Public Health Threats and Pandemics

FRIEDEN: Today we have Dr. Atul Gawande for a roundtable discussion. And Dr. Gawande is currently the Assistant Administrator for Global Health at the US Agency for International Development. He is legendary in the health field, not just a renowned surgeon, but a wonderful writer who has written a series of important and best-selling books on health and health care–one of them, famously, “The Checklist Manifesto”, which really is quite relevant for our conversation today about primary health care and how to make it work for people–as well as a regular writer in the New Yorker magazine. And if I completed at least a partial introduction, it would take up way too much of our time. So just to say that, Atul, really delighted to have you with us today, and looking–really looking forward to the conversation.  We're going to start with your comments on the issue of primary health care. Just to be clear, for almost fifty years, the world has had a commitment to primary health care, and yet, still, outside of Latin America, Thailand, Sri Lanka, very few low and middle-income countries have strong primary health care systems. In fact, the U.S. doesn't have a strong primary health care system. So how are we going to go from the lofty rhetoric that we've had for half a century to people actually having a provider they trust and can access without financial hardship? GAWANDE: Tom, it's great to see you. And thanks for posing the central question right off the bat. I want to frame it by describing what I see as the challenge and the opportunity of global health. We've had a century of discovery that has doubled our lifespan. Essentially, if you're in the top one percent of income, where life expectancy in the United States was mid-forties in 1900, it is now eighty-seven years if you're in the top one percent of United States because you have been able to be the beneficiary of the last century of discoveries that have enabled capabilities in medicine and public health, that if you have access to them, has that enormous effect. Now the challenge is, we have identified seventy thousand different ways the human body can fail, seventy thousand different diagnoses and conditions. We've approved, in the FDA, nineteen thousand drugs, we have four thousand medical and surgical procedures, and north, I count, of a thousand public health interventions that have significant value. And our job has become to deploy these capabilities to the right people in the right way to everybody alive town by town. I've argued this is the most ambitious thing human beings have ever attempted. We are still learning: How do you make it possible to get all of that capability and the most important components of it in the right way in the right time and not bankrupt society, make it and–and reach everybody? And I see primary health care is the center of answering that question.  I can't have this discussion without also saying a little bit about my role at USAID. I have the best–I have the best medical job that most people in health care have never heard of, which is leading global health at USAID. I have twenty-five hundred people in sixty-three offices around the world touching over a hundred countries. We deploy ten billion dollars in aid for advancing our–advancing equity and survival, and also addressing ways to prevent health threats from abroad, threatening global security and national security.  And so, you know, my natural goals coming in, I've been in this job for two years, were focused on, you know, first addressing COVID. Number two, dealing with and preventing pandemic threats. And the third I made advancing primary health care. And why? First was the fact that we've endured the first global reduction in life expectancy during the pandemic since World War II. It has set back core areas of basic public health work. We've seen declines in vaccination of children, sixty-seven million children who've missed vaccinations, declines in basic access to sickness care, rise of infectious diseases, setbacks in our efforts to eradicate polio, and turn TB, malaria and HIV into manageable endemic respiratory illnesses. We've seen declines in health services for maternal and child-health survival. And these are in the low-income countries of the world. But we've seen setbacks and health services in every country in the world.  We have the indirect effects of COVID, of the diversion of resources away from health, economic damage resulting in health budgets slashed, disrupted supply chains for health. And so we've seen development happen in reverse. And we have set a target at–in our program, that with the countries we work with, that we want to see that we're getting to better than pre-pandemic levels of mortality by 2025, just want to see us catch back up to what to the ground we've lost. And so we're tracking the percentage of deaths occurring to people under fifty, as a marker of whether we're getting to the place we want to be. So how do we do that? It's not going to be by going disease by disease and category by category. It's going to be because we recognize that there is a basic scaffolding at the community level, which is primary health care that delivers the vast majority of interventions that most advance our lifespan.  All–virtually all of our work flows through primary health care. Whether it's being, as you've called it, Tom, having an epidemic-ready health system, you know, it's going to be frontline primary health-care workers who are going to recognize when someone has an unusual fever or unusual cause of death, and recognize that the alarm bells have to go up and this needs investigation for a possible pandemic outbreak. But it's also the same people who are doing the vaccinations and doing the child prenatal care and the TB detections and so on.  There is robust evidence that investments that raise coverage levels for the essential services end up decreasing mortality, and that primary health care is in the center of it. I can–we can walk through some of the evidence around it. There's been randomized trials of putting, for example, neighborhood health posts into place in a place like Ghana, where people were trained to a nurse level, not even at the physician level, with outreach workers, community health workers attached to the clinic, who were in sufficient numbers to touch every home at least once every three months in order to do preventive education, assess needs and make sure people are connected into the system, “Oh my gosh, you're pregnant, you need to get into prenatal care”, and be integrated into the next level of primary health care. And the result was within three years, a fifty percent decrease in child mortality, a seventy percent decrease in seven years, a decrease–an increase in the contraceptive use rate enough that the fertility rate dropped by one birth per family. And that impact then was replicated at scale. And this is where it gets super interesting to me.  What we see across countries is the richer you are, the higher your lifespan, and it's like one to one. It's a very tight relationship. But there are a few countries that are positive outliers. And, and you named some of them. Thailand is one where we supported Thailand to build its–build up its health system, meet public health goals. And they did it by building on a primary health-care scaffolding, like the one that's in Ghana, and you know, it got them through addressing malnutrition, and that community support could recognize malnutrition, water and sewage issues, and connect services, but then maternal and child-health survival, and then non communicable diseases. So that today that Thailand with three hundred dollars per person per year for health care achieves the seventy-nine-year life expectancy, which is actually now higher than the United States where we spend thirteen thousand dollars per person per year. You have Portugal, Chile, Costa Rica, Ecuador, Panama, four countries in Latin America that exceed US life expectancy. Chile and Costa Rica have the highest life expectancy in North and South America, tied with Canada. And all with a scaffolding, where there is not just a clinic in a box where a primary-health clinician can be there to provide services, but have this other component of a community health worker, which we will need to talk about, doing outreach to make sure that–in every society there are people who are disconnected from the system–and they are connecting households and families into the system to make sure they have the critical needs met, wherever they are in the life course. I'll note that when we needed to get COVID vaccinations to ninety-five percent or more of the elderly, people over sixty-five, even though we have universal health coverage and insurance, we could not get over three quarters of them covered without hiring what ended up being more than a hundred thousand community health workers who are from communities going in their community, door to door, and offering vaccination, making sure that people were pulled in the system who weren't. And we got to ninety-five percent of people over sixty-five, Republican and Democrat, this was not, this is not partisan in any way.  So how to pivot, how to how to drive to action in PHC. USAID is oriented like many public health programs and the NIH, largely in in terms of these, what we call vertical silos of TB, malaria, maternal and childbirth related care, vaccinations and so on. And that means that you can make enormous advances and not necessarily have built up the strong horizontal health system, a platform that you build on, that scaffolding that I talked about. And so, what we set out to do was learn from what has made those programs successful, establish clear targets for the strengthening of primary health care, focus on a workforce that is enabled at a community level, and collaborate with others: the governments, private sectors in these countries, the civil society, and with other aid sources to make progress.  We launched what we call Primary Impact last fall. In seven countries we made–we chose seven countries that were doing what the WHO’s Director General Tedros had called for which is making a radical reorientation of their health systems towards primary care. And that meant that they were putting a larger percent of their health budgets into primary care. And we were looking for places that had demonstrated that they were making those investments to have more of that community health capacity. Often it was signified by World Bank support, World Bank, you know, seeking loans and development assistance from the World Bank, which is one of the largest–probably the largest source of funding for system-based interventions. They were seeking World Bank funds that were primarily focused on their primary health care system. Often the World Bank is where people turn to for the financing for hospitals, and secondary care, but not enough on the primary health care and these seven countries were. There were five in Africa, so Cote d'Ivoire, Ghana, Malawi, Nigeria, and Kenya, as well as in Asia, in Indonesia and Philippines. And with that, what we aim to do is ensure that where we're supporting HIV programs to get to critical HIV targets, or TB, to get to the targets for elimination of TB, etc., that we were doing it in ways that we're connecting to help build the country primary health system, according to country led plans.  So, for example, in Indonesia, they had started with less than twenty percent of their budget going for health care, going for primary health. They have sought–they have gotten 3.8 billion dollars in loans from the World Bank over the next five years focused on investments in their health system, and they put the primary focus of that on the primary health system. So the result is, already today, they're at thirty-four percent of their budget going to primary care, it’s going to go to fifty percent of their budget going to primary health care. I’ll note we have less than eight percent in the United States going to health care.  