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Sonya Stokes, assistant clinical professor of emergency medicine at Mount Sinai’s Icahn School of Medicine and fellow at Johns Hopkins University’s Center for Health Security, leads a conversation on equitable vaccine distribution and pandemic preparedness. FASKIANOS: Welcome to the CFR Winter/Spring 2021 Academic Webinar Series. I'm Irina Faskianos, vice president of the National Program and Outreach at CFR. Today's meeting is on the record, and the video and transcript will be available on our website, CFR.org/academic. As always, CFR takes no institutional positions on matters of policy. We're delighted to have Dr. Sonya Stokes with us to talk about equitable vaccine distribution and pandemic preparedness. Dr. Stokes is an assistant clinical professor of emergency medicine at Mount Sinai’s Icahn School of Medicine. She's also a fellow at Johns Hopkins University's Center for Health Security. She specializes in health systems strengthening in low- and middle-income countries, and her research focuses on increasing access to trauma and acute care in resource-limited settings. During the initial outbreak of COVID-19 in New York City, she was part of the frontline response treating patients in the emergency department. In addition to her clinical work, she served on the Mount Sinai Health System Best Practices Committee for evaluating and managing COVID-19 patients and contributed to the COVID-19 mass casualty triage protocol. She's a term member at the Council on Foreign Relations and she contributed to the CFR-sponsored Independent Task Force report that was released and titled Improving Pandemic Preparedness: Lessons From COVID-19. We released that last fall. So Dr. Stokes, thanks very much for being with us. It would be great if you could talk about pandemic preparedness, what we've learned, and what you're seeing in terms of the vaccine rollout and how we can make it more equitable. STOKES: Thank you so much, Irina. And I also have to say thank you to the Council on Foreign Relations, to Tom Bollyky, and to all the members of the Independent Task Force on preparing for the next pandemic. It was a wonderful learning experience for me, and I hope that we can share some of those lessons today. But before we begin, I would like us to first define our terms. What do we mean by equity, especially when we're talking about equity with respect to vaccines? Do we mean equity for the purpose of averting excess mortality or excess death? If so, how are we measuring this? I want us to begin by looking at some of the different metrics for mortality because what seems like common sense can quickly become more complex. I'm going to be looking at information from Johns Hopkins’s mortality analyses. So in their tracker, they look at the twenty countries most affected by COVID-19. And they report on a specific metric called case fatality ratio. Interestingly, that's called CFR. I will try not to use that term specifically so we don't get confused today, but that is looking at which countries are having the highest number of deaths per hundred confirmed cases. We go to the tracker. What are the top five countries there? So that looks like, as of the last twenty-four hours, Mexico, Bulgaria, Peru, Hungary, and Italy. Okay, is there another way of measuring this? Yes, we can look at the overall deaths per one hundred thousand of the population. According to Johns Hopkins, those top-five countries are actually some of the same, including Hungary, Bulgaria, Italy. The United States makes the top five there. But then what are we talking about again? Are we talking about averting excess deaths? Well, that does not necessarily immediately correlate with the places that have the highest number of deaths. We also have to look at other metrics, like the overall burden of disease, the number of cases, right? When we start looking at that, the number of countries that make the top five start to shift. But maybe we also shouldn't be looking at just the number of cases total, maybe we need to be looking at which countries have rising numbers of cases, right? And then that starts to change as well. In fact, actually, if you look at the daily number of new confirmed cases, which countries are having a doubling of cases? The actual top five there is very different. For example, you have Papua New Guinea that's making the list there. Somalia makes the list there. So again, when we start talking about the terminology of equity of averting excess mortality, we need to make sure we're being very specific on how we're measuring it because the real-world implications of this when we start talking about vaccine equity have some consequences to that. This is something that was talked about very early on in the Independent Task Force on preparing for the next pandemic. In fact, it was anticipated in the report, and I highly recommend that you look at some of the recommendations that were made specifically in the report. But these were the concerns for the reason of the formulation of the coalition that's looking specifically at global vaccine equity, or COVAX, and that includes an alliance between the WHO, CEPI, Gavi, amongst others. These are the people that are trying to make sure that we are addressing all of these metrics and making sure we're getting vaccines to the places that need it the most. And then when we look at those numbers we can see because there are comparisons that we need to make absolutely direct factual statements about. So, as of now, we have almost 460 million doses of vaccine that have been administered; 76 percent of this has been in the high-income countries. And then, of course, if we're looking at COVAX, what have they been able to do? Thirty-two million vaccines to fifty-seven countries that they have been able to distribute or actually, I apologize, they've been able to cover the cost for in terms of the actual logistics of how that happens. That even gets more complex than that. And again, these are actual conversations that we need to have, because the real-world implications actually translate to this issue of increased mortality of excess deaths. That is the purpose of what we're trying to avoid here. And so from here is where I want to make sure that we're opening up the discussion leading from this position. It is a discussion, guys. This is not me lecturing at you. We call this a question and answer, but I actually want to make sure this is a conversation. There are aspects about equitable vaccine distribution administration that I might not have the answers for but you may. And so I want to make sure that we keep the conversation going in that respect. And from here, Irina, I want to start things off and see if there are any questions I can answer right off the bat. FASKIANOS: Great, thank you. For all of you, you can raise your hand. Click on the “raise hand” to ask your question or else you can type your question in the Q&A box. If you choose to write out your question, please identify the school that you're with so that we can identify you properly. And let me see. We have a first question from Babak Salimitari. Q: Hi, Dr. Stokes. My name is Babak. I am a second-year econ student at UCI. I have a question. What we know about COVAX, which is trying to get vaccines into countries that are more, I'd say, are less developed than us, but one thing that we've also seen is vaccine diplomacy. We've seen how countries like China are using their supply chain in order to get vaccines into countries that don't have the means of getting them. And they're giving away vaccines like Halloween candy. My point is we don't really know what's in those vaccines, those Chinese vaccines, because they've never had peer-reviewed lab studies or actual scientific data behind them. How do we know that those vaccines are safe and aren't going to jeopardize the lives of the people that they give them to? STOKES: Thank you so much for the question, Babak. You actually highlight several different points. I want to see if we can unpack each one of those and then actually answer your question. So you do bring up a good point about COVAX, about areas where we're still going to have disparities even in the advent of COVAX. For example, COVAX only plans to vaccinate 20 percent of the global population, right? So we're still going to see shortfalls, and then even within that 20 percent, they have a funding gap. There's approximately a $27 billion funding gap right now that WHO's framework for COVAX is trying to make sure that they address. If anyone is interested please look up the ACT Accelerator through WHO and then you can see some of the ways in which, from an economic standpoint, people are trying to make sure they address those shortfalls. But then with the question about vaccine diplomacy, the converse of that is vaccine nationalism, right? We're seeing that everywhere. Part of this is actually, I think, that we want to bring up how China has been aggressively pursuing vaccine diplomacy, but that doesn't happen in a vacuum, right? They're able to do so because we are not offering what Tom Bollyky calls a compelling alternative, right? We are not engaging. So to a certain extent to answer some of these questions, I mean, we really do need to come back home and address our lack of engagement. And again, that's partly due to just overall, I mean, every country is going to want to vaccinate their own populations, of course, but then this issue of vaccine nationalism that, again, we need to be sure that we're doing our part to remain engaged to offer those compelling alternatives so that when we do then go to these conversations of your question, how do we know that, for example, Sinovac and the different vaccines that they're offering from China, what do we know in terms of what is the components in them? Are there any safety issues? There are multiple governing bodies, for example, that are analogous to what we have here in the U.S., the Food and Drug Administration, FDA. They have their own in China and the independent way that we would look at this is through peer review. I agree, we still need to go do peer-review processes. I would say that part of making sure that we do not engage in the misinformation or vaccine nationalism that is actually hurting us overall is to allow us to have those channels of peer review so that we can have very clear, very direct discussions that are about safety. Your concerns are valid. Those are concerns that we should have for all drug formulations. And again, the answer to that is not necessarily making it more about politics but making it more about the science. FASKIANOS: Great, thank you. I'm going to take the written question from Elizabeth Alfreno, who's a student at Ohio University, "Seeing as though it is difficult to make the vaccine mandatory for everyone or not everyone is able to take it, how are we able to move forward in this pandemic to help bring it to a close? If not everybody universally is able to have equal access to the vaccine, does that counteract the progress we're making towards overcoming the pandemic?" STOKES: Thank you so much for the question. And vaccine mandates is something that I found interesting, because it's been happening even before we had vaccines available, right, this discussion on how we actually operationalize distribution and administration of the vaccines. The reason that I don't think that we're anywhere close to having this be a real-world discussion is because, again, exactly how you point out, this coming back to it has to be not just available, but accessible to the global population as a whole before we start talking about things like mandates or even vaccine passports or any of these discussions. It gets even more complex than simply making sure that we're distributing equal doses. I'm going to run through, for example, again, you're talking to somebody who's an ER doctor that looks at health systems strengthening, right, and specifically looking at areas that are low- and middle-income countries, areas of armed conflict. I'm going to take one place that I worked in eastern Congo back in 2017-2018. So let's run through how we might actually go through from now that we have the vaccines where the technology is there, how do we actually get them to the people that, say, for example, in places where I've been working in North Kivu Province, right? Well, again, as pointed out by Tom Bollyky and the group at Think Global Health, there are some supply-side issues that are going to be massive problems that we need to address. So that is manufacturing issues and raw material issues that are just about the production of vaccines, okay? Let's assume that we actually fix that. That's a really big assumption. Now, we also have to deal with who is actually then going to be getting those to people, right? We do have several agencies that do this very well, UNICEF being one