpox vaccine in the late 18 century, which really comes to the United States in the early 19 century—the colonies and the early national United States treated disease, and specifically smallpox we’re talking about here, through inoculation—which, as many of you know is essentially injecting the disease into the body. There was some religious opposition to this practice. Especially, there were huge debates over it in the early 18 century in colonial New England. But much of the opposition to smallpox inoculation was based largely upon just the danger of the practice. People died as a result, and sometimes the inoculations were botched and the disease spread even further. But having said that, there were—there were religious leaders, some of the most prominent religious leaders in the 18 century, who did take the inoculation and advocated for the inoculation, most famous being Cotton Mather, the 18 century minister in New England, and then later Jonathan Edwards, who died as the third president of the College of New Jersey—Princeton—from taking the smallpox inoculation. So, there’s this early phase, I think, of inoculation. I’ll go through that very quickly simply just to register that, at least, because this is very different than, say, vaccines. When vaccines begin to kick in—literally from the Latin word vaccus, for “cow,” right, the injection now of cowpox into human beings—you have this kind of second phase or this second era. Much of the legal history of this centers around mandates that local communities/towns/states put into place. Massachusetts is at the forefront of this in the 19 century, issuing mandates for the smallpox vaccines. The high point here is in the early 2h century—and perhaps Dr. Mello will say some things about this as well—with the famous 1905 case Jacobson vs. Massachusetts in which the Supreme Court of the United States decided that a Massachusetts vaccination law did not violate the 14 Amendment and a state, essentially, could constrain individual liberties to protect public safety against smallpox outbreaks. And then, really, the only other time—and again, Dr. Mello can correct me if I’m wrong on this—that the United States Supreme Court deals with vaccines is seventeen years later in a case that, essentially, allows for mandates of children to be vaccinated to go to public and private schools. So much of the opposition to these Supreme Court cases were oppositions based upon individual liberties, right, that government is intruding on our individual liberties, or the ineffectiveness of the vaccines so why do we have to mandate them, or perhaps there were arguments made that smallpox is no longer as much as a threat as it once was, so why do we need these vaccines. But I guess the point for this discussion is there was very little religious opposition. Whatever religious opposition came to vaccine mandates in, say, after the Civil War and before World War II were largely from kind of out-of-the-mainstream religious sects like, for example, the Christian Scientists or the Swedenborgian Church, a small little sect in Pennsylvania. Even the Christian Scientists in—or at least in the late 19/early 20 century received so much public pressure—because their children were dying in Christian Scientist schools, the disease was spreading among the community, the received so much pressure that even Mary Baker Eddy, the founder of the movement, told followers to take the vaccine and essentially pray once they took the vaccine that the vaccine wouldn’t kill them, right, was their approach to all of this. So, I think in this period from roughly, say, 1800 to, 1940 or World War II, there’s not a whole lot of religious opposition to vaccines. There is opposition, but very rarely is it framed in religious terms. I think that leads, then, to a third era, really that sort of takes off in the decades following the polio vaccine in the ’50s and then the measles vaccine, which was in the early 1960s, and I think most of the debate here focused on vaccination of children in schools. For example, Christians and other religious groups, I would say most of them overwhelmingly saw the vaccine as a gift from God, right? I mean, it’s amazing to read newspapers in the 1950s and 1960s, and seeing these religious leaders of all types, including evangelical Christians, talking about the polio vaccine as something that God has brought as a special gift to fight disease. Having said that, this is also the era where you begin to see religious exemptions for the first time—the actual phrase “religious exemptions” being used. I think a lot of this has to do with the idea of religious exemptions for all kinds of things, not just vaccines, are introduced into the kind of legal and political sphere with the Civil Rights Act of 1964, which of course prohibits employment discrimination based on color, race, religion, sex, national origins. So you do see pushes here for religious exemption, but again they are still largely by sects like Christian Scientists; the Amish; in some extent I think I’ve seen cases of Jehovah Witnesses  pushing for religious vaccines; but again, nothing kind of mainstream, right? There are a series of smaller cases, local cases, state cases in which these things are debated. Maybe we can get into them during the Q&A. But mostly the Christian Scientists are at the heart of these discussions, looking for some type of religious exemption. And then if I could just bring it up to the present before I close, finally, I think COVID-19 has brought us into a kind of fourth phase. It’s a much more complicated and complex phase and debate over religious exemptions. A lot of things happened. At the end of the 20 century you had this Lancet article published by Andrew Wakefield which suggested that vaccines, especially the MMR vaccine—the measles, mumps, rubella vaccine—led to autism in children. I think—it was completely, completely debunked. That was proven to be a fraudulent claim, but I think it did empower a certain kind of anti-vaxxer movement led by a few celebrities. Some of us may be familiar with those names. And then with this growing anti-vaxxer community, I think, again, led by these prominent celebrities, the call for religious exemptions kind of entered much more into the mainstream than they were before, or at least as much into the mainstream as—let me put it this way. I think they entered the mainstream alongside the rise of cable news outlets, social media, and so forth in a way, perhaps, that we haven’t seen before in American history. Maybe “mainstream” is the wrong word there, but certainly you have more appeals to these kinds of religious exemptions than you’ve seen before. But I think it’s also during this period that Evangelical Christians have played the most prominent role in calling for the rights to religious exemptions in a way that they had not before. So I think this is the point where we are at now. Again, I think most of the religious exemption claims that I see are coming from—not entirely, but coming from Evangelical Christians and conservative Catholics. But overall, the discussion of religious exemptions has not really been delved into very much by American historians. There are some very, very good books on anti-vax movements that cover religion. But I think one of the reasons why historians have not really dug deeply is because religious exemptions is really only a recent phenomenon. So maybe we could flesh this out a little bit more during the Q&A, but I’ll stop there. FASKIANOS: Thank you very much. Dr. Mello, can you talk about the legality of religious exemptions to both the COVID-19 vaccine in places that have imposed mandates and how religion is being used as a loophole? MELLO: Well, maybe I’ll start with the last part of your question there because I think that maybe merits a little bit of unpacking. I think the term “loophole” is pretty charged. The fact is that the law has long recognized the right of sincere religious objectors to request an accommodation when there is a vaccination mandate. It might be reasonable to raise the question about whether that exemption is being stretched to a point where it was not intended to go for COVID, and I’m happy to talk about that. But as I intimated, the law—both statutory, the laws that Congress and legislatures make, and constitutional law—has long recognized that religious liberty can be implicated by vaccination mandates and has made provision for that. And maybe it makes sense for me to just dwell separately on those two bodies of law. The statutory law, federal civil rights laws and to a lesser extent state civil rights laws, are mostly important for employer mandates. If you’re a reasonably large employer, you are covered by the Civil Rights Act of 1964, Americans With Disabilities Act. If you receive federal funding, you’re covered by the Rehabilitation Act. And these laws protect certain classes of civil rights, including the right not to be discriminated against based on race, disability, and religion. And so employers have to offer what the law calls a reasonable accommodation for religious objections unless it would pose an undue hardship on the employer. What does that mean? Well, a reasonable accommodation in the context of the COVID vaccine would be something like you have to get tested once or twice a week, you have to wear a mask at the worksite, depending on your occupation you have to work from home. These are the types of things that would be within the realm of the reasonable. Now, what constitutes an undue hardship under Title 7? That’s actually a really employer friendly standard. If the employer can just argue, look, this is more than a minimal cost burden on me to do this, for example to provide test kits to everybody twice a week, it’s quite possible that a court would say, OK,  you don’t have to provide that accommodation. In other words, you don’t have to accommodate a religious exemption in that way. There is another important aspect of the civil rights law, which is that if a person poses a direct threat—meaning they—a court would deem to pose a substantial risk of substantial harm to others, that cannot be reduced by reasonable accommodation, you don’t have to accommodate their religious objection to vaccination. And that obviously has a lot of traction in the realm of infectious disease. That was the reason for the direct threat exception. Now, COVID’s not a wildly infectious disease. It’s not measles. There are other things that we know are effective in preventing transmission. But that too is available to employers who don’t want to accommodate a religious objection. What tends to be on the employee-friendly side is how employers are supposed to treat requests for religious exemptions, which is to say they’re supposed to give people the benefit of the doubt. If the employer is aware of facts that would lead the employer to believe either this is not a religious belief, it’s something else—it’s just sort of philosophical, personal in nature, or it’s political, ideological in nature, or it’s not a sincere religious belief, then the employer can request additional information and scrutinize it a little bit. So, for example, if this was the first time the employer has ever raised a religious exemption to a vaccine— she’s gotten dozens of other vaccines in her lifetime—that’s salient information. But under the civil rights generally you’re supposed to give people the benefit of the doubt. And employers tend to get into trouble when they look too hard behind those claims of religious belief. Now, in nonemployment contexts, what’s most important is not these federal civil rights laws, but rather the Constitution. And here the law is a little bit less crisp, as is always the case when we compare constitutional to statutory law. And here, it is also increasingly unsettled as to what is constitutionally required in terms of accommodating religious exemptions. So let me give the basics, and then I’ll talk about three things that I think are under contestation right now. And when I say right now, I mean literally right now. Every day in my inbox there are two to three new court rulings coming down in this specific area. It is wildly unstable territory, from a doctrinal perspective. The basics, as John intimated, the Supreme Court has never held that a religious exemption to a vaccination mandate—and here, we’re thinking about state, or city, or school district mandates—is constitutionally required. And most lower courts haven’t either. Instead, lower courts have applied something called “rational basis review” when they’ve been evaluating challenges by religious objectors. And that merely requires a judge to say: Is what the state or school district is doing here in pursuit of a legitimate state interest? And is it reasonably related to that interest? And in practice, that comes down to an inquiry that sounds an awful lot like, is it crazy? If it’s not crazy, the court is going to defer to what the government has done. And that’s been the lay of the land for vaccination mandates for a very long time. Now, when somebody’s religious objection gets denied by a school district, let’s say, courts will look at the procedures used to deny that request and make sure