And the focus of our support is in five areas. We’re enabling integration of service delivery, so we don't just have a malaria worker or a TB worker but integrated so that they're able to see a variety of conditions and capabilities and increasingly work across the lifespan and not just on children and pregnant women, which is often where we're concentrated, to a broader base of services. Strengthening governments at the subnational level, most primary health care is managed at a local or state level, where there isn't as much expertise in quality improvement, or monitoring the system. Third, around having enterprise digital health systems that enable those workers to be part of the larger digital health system. And then having support for the government in developing their universal health coverage financing systems, their domestic financing approaches, in ways that capture and support their primary health care system, improve the benefit package for primary and preventive care as critical components of that work.  And so our next efforts are in expanding our focus countries in this coming year to a larger group, building out expertise with our health directors in those sixty-three countries–sixty-three country offices. We have joined it with the World Bank in aligning what we're doing especially around something called the Global Finance Facility that brings multilateral donor money into primary health care but has been underfunded. And then also working with other donors. At a country level, we launched something called the Community Health Delivery Partnership, as an effort to move in more lockstep with many countries around the world.  Finally, I'll end by saying there's a kind of reverse opportunity that has been created out of this. There's been, for several years, dashboards around that begin to track how primary health care investments are going. For example, looking at the percentage of health budgets–percentage of budgets going to health and the percentage of health budgets going to primary care. Massachusetts became the first state this year that has put out a state dashboard on the condition of primary health care and they were the ones who demonstrated that less than eight percent of health spending goes to primary health care. Milbank then created the first US dashboard on primary health care this past spring, and HHS is taking the signal from that and going to be coming out with a primary health-care dashboard and strategy. But already just a couple of weeks ago, maybe it's been a month now, CMS, the Medicare-Medicaid program, established billing codes and capacity for community health workers to be paid by Medicare and Medicaid. And those are the things that become dramatic game changers everywhere. So, Tom, back to you on this. Hopefully that got us started. FRIEDEN: Great, really exciting and interesting and wonderful. Let's start with the issue of the balance within the health-care system: to put it bluntly hospitals versus primary health care. There's an over reliance on hospitals that, as I travel around the world, I see it country after country, it's certainly the case in the U.S., and there are multiple reasons for that. Many of the hospitalizations are necessary medically, but unnecessary if there had been good primary health care. But there isn't really a financial incentive to prevent the preventable hospitalizations. And there've been discussions of using total cost of care models or capitation.  What we see though, is this kind of gravitational pull to the hospital and escaping that is going to require more than exhortation. It's going to require, I think, changing the financial incentives within the system. How do you see that happening? We're not opposed to hospitals, hospitals are really important. And there are very many important things for them to do. But we don't want them either gobbling up all of the costs, all the budget of the health-care system so we can't do primary care, or spending so much of their time caring for people who really should or could have been cared for in the primary health-care system. How do we rebalance the hospital situation? GAWANDE: So I promised I would try to give you MSNBC answers and not stories, but of course, a story comes to mind. So Jim Kim, primary physician, became the head of the World Bank–this is now more than a decade ago–comes in and discovers the World Bank is one of the biggest financiers in the world of hospital building. And he's in Hungary, and they tell him, “Our beds are full, we need more–we need more hospitals”. And he's, you know, been asked to approve a country plan that's requested, you know, bigger loans. And he happens to be there on a visit, so he goes into the wards, and he sees that it's full of people. In the ICUs, with people in diabetic crisis, who are being diagnosed for the first time with diabetes, sent out, you know, after days of requiring intensive care to have survived it, given insulin, and told, “This is what you're supposed to do, manage your diabetes”. And there's no primary care to take care of them, and so they bounced back three months later, and then they need to build more hospitals. They had more hospitals in Hungary–already threefold as many hospitals in Hungary as Denmark did. So, you know, with a similar population. And so he was like, “What the hell? How do we ask for requests for primary health care?” And the governments weren't asking for them. And they're, you know, they're guided by what you're asking for.  So there were two things that were critical. Number one was the state and condition and the spending on primary health care was not visible. World Bank started to come up with metrics that say, “Hey, how much of your health budgets are going to health care?” Really important. But then “How much of that budget is going to primary care?” And, you know, the levels–there is no kind of stock level of what it can be, we haven't arrived at a norm. But it's very clear, it's like baking a cake. Survival isn't going to work if you don't have enough of one ingredient versus the other, you just get, you know, something that doesn't–if you're making bread, it's not going to taste like bread. And so, when you're making health, you don't get health, if it's all in the hospital and secondary structure. And investing, you know, in middle and low-income countries, in that primary health base requires going north of thirty percent of budgets, and getting to that place. And when they do, you see these sustained efforts, leading to, you know, these life expectancies that way outshine their income level.  The second thing was they created the Global Finance Facility for women, children, and adolescents. And that was a reward system that said, “If you choose to invest your loan in primary health care, with a focus on starting with elevating your child's survival, and your survival of women and adolescents, there will be an add-on to your loan”, so that you will get essentially, for every dollar–every seven dollars that people get in World Bank loans, now if it's in primary care, you get another dollar that gets added on. And it draws then more interest and has drawn more interest in investment from thirty-six countries now since it was launched in 2015, low-income countries that have directed their loans towards primary health care.  The third is really recognizing that we, as sources of aid for global health, have not sought out the country plan on primary health care and investing in it as part of what we're doing. We focus on whether we're getting the outcomes we're looking for, you know, reduction of HIV rates, or reduction of TB rates, and so on. And often, it is recognized that your best results are if you build that primary care system, but where there are weak primary care systems, we're often building around it with private partners, implementing partners coming in and enabling services because the country systems aren't providing them. And that's not building the long term system. And so that's also something that we track increasingly: how much of our development is going into country-led plans, and that's a critical part of what we have to be doing. FRIEDEN: I would love to ask follow-up questions about that, but moving along. We've talked about community health workers, and they clearly play an essential role. And yet, how do we make sure that a health-care system is supportive of all levels so that the community health worker is supplied, supported, supervised, can connect with higher levels of curative care when needed? Community health workers are a really big part of the solution, but they're not the solution. GAWANDE: That's right. So what is a community health worker? I think of it as two different kinds of people who are providing care at a community level. One is often someone at a nurse level, sometimes below a nurse level, who can be the first point of contact for the care itself and can be trained at levels that provide a wide swath of essential care, before having to leave your community to go to the, you know, emergency room or the hospital level or the secondary care level. But then the second component is the community health promoter. They're often volunteer, but are really vital because they do the home assessments, and provide preventive education, often do vaccinations, provide recognition of stunting and lack of nutrition, etc.  And, you know, Africa has twenty-five percent of the world's global burden of disease, but only four percent of the health workers. Those workers, eighty-five percent of them are unpaid community health volunteers who are, you know, not drawn into the system. So in Africa, we have a severe health worker shortage, and we're not seeing them become paid. Africa CDC has set a goal that there will be two million paid community health workers–health workers in the workforce, and you see–and have rallied heads of state behind those goals. Because this ultimately is a domestic commitment. No amount of foreign aid in the world can enable that to come forward.  So, we are seeing now that's happening. President Ruto in Kenya has committed to paying their 108,000 community health workers. Now they will be salaried, and in fact, are salaried now. In Nigeria, the new president has come in and Muhammad Pate, who used to be at the World Bank working on exactly this project, has committed that their 120,000 community health promoters will now become paid, and they've identified the financing pathway to be able to do that. And then organizations like ours can come in and say, “Well, we'll be happy to support training. We'll be happy to support getting them onto electronic systems. We'll be happy to support ensuring the local governments are better trained to support those workers and those systems that make them successful.” And so you are off and running. And those numbers of, you know, that's part of why we formed the Community Health Delivery Partnership is virtually all countries have had these plans, but have not had support, technical assistance, and visibility, that these are, you know, essential, essentially: the investments that we can come in behind and support even as we can't finance all of it. FRIEDEN: Let's talk about digital health for a minute. My perspective, having traveled to dozens of countries is that largely, digital health interventions have failed. They are often designed in a capital city somewhere they look great on paper. If you look at the U.S., we spent more than ten or thirty billion dollars digitizing healthcare and most doctors hate their electronic health records. In our own work at Resolve to Save Lives, we have shown some success with a deeply user-centric information system that understands the ground realities of connectivity and hardware and other things. But we see a lot of, kind of, false promise and false hopes for what digital systems will do. What's your perspective on how digital systems could strengthen primary health care? GAWANDE: There's lots of complex reasons why doctors hate their computers–or nurses [do] or other folks. They're built for many purposes other than making the care itself easier for a patient and a clinician to navigate. The reality, however, is that as you get electronic systems in, even in a reasonably basic way, they enable transfer of information: a record of a patient that allows you to begin to follow whether it's what vaccines they had, their medical history, their medications, and enabling safer, better outcomes of care. There are a few components that, you know, there's been twenty years of apps being built for here, apps being built for there, and no enterprise system that is actually effective. And what you end up having to build is the digital scaffolding to support the primary health scaffolding in the first place. That digital scaffolding has a few basic components. And what countries have to do is have a digital plan and then a lead who implements that plan.  