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J. Andrés Gannon, Stanton nuclear security fellow at CFR, discusses the likelihood of Russian deployment and use of nuclear missiles against Ukraine or its allies, and the implications for the United States should that occur. Jerrold T. Bushberg, chairman of the board and senior vice-president of the National Council on Radiation Protection and Measurements, discusses preparedness for nuclear and radiological disasters at the state and local level in the United States. TRANSCRIPT FASKIANOS: Welcome to the Council on Foreign Relations State and Local Officials Webinar. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR. Thank you for taking the time to join us for today’s discussion. As a reminder, the webinar is on the record and the audio, video, and transcript will be made available on CFR’s website, CFR.org. CFR is an independent and nonpartisan membership organization, think tank, publisher, and educational institution focusing on U.S. foreign policy. We are also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments across the country by providing analysis on a wide range of policy topics. We’re delighted to have participants from approximately forty U.S. states and territories. I’m pleased to introduce our speakers today, Andrés Gannon and Jerrold Bushberg. Andrés Gannon is the Stanton nuclear security fellow at CFR. Previously, he was a post-doctoral research fellow at the Harvard Kennedy School Belfer Center and a Hans Morgenthau research fellow at the Notre Dame International Security Center, as well as a defense fellow at the NATO Defense College. His research focuses on the political origins of military power, what capabilities states arm themselves with and why, and how the distribution of military capabilities affects states’ conduct in international affairs. Jerrold Bushberg is a clinical professor of radiology and radiation oncology at the University of California Davis School of Medicine. He’s an expert on the biological effects, safety, and interactions of ionizing and nonionizing radiation and holds multiple radiation detection technology patents. He is also the chair of the board of directors and senior vice president of the National Council on Radiation Protection and Measurements—the NCRP—a congressionally-chartered institution which formulates and disseminates information, guidance, and recommendations on radiation protection and measurements, and he previously served as a commander in the U.S. Naval Reserve where he was executive officer of the Chemical/Biological/Nuclear Technical Unit 120 Pacific. So thank you both for being with us today. We appreciate it. Andrés, can you talk first about the possibility of deployment and/or use of nuclear weapons in Russia’s war in Ukraine, and U.S. options in response to such action if it were taken? GANNON: Sure. And thank you, again, for having me and thanks to all for participating. Nuclear use and Ukrainian nuclear use, in general, is, to sort of start, a low probability/high magnitude event. So like we think of a lot of natural disasters, we’re forecasting worst case scenarios because the consequence would be incredibly high. Even though it’s unlikely, those are things that we have to prepare for. I think in the Ukraine context there’s three distinct nuclear scenarios that we can see for potential use by Russia, and I sort of order these from the least immediately consequential in terms of sort of death counts, casualties, and other costs to most. The first is, as a signal, I think that Russia has not tested a nuclear weapon since they were the Soviet Union in the sort of late ’80s. But I could see them testing a nuclear weapon either somewhere remote in northern Russia, possibly somewhere near Ukraine, in the ocean or in the sea, to demonstrate a willingness to use a nuclear weapon. Even though the casualty of such an event would be close to zero—such an event would be designed to have a low casualty—there are environmental effects and, more importantly, effects on sort of morale and people’s thinking about the likelihood of using nuclear weapons. So when we think about the consequences that would have for other countries thinking about acquiring or detonating nuclear weapons, there’s, potentially, second order ramifications on that sort of international system. The second scenario is one in which a sort of smaller tactical battlefield nuclear weapon is used and this is a tricky one to think about because, as we’ve seen with a lot of other weapons that are things like chemical weapons, it’s really difficult to predict the effects of even small nuclear detonations an hour, a day, a week later. The radiation that would happen from such an event could be one that blows back towards Russia in ways that could negate their benefits. It could create a sort of no man’s land in the region in Ukraine that will be impassable for some short period of time by military personnel on both sides. But I think that’s precisely the reason such an event could happen or could be sort of logical or strategic on Russia’s end as a way of halting Ukrainian advances. I think that we can think of tactical Russian use of a nuclear weapon in some of these cases where they’ve been losing ground and where the Ukrainians have been seizing territory as being a way of creating sort of a large tank ditch that would be impassable for a short period of time to stop Ukraine from advancing. So I think that that’s the logic that could exist there, particularly in the eastern Ukrainian region. The third most immediately consequential scenario for Russian nuclear use would be a strategic use of a nuclear weapon that wouldn’t necessarily be a sort of large strategic ballistic missile but will be targeted at civilians. This could be civilians that are in Ukraine. This could be civilians that are in nearby NATO countries. I think that the latter scenario is very unlikely since Russia and NATO, I think, so far has sort of tacitly agreed to limit by design the degree to which they’re interacting with each other directly. But I could see a situation where Russia feels that a sort of way to escalate the current attacks that they’ve had on the public in Ukraine, the sort of missile strikes that they’ve been doing recently, to ratchet that up with nuclear use could be a way to break morale in a way that would make Ukraine halt their advances and possibly give up in the conflict, in general. So I sort of want to wrap up there from where I started, which is none of these scenarios are incredibly likely but they are all very consequential. And so I think that when we think about what the U.S. response should be to these situations we can think of the response ex ante—what are things that the U.S. can do in advance to make sure that these events don’t occur—and then what would be the U.S. response ex post in the sense of if they did occur what should we do. In terms of ex ante, I think it’s really important that the U.S. continues to communicate to Russia behind the scenes where red lines are but to remain ambiguous about the consequences of crossing those red lines. A lot of research that has been done on sort of these sorts of threats and red lines indicates that being clear that any nuclear use would be unacceptable but remaining ambiguous about what sort of retaliation or consequence Russia would face is the way to make sure that these threats are both credible because there’s a clear line in the sand that we’re telling Russia not to cross while still making sure that the United States has flexibility in how it decides to respond afterwards, given new information that’s revealed about the consequence, that motivation, the situation at hand, et cetera. And so there’s sort of a lot of secret information that’s existing at the government level but that communication has to continue to happen between the United States and Russia directly. In terms of ex post, I think a lot of the humanitarian aspects of nuclear use are relevant in all of these situations. There’s a lot of very good, important environmental monitoring that’s done by a lot of folks regarding, as I’m sure Jerrold will talk about, the sort of radiological effects of these sorts of weapons, what effect that has on crops and agriculture. We have already seen sort of the effect of the conflict on wheat exports and prices in Ukraine, which would only be amplified in this situation. Transportation, mobility, possible refugee flows out of the region is something that has to be anticipated. And so I think that these are things that sort of matter at the state and local level in the United States because public opinion also matters in a lot of these things. There are about twenty-nine U.S. states that currently have nuclear power plants and there’s 10 (million) to 15 million people last I checked that live within ten miles of a nuclear power plant in the United States. When sort of radiation, detonation, anything that involves the power plants in Ukraine, anything that happens there, I think, would be directly relevant for how U.S. people in state and local regions here feel about the consequences of having nuclear facilities nearby and whether or not that’s something that would, potentially, pose a danger to them. Thank you. FASKIANOS: Thank you very much. Let’s go now to you, Jerrold, to talk about emergency preparedness for nuclear and radiological events in the U.S., what it would mean if such an attack would happen, and how states and locals can best prepare for the threats of this kind. And you are muted. You could unmute or—hold on a minute. BUSHBERG: There we go. FASKIANOS: There we go. Perfect. BUSHBERG: Thank you. All right. Very good. OK. So thank you for the opportunity to present this information, and I think you’ve set it up very nicely. We’re going to just take some—a few minutes to talk about the kinds of incidents that could occur and what their effects would be and the—in particular, those effects that would, if it occurred somewhere else in the world, what would that mean for radiation exposure in the United States and what particular actions, if any, would be implemented. So my comments will cover a broad range of different types of nuclear yields, most of them likely much greater than I would anticipate from the discussions that we’ve just talked about previously. But I think before we get into more of the detail, I want to make sure I give you the bottom line up front, which is that even if there was a very large detonation anywhere in Europe there would be no need to take protective actions if you’re living in the United States or even its territories and outside the continental United States, including Hawaii and Alaska so—and the reason for this is several fold. One is, is that—and we know a lot about this because there have been a number of nuclear detonations, I think over four hundred up until 1980. So we know about what the distribution of radioactive materials is like, and there are two principal things that occur. One is that the material—the radioactive material—gets injected into the atmosphere and at different levels in the atmosphere it behaves in different ways, and primarily a material that goes into not the troposphere but above that—in the next level above that, which is over about six thousand feet or so, that material pretty much stays there for a relatively long period of time, and the material that’s lower and the percent that goes into the lower versus the upper really depends on the yield and how far above ground it was detonated and a lot of other technical factors. But I really think the point here is, is that there’s a tremendous amount of dilution that occurs because of the normal dispersion of this material, and also if you look at the air currents in that—in the world they move from west to east. So even if there were a detonation somewhere in Ukraine it wouldn’t take the four-thousand-mile shortcut directly