of them, Médecins Sans Frontieres being one of them. But let's say we actually employ those agencies to get those to people. There are issues about the accessibility in terms of the logistics, cold chain, where are you storing this? How are you protecting the supply? Who's actually going to be administering it? Then you come out against some of the other aspects of demand. So it's about awareness and acceptance within the communities. That's where misinformation has become such a big problem. So again, equity becomes these real-world bottlenecks all along the way that we have to address, both individually and then collectively. So vaccine mandates, I think, is not something—I know that we talk about it, but again, and it's not that we shouldn't talk about it, but in the real world of where things are going right now, until we address all of those other bottlenecks along the way, I don't think that this is something that is, again, a real-world discussion that has a lot of operational relevance. I don't know if that actually answered your question or just gave you more questions, but it just shows you just how complex this gets really quickly. FASKIANOS: To follow on that, a question from Wendy Hahn, who's a student at Georgia Tech. Just talking about the recent surge of anti-vaccine sentiments and paranoia, how do we deal with that and layer on to that the misinformation about which vaccine is safe, which one isn't? You know, there's been a lot of talk about the AstraZeneca data and how is all of that playing into this herd immunity that we hope to be building globally? It's not just enough to have it here in the U.S. We are interconnected, and we need the rest of the world to be vaccinated as well. STOKES: I love this question. It's a question that I ask all the time. And actually, the interesting part about this is that it's not actually a new question. This has been an issue going on for a very long time, well over a decade. With the advent of social media, it's just become more apparent. And the speed with which misinformation is happening is definitely something I don't think we've actually seen before in terms of the healthcare setting. But in terms of how we address it, I would highlight, for example, in Think Global Health, they did publish one of my articles looking at this because I think we can learn more, not necessarily from what's going on with COVID-19, let's learn from past outbreaks, right? There is an article, and I will send all this information to you guys so that you will have actual access to it so you can look through the information that I'm seeing myself. But, I think, let's learn from the people who've been doing this for a really long time that actually have given us some actual ways in which we can get around this. Vinh Nguyen, who is a physician who was working in some of the same areas I was working in eastern Congo with the tenth outbreak of Ebola in eastern Congo. So in 2019—this was published in the New England Journal of Medicine—he was working at an Ebola treatment center for MSF. There was an interesting discussion that actually came about while we were having a problem with people—they're not just reluctant to get a vaccine, they're not just resistant. We had over three hundred attacks on Ebola treatment centers. A lot of this came from misinformation, people getting into the community thinking that community health workers, people running these ETCs, these Ebola treatment centers, were doing so for the purpose of hurting the population, maybe even purposely infecting people with Ebola, which obviously not true, but again, once the misinformation gets out there, it is really hard to counter. Dr. Nguyen actually had a great solution to this. They were saying, “Well, of course, in a community where there's been problems with trust, with violence, it is really hard to come in as an outsider with potential new medications and vaccines to say, ‘Here, this is good for you. You should take this.’ Well, let's actually listen to what they're asking for what they need.” Their solution at MSF and what Dr. Nguyen wrote about was let's give the people what they need, what they're asking for. Treatment for malaria, measles vaccination, right, measles, which has killed so many more people in central and eastern Africa than even COVID-19, right? Let's actually do that. And when we do that, we actually build trust with those communities over time. That trust is one of the best ways you can counter misinformation. The Center for Health Security at Johns Hopkins actually just recently published a great report about how we need a more coordinated effort on how we manage medical misinformation, at least from the national standpoint. But again, I think that while those points are absolutely wonderful—and I highly recommend that you read that report—I think there is some core issue we do need to address here and that is how do we actually just reestablish trust within our communities from us as clinicians and public health practitioners, listening to people, giving them what they're asking for what they need, right? I think that is actually one of the more powerful tools that we can use to combat misinformation. FASKIANOS: Thank you, I'm going to go next to a raised hand, Mojubaolu Olufunke Okome. Q: Thank you very much. I find your presentation excellent and really what we need. Well, what I just wonder is why there is so little learning from past experiences. Because a lot of the ways in which the pandemic, the current pandemic, has unfolded resembles the 1918 flu pandemic. A lot of the responses that people have in spite of the passage of time is very similar. So lot of harm has been done as a result of, you know, muscular nationalism. So how really quickly can a lot of the harm that's been done be undone to—because there's a deficit in trust as a result of people believing the anti-vaccination rhetoric. I mean, WhatsApp for the Nigerian community has become this director of passing on this bad information. I'm Nigerian. I teach at Brooklyn College in political science. And I’m Nigerian. I wonder what can really be done to knock out the bad information in a quick way that would enable people to embrace the vaccine. And it's not only there in Africa, there are people here in the U.S. also who are dead set against being vaccinated. So, that being the case, somebody else asked, how are we going to get to herd immunity? How are we going to build trust? And then in terms of equity, there are many of these vaccines that you need refrigeration at a level that is not available in many developing countries. So, how do these obstacles gets surmounted? Then patents, a lot of pharmaceutical companies are holding on to their patents tightly. You saw this also in the HIV-AIDS pandemic. So, what can be done to persuade the loosening up of patents so that affordable vaccines, generic, can be produced and then disseminated? STOKES: Thank you so much for this question. And actually, I would love to find a way to continue the discussion with you offline because I have a suspicion that you will probably have better answers than I have to give to you. But what I will say is this, we do have some amazing resources out there right now and people who are advocating for those. I would like to say that, specifically, there was a meeting that was just held recently. They call it the “Panel on Panels” that had the head of the WTO, Ngozi [Okonjo-Iweala], speaking with Tedros [Adhanom Ghebreyesus] and it was a wonderful thing what they were talking about. They were addressing some of these specific issues. They had a very clear plan. One is trying to connect vaccine manufacturers with other companies who have excess capacity to ramp up production. Two is a bilateral transfer of the technology between companies as well as production. So that we've actually already seen between AstraZeneca and places like in South Korea and in India. They also talked about a third point of coordinated technology transfer licensing. Again, what you're talking about in terms of both patents and issues related to the information that we have from the amazing innovation from the pharmaceutical companies who have come up with these vaccines. So I think, again, there are ways to do that. There are people who are advocating for it. I highly recommend that you go to the people who will be the greatest advocates for that. So you're going to see that from people who are supporting those proposals from the WTO, as well as the people who are supporting policies outlined in the Global Fragility Act. So that is one side. Second, again, that's perspective, right? But how do we do this in the short term? Again, I'm your operations person so it's not just long-term thinking, pandemic preparedness. I'm thinking of right now. So not for the next pandemic, not necessarily even for the next wave. I'm thinking for next week, right? How do we do that? And so again, I'm going to circle back to that question I asked you from the very beginning. What do we mean by global vaccine equity? Is it for the purpose of averting excess death? How do we avert excess death, right? Well, again, some of these conversations are going to be better dealt by people who are from your background, the economics, or people who have the background in ethics. But if I look at the operations and then also the issue of misinformation, and I look at the guidance that was given by Dr. Nguyen from that amazing insight from just the Ebola response in DRC, why not actually—let's figure out some of the mechanisms that we can avert excess death right now to build trust in communities. So the World Food Program has actually highlighted a huge problem that's going on globally and that's food insecurity. And so why not address that issue that's going on? I have a suspicion that if we were to go out and say, “We're going to look at the funding shortfall that they have at the World Food Program,” which I believe right now is somewhere in the ballpark of $266 million because they're looking at three million refugees in eastern Africa that have this problem of food insecurity. Well, if we can address that, we improve their security and that actually, guess what, improves trust and will help. It's not a magic bullet for misinformation, but it certainly will help, right? I think if we address some of those issues, again, give people what they need. Let's also, in the process as we're talking about global vaccine equity with respect to COVID-19, let's talk about global vaccine equity with the places where people in eastern Africa are dying from measles, right? The measles outbreaks that continues to hit DRC and places like Central African Republic, let's make sure we're not forgetting that part and give people what they need, what they've been asking us for. Let's actually listen to them and respond appropriately. That's pandemic preparedness as well, right? So, again, because we may not be able to meet some of the issues that are true supply-side shortfalls when it comes to COVID-19 vaccines, those discussions are happening with people that, again, will know this much better than any information I could give you. I do know about some of these other areas that we can address, and when we do that in concert, then again, that's how we build that trust. That's how we start battling misinformation when it comes to vaccines or medical misinformation in general. FASKIANOS: Great, thank you. A lot of questions. Next question from Maggie Chambers, who's a senior international business major at Howard University, "Recently the Quad countries committed to giving one billion doses to people around the world. How do you see this changing the tide of the spread of the virus and the return to normalcy?" STOKES: Thank you. And that is, again, when we talk about the distribution and the commitment of countries to make sure that we're doing allocation of vaccine doses, yes, absolutely, that solves one piece of that puzzle, that puzzle of supply side. But remember that sort of chain that I described for you. There are also of these other bottlenecks that we have to remember that we're not missing in the process of it. So how do we actually do the logistics of that? Who is going to be addressing cold chain storage, administration, and then, of course, all the other aspects of community engagement? So yes, absolutely as a solution to supply side, making sure that we're getting all the countries that have been able to have that amazing purchasing power of allocating vaccine doses to their own countries. I think that Kaiser Family Foundation has a wonderful article that sort of summarizes this where they say less than 20 percent of the global adult population is from the high-income countries, more than 50 percent of vaccine purchases have happened within these countries. If you include middle-income countries, that's more than 75 percent, right? So if we can address that sort of