The plan has to allow for four things to happen. You need an identifier for a patient–for people–that can follow them, that is their identifier, you know, wherever they go in the system. You need to be able to connect different sources of information that that identifier carries with it. You might have gotten immunizations here, a hospital visit there, and end up going for a child delivery in a birth center. And you need the information to be able to be connected to your identifier from those different sources without, you know, being controlled or owned by the government. So it has to have a private connection. The third is a clinician has to be able to receive that information and have access to that system. And they themselves need a smartphone, a tablet or a computer to make that happen.  Once you have that–India is now, in several states, having built systems that enable that kind of function, and you get the ability to layer on top of that, applications that actually work and matter and are updated over time for clinicians to use and have an ecosystem where people are building around this core platform. We don't have that core platform in the United States: a common identifier, a way your information can be connected between spots and a common language and agreement to do that. But you will see now more and more countries that are building on that kind of system. Kenya has established its national digital plan. Indonesia has now done it, India has done it. But you know, we're almost having to go back to basics at this point of making these pieces come together. And then you get to: Here's the intuitive way to track people's blood pressures or the immunization records so that clinicians can enter the system. But it requires that initial scaffolding. FRIEDEN: I want to open it up for the group. But I'll ask you one last question. There's been a long-standing discussion, debate, disagreement between what’s sometimes called selective PHC and comprehensive PHC. With the understanding that we'd really like to provide comprehensive PHC, but since, in many countries, we're not even providing selective PHC, we probably have to start somewhere. Where do you stand on this? And how do you think checklists are relevant for strengthening PHC? And then we'll open it up for questions. So think of your questions, because we'll turn to the group next. GAWANDE: You know, I'm coming in from the outside. I'm a surgeon, so what do I know about primary health care? What I see from visiting all the places that you've been to many more times than I have–even as much as I've gotten to see things–you always start with something that's selective PHC. There's nowhere to start except selectively. You know, in Costa Rica, they started with providing malaria services, nutrition assessment, and some basic vaccinations. And then on top of that, as those workers became more skilled and malaria got almost eliminated, they then expanded to being maternal and child health services and about childhood illnesses. And they were working with a checklist, you know, it's often an integrated management set of algorithms around how you manage the child with a fever, how you manage the prenatal visit, the postnatal visit, and so on, and the services widen. But now, over time, those clinics, each of them have, in Costa Rica, you know, by the year 2000, they had grown to match US life expectancy. And by the mid-2000s, they'd exceeded life expectancy in the United States, which meant that you had to be able to see people who were coming in, who had everything from depression, to diabetes, and hypertension, to geriatric needs. And the capacities were, you know, now they’re physician led with a primary physician–a family physician–have nurses on the team, a pharmacist, and community health promoters who go door to door: they're called EBAIS workers. And they're able to track and assess a very broad range of people's illnesses. It's much more comprehensive. It's never fully comprehensive, and you have things you have to refer up the chain, but they know their communities, they know their needs.  And they in a way we don't–in many countries they set public health goals that, you know, in our community, our biggest killers are, it might be hypertension, it might be cervical cancer and wanting to get HPV vaccination, it might be COVID and they want to get the COVID vaccinations out. But in any given year, they have their goals for the top five killers across the life course. And they're making sure that on those they're getting the ninety plus percent performance, reaching people, not letting anybody fall through the cracks. And that's simply an approach we don't take. FRIEDEN: Thank you. So we'll open it up for questions now. If you have a question, raise your hand or you can, I believe, put it into the chat. If people don't ask questions, I'll keep asking. And you can see the instructions there, you hit the raise hand icon on your Zoom window. While people are asking questions, let me ask you a political question, if I may. The Congress has been willing to fund programs like malaria, TB, HIV. The appetite for funding, primary health care is not very strong. Is that something that you're going to be able to address, especially in this fiscal climate? GAWANDE: So this is so crucial. And it goes back to, you know, we've had fifty years since it was declared that we ought to all be focusing on primary care, but we're not doing it. I totally understand the feeling that if I'm a taxpayer or a congressperson working for the taxpayer, feeling like primary health care is where I pour money into a bucket, and it just comes out the bottom and I don't know what happened here. It should, you know, the critical measure that we're tracking are our essential health service indicators. You know, we should see as a consequence of this work that we're more likely to meet the HIV goals of ninety-five percent of HIV patients getting diagnosed with HIV, ninety-five percent of those folks getting on treatment, and ninety-five percent becoming free of viral load. And it should show that we're meeting the TB markers and meeting the–increasingly closing the contraceptive unmet need. Those indicators that our Congress measures us by should be the ones that we track, and that we're delivering on.  I've added two measures, you've heard me refer to them. One is what are called the UHC Service Indicators. It’s a bundle of fourteen indicators that we should see improving. Those include prenatal measures, immunization measures, TB, HIV, malaria, and health worker density. And we should see that the percentage of deaths that occur in people under fifty go down. And the hypothesis is that when Congress and taxpayers see that for a given set of dollars you're putting into the space, you're getting these outputs then–that will be supported and justified. I see it as not an either-or HIV and primary health care, TB and primary health care, but that we are never going to reach the unmet need and close our goals in these spaces without the scaffolding and it will increase the success of our reach. FRIEDEN: Great. Well, we have a bunch of questions. Let me start with Farzad Mostashari. Farzad? You have to unmute yourself. Q: Hi, good morning. Hi. GAWANDE: Farzad! Q: Hello, hello. This is Farzad Mostashari, currently with Aledade, formerly responsible for doctors hating their EHRs and information not moving where it needs to go as National Coordinator for Health IT. The question I had is actually not about the technology, it's about the financial incentives. You give the example in Hungary where it just makes sense, right? If you're thinking long term, and if you're paying for care directly, for government to be able to do long term planning and say, “We're going to invest more in primary care now and it's going to reduce our acute care costs down the line.” In the U.S., we don't have the central division of care and the government has created a way for private actors to–if they improve primary care–to capture some of the value created in reduced hospitalization and acute care spending. And that's what I'm engaged with currently.  Do you see–on those two sides of the coin, do you see globally, on the government sponsored health care side, what's the barrier to government's thinking long term like that? Is it that they don't really believe that more primary care is going to reduce total cost over the long run? Or is it having a short investment horizon, and then what could be done on that? And then on–where healthcare is privately mostly provided, do you see any other examples of countries that have followed the kind of risk-sharing model that the U.S. has done. GAWANDE: It is true that everywhere, it is hard to convince people to invest in what's going to save lives, you know, ten years, twenty-five years, fifty years, in the long run. There's a study I read about, I think, more than a decade ago, but I was enthralled with, which looked at bridges, and that you could keep bridges alive for a hundred years or more, if you provided maintenance services on those bridges. And every state has its maintenance fund, and every governor raids the maintenance fund in order to build a new bridge, right? So, we are chronically, you know, it shouldn't be that the majority of your spend is in the maintenance fund and the minority is in the building-new-stuff side. And you–there's an optimal level, but you know, on the political horizon, you don't get credit for the bridge that doesn't fall down, you get credit for the bridge that you built, right? And so, everybody's maintenance funds are too low. The way we use–our percentage of spending on maintenance is always lower than we want.  All of that said, what I've seen in the countries that establish this work is that the value–Costa Rica is a nice example because I dug into it, but it's similar in Chile, Thailand and other places, but I know the politics of it better in Costa Rica. When they didn't exist, it was seen as a huge expense. And then they built having a community health-care capability that had a clinician and a visit to your home at least once every three months to assess your needs. And then it got its own momentum that once those places had those services, other places wanted those services. It's like, you know, we don't always invest in schools, but it ultimately pays off to have a school, and communities that have those capabilities want them.  It is also the case that I have seen that those public health–those public platforms with a primary-health structure have been virtually always built on a public government basis, whether it's local, state, or national government building, that core scaffolding. And on top of it, there's always a private sector that people can choose to go to, instead of that system, but that that system was always making sure that people were not falling through the cracks, that there was some outreach. And the public system is rewarded for prevention, is sustained on the basis of what its outputs are for actually making health achieved. Whereas the private sector is almost always rewarded for acute needs and it's very difficult that people don't pay for and tend not to buy expensive insurance for what they do on the preventive side. It's not that it's hopeless.  So, where there are the capitated models, as you talked about, a panel fee or a subscription that you pay, and the Medicare approach with Medicare Advantage, in theory, enables those services to happen. But no one screams about whether, you know, “No one came to me to offer me my COVID vaccine!” They scream about what happens if your acute care didn't follow through, and they sue, and they do all of those kinds of other things. So the, you know, we are always swimming uphill–it's public health–in seeking resources and enabling what pays off in the long run, you know. We don't miss smallpox. We didn't reward any politicians for getting rid of smallpox in the world, but it was a huge payoff. And it's still–I see it as a fundamentally public function with the private sector needing to come in and as far as we can, enabling on the private sector side, support that can, you know, reward and recognize the value that gets paid off.  