The CommonHealth

In the fourth episode of our Live From Munich Mini-Series, Steve is joined by Tom Bollyky, the Senior Fellow for Global Health, Economics, and Development and Director of the Global Health Program at the Council on Foreign Relations. Mr. Bollyky attended the Munich Security Conference “to keep the conversation about the response to the COVID crisis still on the national security agenda”. National security and global health have been historically linked, as exemplified with the birth of PEPFAR. Could the war in Ukraine lead to a similar program for Covid-19? And what are the major obstacles in creating pandemic preparedness policy?Tom Bollyky is the Senior Fellow for Global Health, Economics, and Development and Director of the Global Health Program at the Council on Foreign Relations. 

Two years ago, Dr. Jeremy Farrar joined Steve for the first iteration of Live From Munich, when the Covid-19 Pandemic was just emerging. Today, for episode #125 and the third installment of this Live From Munich mini-series, he returns to discuss this murky transition into the next stage of the pandemic. Dr. Farrar predicts that “political interest will wane from the pandemic because other events take over.” Politics are turning towards an exhausted, frustrated, even sometimes violent public. “We all feel fed up with this pandemic. But our emotional state doesn't determine the outcome of the pandemic.” We must be prepared for all scenarios, not just the ones we prefer. Dr. Farrar takes a lesson from the Munich Security Conference: “The truth is that the security community does this all the time. They think of a central scenario that is the most likely and they put most of their planning around it, but they do not ignore the other scenarios.”Dr. Jeremy Farrar is the Director of Wellcome Trust. 

In episode #124, the second episode of our Live From Munich mini-series, Steve is joined by Seth Berkely, CEO of Gavi, The Vaccine Alliance, “the largest purchaser of vaccines in the world”. He speaks on strengthening health security: “Do we prepare for our hopeful future? Or do we prepare for reality?” “The right thing to do is to continue to prepare for worsening variants, worsening disease. And the best way to do that is to make sure high-risk people all over the world are as protected as they can be.” We are only as safe as our neighbors. Longterm, "it hurts the world if new variants appear, get the chance to circulate, and then jump out again, as we’ve seen.” Different vaccines have different advantages for various levels of infrastructure, and “we want to get countries to a place where they can say we have the right vaccine, in the right place, at the right time to meet the needs of our population.” “We’re fools if we don’t keep in mind that we have to protect everyone in the world.”Seth Berkely is the CEO of GAVI, The Vaccine Alliance.  

Dr. Nkengasong, Director of the Africa CDC and soon to be head of PEPFAR joined us for this 123rd episode, and the first episode of our Live From Munich mini-series, a collection of episodes recorded at the Munich Security Conference. He is a leader in the initiative to incorporate global health in security discussions like the Munich Security Conference. “We have seen how an outbreak of a disease can truly be a health security matter, and also human security, as well as even going as far as a national security threat.” The Covid-19 pandemic has shown us “the need for us to look at the security from a human perspective”, that “we are more connected as humanity”, and “the inequalities that we thought existed are more profound within countries between countries and between regions than we thought”. As North America and Europe begin this murky transition to the next stage of the pandemic, Dr. Nkengasong is concerned that we will “begin to refer to COVID as a disease that will soon be over in the US. And then of course, because of that, it becomes one of the neglected tropical diseases where we now have to rely on foundations or charity to take care of.” He recently called for a pause in vaccine donations: “we're saying that we have a lot of vaccines in the country. Now our problem is vaccination”. “I'm a big believer in that we should always pause to evaluate where we are in response, and then make corrective actions”. How will Africa overcome its major challenge of vaccine hesitancy? “I think every good public health practice as you and I know is local. The concepts are global, but in practice is local, which means Africa must take its own socio-cultural context and deal with it and then find the touchpoints”Dr. John Nkengasong is the Director of the Africa Centres for Disease Control and Prevention, and has been nominated by President Biden to be the next head of the Office of the Global AIDS Coordinator in charge of PEPFAR, the President’s Emergency Plan for AIDS Relief.  