discrepancy by this, yes, that is a solution for the supply-side problems that we need to continuously engage with, especially in the United States. And for our other question that we had earlier in terms of vaccine diplomacy, that also addresses that issue. I would alert you to one issue though—normalcy. Careful with that term, what gets us back to normal. I want to take a moment for everyone here on this call, by the way, to recognize all of you what you have gone through in this last year. And if it's hard to hear what I'm saying, because again, when you keep hearing statistics or people speaking at you, it can be a little hard to take in the information. Why is that? Because, well, what everybody has gone through has been—and I use this in a very deliberate term as someone who is an emergency physician—that's trauma, which we are engaging in continuously. It’s a trauma response. I don't call it post-traumatic stress syndrome, because we have to get to a post period, right? But it is very real. You have to make room for that. You have to allow yourself some time to also disengage, to have doubts about what people are telling you, when to disregard what we're saying. Leave yourself and your brain some room to be able to process, come back to it, continue the conversation. And then when you do, it's not that we're getting back to normalcy. Right now what I want us to get to is a place where we're okay and then eventually somewhere better. That's where I want to get us to. I don't want to go back to normal because you know what, in a lot of places where I used to work, that wasn't such a great place anyways. So let's figure out how we do this. I think one of the most amazing things that could potentially come from this, we're not there yet, but if we continue engaging in these conversations, we'll get to somewhere that, again, when we look back on this, it would have been worth it, right? For all the death and despair that we've gone through, let's make it worth it. And I do believe that we will do this if we continue these conversations. FASKIANOS: Thank you. I'm going to take the next question from a raised hand. Tanisha Fazal. Q: Hi, thanks so much for taking the time today. I'm a political science professor at the University of Minnesota. You've been talking a lot about misinformation. I wanted to ask you about lack of information or data issues, especially when it comes to sub-Saharan Africa because of your background working there. One of the things that I've been trying to figure out, when you look at Our World In Data or other data sources, for example, is how much of what we're seeing in terms of the numbers is due to—particularly, again, in sub-Saharan Africa—is due to a lack of testing versus some of the predictions that you were hearing, maybe last summer that because of skewing younger, the COVID-19 pandemic wouldn't be as bad in Africa. So I was wondering if you could just speak a little bit to what your sense is of how severe the pandemic is in sub-Saharan Africa. Also because you were talking about other diseases and maybe they have just always overshadowed an illness like COVID. Thank you. STOKES: Tanisha, thank you so much for that question. I'm going to reference two people in particular who have been just phenomenal resources for getting information like this. One is in your actual neighborhood—Michael Osterholm, your team at CIDRAP. I follow that team relentlessly. I think they've been some of the most amazing public health practitioners in the public spaces, particularly in communicating information in a way that actually gives us the best immediate guidance for what's going to happen in the next few weeks. And by the way, if you did not listen to the live stream that happened from Michael Osterholm in CIDRAP yesterday, please do it. You can even disconnect from this if you don't have time. I would say go listen to that. If you listen to that, learn from it. It can save your life. Okay, one. The second person I follow when it comes to specifically epidemiologic methods in complex emergencies is Dr. Les Roberts over at Columbia University. It's actually his surveillance system in DRC that I was helping with back a few years ago. Now, how do we get the information if—you are absolutely correct, there is underreporting happening in central Africa and eastern Africa. There is underreporting that's happening, by the way, six blocks from where I am right now here in New York City. We have underestimated COVID-19 at every turn, and we are absolutely globally everywhere behind with testing. So that's everywhere. And, yes, of course, just like we have global vaccine inequities, we have global testing inequities when it comes to COVID-19. So if we know that there's a problem with testing because we just can't get tests there, we don't know how we can get that operationalized. What are some of the other ways we can do it? So Les Roberts describes this as a method called triangulation. If I cannot directly measure by a test, what is another way of looking at it, okay? Because when it comes to, for example, mass casualty incidents, mass death, over a period of time that can be pretty hard to hide, right? You can, and I have seen mass graves in eastern Congo, but again, in the places that we're looking at, right, it would be something that would be hard for us to ignore, especially over this period of time. So I do think that there is a component of this that is underreporting, but when we triangulate the information, we actually do see, well, again, still not seeing the high rate of death that, as we were saying, just as I was mentioning, those countries that were making those initial lists from the mortality analyses from Johns Hopkins, right? And that, I think, is again the multifactorial issues of younger populations, populations that have higher rates of exposure to different types of infectious diseases. There are other issues that are possible factors. I don't think it's appropriate to discuss this in a public setting, because I never want to participate inadvertently to misinformation by something being extrapolated. So I’m happy to talk more offline about these. But again, Jennifer Nuzzo and the team at Outbreak Observatory is pushing for, again, as people are pushing for global vaccine equity, they're pushing for global testing equity. I think both things should be pursued to be able to protect us overall. Again, though, we still do need to be aware of the numbers. Last thing I will actually say, by the way, speaking of Michael Osterholm and the team at CIDRAP, they did highlight something yesterday. They were they were talking about numbers because up until recently, we haven't seen the level of mortality, right, for the number of the reasons we just discussed in central and eastern Africa. But he did highlight some issues that potentially are going on in Tanzania potentially with variants and the dynamics of what populations are being affected, what ages and what people are being affected. That might change, right? We might actually see younger populations more affected. We need to be aware of that. And so just because what has happened in the past might not necessarily be what's true in the future for COVID-19, again, all the more reasons to have the discussions on vaccine equity. FASKIANOS: Thank you. So in the chat somebody wanted you to repeat the names. It’s Mike Osterholm and Les Roberts, those were the two. Jennifer Nuzzo is also, in addition to her post at Johns Hopkins, a fellow at CFR, which we're happy to have her part of the team. And so building on that, Kevin Lockett, who's a student at Ohio University, referenced Osterholm and [Mark] Olshaker talking about developing a universal coronavirus vaccine that would target the pieces of virus particle that all variants share, saying we require an effort on the level of the Manhattan Project. So his question is, “Given that this is a global issue and it's spread outside of national boundaries, how can legal mechanisms be used to incentivize countries together their respective resources to work collectively together toward producing a universal coronavirus vaccine?” STOKES: Thank you for the question. And I will once again highlight my biases and limitations—emergency physician. Yes, I do know health systems strengthening, but when we're talking about more specifically about not necessarily vaccine distribution administration, but development, innovation, right, when we talk about things like that, I defer to the experts on that. I will highlight a couple other people—Angela Rasmussen and Luciana Borio. In addition to the team at CIDRAP, these are the people that I look to. Also I will say Florian Krammer, who's here at Mount Sinai’s Icahn School of Medicine. These are the people that I look to when I need guidance, specifically there because, again, we need to know what our biases and limitations are. Now, if we try to translate and say, again, we resolve these issues of innovations, we do get something on the level of a global coronavirus vaccine. Again, a big assumption there, right? And how do we leverage in terms for addressing some of those issues from not just manufacturing but a legal standpoint? Again, please, I would highly encourage you to look at the WTO, who has portrayed some of the issues that have been voiced there in terms of how to address these issues. I will say this, even in the advent of the legal framework, let's say, for example, we do address issues that are arising, let's say about patents regarding the innovations, right? Please don't ever forget, again, operations. Remember, where is this excess manufacturing capacity that we're going to find? We need to make sure that we're highlighting those places. It's not just the ability for people to do it, they need to have the quality control to do it. A good example of what's happened with this is Merck, a fantastic pharmaceutical company that has stepped up when their own development they decided, “Look, our vaccine, does not seem to be meeting the efficacy numbers we want.” And so they're supporting other pharmaceutical companies to do production. That's a perfect example right there. So trying to take Merck, which continues to be this leading company in terms of not just innovation, but just ethics. Following that model, seeing how we can extrapolate from there, I think that is a good guidance for us. FASKIANOS: Fantastic. I'm going next to a written question from Kelsey Thompson, who's a student at Fletcher School at Tufts, “What have you seen being done regarding vaccination of displaced populations, refugees, and those in armed conflict zones? I've seen recent articles about state responsibility for vaccinating displaced populations within their borders but wasn't sure if there were greater international efforts supporting their vaccine and overall COVID-19 health care that you might be able to talk about.” STOKES: The most unfortunate aspect of this is I can answer this quite simply. It's not happening. I would rather us just be straightforward and honest about this. There's a lot of talk about it. There are a lot of papers that are going to be published; I'll have to read a lot of them. The operational relevance of this and the real world lives saved, again, there's a reason I brought up that. It was more than just a thought experiment. It's real problems that me and my colleagues actually have to talk about, among them Les Roberts and Craig Spencer. How do we actually get vaccines into arms of those people that are at risk? There are other conversations that then come up again. We want to make sure as we're having those conversations about COVID-19 vaccine equity that we're not in the process displacing some of those other really crucial interventions that would actually save immediate lives there. So notice in the entire time here, I haven't really talked about suppression of variance, right, as a primary reason for global vaccine equity. I focus on reducing excess deaths because, again, I think when we talk about suppressing variance, the irony in the conversation of equity is that sometimes it actually displaces issues of equity with respect to averting excess death, right? We're talking about suppression of variance because COVID-19 remains the number two cause of death now for high-income countries. But again, if we're having that conversation and not addressing the actual causes of mortality in the places that are low- and middle-income countries, specifically in places of humanitarian help or refugee and IDP populations, again, you have to do both, right? Both is necessary and definitely not one without the other, not one that actually is going to in the process take away from the things that they actually need right now to save their lives. And again, I will say it until I turn blue in the face, which might be a sign of COVID-19, no, please, please, please, look at the people who are doing those real-world