that they are fair procedurally, and that the hew closely to our standards about what constitutes a sincerely held religious belief. And here the analysis looks pretty similar, as it does under federal civil rights law. They’ll look at, you know, is this person articulating something that sounds like it’s about God or a belief system that stands in the place of God? It’s bigger than vaccines. It’s kind of an organizing framework for their life. And does it actually prohibit them from taking this vaccine? They don’t require that petitioners be members of a recognized or established religion. They don’t require that they attend services or make other performative gestures demonstrating their allegiance to the religion. They don’t require that a clergy member provide an attestation saying: Yes, indeed, our religion prohibits this from happening. Nevertheless, even without those indica, they may still—and often do—find that a belief is not religious in nature. For example, some cases have involved vegans arguing that veganism stands in the place of a supreme being in terms of the organizing framework for their life. And most courts have said, hmm, not quite. That does not rise to the level of a spiritual or religious belief. OK, so that’s the basic. For a long time, lots of deference to organizations that want to impose vaccination mandates, even in the face of religious objections. What’s being contested now in courts across the country, and I believe soon at the Supreme Court, is three things. First, what is it exactly that constitutes a sincerely held religious belief? Now, I’ve outlined certain things that the courts have established you don’t have to show, like your pastor agrees with you about the religion having—you don’t have to provide this attestation that the religion bars you from receiving the vaccination. What’s going on now though kind of steps beyond this. It’s not that the person is failing to produce a letter from a clergy member saying, yes, I back them up on this claim. It’s that the clergy members have actively gone out in public and said: No, we don’t bar COVID vaccination in our religion. Our religion either has nothing to say about this, or we are going on record as saying in our church we want people to get COVID vaccines. It is acceptable. It’s consistent with doctrine to get COVID vaccines. There is no bar here. And nevertheless, there is a person who identifies with that religious belief system who comes forward and says: Yes, but my interpretation of the Bible, of Catholic doctrine, is that I shouldn’t get this vaccine. And it doesn’t matter that the religious leader has said this. What do you do in that situation? Right now, the lower courts are split. The Second Circuit Court of Appeals, which is a fairly high-level federal court of appeals, just days ago joined at least one other district court, a lower-level federal court, in holding that a member of a religious denomination can assert their own interpretation of doctrine. And they cited a Supreme Court case that indeed seemed to suggest something along that line. At least two other courts have held otherwise. For example, there was a case against UMass brought by a Catholic athlete. And the court said, look, UMass doesn’t have to accommodate her request. She did not provide any reason to think that the Catholic Church is opposed to vaccines. And they’ve come out as saying that they are not. So there’s a split right now. And it’s really important. It’s really important because religious leaders have begun to line up in making public statements either in favor of—or, let’s say either not opposed to or opposed to the vaccine. So it matters whether those statements, or to what extent those statements, have legal weight. The second reason is many people have begun filing religious exemptions. And it’s not always clear, as your suggestion when we opened the session here kind of intuited—is that it’s not always clear that it is sincerely religious, as opposed to something that looks more ideological. And so when you have a very, very large group of people looking to kind of shoehorn complaints about the COVID vaccine into religious beliefs, it really matters how wide the interpretation of sincere religious belief is going to be. I think, as John suggested, the group of people who is opposed to the vaccine now is just orders of magnitude larger than it has ever been for any other vaccine, and much broader in its reach across different religions or different age groups. It’s a new phenomenon. That makes it harder to tie to religious beliefs and might raise a suspicion of something else going on. And then the third reason that this really matters is that some pastors have started issuing letters by the hundreds or thousands for parishioners attesting to their—you know, to say that their church opposed COVID vaccination. And then people are sort of wielding these to try to get religious objections granted. So this first question, what constitutes a sincerely held belief, really matters. The second question is whether a government unit can offer a medical or a pregnancy exception to a vaccination mandate, but not offer a religious exemption. Historically, as John said, the answer has been yes. And the trend in the states has been in that direction, towards eliminating everything but the medical exemptions. But again, just this week there was a ruling relating to one of our California school district’s vaccination mandates for students that suggest otherwise. That San Diego Unified School District has an exemption carve out for pregnant students. Not clear why. Not really medically based. (Laughs.) It had that, but not a religious exemption. And the Ninth Circuit Court of Appeals, another big federal court of appeals, issued a kind of summary opinion, not much reasoning, but sort of hints that the reason it found that unacceptable is that under a prior Supreme Court ruling called Tandon, relating to broader stay at home orders that affected religious congregations in the earlier stages of COVID, you cannot treat any comparable secular activity more favorable than you treat religious exercise. So what the court saw in that school district mandate was unequal treatment of people who had pregnancy-related objections on the one hand, people had religious objections on the other hand. The pregnant people were treated better than the religious objectors, and that’s not OK according to this appellate court’s interpretation of this decision in the Tandon case. Furthermore, just before Halloween, the Supreme Court issued an opinion that didn’t tell us much as a majority, but three of the conservatives issued a dissenting opinion that made it very clear that they think Maine’s healthcare worker mandate, which has no religious exemption, is unconstitutional for the same reason. So this would be a big sea change in public health law, if—as I think it inevitably will be—the Supreme Courts holds on its face that religious exemption is now going to be required if you offer a nonreligious exemption of any kind. And that leads into the third area that’s under contestation right now, which is a little bit more difficult to explain, but I’ll try to do it quickly and simply. And that’s the question of what standard of judicial scrutiny applies, when vaccination mandates get challenged. As I mentioned before, usually courts apply a rational basis for review, asking only is there a legitimate state interest here and is this intervention reasonably related to that interest. There is a different standard called strict scrutiny, which almost always results in the invalidation of a state’s action. And it asks instead whether the state has a compelling interest that cannot be achieved through any means more narrowly tailored than the one that it has chosen. In this case that I mentioned before, Tandon vs. Newsom, involving California’s stay at home orders, a five-to-four majority of the Supreme Court adopted what legal scholars have come to call this most favored nation rule, that says a law that looks general has to be treated as targeting religion, and therefore has to get strict scrutiny if it makes an exception for some secular activities but not for comparable religious activities. So even if your vaccination mandate applies to everybody, again, if it has an exception for pregnant people, or people who have a history of a contraindication medically, but not for religious exemptions, now you’re in strict scrutiny land. And now courts are going to make it very difficult to uphold that claim. Further muddying the waters, in June of this year in a case called Fulton vs. City of Philadelphia, the Supreme Court held that it won’t consider a law to be neutral—in other words, not targeting religious practice—if it contains any process for considering individualized exceptions or exemptions. So, think about that. Now if you have any process through which people could apply for a medical exemption, or potentially also a religious exemption, but there is room for the state to, like, exercise some discretion in considering those requests, now that’s not a neutral law. And if it’s not a neutral law, it gets strict scrutiny. So where are we now? Nobody knows. One read of the situation is none of this really matters too much because virtually all mandates do contain religious exemptions. So it’s unlikely to attract the Supreme Court’s attention. I don’t think that’s right. (Laughs.) First of all, a lot of mandates don’t contain religious exemptions. A lot contain religious exemptions that aren’t well administered. So I think it’s very likely the Supreme Court will turn to this. Another, and I think better, read of the situation is that it kind of creates a potential catch-22 for organizations adopting mandates. If you don’t have a religious exemption, you might get strict scrutiny under Tandon because these medical contraindications are treated more favorably than the religious objections. But if you do have a religious exemption process, well, now you’ve got a problem because now you’ve got this process for considering individualized exemptions, and that could trigger strict scrutiny. So it seems like either way you turn, as a mandate designer, you might have a problem. Now, just this week the Second Circuit in the New York City case tried to toe the line saying, well, a state could carve out some objectively defined categories of people who are exempt, and therefore it wouldn’t be this individualized process of exemption and it could potentially evade strict scrutiny on that basis. But you have to be really careful about how you do this. You can’t, for example, give too much discretion to people who are evaluating these exemption requests. So to summarize here, there are three critical issues on which we have no idea where things are going to land in terms of the law. And, again, this is really astonishing to people who study this area of law. It is just introducing incredible tumult in an area that I’ve always been able to teach in about fifteen minutes to law students because it’s so well settled. And it has really, really profound implications in a setting in which a quarter to a third of the country is deeply resistant to receiving vaccines, the situation in which we’re not confronting the omicron variant, we potentially need to revaccinate and to extend vaccination beyond the 65 percent ceiling that we’ve hit here. So, again, the implications are really profound. FASKIANOS: Well, thank you for that. That really was informative and very complex. And you really gave us insight into how to think about it. I want to go to all of you now for your questions. You can either raise your hand by clicking on the “raise hand” icon, or—and when I call on you, please unmute yourself and state your name and affiliation. And if you want to write your question in the Q&A box, feel free to do so, but I ask that you include your affiliation so that I can read it, and also identify you properly. You can also, if you want to direct your question to either John or Michelle, please do so. So I’m going to take the first question from Lawrence Whitney, who has a raised hand. So please unmute yourself. There you go. WHITNEY: Hi. Lawrence Whitney, ACLS leading edge fellow at the National Museum of American History. And I’m interested in the issue of a lot of religion scholars are looking at the way in which religion has become heavily politicized, particularly during COVID. And, for example, some research indicates that the label of evangelical no longer applies, particularly as a religious category but as much more a political category, right? So that we have Hindus and Jews and Muslims identifying as evangelical, largely because they understand their religious affiliation and conservative political views to be the defining characteristic of what it means to be evangelical. So I wonder if you could comment on the extent to which these religious exemption requests are really mechanisms for getting politically motivated behaviors through what would otherwise be an unavailable avenue of access, right? You can’t get an exemption for your political views, but you can for your religious views. So we turn our political views into religious views in order to get