The fact that in Medicare people can hold on to–tend to hold on to people's households for–or at least families for years of time, does provide some incentive for making sure those private primary needs are met and pay off in the long run. But you know, you're in the middle of that grand experiment and seeing whether it actually ends up translating into more of that prevention. FRIEDEN: We have a bunch of questions. So let's try for crisp questions and crisp answers. Charles Holmes– GAWANDE: The answers have been crisp so far–questions have been crisp so far. I'll work on the answer being crisper. FRIEDEN: Charles?  Q: Thanks so much, Tom. And thanks, Atul. This has been amazing. And thanks for all you're doing too, with Primary Impact and also really trying to leverage the multilateral funding into primary care. Two really click questions. One is, you know, primary care is almost more than anything else entirely–almost entirely workforce dependent. We see so many challenges with government management of their health-care workforces, they tend to have a lot of trouble with performance management, a lot of trouble with the administration and expansion of those groups. As we move towards more of a paid workforce, how can we make sure that we're investing in those performance management systems that have really bedeviled so many of the countries that I interact with? As we try and, you know, expand the roles that the primary health-care workforce can–that management–is really invested in?  Secondly, how can primary health care in this sort of post–so much to COVID vaccination, yet, we're left with so much sort of vaccine hesitancy. We're moving towards more adult and adolescent vaccines like TB vaccines, for instance, in the next few years. How can we–how can primary health care help rebuild that trust to ensure that we do even better next time? Thanks. GAWANDE: I'll try to do this as tightly as I can. So, on performance management in primary care. I mean, we have across the board, it's not exclusive to primary care, secondary care, hospital care, delivering health care is very complex. It involves huge–the amount of coordination and system building that's required is massive. And we're still learning: How do you manage that quality and performance? But we've made huge strides. You know, the more we learn how to measure, how to set targets, goals, that are–that we all aspire to as teams, and the more we function as teams rather than individual actors, the better and better the results we're getting. And, you know, it's the slow, as I said, it's a generational problem. It's not a one-time fix, it is mastering that art.  What I will say, however, is for all of the difficulties, you know, Chile has people in the streets just a few months ago, complaining about the quality of their primary health care and wanting to see, you know, better–significant improvements. And they–with a fraction of our income, less than less than a quarter of our income per capita–are achieving an eighty-two-year life expectancy. And so, you know, it's not that we have to get it perfect, it is within reach to make sure that these essential services are there. And the critical component is being able to say that we actually have goals for our primary-health clinics that they should be achieving: getting to ninety percent of the high blood pressure recognized and delivered on cardiovascular disease, the biggest killer that we, you know, as one example, that Tom works very, very hard on. And in the United States, you know, we're barely past fifty percent of us–we don't set a goal. There is no goal that we, you know, we have a cure for Hepatitis B and C, and we have not figured out how to set a goal that we're going to make sure every one of our communities or clinics are oriented towards making sure that that is addressed or that the blood pressure is measured and managed. So that ability to have goal setting, to track it at the primary-health level and marry it to public-health goals, is what many places are doing and what we need more places to be able to do. FRIEDEN: Thank you– GAWANDE: Oh, and then, there was, on the vaccine hesitancy. I'll just say, you know, the more we move past the politicized moment, the better–the better off we'll be. You know, early on, HPV vaccination was really–there was a significant political divide about each vaccination against cervical cancer. And then, you know, the heat was turned down, it was pulled out of the headlines. People, you know, moved on to the next social cultural war. And we've quietly gotten past eighty percent of our adolescent girls vaccinated and dramatic drops in cervical cancer.  You know, Australia, which is–which has similar rates, slightly higher, is starting to see that they can set a goal of eliminating cervical cancer, of the types covered by the vaccine. So there, vaccine hesitancy, I think happens, is addressed at the community level with community health systems, primary health systems, that approach people, talk to them about the facts of what's on offer to save their life. And we see again and again in those settings, if we can make sure that that system is what people have access to, they deliver real results. FRIEDEN: Great. Next question is from Kyla Laserson. Q: Hi, thanks. This is Kayla Laserson from CDC– GAWANDE: Hi, Kayla! Q: Hi. Thanks so much for this, this is great. Just a question about what your thinking is on–especially globally–diagnostics at the primary health-care level, especially for acute febrile illness and partnership with the private sector for that? GAWANDE: Well, so this is where I get to plug one of the things I've been very excited about. I mean, first of all, we're moving diagnostic capabilities like molecular diagnostics to diagnose TB and other conditions, increasingly becoming something that can be done at the primary health-care level. You know, it used to be these genetic–diagnostics can only be done in national labs. Now it can be, you know, we have increasingly portable handheld less than ten dollars a test capacity and that price is dropping.  But what's exciting to me is we're seeing other tools also land. I'm rolling out in seven countries, in our TB program, AI based chest X ray detection systems where you have, on a laptop, a AI based program that will read digital, portable chest X rays that can be done with a–with a system no larger than a backpack, that are deployed at primary health-care levels in Nigeria, in Vietnam, in a variety of other settings. In Nigeria, the combination of a chest X ray, you can do at the primary health care level to screen people or look into whether a pneumonia is present with a molecular diagnostic has contributed to a forty percent jump in the number of TB diagnoses made in the last year. So, I think we have an increasing variety of tools–we're going to be testing out AI based ultrasound for pregnancy as well–that move capabilities that formerly required really high-level radiologists and technologists to have those tools be more and more available at the bedside level. FRIEDEN: Great, thank you. Next, Tom Bollyky. Q: Hi. Thanks so much to Tom and to Atul for this great conversation. I'm Tom Bollyky, I direct the global health program here at the Council on Foreign Relations. Atul, a question I had is obviously we're coming out of the pandemic, many countries are struggling with debt. On one hand, this would seem like a particularly inopportune moment to try to advance this agenda. But there is another way of looking at it. And I wonder how much the conversation around primary health is being seen as part of the discussion of how to have that fiscal restructuring in countries, how to have policies that are more sustainable and more conducive to their debt levels, and to the degree to which you are working with our multilateral bank partners or treasury on those issues? GAWANDE: Yeah, so you know, they have been, I would say they're only loosely connected. The connection that I see–so as you're pointing out, debt levels after the pandemic have risen enormously. A lot of that debt is held by China and by European bond markets. And for health systems in low-income countries, that means you don't have cash to buy pharmaceuticals, to buy vaccines, to buy fuel for getting health workers out. And so, it's devastating for health systems.  And the biggest challenges around trying to get China and public markets to recognize that that needs to be restructured. You need to, you know, expect now that the countries are simply not in ability–don't have an ability to pay, to pay it off and retire some of that debt. But we're not getting there yet. When you're having to do with less fiscal space, because you see countries like Kenya, for example where the budgets, the amount of budget, the majority of the federal budget now is going for debt payment. In a tighter fiscal space, there's a strong case to be made that your top priority has to be primary health care. And coming out of the pandemic, the disruptions in the primary health-care delivery, you know, simply not being able to provide pregnancy services and other things like that are making it critical to have choices that address these primary health needs.  So, it's an indirect effect, it is hard, you know, when you're, as Tom said, when you're facing off budgets for hospitals with urban environments that have more political clout often, and the more dispersed community health needs of a primary health sector. However, a dollar goes so far in this setting, that being able to get a hundred-thousand workers paid in Kenya at relatively low costs, because they're your lowest cost health worker cadre was politically salient, very powerful and important in Kenya, given that they wanted a win in a tightened fiscal environment. As a way to address the debt crisis, it doesn't help provide a pathway out from a situation where the costs of debt are outpacing your growth in your economy and your tax receipts. FRIEDEN: Paying the health workers is one thing. Supplying them may be something else. Jordan Kassalow. Q: Yes, thank you, Tom. As the mortality and morbidity burden moves from infectious disease more to the non-communicable diseases, like hypertension, cardiovascular disease, diabetes, one of the challenges that we see is that many of these top killers are asymptomatic, whereas from my experience working in particularly under resourced places, what drives people into the health system are things that are visceral. And the most common visceral problems to the human being tends to be oral health issues, ocular health and or vision issues, auditory issues. And the problem is those areas have not gotten any, any leverage, any– FRIEDEN: I’m just going to interrupt because we're just about at time. So we have time for a quick question and quick response. Q: The question becomes, how can we leverage these visceral issues that are so common, to both solve those problems themselves, but also to help drive people into the primary health-care system and get them the things that they need for the killers? GAWANDE: Okay, well, two quick things. Number one is the majority of deaths in Africa are still in many of the common public health areas of focus, HIV, TB, maternal child health, malaria. And so–but we've got now a large space that has come for cardiovascular disease and coming when you had the chest pain is way too late. So completely agree. There is–if we go to Asia or Latin America, where we have advanced to the point where those systems are now treating people across the life course, where the infectious disease burden has become quite low. That is, in fact, what they're adapting to do. The needs that they're being called upon to address may be oral, they might maybe eyes, they may be geriatric needs. You know, and they've built out and trained more geriatricians per capita in Costa Rica than the United States has, as a result at that primary health level. So, you do become demand driven. You get people in the door for what they–for the ways in which they feel badly. And then you attach to that your preventive needs to make sure that their care gets to doing–gets to the goals we have for the longer run. Tom, this has been really great as a discussion. I appreciate you inviting me. FRIEDEN: Thank you so much. I’m sorry that we didn’t get through all of the questions, but thank you so much, Atul and thanks for the great questions. It's a great discussion, it's a crucially important topic, and I'm just hoping the coming months and years see lots of progress in lots of countries so thank you so much.