interventions that will help right now—World Food Program. Looking at supporting initiatives from the WTO. These are things that are actually going to translate to those specific issues of mortality in the places where mortality is hitting the hardest, and not because of COVID-19, because that's just how it's been for a very long time. Again, we talk about a better future, right? What do we want to look like at the end of this? I would love it if at the end of everything we've been through with this pandemic that we actually come up with solutions. We commit ourselves to those things that we've been talking about for decades, if not for centuries, and actually find a way to actually have some real-world solutions. FASKIANOS: Thank you. Next question comes from Michael Raisinghani, who is from TWU, "Since we do not have longitudinal data on any of the COVID-19 vaccines, how do we know about the side effects? Is it realistic that we could win the battle against COVID-19 by 2025? And how do we proactively minimize the threat of the next superbug?” Well, you just said that you're not looking at the variants and the next one, specifically, but— STOKES: I mean, this is a great question, Irina. They're all interconnected. It's not that I'm trying to sort of disregard some of these discussions. They're all valid, right? But again, my focus is a reflection of my bias and limitations. I will say this. I get this question a lot when it comes to looking at the safety of vaccines. And I don't just mean from my patients or even from my fellow providers—my family and friends. You are in very good company with people that I hold dear to myself that have these questions all the time. And by the way, even after we have the conversation, we usually have to have it again next week and then the week after that. Do not be surprised. It's an iterative process, right? It's a process that requires, again, I call these conversations because truly we need to have them again and again to remind ourselves. So let's talk about vaccine safety, okay? Within the U.S. the three vaccines that are currently available to us are made by Pfizer, Moderna, and Johnson & Johnson, right? Well, how do we get to that point in the United States, in particular, of not just a distribution but administration of a vaccine? Again, I referenced the FDA. There's another body, the ACIP, that looks specifically at vaccine safety. The rigors of going through that are profound. To get a vaccine administered in the U.S., a COVID-19 vaccine, it's an enormous feat. It's what's one of the miracles truly of the amount of investment that's come from the pharmaceutical companies, from funders, from governments to get this going, right? I should also tell you, guess what, we could have probably done this with a lot of other diseases. But again, we just have not had that level of collaboration, right? But again, it happens absolutely with this very intense review process of safety. Now, so I can tell you right now that in terms of when we talk about long term, right, I have people that are asking me, “Well, how do we not know five, ten, twenty years from now we're not going to see some side effect?” Again, I’m always going to be straight. Anyone who tells me they can know what's going to happen in five, ten, twenty years clearly hasn't learned anything over the last year, which is, we need to be dynamic, and that we learn new things all the time. I will tell you this, in addition to the very rigorous safety review that the FDA does, we have now had hundreds of thousands of people that have been in the original vaccine trials for almost a year. Remember I talked about that process of triangulation, right? Well, I can't get a time machine and go twenty years from now to see what the vaccines are doing. Then what do I do? I triangulate that information. We have not seen anything other than we have had some severe allergic reactions, meaning anaphylaxis. Like all medications and drugs—and even by the way, sometimes foods do to us—it’s not exceptional to the vaccine at all. Nothing, no reports whatsoever. That's phenomenal, right? And so when I'm looking at how to triangulate information I have right now to be able to tell me what's going to happen later, that's a huge indicator. One. And two, we have, in addition to COVID-19 vaccines, a century of information on vaccine development in general that just shows just how safe they are, right? Truly it is one of the safest things we do in medicine. As an emergency physician, you should take that to heart because I can see all of the different ways in which some of the things we do in medicine that are very high risk. This is one of them that isn't, and it's one of the things that are actually going to save people's lives. I don't like using the term getting us to normal. It will get us to something better, though. So please, please, please, please, when you hear me, it’s absolutely safe and most likely long-term safe. It will save lives right now. FASKIANOS: Sonya, you obviously are on the frontlines of this. Thank you for all that you're doing. I'm in awe of doctors and nurses who have been just on the frontlines in the ER and intensive care units taking care of people. There's been a lot of talk about how people have postponed regular visits, children aren’t being vaccinated for other diseases because of the pandemic. Can you talk about what you're seeing in the ER and your concerns just on sort of what we thought were the normal things or that we knew about in everyday life and your concerns there? STOKES: Any emergency physician who would hear that question would be so thankful for it. Anyone on the front lines, because, yes, this was an issue. It remains an issue of people avoiding regular care for underlying medical illnesses that, by the way, put you at risk for COVID-19. For example, people not following up with their regular physicians for care for their hypertension, for their diabetes—this is a big problem. In the early days of the outbreak, the first wave in New York City, and I can have a very vivid memory of this exact day last year of what it was like in the emergency departments in New York City, it's something I will think about every day for the rest of my life. I could understand at that time people's apprehension of coming to the ER, especially in a pandemic, especially if you watch a movie like Outbreak back in the day. That was, I'm dating myself here, because that was a movie that came out when I was younger. That's again, these are things that people are looking around, again, they're looking for information so that they can know am I putting myself at greater risk by seeking care. And again, this is coming from a perspective that knows, that recognizes in the early days and was something I was concerned about even. The health-care systems have made enormous changes to address these issues, and it's something that I've been highly encouraging of my patients and the people I care most about in this world. Please do not forego care for these issues because in the end we might see, again, when we're looking at mortality and how we measure it, we might actually find, and the CDC has been tracking data on this, that we're going to hurt ourselves in the long term by doing that, that it will actually increase our mortality by doing that. For all of these issues, please make sure if you have access to a primary care physician or a specialist that you're supposed to see regularly, always stay in touch with that physician or that provider and also be highly cognizant of the fact that in the United States that is a privilege, having access to a health-care provider. So what we can also do to help support that is please let’s support initiatives in the United States that supports primary care, because I am very well aware that it is very difficult, even here in New York City, to talk about accessing any health-care provider outside of the emergency department. It's just not something that people have either because of a lack of health insurance or inadequate health insurance. These are things we really do need to address. Speaking of equity, we need to do that at home. We need to do a better job with it. FASKIANOS: Great. I’m going to take a written question from Joanne Michelle, who is a PhD student at the Mailman School of Public Health at Columbia University, “If you could talk about the role of the medical and public health colonial legacies in this discussion and address the myths or misinformation in many humanitarian settings. How do you manage that as you're on the frontlines to deal with those uncomfortable histories to getting people to take the vaccine?” STOKES: Again, I hope that we had some of these answers or at least more questions from this question earlier on, seeing the models of the people who are doing this best, okay, I mean, we should just be very open about some of our failures here. I'm very well aware, by the way, of having the ER doctor in New York City talking about global vaccine equity when I myself had access to a vaccine  and we have health-care providers in South Africa, right now, colleagues of mine on some of the WhatsApp groups that I run, who, again, have not had any access to any vaccine at all. These are health-care providers, right? So the best way I know how to do this is by making sure that we are first learning from the people who, quite frankly, are doing this a lot better than us. I think the best way to address any issues of historical or colonial issues is by recognizing our failures. I don't mean our failures abroad, I mean our failures at home and then taking a step back and asking the people who do this better globally, “How did you do that?” and having them front and center. Let's talk about how we would do that even within the U.S. By the way, if we look at the top-five states that are administering vaccines here in the U.S., New York City is not even making the top thirty, by the way, or New York State. It's Wisconsin. It's Nevada. It's New Mexico. I want to hear from those people. How did you do that? You need to tell us. So I want to actually take a step back, let's accept some of the ways in which we failed, and then let's learn from the people who seem to be getting it right. That's actually how we do it in a real way, in a real-world way that actually, as I said, averts excess deaths and saves lives, which more than anything is number one in the middle of a pandemic. FASKIANOS: Great. I'm going to take the next written question from Beatrice Guenther, who's an associate professor of French and international studies at Ohio State. No, not Ohio State, excuse me, Bowling Green State University in Ohio. Okay. And she wants to know, “What would be your top-three recommendations that you propose for pandemic preparedness?” Or maybe we could state it as what are the top-three recommendations that the task force, the Council on Foreign Relations task force, proposed for pandemic preparedness? Not that we want to think about the next one but— STOKES: I would say that there is a list of the recommendations from the report that are given equal weight. I wouldn't want to say what the top three—to speak on behalf of the membership, I think we all contributed our different perspectives. I will give my own perspective from the report that is in there. I highly encourage you to read it. Again, thank you to all the members of the report. So number one is actually creating dialogue. How do we do that nationally and globally, because that's actually how we do leadership, right? What is it that we're going to do in terms of addressing some of the issues where we have time and again seem to have failed in terms of just the communication? So when we have breakdowns in our chain of command and our lines of communication in public health, what are some of the ways that we can get around that? And then, again, please refer to some of the work from Tom Bollyky and looking at this from the Council on Foreign Relations on some of the different ways in which we can address this. Number two—investment in public health. I'm going to say also primary care, which I think is public health. We really do need to actually address how we invest, what are the means for that, and making that actually operationally relevant. Someone very recently told me that the difference between pandemic preparedness and response is about having responsive responders. We need to actually make sure the responders have a way in which the recommendations, the investment that we do in public health and primary care actually translates to those responders being able to use that—contact tracing, testing, making sure we have adequate surveillance. So that's number two. Number three is I would argue something that is actually a little excerpt that I gave at the end, which is I think we actually need to look at surveillance another way. I think that some of the different ways in the