through the mandate wall. And the ways in which you may or may not see that playing out. And how that causes us to rethink what a religious exemption is. Thanks. FEA: Thanks for that question. I think you’re exactly right about the word “evangelical,” how it’s taken on a kind of—especially since the Trump era—has taken on a kind of political dimension. Well, really before Trump as well. Here’s what I see, and sort of putting a historical kind of gloss on it as well. And Michelle talked about this, right? What is sincerely religious belief? Is there some other kind of thing going on here, or is it religious belief? Historically like I said in my little talk, there have been two ways in which people have opposed—two major ways in which people have opposed vaccines. One is, like, the vaccine doesn’t work, or the science is bad, or it’s going to hurt me. And then second, this claim of liberty, right? Some kind of threat to my liberty. What evangelicals have done in the last forty or fifty years is they’ve essentially articulated a vision of America that is fused with their conservative religious faith. And what does that look like? I’ve talked to dozens of—here in Pennsylvania—dozens of medical professionals, school nurses, and so forth, who have shared with me the kind of things that they’re seeing these religious exemption forms that they get. And what you’re seeing is you’re finding that historic position of defending one’s liberties, one’s rights as an American, which has been there from the beginning. And it’s now being fused with kind of—and this is what I talked about in that piece in the Conversation that Irina mentioned in my bio—fused with these cherry-picking of kind of Bible verses. You know, things like my body is a temple of God or, in Luke 17, Jesus touched the leper and healed him, so I don’t need a vaccine to be healed. You know, these kinds of very commonsense, literal, inerrant interpretations of scripture. And they’re fused together. And usually when they’re fused together it looks something like this, right? The vaccine is a threat on my liberty and rights as an American, but my rights and liberties as an American come from God, right? So this is not just a constitutional or a Declaration of Independence, right, endowed by our creator with certain inalienable rights kind of threat. This is also a threat to the kind of divine order, the kind of nation that the United States is supposed to be. And it’s deeply embedded in these ideas of Christian nationalism, or the idea that America is somehow a Christian nation, is a special nation, is blessed by God. And God has given us rights in an exceptional way that no other nation has. So, I’m not the legal scholar here—I mean, this is kind of how you kind of need to—how do you pull that apart, right? If you have a sincere belief that God created the United States as a Christian nation and endowed us with certain inalienable rights, including the right of government not to interfere in your decision not to get a vaccine, is that a religious exemption? Most evangelicals, including in the recent case of the two evangelical seminaries—a Southern Baptist Theological Seminary and Asbury Seminary—who are suing the state of Kentucky over this right now, that is their position. This is a clear violation of their religious liberty, despite the fact that it’s mostly rights-oriented language kind of baptized with Bible verses. At least, that’s my take on that. FASKIANOS: OK. Let’s go onto the next question. So I’m going to go next to Galen Carey. CAREY: Hi. I’m Galen Carey with the National Association of Evangelicals. So as a religious matter, we’re among those religious leaders who have been strongly encouraging acceptance of the vaccine, and as a matter of loving our neighbor as well as being good for us ourselves. But as an empirical matter, I have the distinct impression that the vaccine mandates may themselves actually be a threat to our public health by hardening opposition to them. And if we consider that the vaccine mandates, especially on companies, may in the end not actually produce that much more vaccination, and it takes employers off the hook because now they can just say, well, it’s a matter for the course, blah, blah, blah. Whereas, without the mandates they may have put in their own private mandates just as a matter of business practice. So I wonder, is there any empirical evidence as to whether vaccine mandates are actually—have been shown to increase the rate of vaccination? Or do they actually, especially in our context now, maybe they actually work in the opposite direction? MELLO: So I don’t think we have empirical evidence about that from COVID. Prior to COVID we had lots of evidence about vaccination mandates, and it’s all that they’re very effective in inducing compliance—again, because very, very few people object to most vaccines. You know, maybe it’s 1 percent, 2 percent, maybe 3 percent. But it’s a tiny fraction of the population. So even if you let those guys go with some flimsy objection, you do really, really well with mandates. Most people go along. When you’re in a 25, 35, 40 percent objector situation, as we are now, it’s a very different calculus. And I share your concern that mandates, at the point at which they were imposed—which was beginning with colleges and private organizations starting June of this year and then now gradually extending down into school districts—at that point we were already pretty well saturated from the people who were interested in getting vaccines. There was, however, a group of people that I think there was reason to think could be picked up through mandates. It has surprised me to see how many people remain in the wait and see category now over a year—or, almost a year into the availability of the vaccine. And that cuts across a lot of different groups, but it’s especially high among certain ethnic minority groups, predominantly Latinos, where we really worry about COVID burden in that population. So it was not irrational to think that by imposing employment-based requirements you could pick up a bunch of people who were not in the definitely not category. They were in the middle, or they were leaning, but hadn’t made up their mind. Or they faced access barriers still, that employers had a direct interest in rectifying once they were required to ascertain their vaccination status. The question is, at this point how much more mileage do you get out a mandate? And in particular, for me, how much are you going to get by mandating it for kids? And there, I think the case is much, much more marginal. I think we’re down to, at this point, a pretty small group who are in the middle or the lean no categories. A much larger group, especially among Republicans, 31 percent, evangelical white Christians, 25 percent who are in the definitely not category. And I don’t see a mandate as doing much other than hardening resistance. That doesn’t mean people won’t comply. They may. But my concern, as somebody who works in public health, is what about the next vaccination? What about childhood vaccinations for their kids? Have we now reinforced a sort of siege mindset among people who don’t trust the government to make health decisions for them that could spillover into vaccines? Because, frankly, I’ll be much more concerned if those folks don’t take their kids in for measles vaccination than I am about COVID vaccination. FASKIANOS: OK. The next question comes from Dr. Nehemia Gordon at Bar-Ilan University. Some of those opposed to forced vaccinations have adopted, quote, “my body, my choice” as their motto. This sounds like a compelling argument. Why doesn’t this apply to forced vaccine mandates from both an ethical and legal perspective? MELLO: Well, I think—(laughs)—it’s not clear what is meant by that. But of course, our dominion over our bodies has never been absolute. And the reason is that certain behaviors that we engage in or health decisions that we determine not to make affect other people, affects their health. And that’s why vaccination mandates have always been sustained historically, as have a limited number of other medical interventions that involve incursions into the body to prevent harm to others. Again, up until very recently even hardcore Libertarians accepted this principle. This was, like, John Stuart Mill 101 that we all have an equal share of liberty, right up to the point where our exercise of liberty affects the liberty of others. And it’s really quite a modern concept to assert that one’s right over the body is absolute. Also, of course, ironic that many of the same voices espousing that theory have such interesting views when it comes to abortion. FASKIANOS: Thank you. Next question. We’ll take a spoken question from Douglas Kindschi. I hope I pronounced your name correctly. KINDSCHI: Yes. You pronounced it correctly. My question is a follow-up, I think, on the issue of religious liberty. And maybe it’s related also to the “my body, my choice.” What about when the objection to vaccine is extended to objections for actual testing? In our university, if you do get an exemption, you’re required to have weekly testing. But the same argument is now being used against weekly testing. MELLO: Sure. And that makes sense, because if I think that I have absolute dominion over my body, that would extend to be required to stick a swab up my nose. It would extend to being required to divulge personal health information to my employer or my school. So it makes sense to me that people’s objections are not limited to needles and vaccines going into the body, because fundamentally, as we’ve talked about already, I think this has only something to do with the vaccine itself and has much more to do with the surrounding context for vaccination mandates, which is that many people already feel incredibly put upon by public health authorities as a result of living under all kinds of restrictions over the past two years, restrictions that have bankrupted businesses, torn families apart, created mental health problems. They were sort of primed to hate any mandate for any kind of COVID-related intervention that imposes further burdens, even something as minimal as the testing. I mean, you can’t get much more minimal when it comes to intrusions than that. It takes literally thirty seconds, involves no pain, very little inconvenience, and the information is treated quite carefully, I think, as is required by law. So I think what you’re seeing here is a more generalized complaint that has something to do with the sanctity of the body, but maybe has more to do with just being fed up with the intrusion of government into people’s lives. KINDSCHI: Is there a HIPAA issue here? MELLO: No, there isn’t. FEA: But I think just to add to that, Irina, at the sort of more macro, kind of cultural-intellectual level on this question, I mean, this idea of Libertarianism, as Michelle said, even Libertarians had this larger understanding some kind of social solidarity or of society. I think Jill Lepore has a good article at The Guardian, for those of you who read American history, about the crumbling of this idea of society, right? I think you can see it really emerging in sort of the Reagan era, where you have individualism becoming so celebrated, at the expense of any kind of social solidarity, any sense of society. I give book recommendations all the time to my students. There was a Princeton intellectual historian named Daniel Rodgers, who wrote a fabulous book in 2001 called The Age of Fracture, in which he made the case that in the Reagan-era any sense of kind of community, national community, solidarity within community, love of—love of neighbor, if you want to put it in Christian terms, slowly began to erode. And you have people like Margaret Thatcher in the 1980s saying things like, “there’s no such thing as society,” right? We are individuals. So I think there’s—, flying about thirty thousand feet on this, there are sort of long-term structural shifts that have taken place in American culture over the last fifty, forty years or so. That also explains this kind of emphasis on—this kind of Libertarian individualistic emphasis that I think is just blossoming right now with these vaccine—in opposition to these vaccine mandates. FASKIANOS: Thank you. I’m going to take the next question from Shannon McAlister of Fordham University, who’s written a question. She’s directed it to you, Michelle. Would you kindly share the sources, laws, courts decisions for the court’s practice of not requiring employees seeking religious exemptions to be members of established religions or to attend services or to provide a letter attestation from clergy indicating that the vaccinating is religiously prohibited? Maybe we can send that out in a follow-up email— MELLO: Yeah, maybe I’ll just recommend, a good starting point would be to look at the Equal Employment Opportunity Commission’s website, EEOC, which has extensive guidance relating to accommodating religious exemption requests. That guidance specifically relates to federal civil rights statutes, but the analysis for constitutional claims is quite similar. FASKIANOS: Great. The next question is from Patrick Stefan, who’s U.S. Army. Interested in the