The Global Health Security and Diplomacy in the Twenty-First Century symposium is cohosted by the Council on Foreign Relations and the recently launched Bureau of Global Health Security and Diplomacy at the U.S. Department of State.  This event convenes a globally representative set of influential policymakers, practitioners, and thought leaders to discuss the global need for better cooperation, coordination, and communication in tackling health security threats, which also threaten national security. Speakers include U.S. Global AIDS Coordinator and Senior Bureau Official for Global Health Security and Diplomacy John Nkengasong, former Chief Medical Advisor to the President Anthony Fauci, Director of U.S. Centers for Disease Control and Prevention Mandy K. Cohen, and UNAIDS Executive Director Winnie Byanyima. Speakers making welcoming remarks include U.S. Secretary of State Antony Blinken (pre-recorded video message to participants), U.S. Ambassador to the United Nations Linda Thomas-Greenfield, and Director-General of the World Health Organization Tedros Adhanom Ghebreyesus.   This event is part of Thomas J. Bollyky's Global Health, Economics, and Development Roundtable Series. Please click here to view the full symposium agenda.

Panelists discuss the future of U.S. foreign policy on global health and ways to address future pandemics, climate change, health-related development goals, and other challenges in a divided country and geopolitical world. This meeting is made possible by the generous support of the Bill & Melinda Gates Foundation.

Thomas J. Bollyky, senior fellow for global health, economics, and development and director of the Global Health program at CFR, leads a conversation on observations and lessons learned from states’ public health responses to the COVID-19 pandemic.  TRANSCRIPT FASKIANOS: Thank you and 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 fifty-one states and U.S. territories for today’s conversation. Thank you for taking the time to join us for this discussion, which is on the record. CFR is an independent and nonpartisan membership organization, think tank, publisher, and educational institution, focusing on U.S. foreign and domestic policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. Through our State and Local Officials Initiative, CFR serves 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. We are pleased to have Tom Bollyky with us for today’s conversation on public health and lessons learned from the COVID-19 pandemic. We’ve shared his bio with you, so I will just give you a few highlights. Thomas Bollyky is the senior fellow for global health, economics, and development at CFR, and the director of CFR’s Global Health program. He’s also an adjunct professor of law at Georgetown University, and a senior consultant to the Coalition for Epidemic Preparedness Innovations. Mr. Bollyky is also the author of the book Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways, and the founder and editor of Think Global Health, an online magazine that examines the ways health shapes economies, societies, and everyday lives around the world. So, Tom, thanks very much for being with us today. You recently co-authored a report on COVID-19 pandemic policies and behaviors. I thought you could talk us through the differences in public health responses that influenced states’ infection and mortality rates, and what you came away through this research for recommendations for future pandemics. BOLLYKY: Great. Well, thank you, Irina, for the kind invitation to be here and that nice introduction. It is—this is, I think, my third time, maybe fourth time, speaking to the State and Local Officials network. And it is one of my favorites in terms of a resource at the Council. I always learn as much from these discussions as I think I am able to impart, so I’m really looking forward the chance—to the chance to speak with all of you. And congratulate Irina and team for pulling together such a useful network. What the thing we’re here to talk about today is—it is—Irina, are you making faces? Is my internet causing trouble? FASKIANOS: Yeah, your internet—I was like, oh, no, his internet is freezing. So— BOLLYKY: Hmm, ah. Well, let’s keep going. FASKIANOS: Let’s keep going. BOLLYKY: And perhaps at some point I will turn off my video and do it just with the audio if it remains a problem. But apologies for that. Again, this paper appeared in Lancet six weeks ago. It’s a year-long study, the product of five different institutions. And I had the pleasure of co-leading that group. And it—what it was meant to look at is what explains the very large differences we have seen between how states, U.S. states, performed in the pandemic. And I think it’s been underreported, but perhaps not a surprise to this group, that while the U.S. overall struggled in the COVID-19 pandemic, not all U.S. states struggled equally. There is, in fact, a nearly four-fold difference in cumulative total COVID deaths from the worst to best performing U.S. states, even once you adjust for all the relevant biological factors—differences in the age of the population or key preexisting health conditions. For most of the pandemic, states like New Hampshire, Vermont, or Washington have actually posted COVID-19 death rates that are comparable to countries in Scandinavia, like Denmark, or in Europe, like Germany. While mortality rates from some other states have actually rivaled the worst-performing countries in the world during the pandemic—Russia, Bulgaria, and Peru. That difference, between top performers and poor performers, is large in health standards, even by American standards. For instance. The U.S. states with the shortest average lifespans come nowhere close to matching Chad, Nigeria, or the worst countries in the world on that measure of longevity. The state variation, though, is a reason for hope. Because if poorly performing U.S. states could more closely match their more successful counterparts when the next health crisis emerges, many lives might be saved. One estimate we have from that Lancet study is that if every state had performed as well as New Hampshire, the second—state with the second-lowest COVID mortality rate—there would have been 504,000 fewer U.S. deaths from COVID-19 during—just during our study period. That would have made the U.S. again, in terms of overall death tolls, very similar to other high-income countries, as opposed to one of the worst-performing countries, which is sadly where we were. I’m going to pull out just four specific themes about what drove those differences, and then I’m going to save most of the discussion about what do we do for this, because I really do intend for those to be mostly a conversation about looking forward and how do we respond to this. But four themes that came out from our analysis in the Lancet. One is—or, theme number one is that the role of health equity, socioeconomic and racial disparities, loomed very large in this pandemic. Larger than it does in many other—even larger than it does in many other U.S. health measures. So what we—what we saw was a cluster of factors—low educational attainment, limited access to high-quality health care, the percentage of people living below the poverty line—had a strong association both with differences between states, and their infection rates, and in their COVID-19 death rates. In many ways, this reaffirms what we’ve seen in the past, that these disparities played a large role in H1N1 and the response there. These disparities combined with racial disparities, which were also significantly associated with state variations in our study, also play a role in differences in seasonal flu vaccination. It’s not just in pandemics or infectious disease. Of course, in other health crises,­ you see these social, economic, and racial disparities loom large. And it will be important to proactively seek to mitigate these differences ahead of the next emergency. And we can talk a little bit about in the discussion of ways to do that. All right. Theme number two that came out from here. Trust, interpersonal trust in particular, played a large role in this pandemic in the U.S. Interpersonal trust, if that term isn’t familiar to you, is the trust we have in one another. And it is actually a finding that has been shown also in many international studies. For example, we did a—the same group did a study in the Lancet the year earlier on the global level. And we were unable in that study to find any connection between country variation and COVID outcomes in many of the leading theories or pet theories of what made a difference in the pandemic—like economic inequality, or pandemic preparedness metrics, or democracy, what have you. We didn’t find any links. But interpersonal trust had a very large and significant association with differences in how countries did. We see the same thing in the U.S. context, that the trust—how we feel about one another, the trust we have in one another, is tied to vaccination rate­s and adoption of health-protective behaviors. And that, in the end, has a large tie to the outcomes and how states did. Meaning that when confronted by contagious novel virus, government—most effective ways for governments to protect their citizens is ultimately by convincing them to protect themselves. And their willingness to do that, particularly in free societies and in U.S. states, depends on the trust we have in one another. And that’s going to be important to foster stronger in the future in thinking about how we respond to these things. Theme number three: The role of politics was nuanced in this pandemic. There is a perception political parties mattered a great deal in the response to this pandemic. But at least from our study, there is no association between the party of the leading state official, or state governor, or, in Washington, D.C.’s context, mayor, and COVID deaths. In fact, out of top ten states that did best, half—five of them are Republican and—five of them are led by Republican governors and five of them are led by Democratic governors. That said, there is certainly a role for politics in this pandemic. And the degree to which states voted for a particular candidate in the last election does seem tied to the adoption of health-protective behaviors, and vaccination rates, and the application of mandates. And that does seem to have had some effect. Which brings me to the last theme to draw out, which is mandates. And by mandates, I mean bar and restaurant closures, gathering restrictions, mandates around vaccination use—or, vaccination, or mask use, or stay-at-home orders. What we find in this study is that the package of mandates, or the broader use—because states tended to use many of them together, and nearly all states used some mandates in this pandemic, usually for roughly—for about a sixteen-month period. And what we found is they were generally associated with fewer infections. But it was vaccine mandates that had the largest effect on deaths. And there’s been a discussion around tradeoffs in this pandemic. We did find some. There weren’t any tradeoffs between overall economy and the adoption of health protective measures, but there were some tradeoffs particularly on restaurant closures and employment and there were some tradeoffs on educational performance in this pandemic. It will be important in the future to adopt—to apply these mandates in a way that they target the most vulnerable and are designed in a manner that it promotes getting back to work and getting into schools as soon as possible. They will also be important to combine with mitigation measures for the period in which they are in place. We can, again, talk a little bit about that. But those are the four themes to start us off, to draw us out. I’m really interested to hear about the experiences you all have had in the pandemic, and questions you might have about this study. And I will put the link to the study in the chat, if it’s not already available to attendees. Irina, do they