report that's trying to address that we want to with respect to the sovereignty of nations, we want to make sure that we are addressing sort of those shortfalls in public health. But I want to prepare for failure. That's what I want. As an emergency physician, it's great if we can restock the National Stockpile, have innovations in vaccine and treatment development, testing, contact tracing. I want all of it. I’m an ER doc. We know a good thing when we see it, and we never turn down a good thing. But what happens if we have those same limitations and parameters all over again, right, what do we do? I want to prepare for that. I would highly recommend and, again, my bias and limitations are pretty apparent here, but I would say we need to invest in how we do pandemic surveillance and response. I would integrate that into our hospital systems, specifically in emergency medicine. This is what we do all day long. I would invest in that globally. I would network us and make sure that your ER doctors, your responders are talking with each other. Because guess what, guys, how did we do this in the beginning? What were we hearing from about this pandemic? We were networking with each other pretty much as soon as the first wave hit here in New York City. And that's actually how we came about saving our patients’ lives and each other. Let's figure out how to actually make that systematic and scale that up is what I would recommend, because we have to prepare for failure again. I don't want to prepare for a future that may never come, all right. I want us to get to somewhere better, but also be prepared in case, in case we don't get there, in case this happens again. And then we will truly be able to get through this together as a community to something that is worthwhile. FASKIANOS: There's been a lot written about how we here at home have not been resourcing or providing adequate funds to the health-care industry. And so, as you know, as we have gone through this pandemic, we're now over the year mark. Do you feel as a health-care professional that there is the determination to start funding and better fund our health-care system? STOKES: I don't know this word determination. I know that there is a demand from us who are health-care practitioners. I know that there's this disparity with the amount of funding that seems to go into the health-care system in the United States, but doesn't seem to translate to actual equity, that our vulnerable patient populations remain even more vulnerable now. It's disturbing to me, in the middle of a pandemic, we're cutting resources to emergency departments. I don't know if there's determination because I don't know this word. I do know it's necessary. It's about our survival. I really hope this translates to something that we can work on together, not just in some distant future. Right now it would be great. FASKIANOS: In the present. On that we will end. Dr. Stokes, thank you very much for being with us today, and for all that you have done and are doing. We really appreciate your service. It is so critical to saving so many lives. So thank you very much. I encourage you all to follow Dr. Stokes at @sonyastoked. You can follow her on Twitter. We will send out additional resources to the groups, things that were referenced. Dr. Stokes does have a reading list, too, so you can get more. I hope you will do that. Again, on our website CFR.org, Think Global Health, which is a global health initiative being run by Tom Bollyky, who is a fellow at CFR, and, of course, ForeignAffairs.com, you can find additional resources. We encourage you to go there not only for this issue, but for many other issues in international relations and foreign affairs. So thank you, Sonya. Our last academic webinar of the semester will be Wednesday, April 7, at 1:00 p.m. Eastern Time with Susan Thornton, senior fellow at Yale University's Paul Tsai China Center. She will talk about the U.S. response to China's Belt and Road Initiative, which is the topic of another CFR-sponsored Independent Task Force report that we just released on Tuesday, yesterday. So, we will send out the link to that so you can read that in advance. So thank you all for being with us. Please do follow us @CFR_Academic on Twitter, and I mentioned the other Council resources. So thank you. (END)

Supply shortages and lackluster distribution rollouts of COVID-19 vaccines have plagued both developed and developing nations, complicating efforts to inoculate populations and reopen economies. As vaccine supply becomes more constrained and virus variants cause greater concern, developed countries are threatening export restrictions and other measures to ensure their populations are vaccinated first. Panelists discuss the potential public health and economic repercussions of this “vaccine nationalism.”

As the one-year mark approaches of the first confirmed case of COVID-19 in New York City, frontline physicians reflect on the first and second waves of COVID-19, and discuss specific steps to improve emergency preparedness and response for the third wave.

Scheffer: Thank you, Julissa, and good day everyone. I am David Scheffer, a visiting senior fellow at the Council on Foreign Relations and the Tom Bernstein fellow at the U.S. Holocaust Memorial Museum. I'm working on a project for both the museum and the Council on the subject of today's roundtable. Today's discussion is part of the Council's Roundtable Series on Human Rights Issues, and it is on the record. Before I introduce our speakers, I want to convey to you that for several years, I've been exploring the social bond market for the purpose of enhancing the funds available to meet the needs of international criminal justice and the victim populations of atrocities. At the beginning of this inquiry, the idea of social bond funding seemed almost bizarre to most of my audiences, whether they be tribunal or humanitarian organization officials. But within the last two years, the social bond market has exploded, not only in its magnitude, but in its range of social policy objectives. The COVID-19 pandemic, and the surge of social bonds in Europe, including with the European Commission, has been a shot in the arm, no pun intended, for this form of private financing for very worthy public causes. Now in the result, bonds that address social themes and appeal to the rapidly expanding class of socially concerned investors have continued to be the fastest growing sector of the bond market, and they have become a pillar of humanitarian investing. The rising appeal has been influenced by evidence that sustainable investments can outperform traditional ones. So while COVID-19 catalyzed the rapid rise of social bonds issued in 2020, the interest in these bonds is expected to last far beyond the crisis, and to increase further in 2021. Meanwhile, victim populations are suffering not only from the pandemic, but also the atrocities inflicted upon them in the past, and currently, such as vast victim groups in South Sudan and Central Africa, the Rohingya of Burma, the civilian population of Yemen, the Syrian people writ large, and the nearly eighty million refugees and displaced people usually fleeing atrocities across the globe. Are their opportunities to meet these challenging needs in the social bond market? To help us answer that question today, we have two experts, one on the social bond market, and the other on the needs of atrocity victims, who, by the way, seek not only reparations, and basic support for their survival, but also justice. And those are expensive propositions. Our first speaker is Maud Le Moine, the head of SSA debt capital markets at Goldman Sachs and based in London, SSA standing for sovereign, supranationals, and agencies. She has a fifteen-year track record at Goldman Sachs and worked on one of the very first social bonds, which she'll describe, and in this position, she interacts with many international organizations, including the World Bank, African Development Bank, and European Commission. She has provided invaluable advice to me over the years about the social bond market. The second speaker is Maya Shah, the head of operations of the Global Survivors Fund, which focuses on victims of sexual violence arising from atrocities in Africa and elsewhere. So she is on the front line along with GSF’s Dr. Denis Mukwege, who won the Nobel Peace Prize in 2018 for his work with victims of mass sexual violence. Prior to joining GSF, Maya worked for twenty years with Médecins Sans Frontières in field positions and headquarters where, until recently, she successfully ran large-scale innovation projects. I've asked Maud to go first and provide her perspective on the social bond market, including briefing those in the audience who may not know much about this specialized market. Maud the floor is yours for about ten minutes. Le Moine: Thank you very much, and good morning. Good afternoon, everyone. And thank you again, David, for having me today to discuss such an important topic in the market. As David mentioned, my name is Maud Le Moine. I'm responsible for debt capital markets coverage of public sector clients at Goldman. And as such, I've worked with a number of multilateral development banks in structuring and issuing debt products in the markets including social bonds. So perhaps I thought I would start with a little bit of background on the ESG bond market as a whole and the evolution of the social bond market specifically. Really, it has started fifteen years ago with the first social bond at the time, not called a social bond. But IFFIm was really the true first social bond issuer. The International Finance Facility for Immunization issued the first bond with a specific use of proceeds at the time directed towards vaccination programs in poorer countries. It has since evolved to include: the European Investment Bank issued the first climate awareness bond in 2007, then the World Bank issued the first green bond. And from sporadic issuance, the market has grown to represent around €400 billion of issuance for 2020, which to give a little bit of perspective represents a huge increase from only five years ago, where it stood around €90 billion. So this is obviously a substantial growth in a very short period of time. But just also to give a little bit of context, it's still a fairly small portion of the overall bond market. It's sub-10 percent of the overall bond market. So really, what are ESG label bonds and what role do they perform in the markets? ESG label bonds are fixed income debt instruments, which means that they are issued in the market with a specific use of proceeds. This is the key difference with any normal debt instruments, where usually the use of proceeds are for general corporate purposes. In this case, they are issued with a specific purpose. They can take several forms. The most common are still green bonds with proceeds directed towards environmentally friendly projects. And in the family of ESG bonds, you’ll also find the likes of sustainability bonds, social bonds, and many subcategories (climate transition, climate resilience, education, sustainability in bonds, etc.). They all perform a very similar function, which is to direct investments towards a specific set of projects. I think that's incredibly key, as they perform the role of aggregating demand towards a specific set of projects that have a social outcome. And since 2017, ICMA, which is the International Capital Markets Association, has worked on a set of guidelines called the Social Bond Principles that really lay out the objective criteria for social bonds. And they are based on four pillars: the use of proceeds, the project evaluation, management of proceeds, and reporting. And the purpose of the Social Bond Principles is to set out a common base for the definition of social bonds and really ensure the transparency and accountability. So the way they work is the issuer, if we take an international organization, such as the World Bank or the African Development Bank, will set out a framework in which they describe the types of projects that they intend to finance. Sometimes they'll have very clear exclusions as well. But generally describe the types of eligible projects that will be financed under that framework. And they also usually explain the performance metrics and also how they will report. The reporting is very key, as investors at the point of investment do not necessarily know exactly how their funds will be allocated into certain projects. They will only know later on when it's reported by the issuer. So the social bond also performs the function of issuing upfront for needs of projects that will be dispersed over time. This is a key element, which was the entire construct of IFFIm at the time, as the needs are usually very important to tackle quickly. And so there's a need to raise money upfront. And projects can be dispersed over time. To give you