to us. It would have to go kind of the long way around the Earth, which will result in even greater dilution. The other aspect of it is that the radioactive material has different life spans, if you will. We call them half-lives. But I think one way to characterize it is that after twenty-four hours approximately 80 percent of the radioactive material that was generated will have decayed and after about two weeks or so it’s about 90 percent. So the concerns are, really, for people that are in that region or for the sort of immediate aftermath within the twenty-four, forty-eight hours, and for them the critical issues are—and we’ll talk about this in a minute a little bit more—are about seeking shelter and preventing contaminations and fallout. OK. A couple other things I wanted to mention. There are a number of guidance documents that are available both from the NCRP and from the federal agencies, and we can provide that link later and make it available to those who are interested. The radioactive material that’s produced, as I said, mixes up in the atmosphere and the dilution and decay result in very, very little of the radioactive material ending up in the United States from a detonation outside of the United States. And so one of the questions that often comes up is, well, can you—would we detect any increase in radiation and the answer is, yeah, we would. Why is that? Well, because we have incredibly sensitive radiation detectors and the amount that we can detect with our detectors is, literally, tens of thousands of times smaller than the level that would be of concern for public health. So the mere detection of a(n) increase would not necessarily pose a health threat and there are, as mentioned earlier, a number of monitoring stations in the United States that are run by governments and states and universities that monitor radiation levels 24/7/365. So we would know if the increase occurred and also if it occurred from a nuclear detonation as opposed to some release from a nuclear power plant. Experts can distinguish between those kinds of releases. So there has been a tremendous amount of study into this, and those kinds of rapid determinations are well within the United States’ and other countries’ capabilities. So I think one of the important things that—lessons learned from other releases—accidental releases—that have occurred like at Hiroshima—I’m sorry, like at Fukushima and at the Chernobyl nuclear power plant accident—is that people have seen a lot of material either on social media or on the internet telling people to take various anti-radiation drugs or so forth and so on, and that should not be done either. There is no reason to take these kinds of medications and, in fact, the vast majority of them are only good for very specific radionuclides and they do have side effects. So the most important advice is to listen to your state and local officials and follow that guidance, and so there will be official guidance available both at the local, state, and federal level. And to help put some of this—the amount of radiation into perspective for you, let’s say that we go back to the 1980s and China’s last aboveground detonation was in multiple megaton, which is a very, very large nuclear weapon, and the average dose to people around the world was, you know, about 1/1000, so about 1 percent of the dose that we all get from natural background radiation. Just to say a little bit more about that, you know, all of us are exposed to radiation all the time from what we refer to as naturally occurring background radiation and it comes both from cosmic rays and as well as the naturally occurring radioactive material that’s in the ground and that gets into the plants and, therefore, gets into the animals, and we eat plants and animals and so we have radioactive material in us. And so, on average, the—in the United States the typical background radiation is about three millisieverts per year and the amount of radiation that you might get, which is—well, to put that in perspective, it’s about the amount of radiation you get from a thoracic CT scan. That’s the amount of radiation, and the amount that you—that people got from those detonations, the very large aboveground nuclear test, was, you know, hundreds of times less than that. So the take home point, really, is that regardless of the yield anywhere outside of the United States, the amount of radiation we receive will be very small. There are very accurate monitoring stations around the United States that can detect very small increases in radiation and the government has a very well thought out and very rapidly implemented program for responding to such events to provide both information and monitoring information. And I think that as long as we don’t overreact to a situation like this and, you know, it is a critical situation but we need to remain calm, listen to the authorities, not overreact or certainly don’t take the advice of individuals who might be going on television or might be coming from other areas but are not representing what we typically refer to as, you know, the consensus of scientific opinion, I think we’ll be fine. So, with that, I’ll wrap it up with that and then be happy to respond to any questions that come up. FASKIANOS: Great. Thank you very much. And, yes, we will send out a link to the sources that you recommend after this. Now let’s go to all of you for your questions and comments and, of course, we—this is a forum to share best practices. So if there are things that you’re doing in your municipality please share those with us. It’s good information for your colleagues. So you can either raise your hand by clicking on the icon and I will call on you. You can also write your question in the Q&A box, and if you do write your question then please also include your affiliation and state so that we can give context. So I’m going to look now for any raised hands. We have two already. So I’m going to go first to Mike Ladd and if you could unmute yourself—accept the unmute prompt, rather—that would be great. Q: Yes, ma’am. Can you hear me OK? FASKIANOS: We can, and identify yourself. Q: Yeah. My name is Mike Ladd. I’m the deputy emergency manager for Clay County, Florida, which is just southwest of Jacksonville. First, thank you so much for the presentation and answering this niche. I think the one assumption that’s made and kind of want to get your thoughts on it is, largely, this discussion is circulated around an initial or one or a singular nuclear detonation. However, there’s a lot of doctrine out there that that may trigger more and what if we have a whole bunch and not—you know, the whole retaliation? I understand that’s very hard to scope and scale. But in some of the commonalities that were discussed about 90 percent, you know, degradation of radiological hazard after about two weeks, what are your thoughts as far as how to sew that into a comprehensive emergency management plan? BUSHBERG: Well, I think that the most important thing to understand is that if you’re talking about a detonation that would be in the continental United States or let’s take it the other direction, say, that there are U.S. citizens in a region where a detonation occurred, you know, the most important thing that one can do is to—you know, is to seek shelter and to tune in to the local emergency broadcast for further information. The real risk is to those individuals that are outside the zone of lethality but are in an area where there could be significant amounts of fallout that could occur over the hours, days, and weeks later. But in the first few hours is really the most important response, or I guess most critical response time. And for that you would want to seek as much shelter that puts—in a building, maybe in the center of a taller building that puts a lot of material between you and the fallout, and that can substantially reduce the risk and the amount of radiation that individuals would receive. So if we’re talking about the sort of worst case situation where individuals are close to such a detonation that would be the appropriate actions. FASKIANOS: Thank you. I’m going to go next to Jeffery Warren. And, Andrés, if you want to add anything please feel free to jump in. Q: Thank you. Jeff Warren, Memphis City Council in Memphis, Tennessee. I just was wondering what Andrés thought about the possibility of this going completely south—it goes along with the question prior to that—and how aggressive we should be on the local level to be thinking about stocking fallout shelters and doing things that have occurred before. GANNON: Yeah. It’s a good thought. I have two sort of things I’m thinking about in response. The first is a weird part of the way that we’ve thought about it, the logic behind why a nuclear weapon wouldn’t be used is your target will fire back and neither side wants to be on the receiving end so no one will use it. That logic seems to make sense until the first missile is launched, in which case if Russia launches a missile on the United States and it’s—well, we’re supposed to respond. That’s what all the books have said, you know, since the 1950s. And that’s sort of a tricky and a hard thing to think through. And so I don’t think that we know, thankfully, given lack of experience, of what that escalation trajectory would look like. But I do think that the military and sort of high-level political officials involved are starting to think about the role that nonnuclear weapons would play in response and having this sort of cross-domain or cross-capability conflict. What that sort of means at the state and local level, I think, is difficult to figure out. But it’s a place that the research is going now that, I think, is important. In terms of what this means for state and local officials in the United States if this were to go south, there’s a lot of sort of research that we don’t know that’s classified regarding targeting that, I think, is something that’s worth thinking about. Nuclear strategists think about targeting, broadly speaking, in two dimensions. You can target what your opponents value, meaning their population centers and civilians, or you can target what is strategically important, meaning their military installations. You know, U.S. targeting is, largely, classified with the exception of some recently early Cold War documents. We don’t know what Russia’s targets would be in the event that they were to attack the United States but they probably have some plans there. I think if I were to speculate, the smartest thing to do in the early phases of a war is to target your enemies’ military capabilities. Those are the things that could be launched sort of against you and that would cause the most damage. So what this means is that states and localities where U.S. nuclear weapons are housed—our ICBM facilities that are in the Dakotas, you know, Wyoming, Nebraska, the Midwest in general—also, possibly places on the coast where U.S. nuclear submarines are based from or where they sort of get their intelligence, refueling, and maintenance. If I was Russia that would sort of be the first round of attack before I started thinking about the Los Angeleses, the D.C.s, the San Franciscos, et cetera. And so I think that that’s sort of a way to think about where this thing might go south if it were to start going in that direction. Now, how far would the escalation go? Would we end up with all military targets on both sides taken out and then we’re swapping city for city? It’s hard to say. But I think that if we think about the first step it would be places that are militarily-valuable targets for Russia to think about in the United States. Q: Well, in Memphis, you know, we just worry about logistics with FedEx. So we’re, you know, wondering how—where we would be on their list. GANNON: Yeah. I can’t speak to Memphis itself but I do think that your point about sort of transportation, infrastructure, logistical