have it already? Sorry, you’re on mute. FASKIANOS: Oh, can you hear me now? BOLLYKY: Yes. FASKIANOS: Great. Yes. They do have a link to the report. So we did send it out in advance. BOLLYKY: Great. FASKIANOS: So that’s great. I’m going to—now it’s great to turn to all of you. Again, this is a forum to share best practices, ask questions, and whatnot. And I want to go first to Dr. Jonathan Ballard, who’s the chief medical officer in New Hampshire—the New Hampshire Department of Health and Human Services in the office of the commissioner, since, Tom, you mentioned New Hampshire being in second—the second good story. I guess Hawaii was number one. So it would be great if you could just react and maybe share your thinking of what you—what else you will do in the future, Dr. Ballard. And if you accept the unmute prompt, that would be great. There you go. Q: Thank you, Irina. Thank you. So the question I have is around health equity and the diversity of the population. So some of the questions I have, particularly around your study, is does this study adequately adjust for the disparities in—related to health equity that we see between New Hampshire? New Hampshire’s one of the healthiest states in the country. And so, you know, the theory is that, well, you’re already a healthy population, you do not have obesity to the degree, you have lower smoking rates, you have high rates of physical activity in New Hampshire. And so is that—was that taken into account already into your study about why some states are performing well? Was it the underlying population was already healthy or not? I would conjecture that it’s not—it’s not simply that underlying fact, because there are several states in your report that are just as—nearly as health or heathier than New Hampshire but did not have the same outcome with the mortality rate. And I think that there several things that New Hampshire did do that was quite protective and did kind of go against the strain of what the national guidance was. Each time there was a recommendation that came out from the CDC or any other national body, we did look at it carefully, and noting particularly the recommendations around the vaccination priority populations. New Hampshire did not follow the national guidance on vaccinating frontline workers. We did a different approach. We looked at social vulnerability index and vaccinated those who had the highest risk of social vulnerability—of vulnerability, but then also looked at—made a big effort to vaccinate the other vulnerable populations, those in congregant facilities, nursing facilities, and other locations. And New Hampshire was the first to get to kind of whatever number you would—each state would get to with its vaccination rate. We had a lot of emphasis on speed, on delivery of the vaccines, and very seldom had any in reserve during the early months. They were all used. And I think a lot of that relates to what you talked to around the interpersonal trust, resulting in us being fastest to get the vaccines out. New Hampshire’s known as a—you know, the live free or die state, and individual liberty, individualism. But we didn’t have a lot of the culture wars. We’re a purple state. We have split government as far as state government versus our federal delegation. And we just didn’t see vaccines getting caught up in that, especially early on. So I just wanted to stop there and, Thomas, would be appreciative of your response on the was—what were the adjustment rates that you used, and did it account for just these healthier states did better, or not? BOLLYKY: Great. So the first one it’s a relatively quick answer, fortunately, which is the adjustment, it does, in fact, account for BMI, it accounts for rates of diabetes, cardiovascular disease. Really, an expansive view of the key comorbidities that might have made a difference in how states performed in the pandemic. So it is adjusted for that. And, of course, it is adjusted for age. I would draw out a couple things at least from our study, but obviously you lived the experience so I take your insights more—as seriously. But, you know, New Hampshire, as a state, is a little healthier than other states. Though New Hampshire’s average life expectancy at birth actually only ranks twenty-third in the U.S. out of states. So it’s around the middle. And its performance in this pandemic was better than that metric might have suggested. There are a few—about New Hampshire. It does have the lowest poverty rate, or percentage of population under the poverty line. It has the highest levels of interpersonal trust in the country. It has relatively few uninsured. Reasonably—among the top ten in terms of access to quality health care. It is also, you know, not a—as states go—not a particularly diverse state in terms of its racial makeup. But the—what people identify as in the U.S. Census. However, as you rightly pointed out, one of the things we’ve—in a follow-up piece that we wrote—pointed out that to the extent that New Hampshire does have social, economic, or racial disparities, the state was quite aggressive about addressing them in its vaccination program. And that seems to have made a large difference as well. In terms of our research, or talking to local officials, also they reaffirmed the view that you had put forward about a strong partnership between states and local communities in terms of enabling some of the local actors to have some agency to respond to what they were seeing as well. But we highlight New Hampshire, in terms of an example because, of course, unlike Hawaii it is not an island. But there is a lot—you know, New Hampshire has many advantages but again, as we pointed out, the health circumstances has some challenges too. And through aggressively addressing some of those challenges, the state did well in this pandemic. And hopefully more states are able to match it in the future. FASKIANOS: Thank you. So we have two questions on interpersonal trust, which I will—I will ask together. So the first one is from Colorado State Representative Parenti. How were levels of interpersonal trust measured? And then, from Alder Regina Vidaver in Madison, Wisconsin, she asked: What are evidence-based approaches to improving interpersonal trust? BOLLYKY: Great. So two fantastic questions. I will start with how we—the data sources we used for interpersonal trust in this study, and then I’ll just briefly reference how it can be measured more broadly. So the short answer is surveys. We have a set of surveys reflecting nine thousand respondents throughout the country, all conducted in 2019. Those surveys asked the question: Do you—how often do you trust others to do the right thing? The responses coded for most of the time being high levels of interpersonal trust. This would seem like a subjective question, but surveys—social scientists have been actually asking that question since the 1950s internationally. And you would be amazed how stable the values are for countries and communities. So that is the way people measure interpersonal trust through surveys. There are also, of course, experiments people do to measure them in a community, or they look to proxy behaviors that are suggestive of interpersonal trust. We use for this—for this study surveys. Now, what would you do with it? Well, a couple of things. Or, what’s the evidence-based interventions for interpersonal trust? First thing I will say is the government of Denmark actually monitored trust at the community level throughout the pandemic and adjusted its public health interventions to reflect those changing levels of trust. That’s just running a survey at the community level. Not cheap, but not impossibly expensive. But to give you an idea, for instance—because they convinced people that they will not the only who is vaccinated, that there won’t be holdouts. But in low-trust populations, they have the opposite effect, where they tend to inculcate hostility and a reaction. So that was used to tailor public health policies for different populations, just to give one example. As a general matter of how you build trust, and how you identify where there is low trust, and what you need to do differently to respond to that in the future. But hopefully that gives at least a start of the conversation around trust. FASKIANOS: Thanks. All right, the next question, we’ll take an oral question from Pennsylvania Representative Arvind Venkat. Q: Hello. My name is Arvind Venkat. I’m a state representative in Pennsylvania. I’m also an emergency physician. I had two questions. One is on did you distinguish in a large state like Pennsylvania, when you’re looking at it, between urban—or, among urban, suburban, and rural areas? Because the response in all of these area was very different in our state during the height of the pandemic. And the second question is, what specific legislative recommendations do you have coming out of your study? Thank you. BOLLYKY: Great. We did look at population density, but we only looked at population density at the state level. So the study in general functions at the state level. We don’t look at whether it’s at the ZIP code level or the community level. So that will have to be a future study. I will say population density, as the pandemic progressed, was less meaningful in terms of having a tie to either infection rates or deaths. And perhaps that might make sense from what we—what you’ve seen, what others—what we all have seen in the rural communities and how the pandemic experience has changed in those over time. In terms of legislative approaches, I think there are a few. I do think it’s important for states with high rates of uninsured, or states that have not extended Medicaid use or are reversing those policies. The study suggests that rates of uninsured did have a significant association with how states performed in this pandemic. Perhaps not surprisingly, and high death rates. So those are one area. Another is we did see an association between states that had adopted more generous family leave policies, or personal leave policies, and infection rates as well. And it will be important, whether they’re adopted on an ongoing basis or adopted in a manner that allows them to be expeditiously exercised in a health crisis, or extended in a health crisis. It’ll be important to have those structures in place. As I mentioned, whether it’s on politics or on social, economic, and racial disparities it’s really important to have ongoing community engagement, or to build these partnerships between state officials and community organizations or faith-based organizations. That’s perhaps less of a legislative matter, but certainly a matter of appropriations. And it’ll be important to have those partnerships established ahead of a crisis, because it is difficult to build them and use them and harness them effectively once the crisis has begun. But great questions. Thanks for participating in today’s call. FASKIANOS: So the next question is a written question from police chief Patrick Finlon, who’s in Village Cary, Illinois. And I’m not sure that this is in your area, Tom, but I will ask it: What were your findings related to the ability/desire to use/exercise governmental authority related to the shutting down of businesses and the application of constitutional provisions? I’m in law enforcement, and our risk management provider advised us not to close businesses for fear of a potential civil rights violation. BOLLYKY: Well, in terms of—what I can use on the use of mandates, in general, is there—although underreported—there is actually a surprising level of uniformity across states. There’s a perception that some states locked down and other states didn’t, and that that tends to vary politically. As an initial matter, lockdowns or use of mandates, rather, at the state level really over occurred over a sixteen-month period. Virtually all states from March until June of 2020 used some policy mandates. Where really you started to see the big differences in the outset of the Omicron wave, between