ways by which courts are entering the fray of defining what religion is and what the boundaries of religion are. It seems that post RFRA the definition of religion has lost any sense of boundary that it might have had in the past based on Protestant Christianity. Thinking about the work of Winnifred Sullivan in particular. I’m wondering what your thoughts are on how the highlight of religion on such a large political and legal scale in our culture with COVID vaccines might shape the way the courts understand the boundaries between what makes something religious as opposed to philosophical or ideological. FEA: I’ll let Michelle respond to that, but we no longer live in Will Herberg’s 1950 Protestant-Catholic-Jew synthesis anymore. I think, again with this age of fracture, the very definition of, is religion, I mean, that’s something for the courts to decide, obviously. But it’s always had a kind of transcendent kind of dimension to it. Almost a kind of faith-based irrational dimension to it. I think all religions in some ways have some degree of irrationality to it. But yeah, I mean, it doesn’t really matter what I think. I guess it matters, right, you show the courts decide on that, when it comes to vaccination. MELLO: Yeah, and the issue is more general too. It transcends vaccination, as I’ve already talked about. It’s also been a major issue in challenges to stay at home orders and other public health interventions. I don’t know what’s going to happen. I do know that the so-called standards by which courts evaluate questions like what is sincere, what is religious, what is belief, are pretty squishy. Nobody’s really very happy with them. They (INAUDIBLE) a lot of different directions. I also know that the single most important legal development of the last four years has been the changeover in the Supreme Court towards the justices who are very strongly in favor of expansive protection for religious liberty. So it would surprise me greatly if the Supreme Court got into the business of deciding that certain things were not religion or religious belief. It seems much more consistent with the worldview of the new conservative majority to say that they’re going to give religious belief claims a wide berth, and really require a very, very strong justification. It also seems possible to me that they’ll be able to sidestep core issues about what’s religious and what’s not using a trick that they’ve deployed over and over again in public health law cases, which is to instead focus on the specific question of is there something else the state could have done besides this thing—whether it’s a vaccination mandate, or a mask mandate, or whatever—that would have been less burdensome and worked just as well? And then we get into a debate, not very well informed by science, about whether the thing that the state did was really necessary, or they could have done something different, is there a better policy out there? And we don’t have to confront hard questions about the scope of religious belief. So that’s where a lot of the fighting has been around. And again, because we have such good alternatives now to vaccination for COVID, if people are willing to do them—which most of the people who resist vaccines are not—but,  if you’re willing to test twice weekly and wear a really good, solid mask everywhere you go, that works pretty well. So, there are opportunities to sidestep this question for a while longer. And I suspect  the folks who are opposing vaccination mandates would probably like that to be the case, because I think this issue is not likely to be decided in a way that favors people who are trying to do intrusive things in public health. FEA: It’ll be interesting to see because, again, the conservatives on the court are obviously, as Michelle said, very interested in these questions of religious liberty. But many of the conservative kind of vox populi, the evangelicals, the conservative Catholics, right, it’ll be interesting to see how they respond to when the Supreme Court makes a religious liberty case or defends the religious rights of, say, a Muslim, or a Native American Indigenous religion, or something to that effect. I mean, just from purely kind of political and cultural perspective. So, if you’re a member of the Christian right, be careful what you wish for when you want religious liberty to be protected, right? FASKIANOS: Right. Just going to the idea of religious leaders—and, Michelle, you had mentioned that this is the first, and I don’t want to misquote you, but religious leaders coming out and speaking strongly about getting the vaccine. Saying they’re opposed to it, or not opposed to it, it’s in our religious doctrine or not. So is that the right approach? Probably not the right approach? Should religious leaders stay out of it? I mean, we’ve seen that there’s been a lot of push from the Biden administration to really have faith leaders help get the message out, because we’ve seen that people who may not trust government are more likely to respond to, be it a religious leader or, their medical professional friend. So what’s the balance? And, John, I’d love to hear your perspective too, because you also mentioned about past pastors in the three eras, four eras, that have spoken out or not spoken out. So where are we? What should religious leaders be doing? MELLO: Yeah. I mean, I don’t think these statements are necessarily going to carry the day in court, but I do think they’re important. It’s important to clear up any confusion that may exist among adherents to a religious denomination about what their obligations as far as practitioners are. And even if there isn’t such confusion, as you mentioned, trust and leadership from the community are really critical components to making a vaccination campaign successful, especially in the political environment in which we live now. Up until COVID local public health leaders in government had the trust of an overwhelming sort of majority of the public. And when they asked people to do something, people did it. And that’s not the case anymore. And so there need to be proxies in organizations that are trusted and are visible in the community. And I know that it’s not difficult for some religious leaders to say things that fly in the face of the governing prevailing political sentiment in the community, but I think it can be very important, again, for people who might have misapprehensions about what the religious beliefs require, but also for people who are just trying to find their way amidst a sea of conflicting messages—many of which contain information that’s not accurate, many of which are pushing a political agenda that is against the self-interest of a community. FEA: And, I mean, one of the reasons why there was not a lot of push for religious exemptions or even religious opposition to vaccinations in the early 20 century was because in the progressive era there was this kind of common sense that you trusted experts, you trusted scientists, you trusted medical professionals, right? Much of the resistance has emerged with this—has coincided with this kind of emerging populism, right, that we see that distrusts experts, that distrusts science, and so forth. So, as far as religious leaders—and this cuts both ways, right? I mean, again, Biden has tried to get religious leaders to speak out. But there are also very, very powerful religious leaders based on very little scientific evidence whatsoever who are promoting resistance to vaccines based upon these kinds of religious, spiritual kind of Christian things. Even going to the extreme—you all heard these crazy things like, you know, Satan or something is inside the vaccine, or the vaccine is whatever. And in a populist society, in which we’ve lost sort of trust in kind of science and experts and so forth, that’s really, really hard to overcome. So there are religious leaders, I think, that are also kind of problematizing this whole thing. Then you have other people who you didn’t expect to—I’m thinking, again, the evangelical community is the community I know best. But you have, like, Franklin Graham, the son of Billy Graham, Robert Jeffress, the big pastor at Baptist Church of Dallas, who have come out and said, get the vaccine. In fact, Jeffress just recently opposed  the requirement for mandates in the military—or, supported it, rather, in the military, which is outrageous—or wild, I should say—considering  all the things he was saying during the Trump era. So, but no one seems to be listening to these voices. It’s kind of like when Trump said he was going to get the vaccine and he got booed off—or, he said “get the vaccine.” He got booed off the stage, right? (Laughs.) If anybody is a kind of authority to many of these populist Christians it may be Donald Trump, but even that doesn’t work. So it’s a very complex situation. I’m not sure how to get around it or how to deal with it. But, I think it cuts both ways. FASKIANOS: All right. I’m going to try to squeeze in this last question from Guthrie Graves-Fitzsimmons from the Center for American Progress. Trump vs. Hawaii was one piece of evidence that the current SCOTUS justices do not apply their defense of religious liberty equally to Christians and non-Christians. What evidence is there that they would apply their thinking equally to all religious groups, and that they are not deferential to conservative Christians? MELLO: I don’t know if I can answer that. I mean, for one thing, the court that we have now, it’s not the same court that we had at Trump vs. Hawaii. And I think that that case in which the court upheld Trump’s travel ban against an Establishment Clause claim on the basis that, well, while some non-Muslim countries weren’t implicated by the ban and—or, sorry—some Muslim countries were not implicated and some non-Muslim countries were implicated, it wasn’t a law respecting the establishment of religion. You know, it’s one data point, but it doesn’t directly give us information about how it would have viewed a similar challenge by a conservative Christian religion. So I simply don’t know whether the court’s expansive protection of religious liberty will be expansive enough to embrace all religions equally or not. FASKIANOS: John, anything to— FEA: No idea. No idea. (Laughter.) FASKIANOS: All right. So I will give you each, like, thirty seconds to wrap up on and leave us with the one thing you want to leave us with. FEA: Do you want me to go first, or you want to? MELLO: Sure. FASKIANOS: Sure. FEA: I mean, I would just say from a historical perspective—and I think Michelle echoed these points too, we are in a new moment. Historians talk a lot about continuity with the past and also change over time. I think in terms of continuity,, there is still this argument about  my body, my rights, please don’t interfere with my choices for my family and my children and so forth. So I think you see continuity there, all the way back to the early 19century on these issues. But there’s also been a profound change. And this is something new, I think, that we’re going through right now with the large numbers of vaccine-resistant people, or at least resistant to the mandate. So I think from a historical perspective I think it’s both/and, as if often is. FASKIANOS: Michelle. MELLO: I guess I would just end by saying it’s somewhat disappointing to me that these really weighty questions about religion and public health are being decided in this particular context, where, as John has said, there’s a lot mixed up in there that doesn’t really look like religion but may, and has, in my view, heavily influence the way judges resolve these cases. I would much prefer to see claims about religion fleshed out in a sterile context, where it’s clearly and truly burdening a recognized religious practice, and not a blurry situation where the line between religion and political ideology has been lost, and not in the lower courts, which  especially given appointments over the last four years, have become very unpredictable places to have disputes resolved, especially for questions of first impressions. So I guess, as I said before, one thing that worries me about all of this is that we will get some law coming out of this that is in many respects sui generis to this very unusual moment that we find ourselves in, yet is going to have profound, long-lasting implications for all kinds of things in the future in public health and outside of public health. FASKIANOS: Very worrisome. Thank you both for your time today. This is a really important and informative discussion, and we really appreciate your bringing your expertise to it, and your perspectives. So thank you. Thanks to all of you for your questions. You can follow John Fea’s work on Twitter at @ johnfea1. And Michelle’s work at @michellem_mello. We also encourage you to follow CFR’s Religion and Foreign Policy Program on Twitter at @cfr_religion. And please email us at [email protected] if you have suggestions for topics that we should cover in future webinars. So, again, thank you, Dr. Fea, Dr. Mello for all the work that you’ve done and are doing. And we look forward to continuing the conversation with all of you on the webinar. So thank you. MELLO: Thank you. FEA: Thank you.