hubs is really important. I know that, for example, in Long Beach they’ve put a lot of work into making sure that the ports there are safe and secure in detecting, you know, possible radiological use and, you know, possible terrorist attacks that could happen there precisely because of the value that these ports have. So I think that that emphasis is well placed in the same way that, you know, we have things like TSA, not necessarily because airports are the most likely to be targeted but because the cost is really high. I think that infrastructure hubs that can do similar measures for security are putting resources in places that make sense. Q: Thank you. FASKIANOS: Thank you. I’m going to take a written question from Linda Lewison, who’s with the Nuclear Energy Information Service—it’s a safe energy watchdog in Illinois—and the question written is other than modeling has there ever been an actual emergency response exercise for a nuclear power plant accident that would release large amounts of radioactive waste into the atmosphere in a relatively short timeframe? We, in Chicago, will probably have, perhaps, an hour or so to respond. Then she notes that there’s more radiological waste in Illinois than any other state. I don’t know who wants to take that. BUSHBERG: Well, I guess—I’m sorry. Was the question what would one do if there was or has there ever been a release from a—there have been—you know, so there was the Three Mile Island accident in the United States, which did not release a tremendous amount of radioactive material. In fact, quite, quite small amounts compared— FASKIANOS: I think— BUSHBERG: —to the others. But was there—and is there something else that they wanted a response to? FASKIANOS: It was more a question about is there—has there ever been an emergency response exercise. Like, what kind of gaming and— BUSHBERG: Oh. Yeah. FASKIANOS: —and responses to—you know, just like we have fire drills or— BUSHBERG: Yes. The— FASKIANOS: —those kind of things. BUSHBERG: Right. FASKIANOS: What’s happening on that front? BUSHBERG: Sure. So the Nuclear Regulatory Commission requires all nuclear power plants in the United States to not only plan an exercise for a potential release but also work with local hospitals and medical and emergency response assets that would be responding to or supporting such an accident. There’s also very detailed emergency planning guidance that details evacuation zones should they be required. In the case of a nuclear power plant accident, you know, we’re concerned about sort of different radionuclides than we would from a nuclear weapons detonation. And there are things like radioactive iodine or something we’d be particularly concerned about and local health officials have planning guidance about whether potassium iodide, which is something that can block the thyroid gland from taking up radioactive iodine, would be necessary and they have stockpiles of this local to the nuclear power plants that are available for local health officials to dispense if that turns out to be a suggested guidance. But, you know, the most important thing one could do if you heard about any sort of radiological release in our national guidance, and this would apply even to a very large release, is to—you know, you would get inside, stay inside, and stay tuned. So if you just remember those three words or three phrases—to get inside, stay inside, and stay tuned—you will protect yourself from the vast majority of any potential harm that can occur because the real concern is fallout or deposition of radioactive material contamination. FASKIANOS: Right. So, Jerrold, there’s a written question, and this is for you to clarify, from Samer Jaafar, who is in Wayne County, Michigan, and, perhaps, this is not what you said but writing—you state not to take KI potassium iodide that you feel will not benefit and—benefit you anyhow. They are advised by the State Department of Environmental Quality of an air sample or dosimeter when it reaches a certain exposure level during our training preparedness for REP. So can you clarify what you meant? BUSHBERG: You bet. Yeah. Thank you for that question. FASKIANOS: That would be great. Thank you. BUSHBERG: Thank you for the question. What I was saying is that if there was a detonation in Ukraine, there is under—there would be no circumstances under which potassium iodide would ever be recommended because there is just not going to be enough exposure to warrant it. Now, that’s different than what I just talked about, which was maybe a release from a nuclear power plant, for which potassium iodide is very effective at blocking just radioactive iodine. None of the other nucleotides that might be released; potassium iodide would not have any effect on those. So planning guidance does provide for state and local officials guidance on environmental monitoring and at what levels they might suggest the distribution of potassium iodide, but that would be a public health decision in coordination with both the state and federal agencies. FASKIANOS: Great. Thank you. I’m going to go next to Ted Voorhees, who has a raised hand, from Orange County in Virginia. If you can unmute yourself. Q: No question. I’m sorry. FASKIANOS: There we go. Oh, you don’t have a question. OK. Q: No. Thanks. FASKIANOS: All right. Thank you.                     I’m going to go next to John Jaszewski. And excuse my pronunciation. And if you can unmute yourself. Q: Now can you hear me? FASKIANOS: We can. (Laughs.) Q: OK. Thank you. I’m John Jaszewski. I’m calling from Mason City, Iowa, which is in northern Iowa. And I’m curious as to whether or not you can forecast, if Russia releases a tactical weapon in Ukraine or somewhere in Eastern Europe, would it follow that they’ll eventually release a strategic weapon toward the United States. GANNON: I can start with that one. I don’t—what that answer depends on is what do we think is Russia’s goal in Ukraine, what do we think is Putin’s goal in Ukraine. And there’s a variety of different answers that all point to different expectations about the degree to which they would go further and escalate in a conflict. Maybe their goal is just material and strategic. Maybe Russia does want this territory, these sort of four areas that they’ve taken, and they want Crimea because they think that it’s a part of Ukraine, and maybe access to the naval base in Sevastopol is helpful. That’s fairly limited. Maybe it’s a little bit more, in that there’s some sort of nationalistic impulse of people that they think are truly Ukrainian people, sort of pushing back against Western expansion and embarrassment since the end of the Cold War and NATO expansion, in which case Russia’s aims are a little broader. Maybe Russia just wants to sort of once again be an imperial superpower and the most dominant state in the world, in which case they really want to push back against the West and they have greater sort of territorial and reputational ambitions. In reality, it might be some combination of all of these things. We don’t know and I don’t know that we’ll ever know. But I think whatever events we start seeing about Russian escalation shed some light on what we can infer as the likely motivations. I think that tactical nuclear use in Ukraine would be helpful—potentially be helpful for Russia towards any of those gains. I explain sort of one way in which it could be helpful to them militarily, and it would be helpful in terms of taking territory and showing the West that sort of they are a powerful, dominant country. I think that if they were to then take the next step and attacking NATO or the United States directly with a strategic nuclear weapon, that’s not a decision that you make if your goal is to get access to a naval base and if your goal is to have control over these four regions, some of which you have kind of controlled so far. That demonstrates sort of larger imperial ambitions maybe at the personalistic level for Putin himself that are very different. So I know that that doesn’t really answer the question because it doesn’t tell you what I sort of think are the likelihood of all of these things, but that’s because I don’t think that that can be answered ahead of time. And I think that people that sort of have—the stronger someone’s opinion is about what is Russia’s true motivation, the less confident I am in sort of the reasons that they’ve given for why that’s the case. But I think that the scenario in which Russia decides that their aims are best served by directly attacking the United States with nuclear weapons is a situation where Russia and Putin’s geopolitical ambitions are largely unparalleled and inconsistent with a lot of actions that we’ve seen so far. And whether or not he thinks that that’s something that would help him because he’s backed into a corner and this is sort of a Hail Mary strategy for maintaining power, or whether he thinks that this is the nail in the coffin for defeating the West, I think both of those scenarios are hard to say. So I think that we have to see many, many other actions happen first before we get that scenario. It wouldn’t be a bolt from the blue. FASKIANOS: Great. There is a written question from Cailey Hansen-Mahoney from the Ohio General Assembly: Have you seen any successful legislation to protect nuclear power facilities/storage at the state level? Any recommendations for best practices for state legislatures to support incident command/emergency planning as we discuss this possibility? BUSHBERG: Well, starting sort of with the last part first, yes, there is—are some outstanding documents. NCRP has a number of documents that speak to these questions directly. NCRP Report 165, which is entitled “Responding to Radiological or Nuclear Terrorism Incidents: A Guide for Decision Makers,” this is free to download from the NCRP website. The NCRP website is ncrponline.org. And so that document is freely available, and there are a number of other documents that NCRP scientists have put together that go into some significant detail about both preparing for, planning, and executing response to radiological releases. Now the—now I’m forgetting what the first part was. Oh yes, the fuel onsite—protecting the onsite fuel. So the Nuclear Regulatory Commission has regulations about the storage or protection of this radioactive waste, which are essentially the materials that once the fuel rods have been in the reactor for a certain period of time and they have expended their practical usefulness that are taken out. And at that point, they’re extremely radioactive. They’re put into pool storage where water is circulated to remove the heat, and then ultimately are put into what’s referred to as dry storage. In the United States today, all of that sort of spent nuclear fuel is stored onsite at the reactors because we don’t have a long-term storage repository in the United States. So the—all of the utilities have precautions and protections of that material, and it is stored in very robust and hardened facilities that would make the release of that material very, very difficult. (Pause.) OPERATOR: Irina, can you please unmute yourself? FASKIANOS: Yes. There you go. (Laughs.) I want to go next to Bill, who has raised his hand. And if you could identify yourself. Q: My name is Bill Stoutenborough. I’m in Madison County, Illinois. I think we’re being a little bit naïve in saying we don’t know what Russia’s goals are. It appears that—let’s go by what they’re doing instead of what they’re saying. They want to weaken NATO. They want to exercise controls over the EU. They had controls with oil lines, pipelines, fertilizer, et cetera. What they—the strongest control they can get is food, and Ukraine has more production area than any other in the European area. They supply over 30 percent of the food to Europe and to other areas of the world. Now, they’re not attacking military targets; they’re attacking infrastructure, such