some states reimposing them and others doing less so. But there’s a lot of uniformity to that at the state level. I will—I will forgo the—opining on the legal merits of the adoption of these, but there have been, of course, a good number of cases that have worked their way through the courts, some of which have gone to the Supreme Court, and they point to a few lessons on, you know, public health authorities/powers, and where they draw from and what they extend to. But, again, I will save that for a more legal discussion. FASKIANOS: Thanks. We’ll take the next question, raised hand, from Georgia Representative Imani Barnes. Q: Hello. Thank you for having me. I don’t think I can turn my camera on. But I was wondering, what type of educational data did you gather from this study? I was wondering the data compared to New Hampshire with other states that—I wanted to understand the disparities, educational disparities, that you gathered—the data that you gathered for educational disparities. And what suggestions do you have to mitigate the learning loss that the children experienced during virtual learning? BOLLYKY: Great. So the educational data we used for is average educational attainment. Again, like our metrics in the study, it is statewide. So by disparities, we’re talking the difference between states, and that average level of educational attainment. It does—didn’t matter a great deal in terms of showing differences between how states performed in this pandemic. Levels of—or access to high-quality health care or percentage of people below the poverty line does seem to have a pathway through vaccination rates, that states with lower rates of—or, a lower average of educational attainment had lower vaccination rates, by and large. So that’s the way we address that. On the learning gap question, I think the real answer is people don’t know as of yet, in terms of we haven’t really had a disruption of this duration and length before. So there are theories of what matters, from tutoring to, you know, more extended engagement or programs with students that fell behind. What I can say from our study is that the tradeoffs on the educational side were significant. All states suffered from an educational standpoint in this pandemic. Some states suffered more than others. It is unfortunately true that the same racial disparities and socioeconomic disparities we see in educational attainment, by other studies that have been done, suggests those were exacerbated in this pandemic. So it will be important to redouble and be aggressive about addressing those gaps. FASKIANOS: I’m going to take the next written question from Crystal Goodwin, who is with the Texas Council for Developmental Disabilities, and serves as a public health and disability integration specialist: If this were something that—if this was something that the study looked at, did the findings show any difference among states based on disability status or disability services offered? Something we found during the pandemic, and studies show, that individual with intellectual and developmental disabilities as a comorbid condition were in the top three of deaths here in Texas. BOLLYKY: I wish it was something our study looked at. It’s an important issue, and I really appreciate you raising it as something that deserves more attention, both by my colleagues and I but others in the future. So thank you for raising the question and, unfortunately, it was not in our study. But I wish it had been. FASKIANOS: It can be the subject of your next study. BOLLYKY: Indeed. FASKIANOS: Let’s go next to W. Abdullah Brooks with a raised hand. Q: Hello. This is—yeah, I’m W. Abdullah Brooks. I’m actually standing in for a representative from the state of Maryland, Scott Phillips. In full disclosure, I’m a faculty at the Bloomberg School of Public Health at Johns Hopkins, and with a background in infectious disease and global public health. First of all, congratulations on a brilliant study. And I haven’t had time to go into a deep dive, but I had just two questions that maybe you could elaborate on, if they’re not in your paper. One is, you talked about the correlation with employment and health outcomes. And given the structure of health care access in the U.S. often being tied to employment status, I’m wondering if you adjusted for access through, for example, those who have public assisted health access. Just to look at the question of health equity or equity in health outcomes, and whether or not there was any difference between those who are on public assistance, had access to public—to health access, hospital, and so forth, versus those who only had access through private insurance. That’s one question, just getting at the issue of equity of outcomes. The second, you have a reference to interpersonal trust. And during the beginning part of the COVID pandemic, the American Society of Tropical Medicine and Hygiene held a series of discussions around this and looked at specifically the issue of trust towards health experts—trust or distrust. And I’m wondering whether or not your paper looks at this specifically with regard to health communicators and health communications, and whether or not you gleaned any insights into messaging. And, you know, whether there were better or worse strategies with respect to trying to get messages regarding, you know, responses to the pandemic, and access to things such as vaccines. Thank you. BOLLYKY: Great. Thank you for such a rich group of questions. And thank you for the kind words about the study. On the employment side, the employment results are fascinating in the study, in that by and large most of the use of policy mandates are not associated with differences in employment. There is an association, in particular, with restaurant closures, which perhaps not surprisingly, given that sector. But there is an association between higher infections and higher employment. And that actually reaffirms what we’ve seen in other studies of the economic impacts of the pandemic. That it may have been less a matter of policy in terms of differences in economic impacts, and more in the responses of the population. So, meaning people that stayed home more cautiously, whether the state ordered you or not, had broader economic impacts. As a general matter, economically what you see in the pandemic is often a fair amount—and this is perhaps why the GDP levels aren’t shifted—or, have no association with the degree of public health response—is that you’re largely shifting economic activity between sectors. So less activity in restaurants and bars means more grocery. And you see some of that shift where all states suffered in the pandemic economically, but it tends to net out, to some degree, in terms of the various sectors positively and negatively affected. In terms of equity in the private and public insurance, we do include both public, private, and out-of-pocket spending—estimates of out-of-pocket spendings in our measure of health spending. We, unfortunately, do not break them down and see how the results might be different depending on the level of spending between each. But that too, like Irina suggested before on the disabilities, would make for an interesting follow-up analysis. So thank you for proposing it. On the trust in health experts, we do look at trust in government. Now, that is not—and we also looked at trust in science in the studies. Both of them also the product of surveys. As you rightly perhaps intimated, you know, trust in government does tend to vary by agency and area. There have been some good studies that have come out that have looked at trust in health authorities. And what you have seen are declines, particularly in trust in state governors, trust in federal health authorities. What I’ve—from what I’ve seen from multiple surveys or studies of this kind, what has really held up are your family physician. Local hospitals, local health clinics still enjoy high trust. They enjoy it across political lines. And that too may be something we can seek to leverage in the future but would be a different lesson than we’ve had in the past, where we have really emphasized having one voice speak in a pandemic, having it be at the federal level, perhaps having it be CDC. What the lessons of this pandemic suggest is that we need more community and local engagement, engaging trusted health sources of information. FASKIANOS: Thank you. I’m going to take the next written question from Commissioner Keith Baker from Colorado. Was the level of interagency—county, municipalities, healthcare, school districts, et cetera—coordination and collaboration evaluated in your report? And were there any lessons drawn from that? So we have another question too on this, about, you know, measurement of the level of intergovernmental cooperation and outcomes. BOLLYKY: Great. Thank you for the good question. No. I haven’t seen a good standardized data source of measuring the cooperation that occurred in the pandemic. There are different measures of polarization people have looked at, but they typically look at the legislature, state legislature, or surveys of the population and how polarized they are on particular issues, or politically. But the interagency cooperation’s an interesting question. But I have unfortunately not seen it well measured, particularly across U.S. states. FASKIANOS: All right. So the next question I will take a written—I see no more raised hands, so I will continue to go for our written questions. Next one from Vice Chair Mary Alford from the Alachua County Board of Commissioners, in Alachua County, Florida: Was good information found in states like Florida, where information shared was of questionable accuracy? How was that information treated—margin of error, sampling from other sources, et cetera? BOLLYKY: Great. So in terms of our study, we do—these are estimated death rates and infection rates. They do tend to be backed up by a variety of sources, including both state-reported data but also zero-prevalence studies and peer-reviewed data, is what we used from that. So that’s how we tried to adjust for the fact that some states may not have been reporting as actively or as rigorously as others. FASKIANOS: All right. Next question from Ellyan Veronica from the Puerto Rico Senate: What data did you find regarding unvaccinated people who suffered violations and interference in educational, medical, or other services by their vaccinated status? Not sure—Senator Martinez, do you want to ask your question? Maybe clarify it a bit? OK. Don’t think—oh, if you unmute yourself, you can clarify. No, that is not working. OK. Q: Yes. FASKIANOS: Oh, good. Thank you. Q: OK. Yes. I’m referring that what is the data did you find regarding the unvaccinated people who suffer interference with their educational, medical, and other services because they didn’t want to be vaccinated? Did you study that matter? BOLLYKY: We did, actually. So we look at vaccine mandates for state employees and vaccine mandates for school employees, and both their association with health outcomes, infection rates, and death rates, as well as whether they have any tie to shifts in employment or in lower educational performance, particularly for fourth graders. We used NAEP test scores. On infections and deaths, they are very much associated with lower rates of both. State employees, of course, it will not surprise people on this call, represent millions of people in the United States. So it’s not a small group. And you do see a strong association with fewer deaths from the use of those mandates. We did not find any tie between the use of those mandates and lower state GDP or lower employment. So nothing on the economic side. You do see an association with lower math test scores. However, almost all mandates were associated with lower math test scores. And what our theory there—so this includes things that have, you know, restaurant or bar closures—. And so the hypothesis is that association reflects the caution in the population. People