John Barry, historian and author of the award-winning The Great Influenza; the Story of the Deadliest Pandemic in History, a study of the 1918 pandemic, joined us for this 122nd episode. He is currently working on a volume on Covid-19: “Writing books makes me happiest and craziest.” He has penned many editorials over the course of the pandemic, drawing lessons from 1918. What has he discovered? “What we learn from history is we learn nothing.” Where are we today? “Until vaccines are widely distributed and there is easy access to antivirals, the virus will rule. … I am optimistic the virus will continue trending to mildness” but there may be intermediate steps. “Mutations are random.” “We are at a potentially dangerous time” if we throw away our defenses and become indifferent or complacent. His high school football coach taught him a lesson for today: late in the game, you are tired and the other guy is tired. “The guy who focuses at the end will win.” That does not mean you “live in a box” and isolate yourself. Aaron Rodgers, while a great football player, “lied” about his vaccination status. He “is a total jackass.” Before becoming a writer, John Barry coached football at the high-school, small college, and major college levels. He is a Distinguished Professor at Tulane University’s Bywater Institute and a professor at the Tulane School of Public Health and Tropical Medicine. 

In 2021, Indiana Governor Holcomb launched the Public Health Review Commission, charged with asking hard questions that cover the waterfront of public health challenges in Indiana and delivering actionable answers this coming summer. Its co-chair, Dr. Judy Monroe, and its director, Indiana State Health Commissioner Dr. Kristina Box, joined us to share what this unusual and promising, fast-moving enterprise is all about. The challenge before Hoosiers is formidable: the state ranks 48th in the country in public health financing. The Commission is off to a quick start staging monthly public meetings and conducting listening tours across the state. It has created a website for public comment and staged outreach to businesses, schools, and universities. Any big surprises? Public health capacities vary enormously across the state – it is “eye-opening.” Indiana’s 49 rural counties especially struggle. Data systems are woeful and antiquated. In the current acutely politicized environment, the Commission is “well-positioned to lift above the politics” and help the state’s citizens focus on the future, especially children’s health. The Commission can contribute to “lifting all the voices.” It can offer space for people who fear mandates are “stripping people of their rights” to vent their frustrations. At the same time, it can convince citizens that public health, when successful, lengthens life expectancy, especially in focusing on chronic diseases. Communications are in urgent need of an upgrade: countering disinformation requires listening carefully to people’s concerns and mobilizing trusted partners in communities, and enlisting and training the next generation of public health professionals. The private sector will be vital partners in any modernization of data systems and in building stockpiles that better meet future needs.Dr. Kristina Box is Indiana State Health Commissioner. Dr. Judy Monroe is the president and CEO of the CDC Foundation.

In Episode 120, the first episode of our Department of Defense mini-series, Joint Staff Surgeon Major General Paul Friedrichs, discusses how the Department of Defense has overcome challenges from the pandemic, incorporating lessons applicable to any large organization struggling to function in today’s environment. Early in the disease the aircraft carrier USS Theodore Roosevelt was sidelined, recruit training and military exercises were interrupted as they searched for answers on how to safely operate. Currently, vaccination rates among active-duty military members are among the highest in the nation and operations continue relatively unimpeded. Domestically, tens of thousands of National Guard and active-duty troops have responded wherever needed to support communities throughout the United States in roles from intensive care delivery to administrative support. Worldwide DoD biosurveillance and research programs designed to protect U.S. forces against disease while deployed overseas play a major role in virus identification and vaccine development - including the mRNA platform which is the basis for the Pfizer and Moderna vaccines. The establishment of the Defense Health Agency presents an opportunity for much-needed organizational streamlining of the extremely wide breadth of military health capabilities, however, it is important that less visible, yet vitally important, assets such as overseas infectious disease laboratories, are able to continue their vital work. Likewise, the impact of active duty medical personnel cuts must be carefully considered regarding the ability to detect, prevent and treat infectious disease threats. As Covid-19 evolves, U.S. military medical personnel will continue to work collaboratively with colleagues at home and throughout the world for answers. Air Force Major General Paul Friedrichs is the Joint Staff Surgeon, the medical advisor to the Chairman of the Joint Chiefs of Staff and responsible for coordinating all issues related to health services including operational medicine, force health protection, and readiness among the combatant commands and the Office of the Secretary of Defense.Read the report here: https://www.csis.org/analysis/department-defense-contributions-us-covid-19-response-home-and-abroad