as knocking out the electricity. That is being done here in the United States. We talked about nuclear. Their former president has indicated they want to move battleships armed with their hypersonic weapons within the areas of the—political areas of the allies supporting Ukraine. They even specifically indicate Washington is within the 600-mile range of hypersonic missiles, which cannot easily be detected because they’re a low-trajectory item. What type of—I guess at some point in time I think we’re going to have to fight Russia. We are being reactive and never proactive. I think that we should proceed in getting the other two Scandinavian countries into NATO. I think we should even allow Ukraine to start its—restart its process into NATO and Article 5. FASKIANOS: Thank you. Thank you very much. Andrés, do you want to respond to that comment? GANNON: Sure. Yeah. Thank you, Bill, for those thoughts. I think that there are sort of ways that we can infer what Russia’s goals might be based on what they’ve done. You’re certainly correct about that. What I think is challenging to do in the long term is figure out: Where would Russia be satisfied? What, for them, is an outcome where they will say we’re OK with this, there’s no other changes that we want to make to the world? Does that mean having part of Ukraine be Russian territory? Does that mean all of Ukraine? Does that mean NATO pushes back to the sort of pre-NATO-expansion boundaries? Does that mean NATO doesn’t exist? Does that mean the United States doesn’t exist? These are all sort of hypotheticals that I think are hard to think about, but all are very different in terms of what they think that—or, what they suggest the U.S. strategy should be. As far as the point about preempting what Russia is doing, I think that’s something that’s currently in discussion by national policymakers. But what’s tricky is Russia isn’t the only thing that the U.S. is concerned about when it comes to great power competition. We saw in the recent National Security Strategy increased concern about China’s activities, the U.S. sort of starting to think about a new tripolar or trilateral world, where there’s two threats that we’re thinking about simultaneously. And so I think that as we think about what, if anything, should we do to weaken Russia, where those resources come from is an open question that I don’t have the answer to, but that I hope that those that are in charge of making those decisions are thinking about. FASKIANOS: Great. Thank you. Jeffrey Semancik has written a couple things in the Q&A—suggestions, best practices. And I thought maybe you could just share with the group rather than having me read. And so I would like to invite you to unmute yourself. Q: Yeah, hi. This is, yeah. Can you hear me? FASKIANOS: We can. If you can just identify yourself too for the group and just— Q: Yeah. This is Jeffrey Semancik. (Off mic.) FASKIANOS: OK, we can’t hear you now. (Laughs.) Jeff, can you—we can’t hear you anymore. OK. Q: I got it. No, I got it now. FASKIANOS: OK, good. Q: So, yeah, I’m sorry. Just we’re in a conference room here trying to organize some stuff. But so just wanted to point out a couple resources available to state and local officials. I think Jerrold presented NCRP reports. There was also some recent guidance from FEMA related to a nuclear detonation published in May of 2022 that’s available from FEMA’s website. And finally, there is a group that we’re working with to try to build nuclear subject matter experts on nuclear—on response to nuclear and radiological events. It’s called the Radiological Operations Support Specialists, the ROSS. And I provided an email address for folks that are trying to work through some planning guidance. And these are folks that are volunteers of a type by FEMA that can come in and provide consistent—you know, some information consistent with the latest guidance documents, help you understand the consequences, answer your questions on a local and state level. So may be something that folks might be interested in. And I provided an email contact to FEMA if you’re interested. FASKIANOS: Fantastic. So, yes, in the Q&A—and Jeff is with the Connecticut Department of Energy and Environmental Protection. The email address is [email protected]. And, again, we will be sending our links, and we can include that email address too, so that you can go there as well, along with the Report 165 that was published by the NCRP. OK— BUSHBERG: Let me just mention, if I could— FASKIANOS: Yes, go ahead, Jerrold. That’s great. Thank you. BUSHBERG: You know, Jeff, thank you for reminding me about those, that I hadn’t mentioned them. But, you know, the Nuclear Regulatory Commission, the Department of Agriculture, Food and Drug Administration, the CDCPA, and FEMA, as you suggest, all have excellent documents on various aspects of responding for—responding to and planning for such events, from very small to very large. And we will provide all those things to the audience, for their use after the conclusion of this event. FASKIANOS: Great. Thank you. I don’t see any more questions from new people, so I’m going to go back to Linda Lewison, who has written a few in the—in the chat. But maybe you could talk a little bit about how is the U.S. protected from the new super weapons from Russia that are going around the world in submarines? Are they—can get they got into a position to attack our coastlines? And, Andrés, maybe you can answer that. GANNON: Yeah. So the new Russian weapons have largely puzzled me, to be honest, because they don’t offer anything new for Russian in terms of targets that they can hit, or in terms of the lethality of potential strikes that exist there. It’s largely been an open secret among the superpowers, even since, you know, the Strategic Defense Initiative way back during the Cold War, that missile defense is almost impossible. It’s incredibly difficult to do. If there was a target in the United States that Russia wanted to hit, they have been able to hit it for decades. What these new weapons do is they provide some degree of speed, which might be helpful in terms of—to minimize the amount of preparedness that can happen at the local level. But I think that that’s largely minor. And a lot of it is political. It’s a way of showcasing their sort of increase resolve or their willingness to do things, because they’re investing more in being able to sort of have a high-technology military. There’s also a lot of just prestige-related reasons why countries want to have the best and the shiniest military capabilities, even if they don’t offer that much strategic utility on the battlefield. We see this a lot with conventional military capabilities, where some of the best U.S. aircraft carriers, for example, or naval and air capabilities are ten, twenty, thirty, forty years old. And they’re really good. Nd the newest ones are marginally better, but not that much better than some of the capabilities that we’re largely relying on. So I think that we should think about these new advanced Russian hypersonic missiles, et cetera, as being less about having military utility in terms of giving them an edge in a conflict, and more about having political utility in terms of how Putin and the Russian government sell this to the Russian public, how they communicate this to the United States, and how they think these things would impact U.S. resolve. So I think a lot of it is theater. And I don’t say that to diminish it. I think that theater is really important. I think a lot of politics is about theater and communication. But it’s about sort of communicating things rather than enacting particular military things differently. FASKIANOS: Thank you. Cindy Wolf has raised—a raised hand. If you want to unmute yourself. Q: Hi. I come from a county that is surrounded by various military installations. But we are remote, and we are an archipelago. So I have some interest in a clarity on time scale and kind of some red flags that we might want to look for in terms of this Ukraine-Russia conflict escalating to something where we would start to need to be concerned about educating our people want to do on short notice. GANNON: I can start with that one. One place that Russia has been oddly unimpressive in the Ukraine conflict is electronic warfare. We have not seen many successful uses by Russia on that front. There’s some sort of hypotheses people are positing now for why is Russia’s electronic warfare so bad? And to clarify, what I mean by that is the parts of warfare that deal with, like, jamming, radar, and communications, making computers unable to work and function, radios, things like that, maybe Ukraine is really good at defending against electronic warfare. They have capabilities that are decent, but nothing that should be way better than what Russia is doing. Maybe Russia can’t jam because their equipment is too similar to the Ukrainians, and so they sort of get their wires cross and it could affect them. But I think that’s an under-discussed part of the Ukraine conflict that has ramifications for exactly what you described. If Russia were to sort of be engaged in a direct conflict against the United States, the first two things that they would need to do, or would be smart for them to do, is, as I mentioned a little bit earlier, direct kinetic attacks on capabilities that would be relevant in U.S. first strike. So targeting U.S. ICBM installations, places like bomber bases where we have sort of nuclear-based bombers, et cetera. And the second is for other things, especially naval and air capabilities, electronic warfare-type strategies to deal with command and control centers that communicate to U.S. capabilities that are deployed further away. So, like, U.S. submarines and surface fleets have communication with the mainland United States for the types of operations that they’re doing overseas. The sort of general best practice in militaries is rather than try to attack every single boat, attack the command and control centers that communicate with those boats to render them in the dark. And that’s a place where we’ve seen Russia performing poorly. So on the one hand, I think that’s some sort of vote of confidence, in an answer to your question, that I don’t think that Russia will be able to turn the lights out at U.S. military bases in the continental United States very, very quickly. On the other hand, that’s something that they know they’re going to have to do. And so I think that this is a place that I expect Russia to try to increase investments to how successful they can be at doing so, given sanctions and the amount of spending in their defense industrial base, I think is hard to say. But I think if you are in a locality that is militarily relevant for the United States, for reasons that are not the first forty-eight hours of warfare—meaning, ICBMs, nuclear bombs, et cetera—then I think that the electronic and the sort of grid capacity is the one that’s the most important to think about, in terms of the immediate effects. FASKIANOS: Thank you. I’m going to take—go ahead, Jerrold. BUSHBERG: Yeah. The only thing I would add to that is I think she asked about, you know, preparation and training. And I believe Jeff was the one that mentioned the FEMA documents and all the planning guidance for response to a nuclear detonation. It’s the third edition that was published in May of 2022. And it is the most recent complication of information that provides guidance not only on preparedness but response and also the guidance for emergency response part of the community, as well as local and state assets. So I would heavily recommend that. And, again, we’ll provide these links after the meeting. FASKIANOS: Great. Thank you. I’m going to take a written question from Commissioner Tyler Shuff, who is the commissioner of the Seneca County Commission: Why aren’t our schools teaching kids what to do in case of the bombs getting