Please join our panelists as they discuss the latest COVID-19 developments, the risks of the Delta variant, mask and vaccine mandates, booster shots, and the possible ramifications of many students and workers returning to in-person settings.

Leana Wen, emergency health physician and former health commissioner for the city of Baltimore, Maryland, discusses how state and local governments can prepare for and respond to COVID-19 variants and future public health emergencies.   FASKIANOS: Thank you. Good afternoon, everybody. Welcome to the Council on Foreign Relations State and Local Officials Webinar. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR. We’re delighted to have participants from 49 U.S. states and territories with us. Today’s discussion is on the record. As you know, CFR is an independent nonpartisan membership organization, think tank, and publisher focusing on U.S. foreign policy. We’re also the publisher of Foreign Affairs magazine. And through our State and Local Officials initiative we serve as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. So I’m pleased to have with us today Leana Wen. We previously shared her bio with you so I’ll just give you a few highlights, and to say that we will need to end a little bit early because we are perfectly placed. President Biden is announcing his pandemic vaccine plan at 5:00, but an embargoed copy has been released. So we’ll be able to hear some insights from Dr. Wen on that. Dr. Wen is an emergency physician and visiting professor health policy and management at the George Washington University Milken Institute School of Public Health. And she is the author of Lifelines: A Doctor’s Journey in the Fight for Public Health that was just released in July. Previously she served as health commissioner for the City of Baltimore, where she led the nation’s oldest continuously operating health department. Dr. Wen is a member of the Council on Foreign Relations and has received numerous recognitions, including one of Time Magazine’s 100 Most Influential People. Dr. Wen, thanks so much for being with us today. It would be great—I’m just going to throw it open to you—over to you to talk about the current state of the COVID-19 pandemic, and where we are now, and any insight you can share on what we will hear from President Biden shortly? WEN: Wonderful. Thank you very much, Irina. I’m glad to join you and also glad to join our state and local officials. I mean, what a time it’s been for all of you, for all of us. And I just, first of all, want to say thank you, because you are really on the frontlines. And I think you’ve all seen too how unfortunately COVID has become so polarized, so politicized. And you are the ones who are delivering messages that people don’t necessarily want to hear. And I think you’re on the frontlines in more ways than one. I mean, you’re also on the frontlines of getting and dealing with misinformation, disinformation, but also in harassment and in messages directed at you in ways that are totally inappropriate. But you still do the work and serve your communities, and I just want to thank you for them. Now, I don’t think that we’re in a very good place at all in the U.S. I mean, we reached a point back in June/July where we were seeing consistent declines in the numbers of infections. We were down to just over 11,000 daily infections. But now we’re seeing these surges, to the point that we’re having about 150,000 new infections every day. And I was just looking at where we are now compared to last—to Labor Day. We are now at 300 percent the level of COVID-19 infections compared to last Labor Day. We are at more than—at two-and-a-half times the level of hospitalization compared to last—compared to a year ago. And we’re at nearly twice the level of death compared to last year as well. And so in total, that is not a good picture of where we are, especially because we have vaccines. I mean, my colleague at CNN, Dr. Sanjay Gupta, was just saying that if you had shown us these statistics a year ago we might have said, oh, well, in that case we didn’t develop a vaccine, because it would seem hard to believe that we have vaccines that are safe and very effective, but we would still be at this point. And why are we at this point? Because only 54 percent of Americans are fully vaccinated. Now, we could have avoided this point if it were not for the Delta variant, but also if it were not for the fact that so many people remain unvaccinated. And so Irina mentioned the announcement that President Biden is going to be giving. I have an embargoed copy of the plan that was embargoed until 3:30 Eastern, which was, you know, half an hour ago. So I can now talk to you about the plan. But it’s a six-prong strategy that really would not surprise any of us who have already—who have been following this. I mean, it talks about testing, masking, and keeping school safe. It goes into a lot of detail about vaccinations. And I think that the Biden administration is using many of their levers in order to increase vaccinations. Not as many as I would like, and I’m happy to talk about that too, but there is a lot that they are doing. So for example, they are announcing that all federal employees and also contractors with the federal government now need to be vaccinated. There’s now not a testing opt-out option. Another big—another big item that’s going to come is they are directed—the federal government is directing—or, the White House is directing OSHA to develop a rule that requires vaccinations for—or testing—or weekly testing for all companies that have one hundred or more employees. That’s a big deal. That’s 80 million Americans who would be affected. In this case they are giving an opt out. They are saying: Either require vaccinations or weekly testing, but I think that is going to be a big deal. We know that many businesses have already voluntarily taken the step of requiring vaccines, but also a lot of businesses have not. And so I think this gives businesses cover that want to do this. And now they can point to OSHA and say, hey, this OSHA rule is coming. That’s why we’re doing this. I think that will be really important. But, I mean, I wish the federal government would go even further—for example, requiring vaccinations for travel, for interstate travel, for planes and trains. And in the meantime, I wish that we would do more to abide by actually what the CDC recommendations are, which, as you know, are requiring indoor masking in places with substantial or high transmission, which is most of the country. That is not the case. I mean, my—you know, I think there is this cognitive dissonance sometimes that we have. We—and I’m sure you all experience this too—we talk to some people who are pretty blasé about COVID, who might be vaccinated or even are unvaccinated but don’t really think that COVID poses much of a threat. And on the other hand, we have people who are really afraid of COVID, are not resuming many aspects of pre-pandemic normal, cannot wait to get booster doses, et cetera. And I think we’re living in this very strange, bifurcated world at the moment. But in any case, I think that there’s a lot of work. To summarize, we are not at the place that any of thought or wished that we would be at this point. But I think there is a lot that we can do to get us to a much better place. FASKIANOS: Thank you very much. We’ll go right now to questions. You can raise your hands and unmute yourself and tell us who you are and—to give us context of the state from which you—where you’re sitting. Or else, you can write your question in the Q&A box. And if you write your question, it would be great if you could include your affiliation and I will read it. So the first raised hand—sorry as I am juggling. How long have I been doing this? Is Liz Johnson. Mayor Liz Johnson, if you could unmute yourself. OK. I’m going to go next to Councilman Wilkerson. And we will come back to the mayor. Go ahead. Q: Hi. How are you? FASKIANOS: Fine, thank you. And where are you tuning in from? Q: I am from Killeen, Texas—in the wonderful state of Texas. I would like to ask Dr. Wen—first of all, thank you for having this forum. I would like to ask you to get a little more into depth about the concerns that we should have about school systems, because a lot of our municipalities are working with our school districts, and the concern that some may have or some not have with the opening of the school districts at this time of year. WEN: Yeah. It’s a really good question. And I know this is one that we’re all wrestling with in different ways. You know, recently I was on a Post—on a Washington Post podcast with Hannah Nathanson, who is the educator reporter for the Post. And she made a comment that really stuck with me. It was something about how at this moment—I mean, based on her reporting all over the country—the range of what we’re seeing in terms of this piecemeal approach to reopening schools is as wide as one can possibly imagine. I mean, you’ve got some places that are going above and beyond the CDC recommendations when it comes to the layers of protection—which, you know, is good, right? I think the CDC approach of talking about layers of protection, that we need as many of these layers in possible, kind of like in the winter when you’re cold. You know, you want as many layers as you can. And if you’re replacing—if you’re removing one layer you replace with another. So if we can no longer do distancing, we’re replacing it with having as many adults being vaccinated as possible and doing regular testing, indoor masking, et cetera. You’ve got that one extreme. Then you’ve got many schools reopening as if it’s 2019, without any restrictions at all and without any kind of indoor masking, unclear even what their protocols for quarantining and isolation are. I mean, I’m very concerned. I mean, I think essentially, we have subjected our children to a natural experiment that they did not sign up for, where children in different parts of the country are exposed to dramatically different environments. The schools that are relatively responsible but are not implementing all these measures, I think they’re going to see a lot of cases. And hopefully they’ll be quarantining students accordingly. Although, of course, the consequence is that children are going to be missing out on school. I guess from a public health standpoint, I and many other experts are really worried. I mean, we’re really worried about the consequences. We’re really worried about why we’re even doing this in the first place. You know, when we know what it takes for schools to reopen safely, why aren’t we doing everything that we can? I’m the parent of two young kids. I have a four-year-old also who just started preschool. I’m here in Maryland, and I feel so fortunate that I live in a jurisdiction where we do—we are following all the—all the guidelines. But I would really worry about—if we were living in a different area. I worry about all these parents who are being subject to very different types of environments. So I’m not sure that I’m quite answering your question. Q: Well, yes, that was helpful. As far as statistically speaking, I know that there’s a consensus out there, or there’s some who may think that children are less susceptible to this, of course. And I think that the science has kind of played that out. But to what—to what level should we really be concerned with sending our kids back into a school environment? And also, you know, what kind of innovative ways can we do—because I’m the parent of