who were less likely to send their children to in-person schooling, those children tended to—or, those states where that was happening at a greater rate—to do more poorly educationally. Because math is something that, I can say as a parent myself, parents don’t teach as well as the school settings do. So it really does seem to be a stronger tie between in-person schooling and better math test performance, at least for fourth graders. Sorry, that’s a long-winded answer. But most of what you could say is, no, I don’t see any educational, economic, or deleterious health outcomes from those vaccine mandates. FASKIANOS: So I’m going to take the next written question from Dawn Gresham, who is a community liaison in Senator Liz Krueger’s office of New York Senator Liz Krueger: It seems as though it would have been helpful if messaging had communicated that there would be saves in community infection levels requiring additional safety measures to be followed at times, and relaxing safety measures where possible. Because this did not happen, it made it more difficult to discuss reinstating certain measures when it would have been helpful. Can you share thoughts on best practices for handling communication? And, Tom, I’m going to add onto that. I think we’ve seen some backlash against other vaccines because of the experience of COVID-19, which could be potentially alarming for things that we have not had problems with, because vaccinations have been measles, and whatever, and how we deal with that. So can you talk about messaging and vaccines going forward for other diseases? BOLLYKY: Great. So on the communication side, I completely agree with the questioner on the premise that we struggled to educate the population on the fact that this was likely to evolve and to change. That is actually—there have been a relatively large literature on communication in this regard. And this ties to the earlier question we got about trust. In addition to monitoring levels of trust to try to tailor programs to low-trust communities, we do have good research on communication strategies that preserve the levels of trust you already have. So less on how do you build it in crisis, and more about how you slow its erosion. And one of them is—or, two of them are related to your question. One is transparency. So saying the quiet part out loud. For instance, there is a great study that looked at—they presented two groups of individuals with—or, two groups of individuals, rather, with information about a hypothetical vaccine. One of those groups received information about—that was vague about the side effects but suggesting that there may be some but somewhat vague about what they were. Another was very specific about the range of things you might find in those circumstances with the vaccine. And what you found in that is not that you had a higher rate of people willing to take the vaccine between those two populations, but the population that received more detailed and complete information expressed higher levels of—or, more sustained levels of trust in the health authorities that provided it. Suggesting, again, that transparency is important, but also—and this is the second lesson—trusting the population. In order to be trusted, governments have to be trustworthy, but they also need to trust the population to be able to understand what they’re communicating. And that is something we struggled with throughout in this pandemic. FASKIANOS: Thank you. I’m going to go next to a raised hand from Paul Rotello from the city of Danbury in Connecticut. Q: Thank you. Yeah. Paul Rotello, City Council, Danbury, Connecticut. Connecticut, in terms of geography, is one of the smaller states. In terms of population, it’s relatively moderate. I think it’s about thirtieth. Both Vermont and New Hampshire are not particularly big when it comes to geography, but they’re much bigger than Connecticut. Their populations are quite a bit smaller. So I was just curious as to what—there seems to be a little bit more elbow room, or maybe a lot more elbow room, in Vermont and New Hampshire, compared to Connecticut. I was curious as to what density played in your statistics and your analysis. And how would you even go about figuring that, because while you can live in a somewhat agrarian community, you may spend a lot of time in town at diners, and post offices, and things like that, or even at jobs? How do you tease that out? And were you able to tease that out? And did you see a difference? Thank you. BOLLYKY: Great. Well, I’m happy to get the question. I actually grew up in Stamford, Connecticut. So I know Danbury quite well. I went to high school in Fairfield. And so it’s nice to meet you and have this engagement on this. Connecticut, as a state, actually does well in our study also. It is ranked seventh in terms of standardized deaths. So, again, adjusting for the biologically relevant factors. We did not see a strong tie between population density and infection or deaths in this study. The reason why is over time—in the beginning, it mattered, in terms of the spread of the virus to communities in the initial wave of the pandemic. But over time it was more around economic geography. Congregant housing, people—percentage of essential health workers, people with a greater ability to avoid people that are infected or isolate on their own is tied more to economic geography than the population density. So there are some fairly rural states that don’t do well in this study because of, we suspect, these broader questions of economic geography. FASKIANOS: I’m going to take the last question from Alison Despathy, who has raised her hand, from Vermont. You need to unmute yourself. Q: Thank you. FASKIANOS: There we go. Q: OK, good. All right, thank you so much. So I’m here in Vermont. And my question relates to, back to the trust issue. And this is also sort of stemming from some of the swine flu history and what we saw go on there with a bit of the sort of marketing and propaganda around the safety and effectiveness of vaccines. So with regards to the trust, did you see any data or results surface around the fact that the COVID vaccines were originally sold as safe and effective, and included the ability to prevent COVID and prevent transmission? So there was clearly a level of propaganda, not necessarily intended. But many heard that, you know, this is the pandemic of the unvaccinated. So as actual vaccine impact surfaced vis-à-vis safe and the failure of COVID vaccines to prevent infection and transmission, did you assess the role of propaganda, marketing of pharmaceutical products, and any—? And thank you. BOLLYKY: Great. So we did not assess the role of mis- or disinformation in the study, other than trust levels. The trust levels that we had, of course, they had to, for the study to work, predate the pandemic. So we looked at levels of trust in 2019, the situation, effectively, the virus found us in. So we did not assess ways that might have changed over the course of the pandemic. Other studies certainly have. I will say that levels of trust declined everywhere, even in countries like Denmark or Scandinavia, famously high levels of interpersonal trust. The question is, how quickly and to what degree. And, you know, some of the good communication practices that we’ve talked about, and I’m happy to communicate more about with people via email, do seem to have been effective in slowing that erosion. But we didn’t look at the mis- or disinformation and how that changed trust in the United States. FASKIANOS: Thank you. Unfortunately, we are out of time. I’m sorry we couldn’t get to all of the questions. But I just want to ask you, Tom, to take just thirty seconds to talk about Think Global Health, since we have so many health commissioners and medical officers on this call. If you could talk a little bit about your magazine and what you’re doing there. BOLLYKY: Great. I will do that in twenty seconds, because in ten seconds I want to say that health crises are fought at the state and local level. And I am grateful to all of you for what you did during the pandemic, and what we will need to rely on you for in future health emergencies. I don’t think we’re getting enough attention on what states and localities need to succeed in the future. And hopefully, this study can help spotlight that. Now, that said, on Think Global Health, it’s an online magazine that’s meant to look at how health affects economies, societies, and everyday lives. It’s been up for about three years. It has been—it’s analysis has really been picked up everywhere, from the New York Times to the Atlantic to Fox, across the aisle. More than eight hundred pieces published, from authors from sixty countries around the world. We would welcome state and local members of this network contributing. And it’s ThinkGlobalHealth.org. And thanks, again, for your time today. FASKIANOS: Thank you. And thanks to all of you. We will disseminate the link to this webinar recording and the transcript. We will circulate again the report that Tom Bollyky authored—co-authored, as well as the link to ThinkGlobalHealth.org. We’ve also dropped those links in the chat. You can follow Tom on Twitter at @tombollyky. And, as always, we encourage you to visit CFR.org, ForeignAffairs.com and, of course, ThinkGlobalHealth.org for more expertise and analysis. You can also email [email protected] to let us know how CFR can support the important work that you are doing. And we do recognize all the hard work that you are doing. As Tom does go—not enough attention is given to it. So thank you for all you’re doing. Thank you for being with us. And thank you to Tom Bollyky for your efforts.

Community health workers and their contributions have a central role to epidemic-ready primary health care. Digital systems that integrate community health have further supported this progress. Speakers, Krishna Jafa, CEO at Medic Mobile, and Raj Panjabi, special assistant to the president and senior director for global health security and biodefense at the National Security Council, discuss practical protocols and past experiences of integrating community health with primary care.

The COVID-19 pandemic devastated the United States with over one million deaths over three years. Yet, the burden of the virus was not spread evenly across the country. States like Vermont and Washington had death rates comparable to well-performing countries in Scandinavia, while Mississippi and Arizona fared as poorly as the worst performing nations in the world, Russia and Peru. Speakers, Emma S. Castro and Joseph L. Dieleman from the Institute for Health Metrics and Evaluation, discuss the factors that contributed to those incredibly large cross-state differences in COVID-19 outcomes and the lessons learned from the parts of the United States that performed well.

Prior to the pandemic, staffing shortages were a growing challenge for U.S. health systems. COVID-19 has catalyzed a national crisis in the health workforce with increasing rates of staff turnover and attrition. Seakers, Celine Gounder, senior fellow at the Kaiser Family Foundation, and Craig Spencer, emergency medicine physician and associate professor at the Brown University School of Public Health, discuss burnout and other factors driving away health workers as well as policy options for addressing the staffing shortages. This meeting was made possible by the generous support of Bloomberg Philanthropies

Gun violence has become integral to the American childhood. With an estimated three million U.S. children exposed to shootings every year, the physical, psychological, and societal toll of gun violence on the youngest generations continues to grow. Analyzing this crisis through the lens of public health could shed light on novel ways to alleviate and eliminate the burden of gun violence. Our speakers, Arne Duncan, former secretary of education, and Megan Ranney, academic dean at Brown University School of Public Health, discuss this ongoing epidemic of violence.