stopped? Why and when did this stop? Andrés, have you studied this? GANNON: I have a bit. Part of it is—so, Jerrold was making some good points earlier about sort of the immediate blast radius, and sort of what happens afterwards, the sort of radioactive zone. If you’re in that immediate blast radius, stop, drop, and roll is not going to do a lot for you. I think there was some recognition of that during the Cold War when this was taught, but people need something. We think about sort of the human and the political element of this, I think it’s hard to tell people: Prepare for a nuclear attack the same why that you prepare for an earthquake or a tsunami or a typhoon or a tornado. There is a lot of overlap. Like, 80-90 percent of it is the same. A lot of what Jerrold said about, you know, stay inside, have water, have food, have access to information and batteries and flashlights—that’s the same for all these things. But that’s sort of deeply unsatisfying at sort of a psychological level for people to think, oh, there’s nothing that I should do? There’s nothing that can help if this is nuclear as opposed to just a tornado? And so think that’s a thing from sort of the non, sort of, physical science or radiological perspective. From the political perspective, that’s worth thinking about for messaging, is what can you do to make people feel as if there’s something that is within their control when they come to preparation. I think this is why, like, the iodine tablets are popular, because people can feel, just, I bought something that someone said could help me in certain situations. I think I carry one on me. Oddly, there’s, like, these very small $10 or $15 basically sheets of paper you can have that have a detection of how much accumulation of radiation you’ve gotten on your body. That is mildly helpful in some situations, but it’s not going to make a world of difference. But these are the kinds of things that people want to do and want to think about, something that’s sort of within their control, or some decision that they’ve made. And so I think that your point or your question about why has this stopped in schools is along those lines. That’s just we want to feel as if there’s something that we can do, but it’s really not any different than a lot of the other drills we do for safety. That is, stay calm, stay inside, and make sure that you’re getting your information from trustworthy sources. And I think that last one is a point that we haven’t really explored here and probably don’t have time to, but is an important one for state and local officials to do. We saw, you know, since the 2016 election a lot of misinformation that is coming about politics. And it’s hard to know who to trust. I would be very, very shocked if any nuclear attack was not accompanied by a flurry of misinformation by the attackers about is it safe to go outside? What pills should you take? Where should you go? Who should you listen to? And that’s a place where I think state and local governments can do a lot to inform their people. Here are all the websites, here are the accounts that will tell you the actual information about when it’s safe to go outside. Right, not the person you found on Twitter who sends a picture that says: I’m outside. Everything is fine. That’s the kind of place where I think a lot of education can go a long way, and make people feel as if there is something within their control that they are doing that’s helping with preparation. I think that that’s something that can happen in schools that’s different from fire drills or hide under your desk. But at this point, I think it’s more helpful. BUSHBERG: Yeah, just to amplify that point a little bit—thank you for that—you know, it seems somewhat counterintuitive but I think, you know, people think about evacuating an area that has been subject to such a detonation or an attack. But if you’re outside of that zone of lethality where you haven’t been killed by the blast, that there following such a detonation, people I think instinctively would try and evacuate, or run, or get away. But that’s the wrong thing to do. (Audio break)—detonation is to seek shelter, and seek shelter immediately. And the best shelter is the largest, closest building you can find and be in the—sort of as close to the middle of that building as you can, with as much building on top of you, below you, and on the sides. And this is really to reduce the amount of radiation one gets from fallout. But the most important part of it is that you’re not trying to evacuate, you get stuck in traffic, you know, you have fallout occurring now over the next hours, and that can be lethal from a nuclear detonation if you are exposed to it directly early on. And so I can’t overemphasize the importance of this very, very prompt seeking of shelter, and to stay inside until the emergency and local public health officials can provide additional guidance. FASKIANOS: We have two minutes left. I’m going to just try to sneak in the question—or, a question from Eno Mondesir. If you could be quick, that would be great. And then people—you know, Andrés and Jerrold, if you can answer and give you closing thoughts, that would be terrific. And you need to unmute yourself. OPERATOR: Looks like we’re having some— Q: Sorry. FASKIANOS: Oh, there we go. No problem. Q: Yeah, I just wonder if any of the two experts could tell us how many nations already have nuclear capabilities, and what are the potential ones also? GANNON: So I think the count now is around nine nuclear states. U.S., Russia, China, India, Pakistan, North Korea, U.K., France, Israel. The states that are most likely to develop a nuclear weapon coming up would be Iran, sort of the one that’s being discussed. South Africa is the one case of a country that had a nuclear weapon and voluntarily sort of gave up that capability, which is a real interesting place to—that a lot of people are producing good academic work. So that’s where we are as far as who has nuclear weapons. There’s a weird way of thinking about who’s most likely to use nuclear weapons. Well, one answer is they’re being used every day, and that they are changing states’ calculations about what types of decisions to make and how they interact. Whether that’s a good or a bad thing I think is a subject of very important and unresolved debates, but one that hopefully continues. FASKIANOS: Jerrold, any closing thoughts? BUSHBERG: Well, I would just repeat, you know, really the two key items, which is, you know, if there is a detonation that occurs in Ukraine, there—it will not pose any serious threat to citizens of the United States. And if there were happen to be a detonation in the U.S., outside that zone of lethality it is survivable, if you seek shelter promptly. So we’ll leave it at those two comments. And, again, we can—we will provide these additional links to—where you can go into much greater detail after this seminar is over. FASKIANOS: Wonderful. Thank you so much. So we appreciate you both being with us, Andrés Gannon and Jerrold Bushberg. And again, we will send out the links to this webinar, as well as resources. Please, I encourage you to visit CFR.org, ForeignAffairs.com, and ThinkGlobalHealth.org for more expertise and analysis. And you can email us at [email protected] to offer suggestions of other topics we should cover or speakers that could support the important work that you are doing in your communities. So thank you, again, for being with us today. We appreciate it. And we look forward to reconvening again. (END)

After more than five decades at the National Institutes of Health, physician-scientist Anthony S. Fauci, MD recently stepped down as director of the National Institute of Allergy and Infectious Diseases (NIAID) and President Biden’s chief medical advisor. Here he discusses his thirty-eight years as NIAID director, the international response to the COVID-19 pandemic; the latest developments with emerging infectious diseases; and how countries should prepare for the next pandemic. 

William Hsiao, K.T. Li professor of economics emeritus in the department of health policy and management and department of global health and population at Harvard T.H. Chan School of Public Health, and  Ellen L. Idler, director of the Religion and Public Health Collaborative and Samuel Candler Dobbs professor of sociology at Emory University, discuss the equity and accessibility of the U.S. healthcare system and other healthcare systems around the world, and the intersection of religion and global health. Holly G. Atkinson, affiliate medical clinical professor at the CUNY School of Medicine, moderates. Learn more about CFR's Religion and Foreign Policy Program. FASKIANOS: Welcome to the Council on Foreign Relations Social Justice Webinar Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. Today’s webinar series explores social justice issues and how they shape policy at home and abroad through discourse with members of the faith community. This webinar is on the record, and the audio, video, and transcript will be available on CFR’s website, CFR.org, and on the iTunes podcast channel, Religion and Foreign Policy. As always, CFR takes no institutional positions on matters of policy. We are delighted to have Holly Atkinson with us to moderate the discussion on “Healthcare Equity and Accessibility Around the World.” I will just give you highlights from Dr. Atkinson’s bio. She is an affiliate clinical professor at the CUNY School of Medicine. Previously, she was director of the human rights program at the Icahn School of Medicine at Mount Sinai. Dr. Atkinson is currently an associate editor of the Annals of Global Health, and a member of the Council on Foreign Relations. We’ve dropped a link to her bio and the speakers’ bios in the chat, so you can look there. But I’m going to turn it over now to Dr. Atkinson to introduce our distinguished panelists, and then start the conversation. So, Holly, over to you. ATKINSON: Thank you, Irina. And good afternoon, everyone. I’m really delighted to be moderating this very distinguished panel. Let me introduce you to them. William Hsiao is K.T. Li professor of economics emeritus in the department of health policy and management and the department of global health and population at Harvard T.H. Chan School of Public Health. He received his PhD in economics from Harvard University. Dr. Hsiao is a leading global expert in universal health insurance, which he has studied for more than forty years. He has been actively engaged in designing health system reforms and universal health insurance programs for many countries around the world. Dr. Hsiao developed the “control knobs” framework for diagnosing the causes for the successes or failures of national health systems, and he has shaped how we conceptualize national health systems. He’s published several papers and books and served on editorial boards of professional journals. Dr. Hsiao served as an advisor to three U.S. presidents, the U.S. Congress, the World Bank, the International Monetary Fund, the World Health Organization, and International Labor Organization. Ellen Idler is the director of the Religion and Public Health Collaborative and Samuel Candler Dobbs professor of sociology at Emory University. Previously, she taught at Rutgers University. Dr. Idler received her PhD and MPhil from Yale University, her B.A. from the College of Wooster, and attended Union Theological Seminary on a Rockefeller Brothers Fellowship. At Emory, she holds appointments at the Rollins School of Public Health, the Center for Ethics, and the Graduate Division of Religion. She is a fellow of the Gerontological Society of America. Dr. Idler studies the intersection of religion with public health at the individual, population, and organizational levels. She is the editor of the Oxford University Press book, Religion as a Social Determinant of Public Health, and author of numerous studies on religion’s role in