perhaps an idea of the types of projects that are included as eligible projects under the Social Bond Principles and what most social bonds finance, these would include, for example, affordable infrastructure, access to essential services, affordable housing, employment generation, food security, or any social or economic advancement or empowerment. This is a broad definition of what the project can include, but to give you an idea of what they have financed in the past. So why are they so important? And I think that's quite an important topic of discussion here. And I think, for me, the key is that really any of these projects would not normally be financed directly. They would be too small, too risky for any investors to be financing directly or at attractive economic terms. So really what the World Bank or African Development Bank or any other multilateral development institution, the role that they perform, is to aggregate demand for this product and therefore ensure the deployment of capital in the most needy places. So if we take an example of the World Bank raising a billion bond, for example, they'll manage their balance sheet dynamically. Therefore, this billion will really serve to finance a number of different loans. And over time, the World Bank is able to access the market thanks to its high credit rating, their standing in the market, their global investor following, and their longstanding market presence. They're able to raise this billion at very favorable terms, and they're therefore able to lend at very favorable terms, and this is the key to the entire construct. Given the COVID crisis, somewhat unfortunately, it has resulted in a significant surge in the social bond market last year as a portion of the overall ESG market, given all of the difficulties that countries have faced to cope with lockdown measures and generally the effect that it had on people, small businesses, the healthcare sector, etc. So if we take the difference between 2019 and 2020, the social bond market has almost increased tenfold. So it's a huge increase. And one of the biggest portions of this development was the EU SURE program, which has become one of the largest social bond issuers in the market since they created the program in the summer of last year. The SURE program is a €100 billion temporary support to mitigate unemployment risk in an emergency, and it is intended to be entirely financed in social bond format. They have already issued €53.5 billion of that program and have an entire envelope of €100 billion. So they can fund the rest over the course of this year. It was entirely created as a result of the pandemic and is designed to urgently provide financial assistance in the form of loans to member states. And so, I think the question that we are often asked about social bonds is really, who buys social bonds? What is the appeal for investors? What is the difference between a normal bond in terms of payout structure, and things like that? And so, first of all, I think the background is that, generally speaking, what we are seeing is there is an increasing realization from both public and private sector market participants that a lot more needs to be done in the field of sustainability as a whole. ESG investors and social bond investors can really be any investors. What we're seeing in the market is central banks, asset managers, pension funds, retail investors, foundations, etc. can be interested in this product. Generally, the investor community as a whole is increasingly putting in place sustainable investment strategies, and as such, they're trying to find suitable financial products to fit their strategies, and social bonds are one very good example. How are investors repaid? Well, social bonds themselves are really used to finance loans. So the purpose of these multilateral organizations is to aggregate the demand. They have the expertise on the ground. They are able to do the due diligence of the project, and they have backings of governments that are their shareholders and, therefore, have higher credit ratings and are able to access the market at favorable terms. As such, the projects themselves really finance loans and therefore generate a return themselves, part of which is paid to investors in the form of usually a fixed rate coupon. Some instruments have been designed to have a slightly different payout structure with predefined targets. For example, it's been seen in KPI-linked bonds, where there is a step-up or step-down coupon when the targets are met or not met, depending on what the targets are. But the very vast majority of social bonds issued in the market have a fixed coupon and therefore fixed return to investors. I think that's quite an important point because the growth of the social bond market is also driven by the depth of the fixed income investor base. And this is an investor base that's generally focused on the liquidity and generally conservative in their risk profile. And therefore, it's important that there is a fixed return. For example, there are other types of instruments that exist in the market, such as social impact bonds, and it's important to differentiate those two social bonds that I'm talking about, because social impact bonds are slightly different instruments. They're generally much smaller in size, and they have a payout structure that's directly linked to the successful outcome of pre-agreed social benefits, but they are much more similar to equity products in nature, and they are much higher risk instruments, and they do not have a fixed return. So they are different instruments. They are called bonds as well but generally not issued as broadly in the market as social bonds are at the moment. Scheffer: Maud, if I may, perhaps another thirty seconds or a minute, and then we'll move on to Maya. Le Moine: No, of course. I mean, I think that's a broad overview. I think you wanted to discuss specifically, the application that it can have on international criminal justice, but I can take it as a question afterwards. Scheffer: Exactly. Thank you so much. That's an excellent brief. I'll share that with every student I ever teach. Maya, the floor is yours. Shah: Thank you. So good morning, and good afternoon, everyone. And thank you, David, for inviting me today. And as you mentioned, yes, I'm the head of operations for the Global Survivors Fund. So this is a global fund for survivors of conflict-related sexual violence. The fund’s mission is to enhance access to reparations and other forms of redress for survivors of conflict-related sexual violence across the globe. So the fund was established in October of 2019 by Dr. Denis Mukwege and Ms. Nadia Murad, a survivor herself, after they both received the Nobel Peace Prize in 2018. It is also the realization of a vision that was long held by survivors through the SEMA network. So this is a network of survivors from over twenty countries in the world that have been lobbying for reparations. Additional to this, the fund was endorsed by the UN Secretary General in his statement to the Security Council in April of 2019, where he strongly encouraged governments to support this fund. So what is the purpose of the Global Survivors Fund? Well, it's to fill a gap in addressing the rights of survivors by providing interim reparative measures, and this is when states are unwilling or unable to do so. And while we recognize that it is a government's responsibility to provide reparations, often they are not able or not taking this responsibility. But we cannot leave survivors behind, because reparations are a right. So the main principles to the fund’s approach are, one, a survivor centered approach, and this is really to co-create projects with survivors, so not for survivors but really with survivors. The second fundamental approach is local and contextualized solutions. So really looking at the different countries where there are projects and the local solutions available in those countries with survivors. The third is a multi-stakeholder approach. So that's including survivors, civil society organizations, activists, local authorities, and UN agencies within what we call the steering committee that runs the project, so that there is a lasting impact of these projects. So the three main pillars of our work at the fund are what we call act, advocate, and guide. The act pillar is really to provide interim reparative measures. So we work with local civil society organizations that are our implementing partners, and we provide interim reparative measures in the form of compensation. Currently, we have three projects in the Democratic Republic of Congo, in Guinea, and in Iraq. And we're looking later this year to open in Central African Republic and Nigeria and possibly South Sudan. I was in the Democratic Republic of Congo three weeks ago, where there is an estimate of between 200,000 and 400,000 victims of conflict-related sexual violence. And I was discussing with the head of the National Survivors Movement there what it means. And she basically said that survivors, what they want really is an acknowledgment of the crimes that were committed against them, to not be blamed for what happened to them, and to receive some sort of compensation. And whilst at the fund, there is no way we're going to be able to cover all the victims of conflict-related sexual violence in the Democratic Republic of Congo. What we can do through our project is to show that interim reparative measures are possible and to act as a catalyst then for governments to take on the responsibility. The second pillar of our work is called advocate, where we really want to make survivors’ voices heard in order to influence at the international, regional, and national level policies that will then prioritize reparations and allow governments to take their responsibilities in providing reparations. And that leads me to the third pillar of our work, which is the guide pillar. And in this pillar, this is where we look to provide technical assistance and expert advice to support governments who want to put in place reparation programs, but to ensure that these programs are really survivor-centric and that they have a survivor-centered approach. Another part of our work is we are currently doing a country mapping study of over twenty countries to look at the state of reparations in different countries around the world and then to be able to make a better informed decision of where we want to put in place projects. So currently, the fund is funded through institutional funding, so through government donations. But in general, there is not a lot of sustainable funding for human rights abuses, but specifically for conflict-related sexual violence. And the needs in this field really vary from the immediate life saving needs of health care and psychosocial support, then to much more long-term needs, such as restitution of livelihood, education, support, and financial compensation, which these require, of course, substantial resources and extended periods of time. And as I mentioned before, when you look at a contextualized approach, these kinds of reparations are going to differ whether you're doing it in Ukraine compared to Central African Republic compared to Iraq. You know, one size doesn't fit all in these different contexts. But I don't think that this should be a deterrent to start providing reparations, and neither should having to put in place all the transitional justice mechanisms before. We strongly believe at the Global Survivors Fund that reparations are a right. Survivors have a right to them. And therefore, in fact, when you put in place interim reparative measures, often you are empowering survivors by making them reestablish dignity, have livelihoods, have health care, and so to be able to benefit from this, to be able to then go through the transitional justice mechanisms. But of course, all these need some form of sustainable financing and innovative financing mechanisms. So I hope that we'll be able to discuss this further today. Thank you. Scheffer: Thank you so much, Maya. That is excellent. I'm going to ask a few questions and then at the thirty-minute mark, or approximately that, we'll open it up to the audience. Maud, could you dip into what we worked on for a couple of years whereby we were looking at a particular type of social bond that is of an endowment character that's generating annual revenue. That could be extremely useful either for a tribunal or for an organization like Maya’s that might be looking for a steady stream of revenue year after year as sort of a base set of revenue that they could rely upon, as opposed to a huge expenditure of money in the first or second year of a bond. Le Moine: Yeah, absolutely. I know we've been discussing this for a couple of years. So first of all, perhaps I should mention that it's an extremely worthy cause, and one that should generate interest from ESG investors. I