two school-age—well, actually, one’s in college and one’s in high school. How do we get the message out to the kids from a municipality standpoint? And maybe you can speak to something as far as what President Biden’s going to announce today. How can we make the importance of being safe in this type of environment for those type of kids, for kids that are entering into the school system? WEN: Yeah. I mean, you make a—you make some really good points. And I think one thing that we need to make very clear is that children are affected by COVID. There has been this untrue, and I think very unhelpful and dangerous, narrative that somehow children are not affected by COVID. And it’s because of a comparison that never really should have taken place, as in what we have been saying from the beginning—which actually is true, but it’s not helpful in this context—is to say then, well, the majority of people who have died and have gotten hospitalized are older people. It is definitely true, and also true that children make up a small proportion of the total number of individuals who have become severely ill. Also it is true that children tend to become much less severely ill than adults from COVID. But that is true for so many other illnesses as well. Children are resilient. Children are not supposed to die. I think that is the key that’s missing here. I mean, when we’re looking at what’s happening around the country, we know, of course, that kids twelve and old are eligible to be vaccinated, but under twelve they are not. When we have something like the Delta variant that’s so contagious, what’s gone on is that those who are left to be infected because of this very contagious variant are children. And children are now being—are now being affected in large numbers. In fact, the American Academy of Pediatrics just released the number saying that more than one in four of the new infections are now occurring among children. We are now having more than two hundred kids being hospitalized every single day around the country. Tens of thousands of kids have been hospitalized during the pandemic. The hospitalization rate for children is 2 percent. So 2 percent of kids getting COVID are now getting hospitalized. And hundreds of kids have died. Thousands potentially could have long term consequences from COVID. I wrote an op-ed back in June about what if we had looked at this differently and instead of comparing kids’ outcomes to adults, what if instead we said: There’s a new illness out there, and that illness only affects children. And by the way, hundreds of children, including previously healthy ones have died, tens of thousands have been hospitalized. How might we react to that kind of news? I mean, that is what’s happening. COVID is now one of the top ten killers of children. I mean, that cannot be acceptable to any of us as parents or as members of society. It’s our job as adults to protect our children. And I guess the final thing that I would say here is when asked about this issue, in particular in relation to schools, isn’t it our job as adults to protect our children? And if that’s the case, then what are we willing to do to do that? I mean, I guess I find it hard to see. Again, I have a four-year-old. I don’t think it’s very difficult—my four-year-old thinks that wearing a mask is just fine. That’s really all he knows, frankly. And, you know, wearing a mask and not going to school when you’re sick and doing regular testing, that doesn’t seem like a big price to pay in order to safeguard our children. Q: No, Dr. Wen. Thank you very much for that education, because that’s the first and most powerful thing I’ve heard about the advocacy for masking up and getting vaccinated for children entering into the school system, because a lot of us don’t know this is a top ten killer of children at this time. So that’s very powerful, necessary information. We can pass it onto the citizens to make sure that we’re doing the right thing. Thank you very much. FASKIANOS: Thank you. I’m going to go next to William Murray, who wrote a question and also has raised his hand. Q: OK. Well, thank you so much for participating. This is really a great thing. There’s so many questions that local officials have. We’re confronted daily with rising rates here in our own village, the village of New Paltz in the Hudson Valley and upstate New York. One question I had that I wrote about is—or, questioned, is that with the high transmissibility of the Delta variant, there doesn’t seem to have been any modification to recommendations to prevent spread. All that we’re reading is the same sort of information based upon, you know, variant A, if you will. But given how much more potent this one is, one would think there would be changes in ventilation recommendations, distancing recommendations, that sort of thing, given how quickly it can spread. Any thoughts on that? I haven’t seen anything from the CDC upping—you know, maybe we should be eight feet apart, or maybe we should all be wearing three-layer masks, or maybe, you know, ventilation systems aren’t going to be able to handle this particular variant. WEN: Yeah, it’s a really good point that you’re making. And you’re right that we are dealing with something different here. I mean, not totally different, in that we’re still talking about a respiratory virus. It’s still spread through the same route. But the Delta variant is a lot more contagious. And when something is more contagious, it means that the activities that we once thought were pretty safe are now going to be higher risk. And so also we know, based on a study done by the Chinese CDC, that an individual carrying the Delta variant carries one thousand times the amount of virus compared to somebody with the previous variants, which I think is also—just tells us something about the transmissibility of this variant compared to before. And I think another reason why our schools, as they are reopening, we really need to take every precaution. You know, what the CDC has done—and I think this is the right thing for them to do—was to reinstate or was to encourage local jurisdictions and states to reinstitute indoor mask mandates. And that’s something that I know some states and cities have done, but the majority have not. I wish that they would do this. I mean, we really understand about how transmissible the variant is, and having indoor—at least having indoor mask mandates is important. I would add—and I agree that the CDC has not said this—but I would add that a cloth mask is not sufficient. We should at least be wearing a three-ply surgical mask when we are in public places. And I would recommend if people are in higher risk areas and traveling, for example, with prolonged exposure, for long periods of time, close quarters with people, to be wearing an N-95 or KN-95 mask. We know that the quality of mask definitely matters and it’s also something that very much impacts the wearer as well. Now, another element that I do think—I mean, I think you make an interesting point about should we be changing anything about distancing or anything else. I mean, I think at this point my major concern is that people have just really let down their guard. My family and I were at the beach over the holidays, over the Labor Day weekend. We were in an area of the country that actually has generally—last year we were there at the same place. They had mask mandates and everybody was wearing masks in grocery stores. This time maybe one in five, one in ten people were wearing masks inside a public grocery store with a lot of people. I’m more concerned that people are not following the rules that we already have. FASKIANOS: Thank you. So in the interest of time I’m going to group some questions here. So Keith Hooker. Will the OSHA rule/guidance on vaccination apply to state and local governments as well or only to private businesses? And somebody else asked—let me find it—about would they also apply to colleges and universities? State Representative Lori Gramlich from Maine. WEN: I do not know the answer to these questions. I mean, those are the questions that I have as well. I don’t know. My understanding is that the White House has directed OSHA to develop this rule. The rule has not even been developed yet. And so I don’t know. But I think that’s something that we should ask for clarification from the Biden administration. FASKIANOS: Great. I’m going to go next to Susan Hairston, who has her hand raised. Q: Thank you, Irina. And thank you, Dr. Wen, so very much. I have been dying to hear from you all. I’m a councilwoman in Summit, New Jersey. And we have an amazingly high vaccination rate in our town. And I am shocked by the number of increasing incidences. And so it really does beg to ask, is what we’ve been doing not making a difference? And it seems like it’s ammunition for the people who are opposed to it. And so I hear you loud and clear that we have to keep insisting on the norms about mask wearing and social distancing because there’s a competing interest. Business is saying: Open up. Let me us get back to normal. Let us get back to making jobs, stopping unemployment. And all of these things are competing. And so what I wanted to ask you about, do you think there is the threat of a shutdown being necessary, since we have Delta, we have Lambda, I hear there’s another one. Would that be something that would be a short-term effect? We’ve seen it happen in other countries. I believe that’s Australia and China continues to do that. And then the other thing that I’m finding alarming is it is our police and fire and some of the first responders who are some of the folks who are not getting vaccinated. And that’s been a challenge. And so I’m just wondering, is a shutdown something that might be on the horizon? I know it’s really an awful thought, but I just don’t understand. We feel like we should have learned so much more about this. Thank you. Appreciate what you’re doing too. WEN: Well, thank you for the excellent questions and for the points that you’re making. So a few things: One is that I don’t think we should say that just because things are in the wrong direction that our efforts were for naught. We don’t know our own counterfactual, right? I mean, had we not increased our vaccination programs much earlier, had we not implemented mask mandates much earlier, had we not done all these things that you all have been doing, and doing education and outreach, imagine where things would be now, right? I mean, I think we can’t think about, well, things are terrible now and therefore there was no point to doing all these things. Actually, it should be, well, what more can we—what can we—what more can we do? Well, we know that—I really believe that in this country—not necessarily in other countries, where the cultural contexts and political dynamics are different—but in this country I strongly believe that vaccines are our best and only way out. And that’s because the restrictions, the lockdowns that we’re seeing in other countries are never going to happen. I mean, New Zealand, Australia, they closed down the entire country for a couple handful of cases. That is never going to happen here. There is no political will to do that, even in places that might be amenable to doing these things. I mean, there is just no—the thing with our country, as I think you all know firsthand, is that the places that have the outbreaks—the largest numbers of outbreaks—are also the places that have resisted mask and vaccine mandates. So to think that these places would somehow go