health. She is also an associate editor for PLOS One. Welcome to you both. Bill, let’s get started with you. We have a gathering of individuals today, many of whom are from the faith-based organizations and institutions. And I’d like for you to describe what the control knobs approach is to formulating health policy. And of course, particularly in the context of what we’re talking about today, which is equity and accessibility to health care. HSIAO: Control knobs is a new analytical approach for health policymakers and analysts, as well as for the public, to understand health policy. Let me give a brief history. Traditionally when we look at health care, we look at the inputs—how many doctors, nurses we have, and how many hospital beds, and community centers we have. That’s the input. This new control knobs framework is saying, no, let’s look at the output, the outcomes, that’s what we care about. And such as equity in health outcomes, equity in reducing the poverty caused by health expenses. And to look at how these outcomes are produced, we identified major so-called “control knobs” that determines the outcomes. That’s including financing how you organize health care—for example, do you rely on the market, or do you rely on the government—and the payment system, how do we incentivize the providers, and the regulation. And here, my last point, to determine the outcomes there you want to look at the equity of the health outcomes and the reduction of impoverishment due to health expenses. ATKINSON: Well, let me stop you right there, Bill, for a moment. And can you give us a working definition of what you mean by equity? And how do measure that? It’s obviously an ideal that we have as an outcome, but how do you actually measure equity across a national health plan? HSIAO: Well, not being a philosopher, like Ellen, because I work more on the practice side, that equity is a principle made very well known by John Rawls, the theory of justice. That under a veil of ignorance, we want to give more resources and health services to the most disadvantaged people. It can be the poor people, the handicapped, the ill people. But these people could be disadvantaged for genetic reasons, social reasons, and environmental reasons. So it’s very hard to classify them, to say really what is due to their circumstance versus their free will, let’s say, to control their weight. Therefore, in the health policy world, we actually change that word “equity” in practice to “equality.” We want to give everyone equality regardless of income, gender, race, region, education, and so forth, to see whether they have equal outcome in health—like, their health status, as well as how many of them get impoverished because of health expenditures. So with that, we can actually measure it, because you can measure the health status of people regardless their circumstances. So in practice, we actually practice equity translated into equality. And Ellen may disagree with that. ATKINSON: Well, you’ve really raised the issue of what we call the social determinants of health. And Ellen, of course, in the introduction, I mentioned this marvelous book that you’ve edited, which is Religion as a Social Determinant of Public Health. Before you talk about religion as an SDH, as we call them, tell us what a social determinant of health is. IDLER: Sure. Thank you. I’d be happy to. (Laughs.) It is really the paradigm for public health and epidemiological research these days that you think about the most upstream factors that determine the health status of individuals. It’s not the close-in kind of health care or health behaviors that are the most important. It is those social determinants of health that have everything to do with income, and wealth, and education. And the World Health Organization had a commission on the social determinants of health in 2007. The concept was around for a while there, but it really got a very official designation with that WHO commission that was led by Michael Marmot. And the definition from their report is social determinants of health are the circumstances in which people are born, grow up, live, work, and age. And I love that definition because it captures the life course aspect of health. But it does begin at birth. I think about these social determinants’ circumstances of birth and I always think about the parable of the sower in the Gospel of Matthew. The sower sows the seeds. And some of the seeds are scattered onto rocks. And some of them are scattered to very dry ground and they can’t grow. But other seeds fall on fertile ground, and they have sunshine, and they have enough rain to grow and thrive. And the point about that parable and the point about the definition here is that people don’t choose the circumstances of their birth. We are born, some of us, into very advantaged situations, and others of us into very disadvantaged ones. And we didn’t choose those. We were given them. And for some of those people, religion is present in the social world that they’re born into, and for other people it isn’t. So our purpose in that book was to take a look at religion among the social circumstances of birth. I will mention that the World Health Organization did not include anything about religion in their report, which struck me as a notable absence, being how important it is as a circumstance. ATKINSON: It is an interesting oversight, isn’t it? Well, tell us how you conceptualize this. In the introduction I also spoke about the fact that you published and thought about this on an individual, population, and organizational level. Tell us about how you conceptualize religion as a social determinant of health. IDLER: Sure. I’ve been thinking about this for a long time. And I was really helped out by a group of researchers at Harvard, who published in July in the Journal of the AMA a big, systematic review and meta-analysis of studies on religion and health. There were two panels. One of them studied religion and spirituality in serious illness. So those were mostly patient studies. And the other study, the other panel, was for, they called it, health outcomes. So those were more epidemiological population-based studies with representative samples, so that the estimates could apply to a larger group. And that second group found a really, really strong evidence of association between how often people attended religious services and their rates of survival. So the higher the frequency of attendance at—the attendance part is critical. It’s the social part—(laughs)—of joining with a group of people on a regular basis. And people who had that social tie were much more likely than people who did not have that social tie. And there’s what epidemiologists call a dose response relationship. So the higher the frequency, the greater the survival. And at various steps along the way, survival declined. But that was one of the findings. There were many findings. But that was certainly one of them. And it was the one for which the researchers said there was the strongest evidence. So I would call that the evidence at the microlevel. It’s a way to think about the way religion plays out in the health arena. And in the lives of individuals, the presence of a religious community and attachment to it is definitely protective of health. That was really strong evidence with respect to mortality and many other health outcomes that they look at. But there are other levels. We can think about it at the institutional and also at the state level. But I don’t know if you want me to stop there and—(laughs)—or talk a little bit about those two. You let me know. ATKINSON: Yes, we’ll get to that. Bill, I want to get you in the conversation here about how do you see that religious faith fits into this control knob framework? You’ve worked in numerous countries, over twenty countries, working on revision of their healthcare systems. And what’s been your experience of how religious faith fits into the control knob framework? HSIAO: It fits very closely and tightly because we have to—we asked the countries to define their goals for health care. And where equity is the principal, equity or equality of health outcomes and a reduce of impoverishment. So what determines the equity part? Well, in the books I’ve coauthored with three others, we emphasized the ethics, ethical values, of a nation. We show you how important this is. For a country, when my team and I go in, the first thing I ask them to do is, one, to form a steering committee to define their equity principles based on ethical principles, values. But of course, ethical principles are influenced strongly by religious faith. And now also we ask them to allow us to have focus groups with the public, or even large public meetings. Again, common people’s values of equity is influenced by religion. So in my work under the control knob is that actually religion has a very close tie and strong influence on the goals a country sets for itself. But it’s different between countries, though, because their values and their religion can differ greatly. ATKINSON: Well, I think this is an area here in the United States that we certainly could pay more attention to in terms of the ethics of equity in health care. And, Ellen, I want to return to—you and I had a conversation the other day, and I wanted to return to something we were talking about. We were talking about what faith-based organizations bring to partnerships. And I wonder if you can expand upon that for us, about what do you see as the real skillsets and advantages that FBOs bring to movements of social justice, particularly in the context of equity in health care? IDLER: That’s a great way to put the question. Faith-based organizations in the United States and around the world play an incredibly important role in health. And I’ve just been reading for a chapter that I’ve been working on about the amount of aid that goes to more and more faith-based organizations around the world, and accounts for a good amount of global health spending, especially by philanthropic organizations like the Gates Foundation. And in the United States, there have been many examples of real, I think, sort of organized efforts in crises, especially, to respond to them. And in April 2019, we did a special section of the American Journal of Public Health featuring the work of faith-based organizations as partners with public health in meeting public health goals. And one of the chapters, just to lift up one example, was by my colleague at Emory, Mimi Kiser, who was one of the principals in the interfaith health program that began at the Carter Center in the 1990s, and then moved to Emory around 2000. And the interfaith health program in 2009 worked together with federal government agencies to organize faith-based organizations’ vaccine drives for the H1N1 influenza response. And from that, they developed ten sites around the country where vaccinations were given to especially hard-to-read populations. That was the title of the article was, “Faith-Based Organizations Role in Accessing Hard-to-Reach Populations.” One of the sites provided over four thousand vaccinations and more than 40 percent of the people who were getting them did not have health insurance. And this is after the Affordable Care Act. So they were getting flu vaccines, for free, into communities. And, for example, one story was about how well one particular group could go out to vaccinate migrant farm workers by being there at the crack of dawn before they went out into the fields to work, and then also being there in the evening when they returned. So reaching hard-to-reach populations is important, and is possible, from faith-based organizations because they play a trusted role in their community. And this particular drive that they might want to be working on is only one piece of the overall mission of that faith-based organization. So it has the context of being a known quantity that has social