think the problem is trying to find a structure that works and fits within the criteria of investments of fixed income investors, if large sums of monies need to be raised, or other types of investors depending on how much is needed. The idea of an endowment social bond is certainly an option. But I would raise a couple of points that I think are important to understand. In order to attract fixed income investors, and I say fixed income investors because they are the largest pool of investors out there in terms of ESG investors at the moment, the fund itself would need to have a certain rating if the fund is to issue a bond in the market and generate interest. And that's unlikely to be a high rating without the backing of certain sovereigns and a structure that, David, we have discussed over the years. If the structure were to work, the fund would need to have, ideally, at least an AA rating in order for the money to be raised in the market at a certain economic term, which would then be able to be invested in the market to generate enough returns to generate a steady stream of revenue. And so a high rating is really the key to making the structure work in order to have affordable terms in the market and be able to invest it and generate the needed returns. Scheffer: Thank you so much. Maud. Maya, you touched on this in your remarks and I want to try to emphasize it to our audience. You used a couple of examples of a gap between the need and the actual resources available to deal with reparations. Could you expand on that just a little bit and sort of emphasize how large is this gap of funding for these humanitarian purposes for victims, particularly when they involve issues of reparations? Shah: Thank you, David. I mean I certainly can't put a monetary figure on it today. But what we know is that the needs of victims are huge, because it goes from life-saving care, long-term psychosocial support, to compensation, restitution, and rehabilitation. And if you look at that, that can be from livelihood programs; reinsertion because often they're completely stigmatized out of the communities, lost all their jobs; education for children, children born out of rape particularly that also are ostracized from society; and if reparations programs are being put in place, it's also compensation on a monthly basis for the survivors. So there is a range of needs that are there, and each with varying amounts, but we can see that the numbers of survivors are enormous. And so yeah, I can't give you a monetary figure, but just the needs are huge. Scheffer: And let me jump back to Maud. We've talked, you and I, about the whole phenomenon of pre-qualified investors. I get this question quite often from organizations. They don't want any and all investors stepping up to help them. For example, if they're a humanitarian organization, they may not want gun manufacturers to be in their investor pool. Can you just expand on that a little bit? When you put a social bond together, how do you structure the pre-qualified investors so that the organization is confident in that investor pool? Or do you do it at all for some of the bonds? Le Moine: That's a good question. When we issue social bonds in the market, it's a fairly quick process. And so there's a lot of preparation ahead of the issuance itself, setting up the framework in place, perhaps marketing for a number of weeks ahead of a potential bond issue, but the issuance itself is fairly quick. The issue will rely truly on the banks and the lead managers of the bond to have KYC. So know your customer. KYC to all of the investors that are in the transaction, and they will have access to the list of investors. And they can choose to exclude some of them if there were any concerns with the background of the issuer. They will mostly rely on the bank’s proposal of allocations and things like that, but they have the ability to exclude any investors if they wanted to. I must say we've never come across an issue, given the types of investors that are generally interested in these bonds. We're talking about central banks and large asset managers that are very well known, pension funds that are also large pension funds, European pension funds, Canadian pension funds, or U.S. pension funds that are very well known. So these are large institutional investors that are very well known by the market. Scheffer: Thanks so much. You know, I think I'll be following strict rules here. We're at the thirty-minute mark, and I want to open up the floor to our participants in this roundtable. I'd like to first just see, I see on my list of participants that Naomi Kikoler is actually with us. Naomi, I wanted to give you a chance to say just a few words, if you wish to. But now would be the opportunity, if you'd like to come on board. Kikoler: Thank you so much, David. Appreciate that. And just want to congratulate also Maud and Maya just for the phenomenal presentations. On behalf of the U.S. Holocaust Memorial Museum, we're incredibly honored to be able to help advance the work that you're doing, David. Along with CFR, I did want to thank our colleague, Erin Rosenberg, and your colleague, Madeline Babin, for their work. I think from our perspective, as Maya especially highlighted, this is one of the most challenging, vexing, and urgent issues that many of the communities that we work with are seeking to find a way to address and are seeking innovative solutions too, so I really commend the effort that all of you are doing to try to find innovative sources of funding. I think we all know, as we look at the experience of the Holocaust, the importance that reparations has played for many communities, while recognizing that you can never truly restore or return a person to the life that they had prior. But the importance of finding creative solutions, as you're doing, is really I think something that needs to be commended. I think the big challenge, and the challenge that I've raised with you, David, at times, and I'd be curious for Maya and Maud to build a little bit on your comments is around the political will, especially of governments and large multilateral organizations, to step up and increasingly support these types of initiatives. I'd be curious where you see there being potential openings. Are there specific governments that you think are particularly promising, or other multilateral institutions that have shown an interest in using things like social bonds? But again, just a profuse, on our behalf, honor to be involved in this particular project, and we very much hope that for the various communities we work with today, the Yazidi, the Rohingya, the Uighurs, and others, that your innovative approach to this will help to ameliorate the very big challenges that they face for the future. So thank you so much. Scheffer: Thank you, Naomi. Maud, would you like to just take on Naomi's question about the willingness of the multilateral banks and of governments and I might also add of large foundations to step into this breach? Le Moine: Absolutely. And I mean, generally speaking, multilateral development banks are incredibly willing to step up to the plate when they can. If you think of all the ones that are currently existing and active in the market, they have responded incredibly quickly last year to the needs of their member states following the pandemic; have mobilized incredible amounts of resources; issued very quickly what was needed to disperse funds very quickly to the most needed places. So I think the multilateral development organization family as a whole has been incredibly quick to respond. And that has shown the willingness of the institutions to help when they can. At the political level, it differs from time to time, I think. We've also seen with the pandemic that there's also a great political willingness to step up. If you think about the European member states incredibly quickly getting together and forming a budget that was on multi-year to support the European recovery fund, but also their SURE program and other initiatives that were done in Europe. And over the years, capital increases of these multilateral development institutions, new ones have been put in place over the last few years in Asia, most notably with the Asian Infrastructure Investment Bank and the New Development Bank, to try and support the needs of specific regions. So I think there's an incredible political willingness as well. Generally speaking, what we're seeing, however, is that the structures also need to be quite clear. And accountability of these institutions is very high. So they have very high standards to uphold in terms of the types of project that they lend to and the result, as they have the impact in the local community. It's very important to guarantee their political willingness to participate. Scheffer: Thanks a lot. And I want to get to our other questioners. But Maya did you have anything you wanted to add to that because you do have government contributors to GSF? Shah: Yes, thanks, David. I mean, we do, but I think there are two things. I think governments sometimes will react when the political will is strongly there, when it affects them. So we saw that, for example, previously in the Ebola crisis, governments reacted when it started happening to them. And now in the pandemic, when it's happening to governments, they will have the political will to react quickly. We do have governments on our board, but I don't think there is enough being done. And the governments where these crimes are committed are perhaps not the ones reacting as quickly or as much as they should be. And while we believe that they do need to be taking their responsibility, I don't think we can always wait for political will to be there because the needs are so urgent, and we need to address them, but it's definitely a joint responsibility. Scheffer: Thanks, Maya, shall we now go to Jonathan Berman. Jonathan, are you there? Berman: Thank you. Sorry about that. I'm in a remote area. So if I phase out again, please go on to the next questioner. But while I'm in touch, David, thank you for hosting this meeting. And thanks also for asking Naomi to say a word. As a Holocaust descendant, it's uniquely gratifying to see the Holocaust Museum active on this topic. Maud, my question actually was for you. I just wanted to go back to what you said about the distinctions between social bonds and social impact bonds. Could you just confirm that social bonds, the terms of the bonds are uncorrelated to the outcomes that are received, and if that's correct, and then on social impact bonds, if you could say a little more about how that correlation is achieved? Thanks. Le Moine: Thank you, Jonathan, for the question. And yes, I can confirm that the terms of a social bond are uncorrelated to the outcome. And that reason is, if you think about the World Bank as a whole, they will have an issuance program per year of somewhere in the context of €60 to €70 billion. And part of this, they issue now all of their bonds under their sustainability debt framework. But if you think about perhaps the African Development Bank, they have a social bond framework, and that is only a portion of their debt issuance, but when they access the market to raise this portion of their program in social bond format, they access the market at the terms that are available to them at the time of accessing the market. What the investor is really buying at the time of the investment is the African Development Bank credit within the context of their social bond issue. So they know where their investment is going, they know the eligible project that will be financed with their funds, but the actual outcome is de-correlated to the terms. The market moves all the time, and at the time of issuance, the African Development Bank will be able to access the market at specific terms, and other times at other terms. However, the investor will have access to the impact of their investment, because all of the issuers of social bonds have the obligation to report on the use of proceeds and what they were used for and what the impact was. So the investor will have access to that. And I guess in theory, they can choose later on in the process to reinvest or not, if they are not satisfied with the impact that they are seeing. On the social impact bond, it's a slightly different construct where usually you have an outcome that is decided between a public institution in an area, if we take early childhood education, for example, where a municipality doesn't have upfront money to invest in early childhood education, but there's a strong correlation between making sure early childhood education is taken care of to influence the greater social benefits later on. And there's a study to make sure that the correlation is important. Then, effectively, it's calculated as whatever the municipality is saving in early investment by the private investor is