for lockdowns, that is just not politically tenable. It is not going to happen. And understanding that reality, we need to do what else we can. And that’s why I think the Biden administration focusing on vaccines is the right step, because that’s the only politically tenable thing that we are able to get through and to get done. And so to your question about new variants that may arise, I mean, Delta is the issue for us at the moment. And that’s because it is so highly transmissible. When something is so highly transmissible, it displaces all the other variants that there are. And so, yes, there are Mu, and Lambda, and these other things that are on the horizon. But if they’re not more transmissible than Delta—and we don’t know whether they are. So I’m not saying that it will never happen with another variant. But Delta has taken this foothold here because it’s so highly transmissible. Could there be new variants that develop that are more transmissible, more virulent, more deadly, and that somehow evade the protection of our immune systems and the vaccines? Possibly. But that has not happened yet. FASKIANOS: Just to group a couple of questions in the chat, how much of—the data on how much of the surge is due to unvaccinated compared to breakthrough cases in the vaccinated population? Can you give us the stats, and how this is very different considering the new variants? And then there’s another question about do you know when the approval will come through—this is like we all wish we had the crystal ball—for children under twelve? Those of us who have children under twelve, right? Do you know what the timeline is now for that? WEN: Yeah. I might need you to remind me what the previous question was because I got so distracted by this—the kids question, as it’s so top of mind with two little kids under the age of twelve. The most recent—the most recent projections we have are that Pfizer, which is going to have data first, that they will submit for emergency use authorization for the FDA for kids in the six to eleven-year-old group—or, maybe the five to eleven-year-old group, sometime in late September. Authorization could come as early as late October to early November, that group. For younger kids, probably not until 2022. And I’m sorry, Irina, the first question? FASKIANOS: So just the first is just what is the data of— WEN: Oh, breakthroughs. FASKIANOS: The breakthrough—the surge—how much of the surge is due to the unvaccinated and how much is due to the breakthrough cases? WEN: Yeah. I mean, it’s hard to have these exact numbers because we don’t have the capacity to do a lot of contact tracing in this country. But based on the numbers that I have seen we know that the vast majority of those who are hospitalized and dying are those who are unvaccinated. Numbers ranging from 95 to 99 percent. So very high numbers of those who are severely ill are the unvaccinated. I’ve also seen numbers that greater than 90 percent of those who are infected are those who are unvaccinated, compared to those with breakthrough infections. We also have a more recent CDC study that looked in the post-Delta world, after Delta became dominant, that a person who is vaccinated is twenty-nine times less likely to be hospitalized compared to somebody who is unvaccinated. And also, that a vaccinated person is five times less likely to contract COVID to get a breakthrough infection than someone who is unvaccinated. So I think there has been some confusion, probably because the messaging from the federal government has not always been great. And I’ve written about the CDC’s messaging issues also. But one of the—one of the things that came out is that I think there has been some misunderstanding about, well, who is more likely to spread COVID—somebody who is vaccinated or somebody who is unvaccinated? Even if it’s true that a vaccinated person and an unvaccinated person, once infected, could both carry the same amount of virus and be just as contagious—which we don’t even know that that’s true. But let’s—even if that’s true, a vaccinated person is five times less likely to get COVID in the first place compared to an unvaccinated person. So if it were me, and I had the choice to sit in a conference room with ten vaccinated people or ten unvaccinated people, I would choose the ten vaccinated people every single time because they are five times less likely individually to have COVID compared to the unvaccinated people. So I think that’s important to note. And I know this is not exactly what the question is asking about breakthrough infections, but I think many people are also asking—and all of you as officials might be getting this question too—of, well, what is the purpose of getting the vaccine if you can get a breakthrough infection? Well, here’s the answer: Nothing is 100 percent, right? (Laughs.) Nothing in life is 100 percent. We don’t stop wearing seatbelts because somebody who had a seatbelt was in a car accident that landed them in the hospital. I mean, that’s not—we don’t stop doing that. You don’t stop taking your insulin because you could still have an exacerbation of your diabetes. And in this case, there’s actually a direct link because if you—the more—so some people will often ask too, well, what is my risk of having a breakthrough infection. Your risk depends on how much virus is all around you. So if you are vaccinated, we know that the vaccines protect you very well but not 100 percent. That means that the more virus is around you because of the unvaccinated, the more likely you are to get exposed to COVID and to get ill. And I think that is really important to take into account. FASKIANOS: Thank you. I’m going to go next to Kevin de Leon, who’s raised his hand. Q: Thank you so much, Irina. And thank you so much for facilitating today’s conversation. And, Doctor, thank you so much for the information. Just a really quick comment and perhaps your thoughts. I mean, one of the concerns I have with regards to the CDC was the criteria when it came to who would be first in line when it came to the vaccination. And clearly in California we’ve lost over 66,000 individuals to COVID virus. Slightly under half of them are from L.A. County. And the vast majority of people of color, but in particular Latinos, Asian Americans, African Americans. So when the criteria was sixty-five-plus, for L.A. County, you know, to illuminate that statistical data point, that meant 86 percent of Latinos were not eligible to actually secure the vaccination. And many of them are frontline workers, essential workers, living in very dense neighborhoods with multi-generations under one roof—grandma, grandpa, mom, dad, kids. A lot of them did not have Blue Cross/Blue Shield, Kaiser, HealthMed, access to HMOs, PPOs, what have you, et cetera. Yet, they’re the one community who were most eviscerated and the ones who were standing in line waiting to pick up a box of food just to feed their children. And the only thing that’s standing between them living out on the streets and keeping a roof over their head is an eviction moratorium, which in L.A. actually extends one year. So for the future, with regards to the booster shot—a third, you know, vaccination—what are your thoughts with regards to targeting those communities that have been hit the hardest as opposed to the generic CDC 65-plus, at the time when the first wave of vaccinations were available? Thank you so much. WEN: Yeah. It’s a great question. And I also just want to mention that I grew up in the L.A. area. I grew up mainly in the East L.A. area, and I went to Cal State L.A. for undergrad. And so very much appreciate the work that you do from a personal standpoint, and certainly know of the communities that you’re referring to as well. So with booster shots—and, again, many questions around booster shots. What we know about the vaccines is that they continue to provide excellent protection against severe illness, but that it looks like their protection against milder breakthrough infections does appear to be waning over time, and especially with the predominance of the Delta variant. I’m actually not so concerned as I was in the first instance when we were first making vaccines available, because that was literally a life-or-death issue, as in in the process of waiting—especially some of these communities that you mentioned that are particularly vulnerable, that are frontline workers, that are communities of color, with low income, multigenerational housing, et cetera—that some of them could have died. If they had—if they had gotten vaccinated earlier, they might have survived. And so I think that’s a—that was a really big injustice, right? And that’s a huge inequity and that’s a major issue. I’m much less concerned now with the booster shots, because the boosters still protect—or, even without the booster, you’re still well-protected against severe illness. That said, I think—I hope that equity continues to be a focus for the Biden team going forward. But I also think that—you know, again, I’m just less—because this is not the life-threatening issue as it was in the first instance, I see it as a less pressing concern as it was before. FASKIANOS: Great. Thank you. There’s obviously a lot of misinformation. There are a few questions about this. Is it a crime for TV or radio personalities to knowingly misinform people on issues like COVID, or can they be held accountable? Is there anything the CDC or the federal government, can they mandate anything, you know, to deal with that? And just to talk a little bit about—there’s some misinformation about people who’ve gotten vaccinated who have died. So and that linkage that maybe they died because they got the shot. Can you talk a little bit about those numbers and put in perspective of, you know, other vaccines and the percentage? WEN: Sure. I mean, I think one of the difficulties with the numbers is there are people who just die, unfortunately, right? I mean, there are people every day who are dying unrelated to anything with COVID. But I think sometimes those deaths have very unfortunately been linked to the vaccine when that is really not the case. That said, there had been a handful—really a very small handful of individuals who actually have died because of—specific to the Johnson & Johnson vaccine and the rare blood clotting issue associated with it. It’s really tragic, and we now know about this issue. But everything in life is about risk/benefit analysis. And in this case, when you look at the fact that 1,500 Americans are dying today because of COVID-19, and the number of lives that the vaccine is able to save, that’s the calculation that have to make at the end of the day. And so I think we really need to talk about how this is—these—we have vaccines for a reason. We don’t want people to get an illness that otherwise is preventable. The—by and large, the side effects are very mild, they are temporary, they are—people fully recover from them. And the—what we need to fear is COVID and not the vaccine. The other issue that—about misinformation I think is a really important one. I mean, the surgeon general, Dr. Vivek Murthy, has announced that misinformation is, in itself, a public health crisis. And I think that’s a very important point. But I think we also—you know, I’m not a lawyer, so I don’t know—I don’t know how to answer the question about accountability and information. But it is of course, as you all know, a challenging issue of free speech versus the necessity of providing—of providing accurate information. I think having—for me, I was