capital in its community and can really play on the assets of that community. ATKINSON: Bill, can you give some concrete examples of how religious faith has shaped health policy? And in particular, what population groups were affected? HSIAO: Well, I can give a couple concrete examples around the world. Well, one—let’s say, in another country. And the obvious way is gender inequality. And some faiths actually do not treat women as co-equal. And when they invite us in to design their health policy, to formulate policy, they reveal that preference towards males, and for sons, and so forth. And we had to struggle with that and try to persuade them that’s not what WHO or UN Declaration of Human Rights, and so forth. That’s one example of it. But in United States, the obvious example is on abortion. And abortion is so closely tied with religious faith of different groups, and I don’t need to explain how that shapes the politics of it and even court rulings, and then—so. But putting in a more positive light, faith, usually I find—regardless if it’s Christianity or Judaism or Islam or Hinduism or—(inaudible)—because I work in all of these countries—they really all embrace certain fundamental beliefs about human beings. And they expect a basic principle that every human being may have some part which is given by God. So there’s a divine part. Usually it’s defined as goodness part of ourselves. And so in using the control knob that we’re trying to say, OK, you want to create equity or equality in the health outcomes of your people? Then which group has been mostly neglected, OK? And Ellen just pointed out, you have interfaith groups. Yes, I observe many interfaith groups doing very good work globally. However, I will just say they don’t cover that many people, I’m sorry to say. You really need government to take a major role to deliver basic health care and basic education to people. You cannot just rely on charity and the faith-based dedicated people. They can make a difference, but it doesn’t make it universal. ATKINSON: Before we turn to you now, how do we move forward in terms of partnerships to improve equity to health care, Bill, I just want to check in with you. So how many nations that you’ve worked with have used this control knob framework to redesign their healthcare systems? And how successful have they been? HSIAO: Actually, I personally got involved with nearly twenty countries around the world. But including the two largest ones, China and India. Together, they have 40 percent of the population of the world. I’m also working in Africa, the Middle East. So among the twenty, the program we actually designed for them, I’m sorry to say, did not take into account the social determinants. So there, let me explain. All the WHO, and the world now, is talking about social determinants of health, which is important. But government structure is not built that way. The minister of health doesn’t control housing, food. There you have to talk to the prime minister or president. They usually pay attention to creating jobs for people. Even President Biden. It’s, how do I control inflation? How do I reduce war? The top person doesn’t get into these issues about social determinants, where he or she has to bring all the ministers together. (Inaudible)—in human rights. It’s a determinant of health. Education is definitely. Environment, income, general equality. And I don’t need to bore you with how many ministers, as far as consensus, you have to bring. So I applaud people who really push for social determinants. And I know—(inaudible). However, the practical world, I discover you really have limitations because the governance structure of the government make it very difficult to make that a reality. And WHO, which I serve on the advisory council, knows that. So I call it a noble vision, but I will argue, let’s pay attention and make a real difference rather than just put out noble vision. ATKINSON: So before we open it to the floor to receive questions, Ellen, how do you see us going forward from here in terms of partnerships that could be established to really help move forward equity and accessibility in health care? IDLER: Well, my long-range plan on that—(laughs)—is to educate students to understand the structures and missions of other organizations so that they can work together. At Emory, we have a dual degree program between the Candler School of Theology and the Rollins School of Public Health. And we have a certificate program. And so we have a structure that allows students studying for a master’s in public health, for example, to sit in a classroom for a semester with students who are studying at the Candler’s School of Theology to work in some faith-based organizations or in local congregations. And because they can influence each other’s thinking about this and make the presence of that other structure real. And I feel like while they’re students now, they will be leaders of their organizations. And ten years from now, fifteen years from now, they could be in a position to see a situation where the possibility of partnership is made much more real because of the fact that they had this educational experience that’s going to carry with them. So that’s my long-term plan. (Laughs.) ATKINSON: And, Bill, from your vantage point as an economist working on healthcare reform for forty years, how do you see that the faith-based organizations could help move the agenda forward? HSIAO: I really think the faith-based organizations actually have a tremendous amount of influence. But you have to go through the intermediate step, apply to your faith, your religious faith, translate that into a set of ethical standards, which I call values, which then can be used in policy. Because policy, including the United States believing we should provide health care through the market, OK? That’s a policy decision. And if you understand through the teaching of the faith that you want to have greater equality, markets cannot achieve that for you. You’ve got the exact opposite. The poor people cannot afford it. And insurance companies will not insure the elderly people and disabled people. So I would urge faith organizations to really understand what criteria that are the control knobs. Which is used, by the way, now close to 36,000 policymakers around the world. The ministry of finance, ministry of planning, the ministry of health. This is through an executive program financed by World Bank that’s done by WHO. So you want to do that translation, that would be what I hope. ATKINSON: Well, thank you, both. I just want to invite our participants now to ask a question. You can either put it in the chat or you can click on the raised hand icon. And we will call upon you. FASKIANOS: Yes. That is correct, Holly. (Gives queuing instructions.) And I’m looking now for raised hands, to see if anybody—oh! We have our first raised hand from Galen. GUENGERICH: Thank you, Irina. And thank you to the panel for a fascinating discussion. I have one very quick question and then one that perhaps a little bit more discussion. FASKIANOS: And, Galen, introduce yourself, please. GUENGERICH: Oh, I’m sorry. I’m Galen Guengerich, senior minister of All Souls in New York, and a member of the Council. A question for Ellen. Do you have a percentage of the decrease in all-causes mortality between the most active participants and the nonparticipants in religious communities? So that’s a simple question. The other question is probably for Bill. You’ve talked a lot about the importance of policy, and the importance of getting government at various levels to do what they need to do policy-wise, so that the inequities are reduced. When it comes to the role of individual religious communities, where is the greatest point of leverage? In other words, it's pretty simple for me to open our buildings and get volunteers to do something like have a vaccine clinic. Where do I point people to effect policy most effectively? Thank you. ATKINSON: So, Ellen, percent decrease in all-cause mortality? IDLER: I can take the first one. It’s easy. So there was a systematic analysis that, if I could just quote a study of my own that was in PLOS One in 2017, we analyzed data from the health and retirement study. And so people who attended weekly or more often were 40 percent less likely to have died by a twelve-year follow-up period—ten, sorry—ten years—compared with people who never attended. And then it was—so it was a 40 percent reduction and then, like, 30 and 20 percent reductions for people who had some ties to faith communities, but yeah. And that’s from fully adjusted models. That’s after taking account of the health status of people at the beginning of the study, and other kinds of health behaviors. And so it’s—and income, and education, and all of those things. So that’s the final most adjusted model, 40 percent difference. HSIAO: My answer to you is that I believe there are two vehicles where the individual religious organization can make the most difference. One is actually, particularly here in the United States, is to get people to discuss the ethical value for health care. And then they can influence other social determinants, as well as the direct health care itself. The second part is to actually engage in some political organizations, like Boston has the Great Boston Interfaith Council, which then they promote political action. They’re very effective because religious organizations have a moral standing. And the people really listen to religious organizations and groups organized by religious groups. Those are my quick comments. ATKINSON: Hmm. Ellen, that reminds me of an opinion piece that I believe you wrote in the American Journal of Public Health about best practices for faith-based organizations and religious institutions to engage in these kinds of partnerships. Can you review some of those for us, that you’ve really been able to identify as those top best practices for an institution to engage in? IDLER: Uh-oh. This is a test. I don’t have that piece of paper on my desk right here, but I will call up some things from memory. I think that mutual respect is one of the most important lessons that come from partnerships. There is some history of distrust by religious groups of public health. And some of the Tuskegee studies and other things that I’m sure we could all mention of very, very bad public health processes that have resulted in even more injustice. So the role of public health as a social justice warrior in our culture—(laughs)—we might think of that as fairly recent. And in the past, it wasn’t always so. And so there are—there is mistrust. And I think that in public health, a lot of times we talk about getting religious groups to do this for us. And there’s an instrumentality to the idea of using faith communities to accomplish some public health goals that doesn’t recognize the importance, fullness, and much broader mission of those public health—of those faith-based organizations or religious congregations. So I would say mutual respect and care in working out and finding where the common ground is is really a big message. Because faith-based organizations or congregations and public health have—they both have missions. And their missions may overlap at times, but most of the time their missions don’t overlap very much. And so finding where there can be common ground is a lot like what we talk about as bipartisanship in politics. Find where you both want to work together on something to accomplish it, and leave the other parts aside. And so it really requires strategy, and being willing, I think, to find where that area of common ground is, even if it’s not obvious at first. ATKINSON: Thank you. FASKIANOS: Thank you. And the next question is, right, from Lawrence Whitney. WHITNEY: Hi. Lawrence Whitney. I’m a research associate at the National Museum of American History and a fellow at the Center for Mind and Culture in