returned to the investor if the social outcome is met. Scheffer: Thanks, Maud. Le Moine: I hope that's clear. Scheffer: Yes, I hope so, Jonathan. Sarah Whitson, I think you're next on our list. Whitson: Hi. Thanks to both of you. Maya, I'm particularly grateful for your characterization of the funds that you're raising and distributing as reparations and not charity. And two questions is why the focus exclusively on survivors of sexual violence, which is, of course, a much smaller pool, and much more idiosyncratic, frankly, than the larger population of victims of violence. And I wonder whether you are looking or considering assisting victims in places like Yemen or Gaza, which are much harder to get to, and yet where the needs are overwhelming, with thousands of people disabled by sniper fire or bomb attacks. And Maud for you, in terms of the social bonds, which, as you describe are effectively loans to governments, what are the criteria? Particularly given the fact that the reason that many of these countries are in such catastrophic economic situations is because they have tyrannical, abusive, corrupt governments, like Egypt, for example, where the World Bank and the IMF continue to provide loans to a government that is wholly corrupt, wholly controlled by the military, which enriches itself at the expense of its own people. So how do you ensure that you're not a part of the problem when you make loans to corrupt, abusive governments, where the World Bank and IMF fail actually to do meaningful due diligence? Scheffer: Maya, why don't you go first on this one? Shah: Okay, thank you. Thank you for that question. Yes, why are we focusing on conflict relating to the sexual violence victims? Because we feel that they are one of the most vulnerable populations. They are often very much overlooked due to stigma and shame and hardly ever recognized as war victims. And they really do merit the focus. And through this focus, we can break the silence because of the stigma. There's so much stigma attached, particularly to conflict-related sexual violence. And to your to your second question, yes, we are looking at, as I mentioned previously, in the country study, one of the countries where we're trying to look and work is Yemen, and Syria both, but particularly looking into Yemen and seeing how we can support survivors, whether they are outside of the country, and then to look to support through, but in very difficult circumstances. So indeed, we're looking into it. Le Moine: Yeah, perhaps I can try to address your question to me as well. I think, first of all, I really cannot comment on behalf of any of these multilateral development institutions on what their due diligence procedures are. However, I would mention that they lend to individual projects, rather than at the sovereign level. The projects themselves are subject to scrutiny and due diligence, and they have the sovereign backing, so that in case the project becomes insolvent and is unable to pay back the loan, there is a sovereign guarantee, which is part of the reason the construct works. So that's a key part of the understanding of how the whole lending works. One thing I would say, though, is that if you think about the number of projects that are financed, it's really absolutely key infrastructure, or education, or healthcare projects on the ground. There might be issues at the broader level in the country where you also have to think about the number of people that these projects help on the ground. And I think that's the real key to these organizations and their purpose. Scheffer: I see that Erin Rosenberg is on our list. Erin, did you want to perhaps ask any questions, since you've been so deeply involved in this project? Rosenberg: Thank you so much, David. Um, yeah, actually, this is perhaps speculative, but I am quite curious of maybe digging into the question of political will matched with the issue of victims of atrocity crimes. I’m wondering whether both of our panelists, just in terms of bringing this concept, and recognizing as Maud you have identified, the types of projects that are typically funded. How would you view in terms of political will or just more generally the viability of projects that are aimed specifically at the reparative aspects addressed by Maya for victims of atrocity crimes? Le Moine: Thank you, Erin, for the question. And I think that this is a topic that David and I have discussed in the past. And I think in the case of victims of atrocity crimes, there's a real strong case for frontloading support. And I think when we think about garnering political support, what is important to try and highlight is that the need to tackle mental health issues, quick economic recovery, integration, and early education upfront have long-term strong benefits. And I agree with Maya when she said earlier that countries step up when it's in their interest, and I think that's part of the answer. In trying to garner political will for this specific topic, it's very important to frame it in the context of the long-term benefits globally but also to specific countries. It has benefits that can transcend the actual quick reparation; it has long-term benefits in the economic development of the country, and therefore, its security, international relations, etc. And I think that's the framework in which to try and garner political support for this specific issue. Scheffer: Thank you, Maud. I see we have Whitney Debevoise, who would like to interject. Debevoise: Thank you very much. This is Whitney Debevoise of Arnold and Porter. I’m former U.S. executive director of the World Bank. This question is for Maud, could you talk about the various initiatives to start to regulate this ESG bond world in terms of standards and the like? And what impact, if any, you think that may have on the growth of this market? Le Moine: Absolutely. Thank you, Whitney. The main development has been the development of the Social Bond Principles by ICMA, the International Capital Markets Association, which followed the Green Bond Principles. And now we also have another set of principles for sustainability bonds and sustainability-linked bonds. Generally speaking, the issuance of the first bonds have always preceded the existence of the principles, and the ICMA body has gathered private market participants, banks, investors, and regulatory bodies to try and understand how to frame the discussion, making sure that there's a common set of standards that are upheld by issuers, and that the word social bonds was not going to be used for just any types of issuance. And the green bonds have been accused of doing a little bit of greenwashing at some point when there wasn't enough of a standard. So I think that's the main development of the social bond market. And it has, I think, helped the social bond market, because it has provided issuers with very detailed guidelines and made the market a lot more transparent and also accountable. So I think it has greatly helped the issuers know how to frame their social bond issuance and how to focus their eligible projects, and it’s also given some confidence to the investor base as well that they are investing in a project that has a certain standard. Scheffer: Thank you, Maud. Can I just ask a question? Oh, I see we have Patricia Rosenfield. Rosenfield: Thank you so much for that question. And the earlier one about the role of philanthropies, private philanthropies investing in social impact bonds, particularly social impact bonds not just social bonds, prompts this question. I'm Patricia Rosenfield. I'm president of the Herbert and Audrey Rosenfield Fund, but I also work at the Rockefeller Archive Center where we look back at things like program-related investments and mission-related investing, and that's what I'm wondering if you're seeing. If foundations or some foundations are increasingly looking at mission-related investing, and divesting themselves of oil and gas and perhaps negative impact investments, if you're seeing an increase in philanthropic assets being invested in social impact bonds, and if not just in the United States, but in other private grant-making activities around the world? Scheffer: Maud, I think that's for you. Le Moine: Okay, and perhaps Maya will have a view as well on what she's seeing on the ground in terms of types of philanthropic investments, but on my side, absolutely. It's a general development that investors are incredibly focused on re-centering their strategies and making the sustainable, or ESG, or philanthropic part a greater part of their investment strategy. Foundations have been, in fact, the very early investors in social impact bonds. So I'm not sure if that has necessarily increased so much, but they were at the very beginning of the product when it first was coined and evolved. So I think that's still the case. In social bonds, specifically, we're seeing also foundations being active. But I would say that it's not the dominating investor base because of the sheer amount of volume that is issued in the market. So they don't represent the largest investor base. We're still talking about larger institutional money being the driver of social bonds. Scheffer: Maya, did you want to add something to that? Shah: Well, I think Maud covered it very well on who is investing. I don't have much authority on that. Scheffer: Okay. Let's go to Jennifer Warner. Warner: Hi, thank you both for your time. This is Jennifer Warner from the Elton John AIDS Foundation. As we're talking about social bonds and how they might relate or be different from social impact bonds, as well, it would be interesting to hear, Maud, your perspective on what problems are best suited for a social impact bond or social bond? So the distinction between why you might pursue one or the other? Le Moine: I think there's one element that's absolutely key to a social impact bond, which is the correlation that we were talking about earlier. So, for example, I have looked in the past at doing impact bonds in developing countries. And very often the problem is that we lack data. So the problem in structuring the social impact bond is that you need a very strong historic correlation between a certain a certain problem and a certain outcome in order to build the case for a social impact bond. And that's really, I think, the key difference between the two. The other thing that is important to differentiate the two is that the social impact bond will generally be a much smaller scale and very targeted. Therefore, it will be municipal level, a small issue that can be tackled with specific investment and has a great social benefit. Social bonds, generally speaking, are much larger, because we're talking about a much larger scale of projects that are being financed. I’m looking at the clock, which is why I stopped here. Scheffer: No difficulty at all. I just want to cover one last issue if I might, and I'm afraid it's a question for Maud. When governments guarantee the social bonds, particularly if it's a reparations issue in the future, it's one way for the government to, and particularly if it's the subject government of the reparations, to actually weigh in with its own responsibility towards the victims. Rather than making a cash payout under reparations to the victims, they can step forward and guarantee a social bond, which, of course, the social investors, particularly if it's AA or AAA, will want to respond to. Can you just briefly tell us how concerned governments are about the contingent liability of providing a guarantee? Why would that worry them? Le Moine: Fair enough. I think the general worry about contingent liability, and that's obviously a very generic statement. It does differ from country to country. But when we look at sovereign or state budgets, if the liability of the guarantee goes beyond the term of the governing body at the time, then it's very difficult sometimes for governments to be sure that the next government will uphold the similar guarantee. So it's difficult for governments to justify sometimes having guarantees or contingent liabilities over a period of time that goes beyond their term. That's generally the issue. But there are systems in place, and the shareholding of a multilateral organization is without limit in time. So, there are plenty of situations where governments have pledged over a period of time that goes beyond their term. But in the discussions that we have sometimes this is the problem that's being raised. Scheffer: Thank you very much Maud. I think this brings us to the conclusion of our hour. I just want to say how pleased I am with our speakers. Maud, I know it was years ago, but you made the London School of Economics proud today. And Maya, for our friends at Médecins Sans Frontières, they're probably asking why in the heck are you at GSF still, so you made both of them proud. Thank you so much to our audience. And we will continue to forge ahead.