In episode #119, Dr. Peter Kilmarx, Fogarty International Center, discusses the struggle to advance contact tracing. Efforts early in 2020 to create a national Covid-19 Response Corps – at least 100,000 needed – were not successful. Instead a “hunger games scenario” ensued in which each jurisdiction scrambled to make its own solution. In our federalized system, each state, and in some instances county, has had to build its own public health workforce while balancing the budget. The lack of an integrated data system made it difficult to track progress. Contract tracing has made only marginal progress in curbing transmission. Experiments in the use of new technologies have not gotten off the ground in most places. New York City is one shining exception where 90% of cases are tracked, and 75% of their contacts. Success in places like New Zealand, Taiwan, and Viet Nam relies on robust, fast testing systems, consistent social support for those in quarantine, and a tradition of public health workers in the communities. Public health in America has entered a period of crisis, in the face of politicization, distrust, and abuse. In the Biden administration, executive orders and the American Rescue Plan have made major commitments towards contact tracing, testing, and strengthening the public health workforce. In the meantime, foundations, civil society alliances, and public health professional associations have played an expanded role. “Contact tracing does work” if the right pieces can be put in place.Dr. Peter Kilmarx is the Deputy Director of the Fogarty International Center, at the National Institutes of Health and is a Rear Admiral (retired) in the US Public Health Service.

Dr. Michael Osterholm, head of CIDRAP at the University of Minnesota, is among the most popular, respected, and trusted communicators on the pandemic. What is the recipe?  Simplicity rules. He learned from his rural Iowa background, “if something doesn’t play at the 10:00 o’clock coffee club at the S&T Café on the main street of my little town, then it’s not going to play.” Be frank and honest: “Always tell the truth.” If dark things such as variants lie in the future, do not shy away from spotlighting them. But be careful of forecasting too far into the future, which can at times be based on “pixie dust.” Appeal to both “hearts and minds.” “Kindness is one of the most important virtues.” In his lauded and highly successful podcast, ‘The Osterholm Report: Covid-19,’ he is able to “combine science, policy, and life all in one venue.” The anti-vaccine movement has gained substantial strength; witness the ‘Defeat the Mandates’ rally on January 23rd at the Lincoln Memorial, which featured Robert Malone, now a celebrity since embraced by Joe Rogan, who compares public health officials to Nazi Germany. “This is the biggest challenge to global health in my lifetime.” It threatens childhood immunizations, generates “death threats I have received.” Many colleagues are burning out and leaving. He and other colleagues from the Biden presidential transition Covid-19 Advisory Group recently laid out a road map for “the new normal” in three Viewpoints published in JAMA. “We can’t keep swinging from surge to surge.” We need a better plan for data, testing, ventilation, rebuilding our health workforce. But we still have to prepare for the unknown. Recall Lewis Carroll’s advice: “If you don’t know where you are going, any road will get you there.” And “Don’t be surprised when you are surprised.” China’s ‘Zero-Covid’ approach, based on draconian lockdowns and mass testing, has delivered far better outcomes than we have seen here in the United States. But it will not succeed in the face of Omicron. “It is like trying to control the wind.” Something beyond ‘Zero-Covid’ is needed.Dr. Michael Osterholm is Director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota.

Dr. Chris Murray, head of IHME, joined us in episode 117 to discuss his recent provocative piece in The Lancet, ‘Covid-19 will continue but the end of the pandemic is near.’ “The Omicron wave is really different,” extraordinarily fast and much less severe. The current massive Omicron wave will infect 50%-60% of the world by March, creating dramatically enhanced population-level immunity. The unvaccinated and never-infected will become quite scarce, as transmission becomes very low. Aided by the advent of antivirals, “Omicron will become another recurrent infectious disease” that in magnitude is going to be like a bad flu season. Major emergency government interventions will become a thing of the past, even as future variants emerge. Americans will celebrate – almost like a post-war moment -- even as America passes the milestone of one million deaths. Complacency is a risk: some will see this shift as a license to do nothing. “We really have to stick to the truth,” strengthen data and surveillance, improve the health system, and better manage future outbreaks. Another risk: those opposed to vaccines, masks, mandates, social distancing may seize on this transition to advance their cause. “I have not yet received an invite from Tucker… or Joe Rogan.”  China, through its Zero-Covid approach, is hugely vulnerable to Omicron which will eventually break out and threaten to overwhelm China’s health system. In this new phase, attention will turn to other pressing global health concerns, including anti-microbial resistance, the subject of a newly released five-year study of its global burden, led by Dr. Murray.Dr. Chris Murray is Director of the Institute for Health Metrics and Evaluations, (IHME), at the University of Washington, where he is also the Chair of the Department of Health Metric Sciences.