Boston. Question about the ways you see different religions interacting in public health situations around the world. And I’m thinking particularly when COVID started there were a number of folks claiming that Confucian societies were better able to handle the pandemic. And then a group of policy experts in Global Policy Journal noted that arguing that Confucianism explained East Asia’s success would be as implausible that Europe and the United States’ failures stem from their Christian roots. No serious study has yet offered evidence for such claims. Of course, two months later Andrew Whitehead and Sam Perry came out with a study pointing out that Christian nationalism actually has been a key factor in limiting our ability to handle the pandemic here in the U.S. So I’m wondering if you could comment on the ways different religions interact differently in these spaces and can be helpful, but also detrimental, to the goals of public health. HSIAO: So you’re asking me or Ellen? (Laughs.) WHITNEY: Yes. ATKINSON: Either. IDLER: Well— HSIAO: Well—go ahead, please, Ellen. IDLER: OK. I’ll jump in. I will say that I was very attuned to the headlines about religion during the COVID epidemic, especially at the start of it. And there were a lot of negatives here in the United States, but around the world too. And some of the outbreaks occurred in religious settings initially. People sing—(laughs)—very often when they are in worship services. And singing is a really bad way to project a lot of aerosols. So I did, with a couple of grad students, a text analysis of articles on religion and COVID in the New York Times, from January 2020 through July 2020. And we also looked at the text for the guidelines for faith communities from the World Health Organization and the CDC. And finally, went to the websites of every religious group around the world I could find that had a COVID statement on it, and analyzed all this text together. It definitely was different from the headlines. The New York Times—we did two things. We did a sentiment analysis, which is based on emotion kind of words, and saw a very strong trend from the quite negative to the reasonably positive sentiment in the New York Times for articles on COVID and religion. And we also did a topic analysis, which showed a considerable overlap between the topics of—that were present in the CDC and World Health Organization documents and the COVID statements that were on the websites of religious groups. And that was fascinating. It wasn’t like they posted the text from the WHO guidelines at all. These were very much faith-based organization statements about their own group’s response. So the message from the actors themselves was a lot more positive than what might have appeared in the headlines. However, I certainly would not want to ignore the fact that religious liberty arguments were being made about the freedom from wearing masks, and not wearing—not getting vaccines. And so, yeah, there was the Christian nationalism, and Perry and Whitehead are great. That was a really, really good contribution from them. So certainly, that was there. But on balance, there was a much more positive response of the organizations on their own websites, but also big webinars that the National Council of Churches ran repeatedly. And so it was a mixed, but on the whole positive, kind of analysis that we got from our analyzing all that text. ATKINSON: Bill, do you want to add to that at all? HSIAO: Yes, because the question is about Confucianism. And I came to the United States at age twelve, but I take a deep interest in Chinese philosophy. So I read some Confucianist writings. I think that Confucianism—Confucianists do not emphasize God or a supreme being. It’s really more a philosophy. And the one major point of philosophy influence this COVID or public health is for the—people who rule, they must actually preserve their position. That means they are looking after the welfare of the people. So in the COVID pandemic, you see the East Asian countries that embrace Confucianism—that’s including Taiwan, Japan, South Korea, and Singapore—these countries’ leaders took action very quickly, unlike the democracy, democratic form of government, like the United States. And then, of course, there are tradeoffs. China has autocratic government. Originally, policy was very good, but then they make the wrong policy with the—as the COVID, the virus, mutated. And so there are tradeoffs under that Confucianist teaching. However, I just want to emphasize, if they were really practicing what Confucius taught, it’s to be a political leader you have to be observant. You show to people you actually can bring them benefit. And I would say you can say there is some compatibility with democracy here. FASKIANOS: Thank you. We have several questions in the chat. So I’m going to take the first one, read the first one from Lai Sze Tso from Gustavus Adolphus College. The translation process for FBOs sounds fascinating. Would there be feedback from local, national, non-FBO health and government administrators? Or are we targeting international charities/USAID? I don’t know who wants to take that. HSIAO: I think that’s for you, Ellen. (Laughs.) IDLER: I’m not sure I understand the question’s point. So I’m—is it about the leverage points, or? I’m not sure I— FASKIANOS: Lai, are you in a position to unmute and clarify for us? If not, we can go to the next question. IDLER: I’m sorry. (Laughs.) FASKIANOS: No, that’s OK. That’s OK. Sometimes with the written questions it’s a little bit more challenging. SZE TSO: Hello? FASKIANOS: Oh, hi, yes. SZE TSO: Hi. So the translation process was referring to when Bill said that for faith-based organizations instead of directly doing work that is charitable with limited effect in a community, that it would be even more effective to translate ideals and goals and ethics into a set of standards. And I was hoping for additional clarification on if that was just at the local and national level, or are we also engaging more widely with international charities, as well as strong influences from organizations like USAID? HSIAO: Oh, I’m sorry. I misunderstood the question. And sorry I throw that hot potato to you, Ellen. (Laughter.) Let me offer my quick comment. I think actually you want to influence health policy decided by the domestic government. And I would consider that the main avenue. So you want influence in a country, the local churches or even mosques can actually influence how people think and express their views about health, about equity, and access to health care. That’s domestic. Internationally, well, actually, the United States under President Bush did this, which I experienced. Any country to even mention, use the word “Planned Parenthood” cannot receive U.S. foreign aid. And during this administration, actually, the population, the birth control and so forth, really took a major hit. So we can look through the government channels. But through the NGOs, with interfaith organizations, they continue to do very good work. However, let me just say this. Historically, the Christian missionaries went overseas offer free education or free health clinic and drugs. (Inaudible)—I’m trying to draw you into my faith. That history is still there. It makes the local people very suspicious when they hear it’s an interfaith organization doing something. They wonder what’s the other motive behind it. And so some interfaith organizations were able to overcome that very successfully, but others may not. Because there’s a variety of interfaith organizations working in the world. Literally tens of thousands of them. That’s all. SZE TSO: Thank you. FASKIANOS: Great. So we have several questions. The next question I’ll take is from Heather Laird. I appreciate the discussion on ethics. I found in the work of mental health, ethical humility is needed. Oftentimes, collective values are missed completely in many charters and ethical codes. Do you find this to be the case across health care in general? This is a question for both of you. As you are looking at social determinants, how do you account for diverse views of equity? And how do you ensure voices are represented? And Dr. Heather Laird is at the Center for Muslim Mental Health and Islamic Psychology. HSIAO: Do you want to go first, or do you want me to? (Laughs.) IDLER: I think we can both try to answer this question. Great question. So the social determinants of health framework originated with researchers in the UK. And that’s somewhat ironic, isn’t it, because of the National Health Service and the provision of universal health care to people that is free at the point of service and has been since 1948. And so I think that was somewhat of a surprise to people, to find out that income and education and the other social determinants play such an important role in health status of the U.K. population, given that they already had a very robust system of health care in place that was equitable and accessible to everyone. In the United States, we understand that people do not all have health care. And still, 10 percent of our population remains without insurance, and many people are underinsured. And we also know that medical bills are a big cause of bankruptcy. So it’s—health care is actually driving poverty, driving inequality in a really bad way. So I guess we sort of know that. And the social determinants of health framework makes sense all around us here in the U.S. But even in other countries, where there is equitable access to health care, quality health-care services, there is still inequality with health. HSIAO: If I understand your question correctly, you want to know about mental health. Is that correct? Let me comment about what I observed around the world. Around the world, the awareness of mental health is not at such a high level as the United States or European countries. And usually, it’s out of ignorance. And because their education level is very low. As Ellen pointed out, that’s a social determinant of health too. And so therefore mental health is neglected. But meanwhile, physical illness is so visible—the pain, or the fever, or disability is so—mental health has lagged behind. Partly, though, I would say religion also has something to do with it, if I may just say. The question is, in your religious faith do you believe psychology is an important part of the human makeup? Let’s say Russia’s system, Russia and the materialism doesn’t believe psychology has any role. That’s not part of our human makeup. And so I work in China trying to overcome that. And they are now trying psychiatry. And they do not—and the social stigma for the mental health is so severe that you have to overcome all these barriers to be able to bring in really medical health. And the educational part actually becomes the first—as far as really educating the public as well as the policymakers—to say how important mental health is. And that that would draw on the literature, really studies, evidence from the United States and from European countries. ATKINSON: Well, thank you, both. Unfortunately, we are out of time. It has gone very quickly. And I am going to turn it now back to Irina. FASKIANOS: Great. I’m sorry that we couldn’t get to the additional questions but, as Holly said, we are out of time. Thank you all for today’s hour discussion. It was very insightful. We encourage you to follow Bill’s work at hsps.harvard.edu and Ellen’s work at sociology.emory,edu. And you can also follow CFR’s Religion and Foreign Policy program on Twitter at @CFR_religion. Please do email us with suggestions for future topics and speakers. You can send us an email to [email protected]. Wishing you all very happy holidays. Our next Religion and Foreign Policy Webinar will be in the new year on protests in Iran, on Wednesday, January 11, at 2:00 p.m. Eastern Time. So we will reconvene in 2023. And again, wishing you all happy holidays. Stay safe and well.