born in China. My parents left China because of the crackdown on free speech. And so for me the idea of limiting people’s speech makes me very uncomfortable. But I also—(laughs)—you know, agree that there’s more that, in particular, social media platforms can be doing so that messages aren’t amplified. FASKIANOS: Right. Amy Cruver put in the chat: Can you share the studies that validate masking in the chat and discuss natural immunity compared to medical vaccines? I don’t know if you can share maybe some of those studies that we could send out to the group, or you could put in the chat, but we can also circulate it for people. I want to make sure we get you that information. WEN: Yeah. And actually, I’m going to put in the chat now all of my recent op-eds. And you can flip through. I’ve written a lot on children recently. But my most recent op-ed is exactly on this issue—which is on the so-called natural immunity versus immunity from vaccination. And, you know, my point in the op-ed is to say, look, if you recover from COVID, just as if you recover from other illnesses, you do get some level of immunity. We don’t know whether it’s better than or not as good as getting vaccinated. But we do know that if you get vaccinated on top of having COVID-19, of having recovered from COVID-19, you have even better immunity. My husband had COVID before the vaccines were widely made available. There was no question that I was going to recommend that he gets the vaccine. And in fact, we now know from a CDC study done in Kentucky that people who are fully vaccinated after recovery are—well, we’ll put it another way. People who are unvaccinated are twice as likely to get reinfected compared to people who got COVID and then got—and then the vaccine. The point that I was making in the op-ed is we should not wait for natural immunity. The price to pay is just too high. By the way, same thing for other vaccine-preventable diseases. We don’t wait for children to get measles, because a substantial portion of them are going to get brain damage. We don’t wait for people to get polio because a substantial portion will have irreversible paralysis. We don’t wait for people to get COVID, because people have long-term consequences, and brain fog, and could end up in the hospital and die. And so that’s why we have vaccines. FASKIANOS: OK. There’s a question—just to clarify something that you said. You said that COVID-19 is the top ten killer in children. Was that for all disease or all—just comparing to diseases or just death for children? So they wanted clarification. WEN: I believe it is death for children. Again, it’s one of the op-eds that I wrote recently that I will find for you and post in the chat. FASKIANOS: Great. All right. So I’m going to go next to Representative Lori Gramlich from Maine. Q: HI. Thank you. And thank you so much, Dr. Wen, for this opportunity. This is really informative. My question has to do with—Maine has done a really great job, in my opinion. And I’d love for you to partner with our CDC director, Dr. Nirav Shah. He’s been fantastic. But we have seen our seven-day average in Maine back in June be right around twenty COVID cases. And as of today, we’re up to 359 COVID cases, which is, you know, obviously an incredible increase. We have hospitals that are seeing increased COVID patients. And we’re really getting to a tipping point. And I’m sure Maine is not the only state where we will have little to no room for other patients with emergent issues. And I know that you can appreciate that as a physician. What kind of protocols do you, in your medical perspective, suggest that we try to implement in terms of folks that could prevent this from happening by getting the vaccine versus somebody that presents with a cardiac event who may not have a space in the hospital? This is really—this is really going to, I think, get much worse before it gets better. And I really appreciate your thought and perspective on that. Thank you so much for the work you do. WEN: Well and thank you for your work and leadership. And Dr. Shah is a friend and colleague who is doing great work. And so you’ve certainly got a wonderful top health official there. He is also the president of the—of ASTHO, which is the state and territorial health officials, and has been doing a wonderful job there as well. So I like the idea of listening of to Dr. Shah’s advice on the ground and his—and his public health guidance there in Maine. But, you know, I think that part of it is—I don’t have a good answer to your question. I mean, the easy answer, of course, is the—we need a combination of approaches. We need to increase vaccinations. We need to get regular testing—which we really need to do a lot more of, by the way. We haven’t talked today so much about testing. We talked about masking, but not so much about testing. Imagine if everyone were to be tested every week, or even twice a week? That would be—testing is not, in itself, a preventive measure, but if people are tested that regularly you’re going to pick up a lot—on a lot more cases that we otherwise might not have. I think part of the issue, and one that we as a country have not really wrestled with, is what is our end goal here? What is the endpoint? What’s the endgame, right? What are we aiming for? We’re not going to get to what Australia, New Zealand, and some of the Asian countries have tried of zero COVID. That’s just not going to happen. But are we OK if we reduce COVID to the level of the flu? I mean, are we going to be OK with about forty thousand deaths every year? Maybe. Right now we’re at half a million deaths a year. So I think getting down to forty thousand would certainly be better. But is that what we’re OK with? Are we OK just getting to the point that our hospitals are not getting so overwhelmed that patients with heart attacks can’t get care? I mean, what is our end goal? And I don’t think that we, as a society, have actually defined that. FASKIANOS: Great. Just going to—the concerns about how fast the vaccine was developed—how fast. The mRNA technology, and there’s been a lot of people worried because it was developed in less than a year. But can you talk about the underlying—what came before, so that it really ramped it up and we were in a good position for this vaccine? WEN: Yeah. I’m glad you mention this because this is one of the common questions that we get, is somehow about the speed of development. Well, this vaccine has—this platform for developing this vaccine has been undergoing science—a scientific research for over a dozen years. And so saying that this is new is not exactly an appropriate way of framing it. It’s a new vaccine because it’s a new disease. But the—because that technology was already developed for so long, this was essentially a plug and play. And that’s what it’s going to be going forward, that if there are new variants that end up developing you plug into this mRNA technology and it’s able to be used in the future. This vaccine, just like others, work in a similar way. Which is, the idea is that if you were to get exposed to a disease you would have immunity going forward. But instead of having you to go through that sickness, and disease, and potential death, instead you get exposed to a component that stimulates your immune system. That’s exactly what the mRNA does. Some people have questions about well somehow is this going to interfere with my DNA. Your DNA is in the nucleus of the cell. The mRNA never enters your nucleus. And so there is no chance that it’s going to be interfering with your DNA. And so I think those are important components to mention for those of you who have to—those of us who have to answer questions about the vaccine. FASKIANOS: Right. There is a question about symptom reductions from different viral treatments. We’ve heard a lot in the news about ivermectin and other things. Can you just talk about ivermectin and other early treatments, versus the monoclonal infusions? What’s the difference, et cetera? WEN: Yeah. Well, I think it’s really important to talk about what works and what doesn’t. We now know that if you have severe COVID that what works if you’re hospitalized are steroids, remdesivir and anti-viral medications, supportive treatment. And you could get ventilation, oxygen, et cetera, if you’re very severely ill. To prevent you from reaching that stage, once you have gotten a diagnosis of COVID, monoclonal antibodies made by Regeneron, Eli Lilly, et cetera—those are—we know that those help to prevent you from ending up in the hospital. So those are meant to be treatment that you get while you have mild illness early on in the course of your illness to prevent you from being hospitalized. There have been other things that have been studied. Plasma, hydroxychloroquine, ivermectin, vitamin D, zinc. All these things have been studied as: Could they also keep you out of the hospital if you get mild illness? And so far, all the evidence points to no. Ivermectin is an antiparasitic that’s—we hear that it’s used in farm stock, I livestock, but it’s also used for parasites, for scabies. So it is a medication that’s used. There have been ten randomized controlled trials—a really great systematic review that was done in Journal of Clinical Infectious Diseases last month—or, I think back in June, maybe—in June or July—that looked at these ten randomized control trials of ivermectin. And they found that even if they’re used in small dose, or large dose, or several days, or one time use, that it does not contribute to a reduction in hospitalization, or symptoms, or mortality. So ivermectin, hydroxychloroquine, all these things are not—have not actually been found to be helpful in preventing or treating COVID. FASKIANOS: Great. And with that, I am sorry, but we are going to have to end early, because I know you have to react to this—President Biden’s announcement. So thank you all. There are so many questions, raised hands. I’m sorry we couldn’t get to you all. But, Dr. Wen, we really appreciate your spending these fifty minutes with us. It was really terrific. And for all the work that you have been doing. Again, I commend to you all Dr. Wen’s book, Lifelines. Also, in the Washington Post she has a new newsletter called “The Checkup with Dr. Wen.” So you should sign up for that. I have. And we will send out a link with—to this webinar so you can share it with your constituents, as well as some of the other resources she mentioned, studies. We’ll collect that up and send it to you all so you can look at it in detail. So thank you all again for being with us, and thank you for all the work that you’re doing, as well as you, Dr. Wen. You can follow here on Twitter too, @drleanawen. So take care, everybody. And please follow the State and Local Officials initiative on Twitter, @CFR_Local. You can go to CFR.org, ForeignAffairs.com for more expertise and analysis. And you can let us know how we can continue to support the important work that you’re doing by emailing us at [email protected]. So thank you all again. Take care. (END)

Panelists discuss the possible origins of COVID-19, including the growing concern that the virus leaked from the Wuhan Virology Lab rather than originating in nature, what the ramifications are for regulating this type of research, and the implications for U.S.-China relations. 

Panelists discuss vaccine hesitancy in the United States and around the world and how misinformation, public confidence, and the efficacy of public health communication may affect global immunization against COVID-19.